Remember when I said his disc was under that PLL ligament? Hence, he got minimal relief from his back pain. What he meant is that we doctors like to talk over our patients thinking we know it all, but if we just did more listening than talking, our patients would make our job easy. Yet this was to be expected had they understood simple low back pain biomechanics.
Let me explain. When you have an L5-S1 disc bulge or herniation, that irritates the local L5 or S1 spinal nerves. Some parts of these nerves go down the leg causing sciatica. However, other parts head back toward the spine and tell the local multifidus muscles what to do. These muscles are deep spinal stabilizers that are critical for keeping the spine bones aligned while you move. Long-term nerve irritation of those spinal nerves cause atrophy and shrinkage of the low back multifidus muscles 3.
What happens next is predictable. Once those multifidus muscles shrink and the L5 vertebra begins getting sloppy uncontrolled movement, the body kicks in the big low back muscles to try and tighten everything down. The goal is to provide rigidity to the whole system which stops some of the sloppy motion ta L5.
Patients often feel this as a back spasm. Which big spine muscle was causing his problem? It goes from the pelvis to the back of the ribs. This is why he felt new pain developing from his back to the back part of his ribs.
This was to be expected due to the multifidus atrophy that was clearly seen on his MRI, but not read out by the reading radiologist. This is why his doctors ordered a completely unnecessary thoracic MRI. What can we do differently? First, we no longer use high-dose steroids for epidurals. Why do we inject that epidural rather than high-dose steroids? The steroids damage local tissue, while platelet growth factors can help to repair tissue and they can also manage inflammation for longer.
See my video below:. While his prior doctors did a test like that called a discogram, they failed to inject anything that could help repair the disc. For issues within the L5-S1 segment an epidural steroid injection may be used to reduce the inflammation around the spinal nerves. Following an exercise routine, quitting smoking, and reducing weight in overweight individuals can help lower the risk of problems stemming from L5-S1.
Injections may be considered for pain relief after nonsurgical methods are tried for several weeks and before surgery is considered. While performing injection treatments, fluoroscopic x-ray guidance is usually used for correct needle placement.
Fluoroscopic guidance and contrast dye help improve diagnostic accuracy and decreases procedural risks. Injections may also be used diagnostically as a selective nerve block to confirm the nerve root as the cause of the leg pain and may be helpful as a diagnostic aid prior to surgery. Surgery is considered when a structural condition that is known to be responsive to surgical treatment is present.
See Microdiscectomy Microdecompression Spine Surgery. The bladder control returned by the eight week after operation and although he was able to pass urine on his own, it took 4 months to recover normal bladder function. His sensation was gradually improved. However, sexual function and tendon reflexes had not returned to normal even 2 years after the operation. Pre-operative lumbar magnetic resonance imaging MRI of year-old male with sexual dysfunction and L5-S1 lumbar disc herniation.
A year-old male was admitted for acute retention of urine. He had no history of backache. Two days before his admission, he had developed left-sided sciatica, followed by urinary retention and impotence. Clinical examination revealed saddle anesthesia, a distended bladder, and loss of anal tone.
The straight legraising test was normal on both sides, there was no motor weakness inthe lower limbs and the Achilles reflexes were absent on the right side. A right side hemipartial laminectomy of L5 was performed immediately and a large disc prolapse at the L5-S1 level was removed.
On the two months after surgery, he was able to pass urine but it took six months for him to recover normal bladder function. One year after operation he was able to have a sustained erection. Pre-operative magnetic resonance imaging MRI of a year-old male with left-sided sciatica, urinary retention, and impotence. A year-old woman admitted with transient difficulty in passing urine, sexual dysfunction, and perianal hypoaesthesia.
Clinically, both the Achilles reflexes were absent and there was perianal hypoaesthesia but no motor weakness. A lumbar MRI revealed a prolapse at the level of the left side L5-S1 disc space, and at operation, disc prolapse was removed [ Figure 3 ].
The perianal hypoaesthesia diminished and bladder control was returned to normal after three months of operation. However, there was no recovery of her sexual dysfunction.
