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Medical Forum / General / General / March 2005lumbago or sciatica?
Grettings from someone bedridden. I was strolling with my nephews in 30 degree weather and got into a rock throwing contest with them. I believe the combination of extreme cold and inhabitual movement has caused this extremely painful lower-back condition. The pain is right above the right buttocks and is continual, an almost burning sensation. However when I perform certain movements, such as trying to change positions in bed, or even walking, I experience an unpredictable and searing pain in the same area. It is really quite unbearable. Is this sciatica or lumbago? I was tempted to self-diagnose the former, since it does seem like a nerve is irritated during those torturous moments. There is some pain around the buttocks and a some in the thigh, but apparently not really enough or far enough down the leg to qualify as sciatica. 90% of the pain is concentrated in the one spot just above the buttocks. Any attempts at diagnosis based on this information and advice for treatment would be most appreciated! : Grettings from someone bedridden. I was strolling with my nephews in : 30 degree weather and got into a rock throwing contest with them. I : believe the combination of extreme cold and inhabitual movement has : caused this extremely painful lower-back condition. : The pain is right above the right buttocks and is continual, an almost : burning sensation. However when I perform certain movements, such as : trying to change positions in bed, or even walking, I experience an : unpredictable and searing pain in the same area. It is really quite : unbearable. : Is this sciatica or lumbago? I was tempted to self-diagnose the : former, since it does seem like a nerve is irritated during those : torturous moments. There is some pain around the buttocks and a some : in the thigh, but apparently not really enough or far enough down the : leg to qualify as sciatica. 90% of the pain is concentrated in the one : spot just above the buttocks. Do a search for "piriformis syndrome" and "piriformis stretch". PS. 85% of back pain is muscular, not disc-based. That is why surgeons rarely do "back surgery" any more. Emma :) >Grettings from someone bedridden. I was strolling with my nephews in >30 degree weather and got into a rock throwing contest with them. I [quoted text clipped - 16 lines] >Any attempts at diagnosis based on this information and advice for >treatment would be most appreciated! One cannot diagnose such a condition without hands-on examination of the patient. The differential diagnosis includes a local back strain/sprain, a ligamentous derangement ("facet syndrome"), or a herniated disc. "Sciatica" is not a medical diagnosis since most cases of pain in the distribution of the sciatic nerve are due to back problems (disc disease) and thus, has nothing to do with the sciatic nerve itself. "Lumbago" is a layman's term for a backache and means nothing medically. Best, Bob Robert A. Fink, M. D. Neurological Surgery 2500 Milvia Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555 ********************************** NOTE: The material above is not "medical advice". Medical advice can only be given after an in-person contact between doctor and patient. ********************************** i know of a young guy who was bed ridden and told that he would soon stop walking . He took steroids for a week and was up and about ! > Grettings from someone bedridden. I was strolling with my nephews in > 30 degree weather and got into a rock throwing contest with them. I [quoted text clipped - 16 lines] > Any attempts at diagnosis based on this information and advice for > treatment would be most appreciated! Dr. Fink has given you good advice. And... See a physical therapist. You will be examined and if nothing warrants sending you to Dr. Fink you will be treated and taught a program of core strengthening exercises to help prevent future similar occurrences. Bending awkwardly or twisting to one side with load may have tweaked one of your sacroiliac "joints". This could cause your symptoms; among other possibilities. Core muscle strengthening and stretching... Zee (been there) >Dr. Fink has given you good advice. > [quoted text clipped - 13 lines] >Zee >(been there) Generally speaking, I think that it is better to see a neurosurgeon or spinal orthopedist before going to the physical therapist, because in some cases (especially in herniated discs of significant size), the manipulation involved in some physical therapy can cause the situation to worsen. It is always better to get a diagnosis before starting a treatment. Physical therapy, by the way, carefully chosen and administered, can be quite helpful in conditions of this type. Best, Bob Robert A. Fink, M. D. Neurological Surgery 2500 Milvia Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555 ********************************** NOTE: The material above is not "medical advice". Medical advice can only be given after an in-person contact between doctor and patient. ********************************** > >Dr. Fink has given you good advice. > > [quoted text clipped - 16 lines] > Generally speaking, I think that it is better to see a neurosurgeon or > spinal orthopedist before going to the physical therapist, I respectfully disagree. Surgeons want to do surgery. Surgical intervention is what they think of when they think of how they can help the patient in front of them. Physical therapists seem to know the difference: this is something I can treat; this is something a surgeon must treat. {Now a chiropractor is a different kettle of fish. I wouldn't let one near me.