Hurt back lifting car wheel out of boot
2009
Question
I would be very grateful if you could give me some further advice on my back problem, from which I have been suffering for nearly six years.
I hurt my back in October 2002 by lifting a car wheel out of a boot awkwardly. I had never previously had back trouble. This gave me (a couple of hours later) some pain in a small area of the lower right back, just above the buttocks, followed soon after by pain down the right buttock and thigh. I did not have, and have never had since, any problem with stiffness or lack of mobility.
Of all the treatments I have had, only two have had any significant effect and both made the problem much worse on a long-term basis (ie I am still suffering the effects now). The first was physiotherapy. The physiotherapist made me do bending-backwards exercises which were supposed to bring the pain back up my leg if it ever went as far down as the calf. This had the total opposite effect – it immediately made the pain worse and brought it all the way down my lower leg, where it has stayed ever since. This also resulted in muscle wasting on the outside and the back of my calf where the pain is.
The second significant treatment was 10 months after the injury when I saw a chiropractor for five treatments on the recommendation of an orthopaedic surgeon. After the last treatment, I started getting pain in the left leg too which gradually got worse over the next few months. This new ‘spreading’ (the only way I can describe it as it covers a large area) pain also spread to my right leg giving me two different types of pain in that leg. After a few months the new pain covered a lot of both legs, in particular the fronts of the thighs down to the knees.
In all I have had four scans and, while the first three showed disc bulging, the latest one (May 2006, in a positional scanner where images were taken standing, sitting and lying down) showed no real cause for the pain – only some degeneration in the L5/S1 disc (and early schmorl's node formation at L2/3). The second scan (October 2003) showed a ‘segmental anormality at the lumbosacral junction’ (partial sacralisation of L5 with the lowest disc space being L4/5). Although not considered important at the time, the osteopath who I saw in spring last year wondered whether that was why the chiropractor's treatment had caused so many problems. He also said he thought the original injury may have been a sacroiliac problem rather than a disc one (although the second scan covered this area, nothing was identified and his treatment did not help).
The other diagnostic tests I had were EMG and nerve conduction tests in September 2003. These showed that the right leg was not totally right but the differences were not significant.
The pain is made far worse by sitting at a desk for prolonged periods. When I am on holiday or out for a day’s walking, I hardly notice it. Other things that bring on the pain are stress, standing on the spot, twisting and stretching and swimming breaststroke (obviously I don’t do this anymore).
As well as ‘spreading’, the pain also often appears in what I can only describe as discreet blobs/large patches on my legs, more on the right than the left. In other words, it is not continuous down one nerve. Also, since about January 2007, the ‘spreading’ pain has often gone down into the soles of my feet with a slight ‘pins and needles’ feel.
The only relief I have had is shortterm from massage, possibly suggesting that this relieves the symptoms but the root cause is still there. I have been given various exercises from every practitioner I have seen but none of them have done any good even after considerable persistence. I am particularly concerned about the muscle wasting in my right calf; while it has not got any worse, and the leg still functions properly, I am determined to resolve it. Various leg exercises I have been given have not helped either. From a conventional medicine point of view, the only way forward I have been offered is a discography, which I have been reluctant to take, and certainly have not been encouraged by your comments on the subject in response to another reader’s letter in a recent copy of Talkback.
I really do not know which way to turn. Any diagnosis/information/ suggestions/contacts you could provide would be extremely welcome. I have spent a phenomenal amount of time over the years researching my condition (and all the time on the Internet makes it worse!). I feel as though I am totally on my own as all conventional routes have been exhausted. If the condition is likely to clear up itself eventually I am quite prepared to put up with it until that happens. I do not know whether this is the case or whether (as I suspect) the root cause still needs addressing.
I do hope that you can help.
Ms S M
Answer
Ms M is certainly ‘an experienced patient’ having received a wide selection of treatments and learned extensively about her situation from the Internet. Having read through her extensive history, the outstanding point is that, after six years and many treatments, no credible evidencebased diagnosis is available! Without a diagnosis, or at least a diagnostic group, it is difficult to suggest a rational treatment. Unfortunately this situation is all too common in the management of back pain partly because it is difficult to identify the likely pain source.
Bearing in mind this problem, it is reasonable to try a few simple treatment options with a reasonable expectation of improvement regardless of the diagnosis or lack of it. When, with the passage of time and a few simple treatments, significant symptoms continue then we must attempt to establish the most likely diagnostic category and define the source of the pain as far as is possible. Having done that, more specific treatments can be suggested.
Ms M has already travelled some way down this route having had physiotherapy, chiropractic, epidurals and local injections all without lasting benefit and sometimes with an adverse effect. Some investigations to establish a diagnosis have been carried out, namely a high-tech postural MRI scan and also electromyography which have not shown any significant nerve damage. What has been shown, and may well be significant, is the ‘segmental anomaly’ at the lumbo-sacral junction. This is a well-known congenital (present at birth) abnormality which often causes little or no trouble. Occasionally, its limited mobility can be sufficient to cause pain where it articulates with the adjacent bone, a diagnostic injection of local anaesthetic to that spot can be illuminating. Alternatively the additional strain of having one fewer working lumbar discs can cause so-called discogenic pain from degenerative change at the disc above. A look at the most recent plain x-rays of the lumbar spine and the postural MRI scan would be helpful.
The other and probably the final throw of the dice if the situation really is intolerable, and this has been mentioned to Ms M, is discography. That is injection of the suspect disc, and an adjacent one as a control, with radio-opaque dye under local anaesthetic to see if it reproduces the pain complained of. If it does then the option of surgical stabilisation to immobilise the pain source would be logical. I would not opt for surgery without discography with an experienced team first.
Alternatively Ms M can rest assured that with the 6-year duration of her symptoms and the extensive investigation she has had, there is absolutely no chance that she has a progressive or severely crippling condition which will confine her to a wheel chair or any other dire consequence. The likelihood is that her symptoms will remain static and probably improve to some extent in her 60’s and 70’s or before. A pain management programme may make the situation more tolerable.
Do let us know what you decide and how things go. We wish you well.
Alan Gardner FRCS
Consultant in Spinal Disorders (Rtd)