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Lumbar MRI -VE?

Exit forum ID Forum Discussion Lumbar MRI -VE?

This topic contains 7 replies, has 2 voices, and was last updated by   Brandon Cohen DC, CSCS October 22, 2018 at 5:55 pm.

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    Michael Vibert

      Does anyone else think that this slice looks like a bulging disc at L4/5? The report says that everything is normal. I have a high clinical suspicion that this patient has pain originating from the IVD. Quick run down from memory:

      A: 27 S: F

      Central pain over the PSISs and ~L3-S1

      Dull, achy, intense


      P+ Forward bending, sitting, housework ect.

      P- Very little, rest (sort of – had to squeeze that out of her) avoidance of painful activities

      2nd order: Insomniac – many years, doesn’t sleep much.

      Exam: (from memory again)

      SLPF – Knees – hurts in her low back

      SLR B ~50d SHF B ~6F – back pain QLF – 90%

      KHE B 8-10″ (can’t remember but it was limited and caused back pain)

      I’ve tried a handful (i think 6 treatments) but have had very little success in applying proper treatment because she is so tender and sore. All progress has been reflexive so I sent her for MR only to get back the report stating that it is all normal.

      My thoughts are that in order of likelihood

      1. Annular tearing that is not showing up on MR

      2. Some kind of “fibromyalgia/stress/metabolic/psychosomatic” thing

      3. Mild/moderate adhesion

      4. Weakness (she hasn’t exercised in a long time and has lost a lot of muscle tone)

      I’ll check on those exam findings and update if they are wrong. But i’m not sure where I’m going on this case right now and this poor person needs guidance. Any input would be fantastic


      Michael Vibert

        One slice off to the right and one through the guts

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        Seth Schultz, DC

          Did the report note any neuroforaminal narrowing?


          Seth Schultz, DC

            I think you’re correct with the disc bulge, it looks to me it’s more lateralized to the left and there also seems to be arthrosis at that level.


            Adam Holen D.C.

              Insomnia throws a curveball into the mix, assuming that creates a more constant systemic inflammatory issue since her tissues never get time to recover. The back pain with KHE likely indicates Seth’s find of facet arthrosis/irritation, but a 50D-B SLR, 6F-B SHF (back pain sx), and 50% SLPF, typically all point to disc (and you would hope a shit ton of adhesion). The 90% QLF enlight of the rest of the findings is also an outlier. What have you treated within those six visits? With only 1-2 graded adhesion throughout (assuming you mean all restricted tests), I’m curious as to what could cause such massive restrictions without correlated imaging findings. Strength is important, but hypersensitivity to treatment would lead me to believe she’s chronically inflamed aside from the disc/facets.

              Outside of a ridiculous inflammatory state, I don’t understand how fibro or even psychosomatic could result in tangible tissue restrictions and a non-response to treatment. Sorry, I have more questions than input, but this is a good case. Hoping to hear more from others.


              Keith Puri, DC

                To determine if the disc is bulging look at the axial images at the level of the vert body and then scroll up to the level of the disc and check if the disc margins extend beyond the ring apophyses. If it does then there is bulging, if not then there isn’t. Try not to over analyze the sagittal images. See the link below of details.

                I agree they are a few things that do not seem to be adding up. I am questioning whether or not her L/sp is the primary location. They certainly are a factors from her Hx that point towards it – (P+, symptom location, quality, intensity, limited SLR, SLPF and KHE) but there are also several factors that might point towards something else – (SHF 6F, P-, QLF 90%, mild/mod adhesion, and her response to tx thus far. Also, her symptom intensity seems disproportionate to her symptoms quality and the MRI findings or lack thereof do not seem to support a pain intensity of 8/10 unless there is a biopsychosocial overlay or some underlying metabolic disorder).

                I am curious about her hips and if they are relevant to her symptoms. SHF limited to 6F is a massive limitation and is certainly a risk factor for hip dysfunction. This finding coupled with a limited SLF to knee and B SLR 50* could support hip more so than the L/Sp. Especially if SHF is large enough to limit SLR and SLPF which 6F might be. I am curious what her symptom response would be to FABER, FADIR and hip impingement test(s). If those reproduced her known pain then I would consider DDH, FAI or an intra-articular hip pathology.

                It’s quite possible I am completely off base but just a few things to consider.



                Michael Vibert

                  Thank you for your responses, very helpful. This is definitely a tough case.

                  I was actually hoping that Keith would drop some MRI knowledge bombs and wasn’t disappointed. I think the reality here is that I would be “grasping at straws” to say that she has overt disc damage. It’s essentially a normal MRI and there is no way that there is a true SOL that is limiting SLR/SLPF.

                  So in saying that the next question becomes could her hips possibly be restricting her from these movements? I don’t think that that is the answer here because when I am testing her ranges I can tell that these limitations are more guarding than tissue length challenges.

                  I did treat here hip restriction and got improvement only to find that it was worse the next visit.

                  Next plan of action for me was going to be to tell her that “The MRI has served us a really worthwhile purpose. It has shown us that there isn’t any severe problems happening in your spine – which is great news. This gives me more confidence to apply treatment without causing more harm than good.”

                  Would it be worth spending some extra time with her and working through the pain she experiences with treatment to see if that can get us some progress. I was holding off on her before due to fear of worsening her “disc damage” But now we can see that there is nothing serious going on there so does this leave me free to tell her to suck it up..?


                  Brandon Cohen DC, CSCS

                    Is there not posterior migration of the nuclear material at L4-5? It sounds like multiple dx, but disc seems most likely. At 27, I would still like to see pretty clear lines between nucleus and annulus. Pain level is too high to explain a little annular tearing though.

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