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Hello And Good Day, I Am Inquiring Regarding My Fiancées
Question: Hello and good day,
I am inquiring regarding my fiancées health. She is a 33 year old female. She has not yet given birth, she is not pregnant and has not been diagnosed with a serious disease. She has regularly cycles. She had some thyroid issues which may or may not be hashimoto, and her physicians were indecisive about it.
For some time now she is experiencing tingling sensations and pain (more than eight months). These sensations and pain start at the lower back, go through her hip and groin and into the calf, sometimes reaching the knee, or even the ankle. At some occasions she feels as if these sensations reach her arms. This pain and tingling sensations, often alternate between the right and left side of the body, with the majority of pain going through the right leg and the majority of sensations going through the left leg. Sometimes she experiences some pain in the middle of her back, inclined to the right side approximately in the height of the rib cage. From time to time, she feels her heart “skipping” and pulsating in stomach.
Her blood pressure is in average 100/60 with puls rate of circa 70.
Due to the fact that this state persists she has undergone many tests which were recommended either by her physician or by specialists as a follow up. I will try to convey them in short.
- 19.01.2018. Spirometry of lungs – ok – Sa02 98%
- 05.02.2018. x ray of heart and lungs ok.
- 11.10.2018. ultrasound of thyroid gland ok but the doctor implies that she has raise anti bodies – maybe hashimoto. Her TSH – 2.41, ft3-4.49, ft 4-17.73.
- She checked her ear nose and throat and received simple antacid therapy.
- 24.07.2018. blood tests – everything ok apart from SE-3 bilirubin 25. Also - eptihelial cells (squamous, round shaped) 2-3, testasteron 4.8, free testasteron 2.5.
Menstrual cycles ok, but the menstrual blood is more translucent and there is less of it during the cycle.
24.10.2018. Gynecological exam ok, papa test ok, ovary ultrasound ok.
Night sweats occurring during cycles.
14.03.2018. and 15.11.2018. Ultrasound of the breasts - ok.
19.04.2018. EKG holter shows mild sinus arrhythmia.
16.04.2018. Ultrasound of pectoral muscle regions shows spasms.
12.04.2018. Ultrasound of abdomen ok, with minor gaul polyps of less than 4 mm
19.06.2018. Rtg LS spine hyperlordosys LS, other ok
13.12.2018. orthopedic exam – ok, foot ok
12.09.2018. electromyoneurography test of legs – ok, but possibility of polyneuropathy of unknown genesis suggested by the neurophysician.
07.01.2019. MRI of lower back fine apart from some benign Schmorl hernias on l2 and l3.
11.12.2018. Tumor markers: AFP 7,8 – high while others ok (CEA,CA 125, CA 19-9, CA 15-3 – ok), Proteins 71 g/L ok, HbA1c- 4.8% - ok, Autoimmune diseases – Hu, Yo, Ri negative, Electroforesys ok.
At this point we would appreciate any diagnosis ideas what the issue might be, and in which direction to go. After one year of testing we have not gotten any closer to a solution. Her status is fine and tolerable but we fear whether there is a possibility of some malign underlining cause to all these symptoms. Having no more faith in our domestic health care we are reaching out to you.
Perhaps it is also important to point out that she walks a lot as exercise that she is not overweight (aprox. 165 cm, 63 kg). There is no previous physical trauma involved. The tingling most often starts when she lies down or relaxes but it sometimes occurs in parallel to the pain. The pain is not extensive but she feels it.
Thank You in advance for Your answer.
I am inquiring regarding my fiancées health. She is a 33 year old female. She has not yet given birth, she is not pregnant and has not been diagnosed with a serious disease. She has regularly cycles. She had some thyroid issues which may or may not be hashimoto, and her physicians were indecisive about it.
For some time now she is experiencing tingling sensations and pain (more than eight months). These sensations and pain start at the lower back, go through her hip and groin and into the calf, sometimes reaching the knee, or even the ankle. At some occasions she feels as if these sensations reach her arms. This pain and tingling sensations, often alternate between the right and left side of the body, with the majority of pain going through the right leg and the majority of sensations going through the left leg. Sometimes she experiences some pain in the middle of her back, inclined to the right side approximately in the height of the rib cage. From time to time, she feels her heart “skipping” and pulsating in stomach.
