& Leg Pain Problems
I offer this information as a physician not much
involved in pain cases, but in the practice of Pathology & Laboratory Medicine at
Lexington Medical Center since 1975. I got into this info while helping two Aunts and some
others. Most of the below relates to situations corrected by neurosurgeons, orthopedic
surgeons, and interventional radiologists. Chronic neck & back pain syndromes are another
arena of complex situations, and I note below a website that might be of interest as it
discusses so many aspects & issues in good layman language.
CALCULATOR: For back problems, a calculator now exists to help a patient to look at odds of surgery or nonsurgery making things better, no change or worse, the SPORT calculator.
The term, dorsopathy, includes all disorders (spinal disease) of the back/spinal area. Pains can arise, in general, from four (4) areas: (1) the actual joint tissue, (2) non-boney tissues around a joint and between adjecent bones, (3) nerve "pinching" (impingement) in that anatomic area, (4) referred pain which is interpreted by the brain as arising in that area due to disorders elsewhere (maybe even bone near the joint). A quick test that a doctor might do is to first inject the joint with an anesthetic (pain numbing shot); and, if the pain disppears, the cause in is the joint itself. Prior to spending huge money on imaging studies, if the joint injection did not make the pain disappear, a few lab tests might be useful. A CBC and a serum CRP can detect infections that may not have caused a fever. In males above 50, a serum PSA that comes back normal is helpful. In both sexes above age 50, the blood test for serum protein along with electrophoresis that comes back normal is helpful. Going to expensive imaging (such as MRI) is then helpful if one is willing to undergo (1) major surgery if a definite problem is clearly identified or (2) radiation and chemotherapy if evidence of metastatic malignancy ("cancer") is discovered.
The "back bone" is a complicated structure
containing the all-important spinal cord which lets out main nerves at regular intervals on
both sides from the top of the neck to about the waist. Injuries, degenerations (bone spurs,
cysts, bulging & degenerating discs, ankylosing spondylitis), and tumors can encroach
(stenosis) on spinal cord and/or nerves and cause "entrapment pain syndromes" or nerve
inflammations (radiculopathy). Associated muscles, ligaments, cartilage, disc, and bone can
be strained, ruptured, torn, or collapsed; and the pain can, in turn, case additionally
painful muscle cramps/spasm. For entrapment and/or stenosis syndromes not responding to
non-surgical measures (such as epidural injections), surgery such as laminectomies,
discectomies, decompressions, fusions, and releases must be done surgically. And I like
the idea of a nerve-oriented surgeon working on this...a neurosurgeon...if surgery is
necessary. An old term for chronic low (lumbar area) back pain is "lumbago". Chronic low back
pain with a prominent pain component running down the back of one or both legs is said to
include "sciatica" (the leg-pain component).
For collapsed degenerated discs, orthopedic
surgeons tend to be the repairers, at least in the low back...treated by surgical fusions.
The more important the nerve and cord considerations (thoracic & cervical areas), the
more I like the idea of a neurosurgeon. The end of 2004 saw the coming to market of an
alternative to fusions: the artificial disc. The FDA approved CHARITE immobile disc (CHARITÉ™
Artificial Disc [DePuy Spine, Inc.]) is available in Columbia, and the MAVERICK mobile disc
is open for clinical trials in Charleston (as of 16 Jan. 2005). ProDisc® (Synthes Spine),
Maverick™ (Medtronic Sofamor Danek), and Flexicore™ (Stryker Spine) are others coming down
the pike. They all will be compared with the CHARITÉ™ Artificial Disc, which has a 17-year
track record outside of the US. See Sciatica, below.
Neck & shoulder pain due to neck disc
disease (acute or chronic spinal disc herniation): Our neurosurgeons, between May 2006 and April 2007, caused (under a
clinical trial) Lexington Medical Center to be the site of the largest number insertions of
the new "PRESTIGE® LP Cervical Disc" by Medtronics in the USA.
All sorts of medical doctors (MD & DO),
Chiropractors, psychological counselors, acupuncturists, physical therapists, massage
therapists, medical & surgical physicians (including rheumatologists), orthopedic
physicians, neurosurgeons, and radiologists are called on for diagnosis and treatment of all
sorts of chronic pain, including back pain. Life-style modifications, medications,
injections, electronic devices, and surgical corrections are used for treatment. For my
money, I'd prefer to see a radiologist (specialist in all manner of body imaging
anatomy & abnormal findings visible by such techniques) for the initial imaging studies
to see if any obvious cause is visible by their techniques. That means that the key images
(CT scans and/or MRI) need to be performed where the radiology talent & high technology
is and where the doctors can discuss the images with your doctor (of whichever of the above
type you choose). At Lexington, among our team of excellent radiologists, the group has a
neuroradiologist (brain & nerve specialist...Dr. Chris McCarty). It may not work to your
optimal, best interests if your doctor makes an appointment for CT or MRI studies somewhere
other than where your doctor can have access to the consulting advice & be able to
personally self-review imaging studies and with the imaging experts.
