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Health Forum    Pain & Pain Management
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Please explain: Tiny L5-S1 left paracentral anular tear and mild diffuse disk bulging?

Additional Details
I am in pain everyday & I am seeing a doctor regularly. He just recommended seeing a neurosurgeon for consultation. I have to take pain medication everyday. I can't sit or stand for long periods of time. I take daily walks.

It means you have a disc that is bulging,not herniated yet. It is very low on your back, it's the lowest level of lumbar and the first section of the sacroel(spelling is wrong).

Lumbar disc 5 and Sacral disc 1. Its the disc between L-5 and S-1. In the disc, there is a fibrous ring that surrounds the nucleus, which is gelatinous. The tear is in the fibrous part of the disc which can allow the nucleus to seep out, but that would be a "ruptured" or "herniated" disc. A "bulging" disc is the fibrous part of the disc pushing out of the disc space possibly into the spinal cord or spinal nerve area. Imagine if you put a sponge in one hand, and then laid your other hand on top of the sponge and pushed. This is what your vertebrae have done to your L-5/S-1 disc. Physical therapy can usually get it back in place, but its a potential problem forever. Most people who suffer from disc issues, always have them again at some point.

not sure what it is but over have of the disks in my back are crushed or miss aligned which you could do bulge.

it means that the cartilage between your 5th Lumbar and 1st lower spinal vertebrae has both a bulge (meaning the cartilage is being sandwiched together with more and more pressure, and the harder spinal disks are compressing the cartilage out of the center, like an Oreo cookie with the filling being squeezed out.)

the tear means there is just that, a small tear in the cartilage between the two joints.

The phrase "Tiny L5/S1 left paracentral annular tear, and mild diffuse disc bulging" are radiographic verbage to describe what the radiologist found to be abnormal and significant for you.

First, you have a significant tear in the outer portion of the intervertebral disc, a tough, stiff and not very elastic ligamentous structure, located below the fifth lumbar vertebra body and above the sacrum, hence L5/S1. This tear is significant because it probably allowed some of the softer and more elastic inner disc (nucleus pulposis) to flow towards the outside into the crack, causing a bulge in the disc that should not be there. The bulge is apparently over a relatively large area, instead of a pinpoint, which is why it is called diffuse.

The bulge is relatively small and was probably not seen to be encroaching on (touching) sensative structures, such as the nerve or the spinal cord and its surrounds thecal sac. This is why it is called mild.

These radiographic findings may, or may not, be associated with your clinical findings of persisting pain and difficulty sitting. It is well known that sitting increases the pressure around the spinal cord more than standing and walking. Increased pressure caused by sitting will amplify symptoms caused by a localized disc lesion. This is why many doctors will have patients perform something called "Dejerines's triad", coughing, sneezing and holding your breath and bearing down as when trying to evacuate your bowels, to temporarily reproduce the same effect.

You are being referred to a surgeon for a consultation to determine whether or not you may require surgery. If surgery is required for the disc bulge the purpose of the surgery would be to reduce or eliminate the cause of your complaints, the intervertebral disc, because it is compressing a nerve root, nerve or part of the thecal sac and its contents. However, If the disc bulge is not the cause of your complaints then the surgery will not help and you will have to recover from the effects of the surgery in addition to whatever is causing your complaintsl. If the bulge is the primary cause of your problems you will most likely be pleased with the surgery, over time. Further, the surgeon will have to determine if your problem is severe enough to require surgery, what kind of surgery will be performed (there are many possibilities - you can watch the University of Washiington medical channel on cable TV to actually see these kinds of surgical procedures and listen to medical researchers discuss the pros and cons of various type of low back surgeries), if you can tolerate the surgery, and other issues.

In many cases the symptoms caused by a mild disc bulge, and sometimes substantial disc bulges, will self-resolve after a year. A number of random, blinded, controlled clinical trials have found that patients with these type of disc bulges and low back pain often due equally well with, or without, surgery, after one to two years. Thus surgery is a final option when all conservative care has been ineffective, unless you have a medical emergency and surgery is needed immediately to avoid permanent neurological damage (which is relatively rare).

Hopefully this has helped explain what the annular tear means, how it is related to a mild diffuse disc bulge, how the disc bulge is related to your low back pain, why sitting is more bothersome than standing or briefly walking about, and why you are being sent for a second opinion surgical consultation.

There are a number of conservative treatments which may or may or may not help you feel better and help your body heal itself. You could try spinal decompressive treatments, where you lie on a table and the spine is carefully and slowly pulled axially (in your case the pelvis and legs would be stretched to increase the disc height with the goal to help the disc heal and reduce the pressure on sensitive neurolgic structures causing your pain). You could try pool therapy, where you would float and walk about in water up to your chest or neck level, and perform activities, to help your body heal itself. You could try a course of conservative chiropractic care (joint mobiliation and spinal manipulation, manual or mechanical traction, passive modalities such as cold or heat, EMS, ultrasound or lazer prior to carefully planned therapeutic exercises (for soft tissue flexibility, joint range of motion, later adding strength and last adding endurance), et cetera. If you are using insurance your gatekeeper (personal health care provider) may only allow you to have physical therapy, which can also be effective (use the same type of passive modalities, therapeutic exercises, but not spinal manipulation) although they often tend to be premature on adding strengthing and endurance exercises so you do not regain your normal soft tissue flexibility and joint range of motion. Sometimes accupunture, by a skilled practioner, can be very helpful, to control your symptoms while the body tries to heal itself. Some medical doctors may want to give you various types of injections adjacent or into the disc bulge to control your complaints while your body heals.

