Hi Jill:
Interesting case. At the outset I would say with this patient, and most
patients with L/S dysfunction, there is no way you can say that her symptoms
are secondary to the discs as described and not some other structure. I do
not believe it is possible to have a significant symptomatic disc and not
also have facet and soft tissue dysfunction too. Surgeons like to say that
is just the disc because I think their bias is to what they can treat. Not
that there is any ill intent. I think it comes from your knowledge base.
There was an interesting study a number of years ago (sorry I don't have the
citation) that showed that patients with lumbar disc problems were treated
by a neurologist they received conservative treatment. A similar cohort of
patients saw a neurosurgeon and they received surgery. The outcomes at ~2
years were the same. I believe the treatment that is offered patients is
most influenced by what the consulting practitioner does.
Some questions for you to help me and others better answer your questions.
Did her leg length equalize with treatment? If not the SI could still be
subluxed.
Have you tried pelvic stabilization exercises?
What does your instructor think?
Epidurals can be effective and could be appropriate for her if all joint
dysfunctions have been resolved and there are no major soft tissue issues.
Douglas M. White, PT, OCS
Physical Therapist, Consultant
191 Blue Hills Parkway
Milton, MA USA 02186
P: 617.696.1974
E: [log in to unmask]
----- Original Message -----
From: "Jill H. Kison" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, November 30, 1999 5:32 PM
Subject: discogenic pain/radiculopathy
> I have a patient with a 6 month history of LBP secondary
> to a slight contained disc herniation at L5-S1 & posterior annular
> tears to L5-S1 & L4--L5. She also has had some SI jt dysfunction and
> facet dysfunction and a significant anatomical leg length
> discrepancy, but the SI and facet problems have resolved due to PT,
> orthotics, and jt injections. The current problem is pain and
> tingling in the S1, some L5 dermatome Sxs, and in the buttocks all
> on the left side, which tends to occur only during acute flare-ups
> which the patient attributes to increased sitting (and standing) and
> increased activity (job is primarily sitting all day with limited
> intermittent activity). NSAIDS help decrease the pain, but the
> patient has had four major flare-ups since the initial injury 6 mos
> ago, and recently the NSAIDS seem to be less effective in relieving
> Sxs. The patient is unable to change the sitting requirements of her
> job or to quit her job, but is quite frustrated by the flare-ups
> which seem to last longer with more severe Sxs each each time. The
> MD has suggested an epidural if Sxs do not resolve after this most
> recent flare-up. The Pt has been in PT from 2x/wk to once every
> other week throughout the course of the injury. Ab bracing &
> strengthening increase Sxs during flare-ups and ST work helps only
> for a day or less. Is there something else I have missed or could
> try? Has anyone had much long-term success with epidurals for
> discogenic pain?
>
> J Kison, SPT, ATC
>
>
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