Acute L5-S1 Herniation

Okay, let's go to case 6. All right, so again, sort of this dovetails nicely. This person was shoveling snow. They had acute onset of back pain and leg pain. And they have this scan here. I think it was right-sided, right-sided leg pain. All right, so who wants to tackle this scan?

All right, Maggie, you're up. So this is a sagittal image. What do you see there? Sagittal MRI scans the lumbar spine. And the discs, I mean, the vertebral bodies all look intact in place. No loss of disc height. And then going inwards. Go down from L1 to down on the discs. L1, L2. Let's say you were dictating this. You were radiologist.

L5-S1 looks to be dehydrated or lost. Yep, it's lost its signal intensity. It's a little bit smaller than L4-5, right? Yeah, so I would say L5-S1, there's a loss of disc height. Loss of disc height, loss of hydration. And we call the overall moniker of that, that is what? degenerative disc disease right there's ddd at l5s1 with a tiny tiny tiny disc bulge okay looks like tiny right there let's follow it out okay we're going one way okay now it's it appears to be more significant right here right down yeah almost going downwards into the canal yep there's a ton of disc material that's squirted out herniated and it's down significantly lower you know than sometimes the disc herniations here up this one's downward migrated basically down to the S1 pedicle level, right? Yes.

So this guy was having a lot of pain. And you can see the neural foramen. How are the neural foramen? The neural foramen, they look open. They're open, exactly. So he has no neural foraminal stenosis. And it was an acute onset. You said he was troubling snow? Yeah. You can see that piece right there. Go to the other side. Looks clear. Clear. So I would say this patient has right-sided or L5S1 degenerative disease. would you say secondary to a L5S1 significant herniation? Not really. They go hand in hand. He has degenerative disc disease at L5S1 and a herniated disc. And let's see the axial. Right.

So here's a normal canal, normal lateral recess, normal disc. You can even see the signal intensity where the hydration of the disc is at this level. We come down the pedicle. The neuroforamina where the nerves are going out. Clear, clear. Coming down into L5S1. okay see some asymmetry right here here's the left s1 nerve root the right s1 nerve root is being displaced and then it sticks out like a sore thumb right here right yes this is the lateral recess where the nerve root should be this is a piece of disc material that's squirted down and is pressing on the nerve and this is perfectly clear on the left side.

This is the S1 pedicle right here. S1 pedicle on the right, S1 pedicle on the left. Here's the sacral alla. That's the transverse process equivalent of the sacrum. And you've got a disc fragment. This is below the disc space because this disc has migrated down. So what will we do with this person? I would say you can offer time because, I mean, I think it's so large that you could consider bringing them to the operating room. But I think because it was an acute onset, giving it some time to maybe reabsorb. And I know how much pain they're in. So I would offer muscle relaxers, heat, rest, and if it got worse or he had numbness, tingling, progressive worsening of walking or bowel bladder dysfunction, come back ASAP and bring him to the operating.

Okay. Let's say they have no weakness. They have some numbness and some pain, but it's getting better. but they're only 50% better. They come back to your office two weeks later. Would you offer a steroid injection or no, because it's an anatomical? You can still offer a steroid injection. It can still get better. I would offer a steroid injection and observation. Yeah, there's two reasons why the nerve hurts. Number one, it hurts because there's pressure on it, but it also hurts because the chemical nature of the disc is irritated. to the nerve.

There are these proteoglycans, which are long branched proteins that sequester water molecules and that protein, that protein acid material is corrosive and irritating to the nerve. So steroid injection can at least take away the chemical irritation from the disc herniation while hopefully mother nature desiccates the disc herniation and it shrinks it's certainly possible that it could shrink or resolve just a matter of time yeah so definitely would offer this person a steroid injection unless like you said they have muscle weakness progressively decline or in some type of bowel or bladder dysfunction which would be unlikely with this and then if they don't improve after one two three shots or i mean if they if they start to improve slightly after one, then a little bit after two, but then take a turn for the worst at after two before three, would you then bring them to the operating room? I favor surgery.

You have to take the patient's temperature and see what what their appetite is for surgery. I want people to come to the OR knowing that they've really tried everything else first, unless it's like, you know, something that has to be done. I want them on board with, well, I've done everything else first and done it the right way. And so, you know, it's an art to, you know, get somebody, you want them choosing surgery, not you. So you've got to bring them along to that level. And that usually is with, oh, you know, we've had two shots and you're somewhat better, but you don't look like yourself. And it's been three months now. You know, can you tolerate another three months like this? Is it something you'd want to do? You could get better at the end of three months or you could still be in pain and then need surgery. So see where they're at. There are some people who want things fixed right away and some people who want to do everything they can to not have surgery. Thank you. And we know that, you know, if you look at, you know, two cohorts of people, one that have early surgery and one that has late surgery, no surgery at five years, they both do about the same. So the key is that the surgery patients get better faster when we're dealing with acute disc herniations.

Got it.