Because there are many options you need to consider thus I would strongly advise you to do some research on your condition and become an expert on the subject. You will ultimately have to decide what is to be done to your body and be responsible for the outcomes. Thus knowledge is literally power (in your case this would be called empowerment). Remember, with the human body there are no guarantees that a treatment procedure will help you and you may feel the same or get worse. Some of the treatments have temporary effects and some are permanent, so be careful. If you get worse some of the conservative options will have a less likely chance of helping your body heal itself.

I have worked with many patients over the years with problem very similar to yours. In most cases conservative care has been very helpful although about 10 percent or less still eventually required surgical intervention (within 5 years after treatments ended). You should discuss your feeling and concerns with your primary health care provider. When in doubt remember that your provider is being paid by you, or by your insurance, and thus in effect is your employee, so you should expect (and cautiously demand in effect) the best possible results with the least risk.

Sincerely yours, Dr. H

That is what is commonly known as 'slipped disk'. Most such herniated disks heal without any problem. Some, however, continue to bulge until the spinal cord is impacted and damaged.
Your doc should be watching this condition carefully.

You have a bulging disk with a tear to the left side between your lumbar 5 and sacral 1 vertebrae (lower back).

It says there is a tiny tear and some bulging of your disk that is at the L-5 vertabrae. To see where the L-5 is just look at a diagram on the web of vertabrae.

You have a small tear in the connective tissue surrounding the lowest level disc. These can sometimes be problematic but not always. It sounds like yours is. I would suggest a course of epidural steroid injections to help with the pain. If the pain keeps returning, a discogram may be in order. The discogram will help determine if the pain is truly coming from that disc. If it is then the disc can be treated with a minimally invasive procedure called IDET (intradiscal electrothermal annuloplasty) or with surgery.

Ask for a referral to a respected interventional pain management specialist.

big pappy
First of all the L-5 means Lumbar region and there are five vertibrae in your lumbar region. So, that is what the five means. The S-1 means your Sacral region which is directly below your L-5 vertibrae. There are 3 of them in the sacral region. I have spina bifida that is in the L-5 region of my spine. It is very painful and i can relate to what your going through. If you have a diffused disk, i would talk to your neurosurgeon about that. They are the ones who handle nerves & spinal cord problems. They might want to consider fusing your disks together to keep them from slipping.

Erik G
Yeah I totally understand your pain. In Nov. of 2006 I had a completely ruptured disk at L4-L5 and the pain from my left buttocks down to my lower leg was unreal. I was operated on by a great neurosurgeon in Minnesota. The surgery was a hemilaminectomy with microdiskectomy, basically they take the part of the disk that has been irritating your spinal canal and surrounding nerves and they remove it. Then, they place as much of the disk back into place, saving as much of it as possible. My surgery was 90 minutes long, easy as can be, instant pain relieve, and no problems. Neurosurgeons have the best training as they go through as 6 or 7 year residency, so they come out very well qualified. Don't worry it is very routine surgery for these surgeons. Good Luck!

Raptor Baby
Basically what this means is your back MRI is the same as many other americans but yours recieved an MRI because you were having back pain. Unfortunately these findings do not result in curative surgical treatment and you get medical management (pain meds, physical therapy). The small tear is not something that is sewn back together and there is no evidence that with time these become large annular tears. Disc bulging is only significant if it compresses a nearby nerve.

Tom Heston
Lots of people have abnormal MRI scans of their back but don't have any symptoms or any problems. The explaination of your question is highly dependent upon your symptoms. I saw a study back in the early 1990's that took a bunch of MRI's of normal, healthy people's backs. Guess what? 50% of the MRI's were "abnormal" in this study. I personally have an "abnormal" disk in my back, but it doesn't bother me very often. So, I simply don't think about it.

So, your question really can't be answered honestly and fairly unless we know about the person experiencing the "abnormality."

Nevertheless, it doesn't sound like cancer. That's good. That's a relief.

Is the person experiencing a lot of pain, enough to be considering surgery? Then they should discuss the issue with a neurosurgeon.

Does the person NOT want surgery? Then discuss options with a primary care provider, and possibly a chiropractor as well.

My gut instinct about this question is that the person with these findings would be best treated medically (and NOT with surgery). I would first of all make sure a non-surgical approach was safe by consulting in person a doctor. Then, I would try to forget about it.

I see MRI reports all the time mentioning a "tiny" this or "mild" that. Almost all the time it is in people who won't benefit from surgery.

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