Her blood pressure is in average 100/60 with puls rate of circa 70.
Due to the fact that this state persists she has undergone many tests which were recommended either by her physician or by specialists as a follow up. I will try to convey them in short.
- 19.01.2018. Spirometry of lungs – ok – Sa02 98%
- 05.02.2018. x ray of heart and lungs ok.
- 11.10.2018. ultrasound of thyroid gland ok but the doctor implies that she has raise anti bodies – maybe hashimoto. Her TSH – 2.41, ft3-4.49, ft 4-17.73.
- She checked her ear nose and throat and received simple antacid therapy.
- 24.07.2018. blood tests – everything ok apart from SE-3 bilirubin 25. Also - eptihelial cells (squamous, round shaped) 2-3, testasteron 4.8, free testasteron 2.5.
Menstrual cycles ok, but the menstrual blood is more translucent and there is less of it during the cycle.
24.10.2018. Gynecological exam ok, papa test ok, ovary ultrasound ok.
Night sweats occurring during cycles.
14.03.2018. and 15.11.2018. Ultrasound of the breasts - ok.
19.04.2018. EKG holter shows mild sinus arrhythmia.
16.04.2018. Ultrasound of pectoral muscle regions shows spasms.
12.04.2018. Ultrasound of abdomen ok, with minor gaul polyps of less than 4 mm
19.06.2018. Rtg LS spine hyperlordosys LS, other ok
13.12.2018. orthopedic exam – ok, foot ok
12.09.2018. electromyoneurography test of legs – ok, but possibility of polyneuropathy of unknown genesis suggested by the neurophysician.
07.01.2019. MRI of lower back fine apart from some benign Schmorl hernias on l2 and l3.
11.12.2018. Tumor markers: AFP 7,8 – high while others ok (CEA,CA 125, CA 19-9, CA 15-3 – ok), Proteins 71 g/L ok, HbA1c- 4.8% - ok, Autoimmune diseases – Hu, Yo, Ri negative, Electroforesys ok.
At this point we would appreciate any diagnosis ideas what the issue might be, and in which direction to go. After one year of testing we have not gotten any closer to a solution. Her status is fine and tolerable but we fear whether there is a possibility of some malign underlining cause to all these symptoms. Having no more faith in our domestic health care we are reaching out to you.
Perhaps it is also important to point out that she walks a lot as exercise that she is not overweight (aprox. 165 cm, 63 kg). There is no previous physical trauma involved. The tingling most often starts when she lies down or relaxes but it sometimes occurs in parallel to the pain. The pain is not extensive but she feels it.
Thank You in advance for Your answer.
Hello and good day,
I am inquiring regarding my fiancées health. She is a 33 year old female. She has not yet given birth, she is not pregnant and has not been diagnosed with a serious disease. She has regularly cycles. She had some thyroid issues which may or may not be hashimoto, and her physicians were indecisive about it.
For some time now she is experiencing tingling sensations and pain (more than eight months). These sensations and pain start at the lower back, go through her hip and groin and into the calf, sometimes reaching the knee, or even the ankle. At some occasions she feels as if these sensations reach her arms. This pain and tingling sensations, often alternate between the right and left side of the body, with the majority of pain going through the right leg and the majority of sensations going through the left leg. Sometimes she experiences some pain in the middle of her back, inclined to the right side approximately in the height of the rib cage. From time to time, she feels her heart “skipping” and pulsating in stomach.
Her blood pressure is in average 100/60 with puls rate of circa 70.
Due to the fact that this state persists she has undergone many tests which were recommended either by her physician or by specialists as a follow up. I will try to convey them in short.
- 19.01.2018. Spirometry of lungs – ok – Sa02 98%
- 05.02.2018. x ray of heart and lungs ok.
- 11.10.2018. ultrasound of thyroid gland ok but the doctor implies that she has raise anti bodies – maybe hashimoto. Her TSH – 2.41, ft3-4.49, ft 4-17.73.
