March 25, 2007

Dear Ms. Smith:

I have received your information (MRI Disc Images, MRI Reports, and letter) and a request for a written case assessment.  In this report, I shall refer to you as the patient.

HISTORY:

In 2001, at age 47, the patient began experiencing pain in the “sacral spine” and in the lower limbs when she stood or walked.  She has been evaluated by several doctors of several different specialties and her current diagnosis is osteoarthritis of the spine.  A rheumatologist “did nothing for me and closed the case.”  In 2003, an MRI of the lumbar spine was completed with no significant findings noted.

With the passage of time, the patient’s pain has “spread up” into the middle back and neck and her ability to walk has decreased down to only a few blocks.   Her legs feel like “cement.”  She also reports that her left foot is “always numb….and she feels sick all the time.”

In 2005, MRIs of the cervical and lumbar spine were again ordered that demonstrated degenerative findings.

MRI ASSESSMENTS:

Cervical Spine:

Image quality was poor.  On the sagittal view (side-to-side view), moderate degenerative change is noted in the form of discogenic spondylosis (decreased disc height with arthritic change) at C4/5, C5/6 and C6/7—the worse affected is C5/6.  Disc bulging—mild to moderate in nature—is noted at C4/5 and C5/6.  The cervical curve is intact without significant stenosis.

Impression: Cervical discogenic spondylosis without herniation or significant stenosis.

Patients Lumbar Spine MRI Images:

From the sagittal-view, there is mild-to-moderate disc bulges vs. herniation(s) noted at every level of the lumbar spine, which is more pronounced at L1/2 and L2/3 (4-5mm in size – see red arrows) without significant disc height loss but with indentations into the spinal cord / thecal sac.  Unfortunately, the axial images are poor, so I can’t determine the species of disc herniation (bulge vs. protrusion, vs. extrusion)  Mild-to-moderate marrow signal change are noted at L2/3.  From the axial view (over-head view)—very poor images—a small disc protrusion is noted—right paracentrally—is noted at L4/5 without significant compression of the exiting L4 root.  An HIZ sign is noted on the sagittal image (green arrow), which may indicate acute annular tear. Facet arthrosis is noted throughout the spine without severe encroaching effect.

[Note: the Arrows didn't come out when I turned the .doc into a .htm file.]
 

1) Spondylosis and degenerative disc disease—multiple levels—without severe stenosis in cervical and lumbar spine.

2) L2/3 and L3/4 disc herniation with cord / thecal sac compression.
   
CONCLUSION:

In the lumbar spine, the patient has moderate degenerative disc disease with two moderate disc herniations at L2/3 and L1/2 with possible active annular tear at L4/5.

ASSESSMENT:

Based on the severe level of patient dysfunction (only able to walk a few blocks), I would recommend a CT myelogram of the lumbar spine and EMG/NCV of both lower extremities, so that we may get an idea of how much cord/thecal sac compression is actually occurring at each level.  (Significant encroachment may then explain the patient’s claudication.) 

Although MR imaging may certainly be deceiving, the image I pasted into this report would appear to demonstrate, among other things, two compressive disc herniations at L1/2 and L2/3 that may well be a pain generator at the very least.  Further workup is certainly indicated.

The trouble with this case, obviously, is that every lumbar disc has been affected by degenerative disc disease, which makes interbody fusion “risky” for invoking the domino effect, i.e., the diseased discs above and/or below the fusion probably will not do well with the added post-fusion stress placed upon them and may collapse or herniate. 

My gut feeling is that the patient should continue to be as active as possible and use medication to combat pain and inflammation, i.e., conservative care.  Moreover, the usage of glucosamine sulfate might be implemented, which may help slow the degenerative process—glucosamine has been shown in randomized controlled trial to mitigate the effect of arthritis.

QUESTIONS:

1) Is osteoarthritis the same as DDD and facet disease?  For your purposes, yes.

2) What are degenerative marrow changes? Google “Modic changes” for more information.  These are degenerative changes in and around the endplates of the vertebrae that are associated with more severe DDD.

3) Could my spine problems be causing my difficulty walking? It all depends on the results of CT Myelogram, which is the gold standard for diagnosis stenosis.  It will tell the story.

4) My pain has spread up…. You may have “bad genetics” for the materials that the discs are built from.  Folks with this problem often experience problems in other parts of the spine as well.

5) Is my spine getting worse.  Unfortunately, this type of problem may worsen with the passage of time and more significant stenosis may develop.  You certainly need to be monitored.  In order to answer this question, I would need the real MRI images and X-ray images.

6) What is causing the edema? It’s part of the degenerative process.

Respectfully,

Dr. Douglas M. Gillard, DC, IDE, QME

DMG:dmg