*** Get your diagnostic imaging (CT or
MRI) radiology pain studies at LMC (for the reasons just stated
If there is a "disc" problem that
less-than-surgery management or treatments (see below) fail at, I'd seek the opinion of a
surgical repairer: neurosurgeon (especially if evidence of spinal cord or nerve entrapment
and problem location in neck or thoracic spine) or orthopedic surgeon.
Among the imaging studies are "plain film" X-rays,
CT scans, MRI, and myelograms with post-myelogram CTs. The last is an additional test some
want prior to final decisions for surgery because it allows computer reconstruction and more
exacting detail as to the configuration of the suspected surgically-curable lesion. If there
is any doubt as to whether your symptoms match exactly with what is seen by imaging and
proposed to be surgically repaired, I'd tend to hold back on surgery and try all of the more
conservative treatments possible. I'd be VERY reluctant to "have my back cut on" in the
absence of an almost "slam dunk" certainty that there is a definite cause of the pain which
is curable by surgery!
If the vertebral body has recently collapsed
(vertebral compression fracture...VCF), I'd seek an interventional radiologist to determine
that the posterior cortex is intact (radiologists are the "imaging" experts...a non-intact
posterior/dorsal cortex is a contraindication for vertebroplasty and kyphoplasty because the
cement could exude through to compress the spinal cord) & then perform a non-balloon,
local-anesthesia, through-the-skin transpedicular (or parapedicular) vertebroplasty (this website is general and not our hospital's). The stabilizing "cement" is
injected & spreads in around the fracture fragments to variably fill the marrow spaces
within the vertebral body...seldom restoring height. However, when vertebral bodies are long-ago
collapsed (and/or "dried out" nucleus pulposus discs have reduced the spaces between vertebral
bodies and/or annular ligaments have been traumatized) for many months to years, they begin to
have repairing and stabilizing bony growths (osteophytes) which attempt to bridge and stabilize
"gaps" and or to stabilize injured non-bony tissue. In doing so, the growths impinge on nerves
and/or spinal cord.
In our area, some orthopedic surgeons &
neurosurgeons perform the high-pressure "balloon kyphoplasty" (this website is general and not our hospital) which theoretically (and
sometimes actually) can restore some height to the collapsed body. Kyphoplasty is also via
transpedicular or parapedicular approach & more likely under general anesthesia. The
expanded balloon displaces bone fragments & creates a void into which the stabilizing cement
Vertebroplasty & kyphoplasty compared here.
My aunt has had miraculous relief between January
and June of 2004 for 4 or 5 instances of osteoporosis-caused collapsed vertebral bodies
treated by our radiologists using vertebroplasty.
Doctors Chris McCarty & David
Knight are the radiologists performing the vertebroplasties at Lexington Medical Center
(Chris is our interventional neuroradiologist & David our special procedures
interventional radiologist). Ask your doctor to request an evaluation or referral by FAXing
an order to 803-791-2519 (or you may call for information, 803-791-2461). Report to the
east-side main entrance (same side of hospital as the ER) on hwy #378 @I-26...hospital's main
number is 803-792-2000...2720 Sunset Blvd., west Columbia, S. C. 29169. And feel free to call
our hospital's medical staff office (803-791-2200) for names of neurosurgeons &
orthopedic surgeons using Lexington Medical Center as "active staff". As of
2008, neurosurgeons tend to do the neck & back surgery at Lexington Medical Center and
orthopedists all other bone & joint surgery.
Sciatica (lower back pain that radiates through buttock & down same leg):
This back & leg pain may be problematic to
cure as it involves 3 spinal nerves & may be caused by one of the above-mentioned
"entrapment" problems (radiculopathy). See Mayo Clinic's file about sciatica. (The following goes for other types of lower back pain not clearly
requiring surgery for relief) A maximum-allowed 24-48 hours of Advil might give relief. If not, a trial of oral steroids might give relief. However, regardless of cause, when relief from disabling pain is
the major acute/urgent desire, anesthesiologist delivered pain-management epidural steroid
injection (of a "depo steroid") can be an initial...sometimes permanent...help (and can help
in some of the above radiculopathy situations). That is, if you've been diagnosed with sciatica
and need pain relief which has not happened with your doctor's initial medication advice, get
some injection relief...surgical correction can come later, if needed. And, injection may
provide all the treatment that is needed in 10-20% of cases. It is a regional injection not
requiring ultra-precise localization. These injections can be repeated as needed (you schedule
another injection if it becomes certain that too much pain has really returned...as of 9/04,
Medicare will allow payments toward 6 per year). Another aunt of mine and several of my mother's
friends have gotten relief with this technique.
