Q: I am a 40 years old man who underwent an MRI Scan for lumboscral spine without contrast enhancement. Scans were performed using T1 and T2 weighted saggital and axial plane. A small Schmorls node was seen in L2 vertebra and erosion was seen in L3 vertebra. Intervertebral discs L2 – L3 disc showed loss of hydration and posterior central protrusion indenting thecal sac. The impression of MRI of lumbosacral spine showed adequate canal, posterior canal protrusion of L2 – L3 disc indenting thecal sac. What is the treatment for this? I am having severe pain in the left leg. Please advise.

A:The MRI picture that you have described can be very misleading. A patient without any physical signs and symptoms can have the same MRI picture. Where as a patient with severe symptoms may also have similar picture. Therefore we always try to correlate whether the pain character, its radiation and its distribution corresponds clearly with what we seen on MRI. You have mentioned severe pain in the leg. However, the disc level you had mentioned does not cause pain in the leg. It causes pain in the thigh. Or is it that you are using leg as a general term, which is below the knee. Assuming you had mentioned the general term leg and your pain is referred to the thigh, the management of such cases is primarily conservative, which is:

1. To allow activity based on pain tolerance.
2. Analgesics (pain killers) and muscle relaxants as per requirement.
3. Once the acute pain subsides to be on a regime of exercises.

The current understanding is tractions and other physical measures do not substantially alter the course of the problem. Strict bed rest is not recommended that is something, which has been discontinued. The indications for surgery are: A - objective criteria:

1. Objective neurological paralysis or weakness.
2. Objective evidence of involvement of urinary bladder and bowel function.

B - subjective criteria:

1. Severe pain unrelieved by painkillers and other physical measures.
2. Pain that gets relieved but comes in recurrent attacks which affects the economic activity of the patient.

C - rarely there can be a case where the diagnosis is in doubt. In modern times with modern imaging facilities this is a rare possibility. Coming back to your case I think you need to consult an orthopaedic surgeon and be on a course of simple analgesics and muscle relaxants followed by course of exercises. If you do not settle with these then your surgeon will have to decide but the guidelines are as above.