Pre-operative a and b , post-operative c and d magnetic resonance imaging MRI of a year-old woman with transient difficulty in passing urine, sexual dysfunction, and perianal hypoaesthesia. A year old woman, she has had left side L5-S1 disc herniation; however, it was not prolapsed, only bulging was noted on the lumbar MRI [ Figure 4 ]. Urinary retention and sexual dysfunction were main problems. After initial evaluation, emergent, standard left L5-S1 partial hemilaminotomy and microdiscectomy performed.
The post-operative period of patient was uneventful. They discharged on the fourth post-operative day. At 6-month follow-up, although bladder was nearly normal, the reduced sensation in the sacral area, and her sexual dysfuntion were continuing.
Post-operative magnetic resonance imaging MRI of a year old woman with disc bulging, urinary retention, and sexual dysfunction. Disc herniation of the same size may be asymptomatic in one patient[ 11 ] , and can lead to severe nerve root compromise in another patient. At present, neurosurgical practice is confronted by an explosion of technology. It can be socially disruptive and emotionally distressing.
The pathophysiology remains unclear. This is interesting point of present study. Akbas et al. They studied patients' sexual problems and sexual behavior patterns before and after surgical treatment of lumbar disc herniation. In last two studies, improvement in sex life after lumbar disc surgery was positively correlated to a reduction in low back pain. Our study is different than those studies because in all of four patients, sexual dysfunctions were related to L5-S1 disc herniation.
However, association of sexual dysfunction and lumbar disc herniation with is not new in medical literature. There is only two cases report about sexual dysfunction related to disc herniation at the level of L, published in Another case about sildenafil treatment in neurogenic female sexual dysfunction caused by L5-S1 intervertebral disk rupture in Interesting point of our cases is that all disc occurred at the level L5-S1.
Sexual and sphincter dysfunction in these patients developed without low back pain and motor deficit. Almost all patients had perianal sensory deficit.
The questions arise as to what extent L5-S1 disc herniations in time and severity of compression are of prognostic significance. The answer is not clear. We can only advise that the longer compression continues the more likely is long-term permanent sexual and sphincter dysfunction which are the most distressing sequelae of patients. Our cases show that compression of the sacral roots at the L5-S1 level, unlike the lumbar ones, may not cause motor signs in the legs, reflex deficit.
Although severe back ache with sciatica should raise the spectre of compression of the CE, none of our three patients with a large prolapsed, and a patient with bulging at the L5-S1 level did not complain any pain. In adddition, they did not have any limitation of straight leg-raising. Saddle anesthesia with bladder and sexual symptoms were the consistent features in our patients.
For that reason, we think that the syndrome, we described here, may be different than classic cauda equine syndrome. Poor recovery of sexual function in all of patients after surgery was a significant feature. Only two CES treated by surgical decompression, the influence of timing on surgical outcome, patients regained partial control of micturition. There was not statistically significant different between pre-operative and post-operative sexual function, anal-urethral SF, and perianal sensation score [see Table 1 ].
All this four patients were operated in 18 months between September March There was an early realization that paralysis of the sphincter and sexual dysfunction are important in patients with lumbar L5-S1 disc disease. We again stress that the leg and back pain may be absent in this syndrome. This point is important for spine and urologic surgeon.
They should be aware of sexual dysfunction in patient with L5-S1 disc herniations. Our all four cases presented during the first attack of lumbar disc disease associated with sexual dysfunction so they have not had chronic disc disease. This may be another important point of this syndrome. Neurological examination should include a careful search for sensory abnormality in the perineum. The sexual, anal, urethral sphincter function score, and perianal sensation scores of patients.
Sexual dysfunction is sometimes a complication following anterior approach lumbar disc surgery. The hypogastric plexus contains efferent pre- and post-ganglionic sympathetic fibers, preganglionic parasympathetic fibers, and visceral afferent pain fibers.
The superior and inferior hypogastric plexuses receive input from sympathetic preganglionic fibers whose cell bodies reside in the intermediolateral cell columns of the lower spinal cord.
These efferent, preganglionic fibers first leave the spinal cord via the ventral roots of spinal nerves and exit the spinal nerves via the white rami communicantes into the lumbosacral sympathetic chain. In addition, contraction of the ischiocavernosal and bulbospongiosal striated muscles, located at the penile crus and innervated by the S2-S4 somatic motor fibers, plays a contributory role in penile erection.
The syndrome, described here, is based on a study of four patients with neurological signs of compression at the L5-S1 level.
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