} Here, few physios are certified to do manipulations. And among those, it is judiciously used and would follow complete examination accompanied by physician's report. And the physio reports back, too, although a referral is no longer necessary. Even though I have had two lower back fusions which affect my neck, my physio (on the faculty and one of few who teaches manipulation) will not manipulate my neck. I was taught to employ other modalities; exercise, stretching, heat, ice, postural modification, traction (hanging from a float belt in the pool). I can handle it. That is what I like about this profession: they teach me to handle it. I certainly wish I had seen physios prior to my fusions. Surgery made me worse. It wasn't until, post op by a year after a failed fusion and losing control of bladder and bowel, unable to sit up or walk, that I was sent to rehab the disastrous surgery. There I found out where medicine's future lies. Not in pharmaceuticals or surgeries, but in rehabilitation medicine (which may of course employ those as part of a successful rehab, as a last resort). I'm not opinionated ....or anything... <smile>. I would assume the OPs general practitioner has made a diagnosis and if not, certainly check with them. But make sure they know you want to see a physio, next. Surgeons, and surgery as a last resort. Better, thank you Zee > some cases (especially in herniated discs of significant size), the > manipulation involved in some physical therapy can cause the situation [quoted text clipped - 21 lines] > doctor and patient. > ********************************** >I respectfully disagree. Surgeons want to do surgery. Surgical >intervention is what they think of when they think of how they can help >the patient in front of them. Physical therapists seem to know the >difference: this is something I can treat; this is something a surgeon >must treat. {Now a chiropractor is a different kettle of fish. I >wouldn't let one near me.} I am a surgeon. I wind up operating on less than 15% of the patients whom I diagnose with herniated discs. The rest respond to nonsurgical therapy, which includes physical therapy, performed by a physical therapist, but *monitored* by me. If the patient shows any signs of deterioration, the physical therapy is stopped, and other treatment (in some cases, surgery) is carried out. >Here, few physios are certified to do manipulations. And among those, >it is judiciously used and would follow complete examination >accompanied by physician's report. And the physio reports back, too, >although a referral is no longer necessary. And there are very few non-specialists (family doctors, internists, GPs, etc.) who are particularly qualified in performing a localizing neurological examination, which is what is necessary in order to make a proper diagnosis of nerve root problems. > Surgery made >me worse. That is unfortunate. While about 10% of operated cases (assuming a proper diagnosis and trial of nonsurgical therapy) do not improve, this can be minimized by careful assessment before surgery (and that is what good specialists are for). Incidentally, fusions are usually not required in "usual" single-level herniated discs in the low back. The unnecessary use of fusions can increase the chances of difficulty later on. >I would assume the OPs general practitioner has made a diagnosis and if >not, certainly check with them. But make sure they know you want to see >a physio, next. Surgeons, and surgery as a last resort. See my comment above about GPs and non-neurological specialists and the accurate diagnosis of nerve root disease. Best, Bob Robert A. Fink, M. D. Neurological Surgery 2500 Milvia Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555 ********************************** NOTE: The material above is not "medical advice". Medical advice can only be given after an in-person contact between doctor and patient. ********************************** > >I respectfully disagree. Surgeons want to do surgery. Surgical > >intervention is what they think of when they think of how they can help [quoted text clipped - 9 lines] > deterioration, the physical therapy is stopped, and other treatment > (in some cases, surgery) is carried out. Yes I know you are a surgeon. > >Here, few physios are certified to do manipulations. And among those, > >it is judiciously used and would follow complete examination [quoted text clipped - 5 lines] > neurological