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Back Problems Message Board

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I suffered from continued sciatic type pain after a one level fusion at L4-L5, and was told there were no signs of nerve compression, and no one could see any reason why I would still be in pain. I was convinced that there was a mechanical reason for my pain, even if it didn't show itself on, I kept looking for answers and someone who could help me.

It took two more surgeries and about two years, but I found my answer. I mention this only to assure you that I can relate to your frustrations.

It certainly sounds like something is causing some L5 nerve compression. The minute I read "three middle toes" I knew the answer to that one! Every spinal nerve ennervates a specific part of the limb or body and the sensations run down a particular path that is called a "dermatome." You can look online for a "dermatome map" and you will see the path that the L4 and L5 nerves cover...and keep in mind with nerve compression or irritation, you may have pain along part of the path, just at the point where the nerve comes out of the spine or along the entire pathway of the nerve.

Back in 2000 I one day developed weird sensations in my three middle toes. Eventually I went to my mom's podiatrist (I was visiting her at the time) who diagnosed me with peripheral neuropathy. I returned home, eventually told this to my doctor who added it to my chart. After my first surgery after I recovered and was still the same as before surgery, the pain management doctor asked me about my neuropathy. When I told him I hadn't had any testing, that a podiatrist just told me I had it, I found myself on my way to having a EMG/nerve conduction study. At this point, I discovered I never had PN, but the toe problem had been the first symptoms of the problems in my lumbar spine!

Now, with those symptoms, the doctor would know to look for some problem that would affect those nerves. However, the MRI does not seem to indicate you have anything much going on. The two possibilities are both indicated to be minor in nature, so no spine specialist is going to jump to the conclusion that they are causing your issues. [B]There is no evidence of lumbar disc herniation, spinal stenosis or significant neural foraminal narrowing. There is mild facet arthropathy at the L4-L5 level. [/B]

Foraminal narrowing can lead to nerve compression, but this would indicate that isn't the case. The facet arthropathy can also cause nere compression...and a problem with the facet joints at L3-L4 turned out to be the culprit of all my problems...but my surgeon didn't discover it until he had my open on the table...and then it was "surprise!!" My facets had worn away to teeny little nubs, which were allowing things to slip around (instability) and causing nerve compression. This was not the least bit obvious on MRI, and none of my doctors thought I had any issues at L3-L4. In your case the facets at L4-L5 are showing signs of degenerative change -- arthritis...this can lead to them enlarging which then results in foraminal stenosis.

The other finding is that the The L5 vertebra is transitional. Transitional vertebrae refer to a congenital anomaly in which a vertebrae has the characteristics of two different types of vertebrae. They typically occur at the junction between two different types of vertebrae, in your case between the lumbar and sacral vertebrae. This can lead to a practioner miscounting the vertebrae if they are not aware the patient has this difference...and could lead to receiving a treatment or procedure at the wrong level.

Generally speaking it does not lead to any problems, issues or pain. However, when you have pain that is coming from the same general area as this anatomical difference, it would be worth at least investigating, in my opinion!

Another thing to keep in mind is that spine specialists only like to deal with bones and nerves. They are a lot less interested in thinking about everything else that goes into allowing the spine to move -- muscles, soft tissue, etc. In the case of a car crash, your body has suffered a trauma and there is no telling what effect the impact may have had on all the soft tissue. This is much more difficult to track down and resolve.

Have you had a flexion/extension x-ray of your spine? This is to check for instability (a spondylolisthesis, which is where one vertebra slips over the top of the adjacent one, resulting in instability and potential nerve compression....)If not, I highly recommend it. Spondy is not always picked up on MRI if it is subtle.

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