- She checked her ear nose and throat and received simple antacid therapy.
- 24.07.2018. blood tests – everything ok apart from SE-3 bilirubin 25. Also - eptihelial cells (squamous, round shaped) 2-3, testasteron 4.8, free testasteron 2.5.
Menstrual cycles ok, but the menstrual blood is more translucent and there is less of it during the cycle.
24.10.2018. Gynecological exam ok, papa test ok, ovary ultrasound ok.
Night sweats occurring during cycles.
14.03.2018. and 15.11.2018. Ultrasound of the breasts - ok.
19.04.2018. EKG holter shows mild sinus arrhythmia.
16.04.2018. Ultrasound of pectoral muscle regions shows spasms.
12.04.2018. Ultrasound of abdomen ok, with minor gaul polyps of less than 4 mm
19.06.2018. Rtg LS spine hyperlordosys LS, other ok
13.12.2018. orthopedic exam – ok, foot ok
12.09.2018. electromyoneurography test of legs – ok, but possibility of polyneuropathy of unknown genesis suggested by the neurophysician.
07.01.2019. MRI of lower back fine apart from some benign Schmorl hernias on l2 and l3.
11.12.2018. Tumor markers: AFP 7,8 – high while others ok (CEA,CA 125, CA 19-9, CA 15-3 – ok), Proteins 71 g/L ok, HbA1c- 4.8% - ok, Autoimmune diseases – Hu, Yo, Ri negative, Electroforesys ok.
At this point we would appreciate any diagnosis ideas what the issue might be, and in which direction to go. After one year of testing we have not gotten any closer to a solution. Her status is fine and tolerable but we fear whether there is a possibility of some malign underlining cause to all these symptoms. Having no more faith in our domestic health care we are reaching out to you.
Perhaps it is also important to point out that she walks a lot as exercise that she is not overweight (aprox. 165 cm, 63 kg). There is no previous physical trauma involved. The tingling most often starts when she lies down or relaxes but it sometimes occurs in parallel to the pain. The pain is not extensive but she feels it.
Thank You in advance for Your answer.
I am inquiring regarding my fiancées health. She is a 33 year old female. She has not yet given birth, she is not pregnant and has not been diagnosed with a serious disease. She has regularly cycles. She had some thyroid issues which may or may not be hashimoto, and her physicians were indecisive about it.
For some time now she is experiencing tingling sensations and pain (more than eight months). These sensations and pain start at the lower back, go through her hip and groin and into the calf, sometimes reaching the knee, or even the ankle. At some occasions she feels as if these sensations reach her arms. This pain and tingling sensations, often alternate between the right and left side of the body, with the majority of pain going through the right leg and the majority of sensations going through the left leg. Sometimes she experiences some pain in the middle of her back, inclined to the right side approximately in the height of the rib cage. From time to time, she feels her heart “skipping” and pulsating in stomach.
Her blood pressure is in average 100/60 with puls rate of circa 70.
Due to the fact that this state persists she has undergone many tests which were recommended either by her physician or by specialists as a follow up. I will try to convey them in short.
- 19.01.2018. Spirometry of lungs – ok – Sa02 98%
- 05.02.2018. x ray of heart and lungs ok.
- 11.10.2018. ultrasound of thyroid gland ok but the doctor implies that she has raise anti bodies – maybe hashimoto. Her TSH – 2.41, ft3-4.49, ft 4-17.73.
- She checked her ear nose and throat and received simple antacid therapy.
- 24.07.2018. blood tests – everything ok apart from SE-3 bilirubin 25. Also - eptihelial cells (squamous, round shaped) 2-3, testasteron 4.8, free testasteron 2.5.
Menstrual cycles ok, but the menstrual blood is more translucent and there is less of it during the cycle.
24.10.2018. Gynecological exam ok, papa test ok, ovary ultrasound ok.
Night sweats occurring during cycles.
14.03.2018. and 15.11.2018. Ultrasound of the breasts - ok.