examination, which is what is necessary in order to make > a proper diagnosis of nerve root problems. I agree. I would add orthopaedic surgeons to the list. And I still think nerve root damage can be diagnosed by physical therapy and treated with a carefully supervised program of progressive exercises in a rehabilitation setting. I am not talking about 3 times a week for 20 minutes. If the op is in a system similar to mine, I think he would be better off starting at a physio. If necessary he will be sent to you. I am not unfamiliar with the idea that physical therapy is something directed by the surgeon and that the physical therapist does not diagnose. In Canada physios diagnose. > > Surgery made > >me worse. [quoted text clipped - 3 lines] > this can be minimized by careful assessment before surgery (and that > is what good specialists are for). Ahh. Good specialists. How do we know this? Do we ask them? They are all good. Licensed, accredited, recommended by someone who knows someone who knows. Heads of major university surgery departments. Do the {fill in the body part} surgery on all the best people; who, after all, should know. "If you do not trust me you should find another surgeon." "Sooner or later you are going to have to trust your physician". Variations of, heard circa 1979, 1981, 1991 and Tuesday. Hackles raised. Questions shelved. We do the best we can. We patients. > Incidentally, fusions are usually not required in "usual" single-level > herniated discs in the low back. The unnecessary use of fusions can > increase the chances of difficulty later on. I agree with your latter statement. As for the former, I imagine it differs according to the surgeon's skill (and therefore what he/she will choose), the jurisdiction standards, and what is prudent in the individual situation. I have never had a herniated disc. The op doesn't know if he does. It could very well be sacroiliac, but *also* sacroiliac. Zee <smile> > >I would assume the OPs general practitioner has made a diagnosis and if > >not, certainly check with them. But make sure they know you want to see [quoted text clipped - 6 lines] > > Bob Thanks Zee > Robert A. Fink, M. D. > Neurological Surgery [quoted text clipped - 8 lines] > doctor and patient. > ********************************** >I am not unfamiliar with the idea that physical therapy is something >directed by the surgeon and that the physical therapist does not >diagnose. In Canada physios diagnose. In the United States, a physical therapist cannot treat without an order by a physician (or chiropractor, etc.). >Ahh. Good specialists. How do we know this? Do we ask them? They are >all good. Licensed, accredited, recommended by someone who knows [quoted text clipped - 10 lines] > >We do the best we can. We patients. One of the best ways to choose a surgeon is to check around with the *hospital personnel* who work with him/her. Also find our who the local doctors in the community send their families to. And find out (if possible) the number of patients who have to be re-operated. I end my commentary with a caution. In a patient with a truly compressed nerve root, it may only take one unusual motion of that interspace (by manipulation or "stretching" or the like) to convert a reversible neurological deficit into a non-reversible one. Best, Bob Robert A. Fink, M. D. Neurological Surgery 2500 Milvia Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555 ********************************** NOTE: The material above is not "medical advice". Medical advice can only be given after an in-person contact between doctor and patient. ********************************** > >I am not unfamiliar with the idea that physical therapy is something > >directed by the surgeon and that the physical therapist does not > >diagnose. In Canada physios diagnose. > > In the United States, a physical therapist cannot treat without an > order by a physician (or chiropractor, etc.). It used to be that way here. For some years now a patient (client) may see a physio themselves, first, and many do, particularly people like me and people with repeat minor sports injuries. But if the problems need x-ray or show any of what would be your concern, they are sent to the general practitioner or sports medicine physician first. Now this is the case in my province. It may not be in all provinces, so I correct my statement. Here, basic universal health care will cover a certain number of physio treatments, and that is partly why the physio does a diagnositc; to give me a score, and to see if what I present with comes under their jurisdiction. I get treated or not based on that score. I have not been denied, but the physio I see is on the faculty, likes to use me to teach her students, and knows I do not *use* her for comfort treatment. I do have permanent nerve damage. But it improved greatly with the intensive rehab. Incidentally, I relapsed badly with statin therapy to the point of new and increased back problems, severe myositis and, I think, rhabdomyolysis.I have recovered quite a bit by using the techniques