Question
Dear Dr. Rahamimov,

Thank you for your email. I have uploaded the scanned images to the following webpage:

http://community.webshots.com/photo/452027442YiLcSZ#

There are a total of 19 images, including physio and MRI reports. All images can be viewed full size in order to see more clearly. Hope you can find them useful (sorry I have no idea what they mean). Thank you very much for your help.

Yours sincerely,

Helen Bin

P.S. If you can't get to the link, please provide a suitable email address so that I can send you a proper link through the email. Thanks!

-------------------------
Followup To
Question -
Dear Dr. Rahamimov,

My father (56 years of age) had develped sciatica recently and was in hospital for more than three weeks.  Although he has been discharged and is continuing his physiotherapy and medications, he is still in constant pain and his condition hasn't improved much.

Listed below is the 'history' of his condition, including symptoms, current medications and situation, etc (written by my father).  I can also send you his x-ray and MRI images (which were taken in the hospital) if you wish to look at them (please provide a suitable email address, as the files are quite large).  My father and I have some questions about treatment options (including surgery, what types and their risks and benefits, etc), which are also listed below.

I would be most grateful if you can offer us some advice. Many thanks for your help!

Yours sincerely,

Helen Bin

P.S. If you are not familiar with this area, please do pass on my request to anyone you know who are the experts. Thank you very much for your help!


A. Symptoms & History of Treatment for Sciatica

Early July 05
Patient experienced slight pain in left buttock. Doctors consulted and X-Ray on lower spine taken.

7 August 05
Sudden severe pain "burst" from left buttock that spreaded down to the ankle when patient moved a sitting stool from a table down to the floor level.

7 August - 30 August 05
Patient took MRI (magnetic resonance imaging) scanning and the results are as per attached report. Patient received physio treatment 2 times daily in hospital while taking medication mainly inclusive of the following prescription:
1. Neurontin (Gabapentine) capsule 300mg
2. Afloxan capsule 150 mg
3. Methycobal (Mecobalamin) 500 ug
4. Arcoxia (eloricoxib, MSD) 120 mg tablet
5. Oxema

31 August - present
Patient discharged from hospital while continuing physio treatment 1 time daily.

B. Patient's Current Situation

While having physio treatment and medication for 5 weeks, sciatic pain on left leg 60% releived, numbness on left foot 40% reduced, but the left leg found weakened and slim (approx. 12mm cir. reduced as compared with the right one), making it much difficult to walk on staircase/steep road although slow walking is possible on ground level.

C. Professional Medical Advice is needed.

Please comment and advise:

1. Will continuous physio treatment be necessary, or surgery to remove part of spinal disc (L4/5) be considered at this moment after 5 weeks medical and physio treatment?

2. If surgery becomes necessary, what kind(s) of method will be considered appropriate so as to redce surgery risks as far as possible whilst expected surgery result will be achieved?

3. What other methods (medical/surgery/physio/body exerecise treatments, etc.) will be advised for early recovery from sciatic pain?

Many thanks for your help!

Answer -
/

Dear Ms. Bin,

Although you have not  described what was written on the MRI report, I assume that he is suffering from a herniated lumbar disc, causing compression and irritation of one of the nerves leading to his leg. This radiating pain is called "sciatica", but the term is misused often.

To answer your questions, please provide the following:
1. A clinical description of you father's symptoms: where exactly is the pain located,    does he have any neurological deficiency, etc.
2. What was he diagnosed with? What was written on the MRI report?
3. I will gladly view his MRI pictures. You can upload them to one of the free picture-hosting websites and send me a link.

Sincerely,

Dr. Rahamimov


Answer
/

Dear Ms. Bin,

The Images you have uploaded demonstrate a far-lateral disc herniation at the L4-5 level on the left side.
A "far-lateral disc" is one of the more controversial pathologies in spine surgery. Usually, a symptomatic disc herniation will be located within the spinal canal compressing and chemically irritating the nerve roots headed for the legs . This irritation will typically cause a distinct clinical picture of pain along the nerve's pathway, numbness over the irritated nerve's sensory distribution of the skin, and finally, weakness and atrophy of the muscles innervated by the specific nerve.

Healthy 56 year old men tend to have asymptomatic disc herniations: they happen to most of us with the years. For us to decide that a specific disc herniation is the cause of the patient's symptoms, there has to be an excellent correlation between the clinical picture as I described above, and the known anatomical distribution of the affected nerve. A "far lateral disc" will usually be outside the nerve root pathway, and therefore not of any clinical relevance. Only on rare cases will it be the source of pain.
If this disc is indeed the culprit, your father's symptoms would be expected to be: pain radiating from the back down to the left buttock over to the lateral side of the hip, across the knee down the medial part of the calf ending at the big toe. The sensory loss should be over about the same pathway below the knee, and the muscles responsible for lifting the foot and toes could be weakened. "Sciatica" is a more generalized term referring to pain from L4 to S1, and is not enough to make the diagnosis.
If your father does not improve with the current treatment, I suggest he has a root block (sometimes called a foraminal-epidural block) of the left L4 nerve root. This procedure involves injecting local anesthetic and steroids over the suspected nerve root. If it is really the cause of his pain, the pain will disappear while the local anesthetic is acting, and the steroids might provide some long-term relief later on. If the pain completely disappears while under the local, and then returns, he might be suitable for a minimally-invasive procedure called endoscopic discectomy. If the root block has no effect, the source of his pain should be sought elsewhere.

I hope your father feels better,


Dr. Rahamimov