19.04.2018. EKG holter shows mild sinus arrhythmia.
16.04.2018. Ultrasound of pectoral muscle regions shows spasms.
12.04.2018. Ultrasound of abdomen ok, with minor gaul polyps of less than 4 mm
19.06.2018. Rtg LS spine hyperlordosys LS, other ok
13.12.2018. orthopedic exam – ok, foot ok
12.09.2018. electromyoneurography test of legs – ok, but possibility of polyneuropathy of unknown genesis suggested by the neurophysician.
07.01.2019. MRI of lower back fine apart from some benign Schmorl hernias on l2 and l3.
11.12.2018. Tumor markers: AFP 7,8 – high while others ok (CEA,CA 125, CA 19-9, CA 15-3 – ok), Proteins 71 g/L ok, HbA1c- 4.8% - ok, Autoimmune diseases – Hu, Yo, Ri negative, Electroforesys ok.
At this point we would appreciate any diagnosis ideas what the issue might be, and in which direction to go. After one year of testing we have not gotten any closer to a solution. Her status is fine and tolerable but we fear whether there is a possibility of some malign underlining cause to all these symptoms. Having no more faith in our domestic health care we are reaching out to you.
Perhaps it is also important to point out that she walks a lot as exercise that she is not overweight (aprox. 165 cm, 63 kg). There is no previous physical trauma involved. The tingling most often starts when she lies down or relaxes but it sometimes occurs in parallel to the pain. The pain is not extensive but she feels it.
Thank You in advance for Your answer.
Brief Answer:
No need to worry about tumor or paraneoplastic disease
Detailed Answer:
Thank you for reaching out with your concerns having to do with your fiancee's condition.
I've reviewed all the lab results you've presented and can tell you that in my opinion, there is a STRAIGHT FORWARD and even COMMON explanation to her condition sitting right in the labs and tests you provided. I'll get to that in a second but I also want to make a couple of comments regarding some of the results you've included for review.
I'm not sure I understand why some of these tests were obtained if her PRIMARY COMPLAINT has always been pain and tingling going down her back and legs. I'm not sure who was the first to suggest a possible tumorous growth that hasn't been able to be detected yet but my first instinct with a presentation such as your fiancee has would be to obtain MRI studies and X-RAYS of the lumbosacral spine. The first thing that should be thought of in such a situation is some type of architectural anomaly affecting spinal nerve roots at this level.
I don't understand why full metabolic panels have been obtained to include things such as TESTOSTERONE LEVELS in a female or ULTRASOUND of the PECTORAL MUSCLES which is considered an INAPPROPRIATE use of ULTRASOUND for diagnostic purposes. There is no evidence that ultrasound studies have any capability of detecting musculoskeletal spasms or inflammation. In fact, the evidence is quite the contrary which shows ultrasound is of no value when making such diagnoses.
Also, the documentation of an FT4 level of 17.73 is HIGHLY ELEVATED (though you've not provided the laboratory norms) and in the face of a normal set of vital signs, sounding as if she were not in any ACUTE DISTRESS physically speaking (blood pressure, heart rate) and a normal TSH....this number is highly unlikely. The condition she would have if anything would be HYPERTHYROIDISM of a significant degree NOT Hashimoto's thyroiditis which would require a HYPOTHYROID state to be present where the TSH is very HIGH and the FT4 is very low...or possibly normal.....but not with the numbers you've presented.
Therefore, either the numbers are mistyped on your end, the lab values reported are in error, or something else is up, etc. If I were the physician ordering the study I would repeat it and see how it compares. If it still turns out to be that high with everything else being normal or apparently normal....I would definitely get an endocrinologist involved because then, there's a really odd case of something that may need to be published. At any rate, now to the bottom line of what may be causing your fiancee's problems.