taught me, but will be admitted for another rehab go-around soon. I have been on the waiting list for a long time. > >Ahh. Good specialists. How do we know this? Do we ask them? They are > >all good. Licensed, accredited, recommended by someone who knows [quoted text clipped - 13 lines] > One of the best ways to choose a surgeon is to check around with the > *hospital personnel* who work with him/her. Yes, but I have found they sometimes feel compromised and worried by being asked. So I hesitate. Physicians wives are good though. <smile> Also find our who the > local doctors in the community send their families to. For an upcoming surgery that is what I did. For the previous disaster, that is what I did. Comme si comme ca. And find out > (if possible) the number of patients who have to be re-operated. The physio I see would know for certain applications. After all, they get to rehab the disasters, like me. > I end my commentary with a caution. In a patient with a truly > compressed nerve root, it may only take one unusual motion of that > interspace (by manipulation or "stretching" or the like) to convert a > reversible neurological deficit into a non-reversible one. I completely agree. Thanks Bob Zee > Best, > [quoted text clipped - 12 lines] > doctor and patient. > ********************************** > >I am not unfamiliar with the idea that physical therapy is something > >directed by the surgeon and that the physical therapist does not > >diagnose. In Canada physios diagnose. > > In the United States, a physical therapist cannot treat without an > order by a physician (or chiropractor, etc.). That is the way it is in British Columbia, Ontario, Manitoba and Saskatchewan. (I have no idea where the poster lives). A physician or orothopedic surgeon (sometimes other specialist) refers to physiotherapy. If the patient does not respond within a reasonable amount of time and various methods, the physiotherapist refers back to the referring physician asking for a re-evaluation and/or more tests. Some physio therapist outfits have physicians on staff and actively involved with supervising the patient care. The one that attempted to diagnose me was incorrect. The next place I tried, the physiotherapist realized after a valiant attempt that there was more wrong than originally thought and referred back to the referring physician for more tests. I've also seen a physiotherapist not refer back, which was a definite negative to the patient. She had had ankle surgery and was proclaimed ready for physio. Later found that the surgery had not been done correctly and had to start over again (after months of trying painful physio and being ordered back to work - damage had occurred as a result of this). > > >I am not unfamiliar with the idea that physical therapy is something > > >directed by the surgeon and that the physical therapist does not [quoted text clipped - 20 lines] > I've also seen a physiotherapist not refer back, which was a definite > negative to the patient. > She had had ankle surgery and was proclaimed ready for physio. Later found > that the surgery had not been done correctly and had to start over again > (after months of trying painful physio and being ordered back to work - > damage had occurred as a result of this). This type of situation can arise when the physical therapy profession is subordinate. Independent physios can disagree with the orthopaedic surgeon or neurosurgeon without fear of losing a job, incurring hostility and/or having a comment put in their file..."insubordinate". Was this a Workers' Compensation case? If ever there was an organization that was the converse of rehabilitation and healing WCB/WC is it; "...being ordered back to work." And it seems to me this was an extremely important factor: "Later found that the surgery had not been done correctly..." Zee How true....I am really aware of no orthopedic surgeons these days that are in a big hurry to perform laminectomies on patients who have been diagnosed as having a HNP. They know of course (given studies over the last 20 years), that conservative therapy oridnarily yields as good an outcome as a surgical one. I remember the days as a medical student in the 70s when orthopedic surgeons filled the surgery schedules with laminectomies. I knew several orthopods (as well as a neurosurgeon), who had a practice consistining almost entirely of laminectomies. Needless to say , when my own MRI showed L/S herniations at L1-2, L2-3, I chose conservative options (the epidurals were quite effective). gtleeee D. O. >Grettings from someone bedridden. I was strolling with my nephews in >30 degree weather and got into a rock throwing contest with them. I [quoted text clipped - 16 lines] >Any attempts at diagnosis based on this information and advice for >treatment would be most appreciated! These are both antiquated terms... The concern is that you might have injury to your nerve roots in your lumbar spine, and you should be evaluated by a physician (don't you think?) H2 |
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