***YOU MUST HAVE BEEN FREE OF ANY
MEDICATION CONTAINING ASPIRIN OR ANY TYPE OF NSAID (check here) FOR SEVEN DAYS PRIOR TO
Drs. Jim Knight and John Caskey
(anesthesiologists) used to provide these services in our Hospital system, usually at our branch
hospital on hwy. #1 & #378 just west of the town of Lexington, S. C. until ceasing in
November 2005. From about then to 2010, I have had friends and relatives be highly pleased with very prompt
appointments for pain consultations, injections, & other treatments at Columbia Neurosurgery and Lexington Brain and Spine Institute.
Here are some other problems that may mimic sciatica:
- Back strain (a back joint strain [sprain] of the joint fibrous & muscular interconnections): tends to be in age 20-40 group with low-back, buttock, and thigh pain and usually precipitated by some unusual physical activity. Likely to be tender if you mash the area.
- Sacroiliitis: degenerative (wear & tear) sacro-iliac joint irritation or "osteoarthritis" often comes to light or is precipitated by a fall onto the buttocks. That joint might be sore with deep pressure to it & its pain also might radiate to the groin on that same side. The leg raising test may cause pain before 60 degrees.
- Low back acute spinal disc herniation (rupture): onset might be related to incorrectly lifting too much weight. A friend can help you do the leg raising test to check.
- Spondylopathy (spondyloarthropathy): backbone disc joint or canal or other bone surfaces develope roughened surfaces, surface thickenings or protrusions of bone or narrowing canals that restrict nerves (could cause some numbness) or spinal cord (could cause some numbness) of smoothness of movements of the spine (or "back").There is no pain in the sacroiliac joint pressing test.
- Spondylolisthesis: this is the slippageof a backbone/spine joint out of alignment. Leg raising test might cause pain between 30-70 degrees.
- Trochanteric bursitis: This can be a spectrum of from low-grade irritation or outright infectious or noninfectious high-grade inflammation of the protective sac (bursa) over the upper thigh-bone ridge under the skin and muscle at the level of the thigh-bone ball-and-socket joint. Putting pressure on this site causes pain. Check HERE.
- Pyriformis muscle syndrome: This is pain is in an irritated or sore pyriformis muscle in the deep buttock that is located between the tail bone & behind the thigh-bone trochanteric area. If the sacroiliac nerve runs through...or is so close to...that pyriformis muscle that the nerve gets squeezed or irritated, then this can resemble sciatica (sef test to diagnose, check HERE).
- Cauda equina syndrome: Whether by sudden traumatic injury or gradual spondylitic tightening of the spinal cord canal around it, a squeezed cauda equina brings on lumbar area pain & partial (with abnormal gait) to totall loss of use of the lower legs a saddle distribution of loss of sensation sensation & function in the perineum (anogenital) area (HERE).
- Myofascial pain syndrome (MPS): If this syndrome (HERE) involves any of the above areas, MPS may seem to be related to the spinal (backbone) structures. And, MPS could co-exist with one of the above.
- Erector muscles low back pain: The erector spinae muscle group has (1) the obvious vertical, dorsal muscle group along each side of the backbone & with all having low-back anchoring on the pelvic bone girdle. (2) The quadratus lumborum (QL) is deep to the above component (anatomy video) and somewhat lateral and the inferior aspect is anchored along the deep margin of the pelvic girdle iliac boney edge...pain-causing QL spasm and irritation being more common in this muscle. (3) Just deep to this is the iliolumbar ligament. All of these are involved inverticle stability of the spine. Self treatment video, HERE. If bad enough, QL pain can recruit pyriformis and gluteus pain and even sciatica.
spondylitis (or a lessor amount of degenerative joint disease [DJD]):
This is a disease causing variable degrees of back stiffening (ankylosing = making it stiff...reduction of flexibility) fusion of the individual, originally separate backbone spinal
components with pain and loss of bending & turning ability of the "backbone". It can
mainly involve segments (say, just the sacral or lumbar region around the waist) or the whole
back & neck. The office diagnosis can be proposed by demonstrating lack of elongation of
the spine when attempting to bend or "curl up". Measuring of the amount of bending
lengthening in the sacro-lumbar area is called the Schober test: the average normal increase
of distance between the marks is 2 inches (5cm.), while an abnormal result is 1.6 inches or
less (4cm or less).
Links (offered...not necessarily
"Spine Universe" keeps up with all
treatments and issues [here].
WebMD's sources on dealing with chronic
pain [here and then put your question in "search"], including the devices such as the one touted by Jerry Lewis
Adam Rostocki's = very interesting,
very educational, & comprehensive website (now...2015...apparently in a book) about nonsurgical and non-drug treatments...by a non-physician for laymen
***give me your comments about this
check out the Highest
(posted 9 August 2004; latest addition 6 July 2017)