You have stated that an MRI of the lumbar spine shows disc HERNIATION at L2 and L3. I don't know if you mean there are 2 consecutive disks herniated or whether there is a disc herniation at the L2/L3 level. In either case, the symptoms produced from such a condition (PRESSURE BY DISK MATERIAL ON SPINAL NERVES EXITING THE CORD) would be exactly likely to produce the symptoms you are referring in your fiancee which are those of pain and tingling (I'd even expect some numbness in the trajectory of the affected nerve(s)) which goes down the back, wraps around to the front of the thigh through the inguinal or crural region and then, end up still in the leg and sometimes perhaps a little farther down. But your fiancee's fit the description of a herniated disk syndrome. Now, what is causing that compression seems to be (from the description of the scan) an condition of arthritic degeneration such as either narrowing of her lumbar canal, narrowing of the spaces through which the nerves themselves travel, or things such as osteophytes or other calcifications that can develop over time due to amount of exertion of the back, heavy lifting, repetitive standing, bending,etc. There certainly could be a tumor but the MRI doesn't seem to have picked up on anything like that so I wouldn't be concerned about it.
Now, CAUTION. The EMG/NCV study you are presenting doesn't seem to correlate with what the MRI is showing and again, here is where one needs to make a decision. I believe that an EMG/NCV done by a good electromyographer should easily pick up what this would be referred to as a RADICULOPATHY...as opposed to a mild polyneuropathy....So again, either the EMG/NCV study is not being read entirely accurately or the amount of electrical change in nerve function at this point is so minimal that it can't be detected. I doubt the latter is true since she's had the problem for a long time. I might consider either repeating the study or looking for another electromyographer who is a NEUROLOGIST with a subspecialty in electrical musculoskeletal problems because the MRI reading and the symptoms she has, for my tastes are right on.
Another word of caution. The use of surgery in this case PRIOR to trying conservative measures of aggressive physical therapy, aquatherapy, medication, TENS units, possibly TRACTION of the back is not suggested. Surgery should only be reserved for cases where muscle atrophy, muscle weakness, or EXCRUCIATING PAIN that cannot be tolerated any longer (after all other methods have been tried) are present. Since the diagnosis of the herniated disk syndrome (HDS) has not even yet been recognized then, she should undergo a good program of conservative therapy that would include the appropriate use of NEUROPATHIC TYPES of pain medication (NOT narcotics or simple analgesics), PHYSICAL THERAPY, and AQUATHERAPY.
PLEASE BE AWARE THAT WHAT YOU'VE WRITTEN ABOUT SCHMORL HERNIAS L2 AND L3 could be interpreted as her having SCHMORL NODES and HERNIAS....or are you mistakenly calling a SCHMORL NODE a HERNIA because those are not the same thing....it could be a translation phenomenon.......
No need to worry about tumor or paraneoplastic disease
Detailed Answer:
Thank you for reaching out with your concerns having to do with your fiancee's condition.
I've reviewed all the lab results you've presented and can tell you that in my opinion, there is a STRAIGHT FORWARD and even COMMON explanation to her condition sitting right in the labs and tests you provided. I'll get to that in a second but I also want to make a couple of comments regarding some of the results you've included for review.
I'm not sure I understand why some of these tests were obtained if her PRIMARY COMPLAINT has always been pain and tingling going down her back and legs. I'm not sure who was the first to suggest a possible tumorous growth that hasn't been able to be detected yet but my first instinct with a presentation such as your fiancee has would be to obtain MRI studies and X-RAYS of the lumbosacral spine. The first thing that should be thought of in such a situation is some type of architectural anomaly affecting spinal nerve roots at this level.
I don't understand why full metabolic panels have been obtained to include things such as TESTOSTERONE LEVELS in a female or ULTRASOUND of the PECTORAL MUSCLES which is considered an INAPPROPRIATE use of ULTRASOUND for diagnostic purposes. There is no evidence that ultrasound studies have any capability of detecting musculoskeletal spasms or inflammation. In fact, the evidence is quite the contrary which shows ultrasound is of no value when making such diagnoses.
Also, the documentation of an FT4 level of 17.73 is HIGHLY ELEVATED (though you've not provided the laboratory norms) and in the face of a normal set of vital signs, sounding as if she were not in any ACUTE DISTRESS physically speaking (blood pressure, heart rate) and a normal TSH....this number is highly unlikely. The condition she would have if anything would be HYPERTHYROIDISM of a significant degree NOT Hashimoto's thyroiditis which would require a HYPOTHYROID state to be present where the TSH is very HIGH and the FT4 is very low...or possibly normal.....but not with the numbers you've presented.
