Right sciatica and hyper-reflexia

In this video review of a 65 year old gentleman’s cervical and lumbar MRI scans, Dr. Castanet will show you his mild spondylolisthesis at L4-5, and his cervical disc/osteophyte complexes at C4-5 with retrolisthesis and an associated cord signal change at that level.

This man came to me with very bad low back pain, right sciatica, and weakness of his right leg. In fact, given the degree of severity of his symptoms and the signs of his gait and physical exam, I was very suspicious for another explanation. His low back MRI scan just didn’t look that bad. The only problem he had in his low back was a modest spondylolisthesis at L4-5. There are a few likely explanations for this discordant clinical picture. One, he did tell me that he has used heat application daily, which will increase the inflammation in the area and make the pain worse. Heat is contraindicated for painful areas that likely are already inflammed. But he has two other, more important considerations here. First, his cervical MRI shows a cord signal change at the level of the disc/osteophyte complex, so his cord has pathology that was probably caused by some extension of his neck, which injured his spinal cord. Second, his spondylolisthesis in the low back, at L4-5, may be more pronounced when he bends forward, than when he is lying supine for his MRI exam.

Right sciatica and hyper-reflexia

Always when evaluating patients, you have to consider the most parsimonious explanation for the constellation of signs and symptoms that you find. As you’ll hear, he has a neurologist who is following his cord pathology. He also has a pain management physician who has provided two epidural injections; one for his neck and another for his low back, neither of which has helped.

He is sent to me by his primary care physician. This may be a case where I can be especially helpful because of my clinical experience in surgical evaluations, having spent 5 years in a neurosurgical practice. So I will see if I can improve his low back pain with spinal decompression treatment, but if he doesn’t improve fast, I will send him for lumbar flexion and extension x-rays to see if his spondylolisthesis is worse, and may explain the severity of his pain and right leg disability. It is also possible that his spinal cord problem is causing his right leg problems. And, as always, we have to be mindful that the patient may not always explain things perfectly, so I don’t accept that his complaint of right sciatica may not be coming from his cord lesion.

If I can help you with your neck or back problem, please call me at 404-558-4015.