Zero current pain score! Still very minor morning symptoms on the left side- see how this continues to unlayer. See the recent MRI and the patient response.
Patient’s experience with his other doctors has been eye-opening.
Dr. Brady exit interview: This is a long one. I go off on a few tangents… Mostly about how the healthcare system is broken (re: they can’t even get his MRI right, nevermind his diagnosis and his care).
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I didn’t know it was possible for a disc to resorb that much, definitely a real eye opener for me. Another video with so many great communication gems.
A beautiful masterclass in the ID system! The nuance of when to look for something like cluneal nerve entrapment was very well thought out and explained. Too often we see providers (myself included) simply treat a bunch of stuff because we saw it a couple of times.
Worse still are the providers that think that’s something to add to the list of things treated because all low back pain patients need it.
Lightyears ahead of everyone else!
So I understand his morning soreness is still most likely coming from either the healing L5 disc, or the remaining bulging at L4, but what is the cluneal nerve mechanism in this case?
He notes only feeling the cluneal nerve distribution roughly 3x/week which lasts a few hours. It makes sense that he notices it when walking with his left leg swinging forward, by his motions/jestures anyway (tensioning the nerve if it’s stuck).
How does this, or any nerve entrapment, not cause consistent symptoms (more than 3x/week) if it’s tensioned during a motion like walking?
Can a peripheral nerve become inflamed/irritated due to the discs, or is it more from being stuck and what he does throughout the day before feeling it? Next day soreness.
Why does it dissipate after a few hours, if conceivably tensioning the nerve with movement would irritate it?
In terms of the discs, L4 really hasn’t changed since his last MRI. Why would L5 have such a good resorption rate, but L4 is relatively unchanged? I understand this is a loaded question, but in this case specifically, do you have any idea why? The scar tissue within the L4 disc has already proliferated to ‘plug’ the torn annulus, limiting resorption?
Sorry for the litany of questions, but I guess I don’t understand nerve entrapments and their general mechanism well enough. These questions are purely out of curiosity to learn and understand the body better. As far as case management help, this case has been incredibly valuable.
I’m learning a lot watching my way through this case! For one, I loved your response to the prevalence of disc degeneration on MRI in an asymptomatic population – it was super clear and concise.
I have a 20-something patient with disc degeneration – his PCP ordered the MRI and explained the prevalence in an asymptomatic population, which he then mentioned to me. I stumbled my way through a response but will definitely be using this response if it comes up again. We are treating the patient in front of us, and they are more than a statistic on a public health report!