A Spine Physician Responds to E-mail Questions About This Cause of Lower Back Pain

You can often learn a lot from other people's questions and how a spine physician might respond to those questions. Therefore, we are sharing our Medical Director's responses to several reader questions that had previously been submitted about low back pain caused by a herniated disc.

Reader Question

I have a herniated disc at L5-S1 causing pain down my right leg for the past few months. I would like to avoid surgery and have been having some success with physical therapy. However, I have recently noticed that some of the exercises are causing me pain down my leg, specifically the piriformis stretching. Why is this happening? Since I've been told I have a tight piriformis muscle, will it hinder my healing if I don't do this set of exercises?

Doctor's Response: Piriformis Syndrome

If the piriformis muscle is tight, this in and of itself can give you sciatica (leg pain). Sometimes getting the piriformis muscle stretched out can actually cause more pain for a while. Unfortunately, the disc herniation itself can cause tightness in the piriformis. If the pain has been going on for three or four months, it might not get better with conservative treatment (e.g. physical therapy) and it may be time to be evaluated by a spine surgeon. If there is a lot of pressure on the nerve root, surgery may actually get you better sooner than continued conservative treatment. See also What is Piriformis Syndrome and Sciatica Exercises.

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Reader Question

My 19-year old son had a discectomy surgery a while ago due to a herniation at L4-L5. He still has lower back pain, but no leg pain. Now we have no diagnosis. He has had MRI's, bone scan, physical therapy, injections, oral meds, and has seen a lot of doctors, but still has no pain relief or answers. We want to get a second opinion, but do not know what type of specialist would be best suited to handle this problem.

Doctor's Response: Spine Surgeon or Physiatrist

If he has had previous surgery, then seeing another surgeon would be reasonable to rule out any surgical pathology. A fellowship trained spine surgeon, either an orthopedic surgeon or neurosurgeon, who specializes in spine surgery would probably be best. If a surgical lesion is ruled out then the only other option is rehabilitation, and this is often best done with a rehab doctor (physiatrist) who specializes in back pain. See What is a Physiatrist?

Reader Question

I have a herniated disc at L5 and sciatica, and have been experiencing numbness and tingling in my leg. Is there a test to determine if and what nerves are being compressed aside from an MRI?

Doctor's Response: MRI

An MRI scan is definitely the best test, but there are other ones. A CT scan does not give quite as good an image but can see a disc if is large. An EMG study of the leg (electromyography) can tell if a muscle group is affected, but it is a very non-specific test and does not pick up a lot of disc herniations. The best test is an MRI scan. If you have claustrophobia, the newer scanners are not tunnels and are much less claustrophobic. See MRI scan of the spine.

Reader Question

I have chronic lower back pain and leg pain that goes down to my left foot. An MRI showed degenerative disc disease L3 thru S1, a diffuse bulge (herniated disc) at L4/5 worse to the left. I am due to have an epidural block for the leg pain and facet injections. I am also in physical therapy. Do you think it is possible to rehabilitate my back to the level of being able to lift in excess of 50 lbs?

Doctor's Response: Physical Therapy or Microdecompression

In all likelihood, it is possible to get back to your formal level of functioning. A lot of the findings that are on your MRI scan were present before you were having much back pain, as these findings are not diagnostic of any specific pathology.

The more important question is whether or not the disc bulge is pinching your nerve root. If this is the case, then the epidural may help calm down the inflammation, after which it would be good to start a physical therapy program. If the injection does not help, then you may want to see a spine surgeon to see if you would be a candidate for a microdecompression (aka microdiscectomy).

Assuming that physical therapy helps relieve your back pain, you should be able to lift 50lbs as your MRI findings do not show that there is anything structurally wrong with your back.