Therefore, either the numbers are mistyped on your end, the lab values reported are in error, or something else is up, etc. If I were the physician ordering the study I would repeat it and see how it compares. If it still turns out to be that high with everything else being normal or apparently normal....I would definitely get an endocrinologist involved because then, there's a really odd case of something that may need to be published. At any rate, now to the bottom line of what may be causing your fiancee's problems.
You have stated that an MRI of the lumbar spine shows disc HERNIATION at L2 and L3. I don't know if you mean there are 2 consecutive disks herniated or whether there is a disc herniation at the L2/L3 level. In either case, the symptoms produced from such a condition (PRESSURE BY DISK MATERIAL ON SPINAL NERVES EXITING THE CORD) would be exactly likely to produce the symptoms you are referring in your fiancee which are those of pain and tingling (I'd even expect some numbness in the trajectory of the affected nerve(s)) which goes down the back, wraps around to the front of the thigh through the inguinal or crural region and then, end up still in the leg and sometimes perhaps a little farther down. But your fiancee's fit the description of a herniated disk syndrome. Now, what is causing that compression seems to be (from the description of the scan) an condition of arthritic degeneration such as either narrowing of her lumbar canal, narrowing of the spaces through which the nerves themselves travel, or things such as osteophytes or other calcifications that can develop over time due to amount of exertion of the back, heavy lifting, repetitive standing, bending,etc. There certainly could be a tumor but the MRI doesn't seem to have picked up on anything like that so I wouldn't be concerned about it.
Now, CAUTION. The EMG/NCV study you are presenting doesn't seem to correlate with what the MRI is showing and again, here is where one needs to make a decision. I believe that an EMG/NCV done by a good electromyographer should easily pick up what this would be referred to as a RADICULOPATHY...as opposed to a mild polyneuropathy....So again, either the EMG/NCV study is not being read entirely accurately or the amount of electrical change in nerve function at this point is so minimal that it can't be detected. I doubt the latter is true since she's had the problem for a long time. I might consider either repeating the study or looking for another electromyographer who is a NEUROLOGIST with a subspecialty in electrical musculoskeletal problems because the MRI reading and the symptoms she has, for my tastes are right on.
Another word of caution. The use of surgery in this case PRIOR to trying conservative measures of aggressive physical therapy, aquatherapy, medication, TENS units, possibly TRACTION of the back is not suggested. Surgery should only be reserved for cases where muscle atrophy, muscle weakness, or EXCRUCIATING PAIN that cannot be tolerated any longer (after all other methods have been tried) are present. Since the diagnosis of the herniated disk syndrome (HDS) has not even yet been recognized then, she should undergo a good program of conservative therapy that would include the appropriate use of NEUROPATHIC TYPES of pain medication (NOT narcotics or simple analgesics), PHYSICAL THERAPY, and AQUATHERAPY.
PLEASE BE AWARE THAT WHAT YOU'VE WRITTEN ABOUT SCHMORL HERNIAS L2 AND L3 could be interpreted as her having SCHMORL NODES and HERNIAS....or are you mistakenly calling a SCHMORL NODE a HERNIA because those are not the same thing....it could be a translation phenomenon.......
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Brief Answer:
No need to worry about tumor or paraneoplastic disease
Detailed Answer:
Thank you for reaching out with your concerns having to do with your fiancee's condition.
I've reviewed all the lab results you've presented and can tell you that in my opinion, there is a STRAIGHT FORWARD and even COMMON explanation to her condition sitting right in the labs and tests you provided. I'll get to that in a second but I also want to make a couple of comments regarding some of the results you've included for review.
I'm not sure I understand why some of these tests were obtained if her PRIMARY COMPLAINT has always been pain and tingling going down her back and legs. I'm not sure who was the first to suggest a possible tumorous growth that hasn't been able to be detected yet but my first instinct with a presentation such as your fiancee has would be to obtain MRI studies and X-RAYS of the lumbosacral spine. The first thing that should be thought of in such a situation is some type of architectural anomaly affecting spinal nerve roots at this level.
I don't understand why full metabolic panels have been obtained to include things such as TESTOSTERONE LEVELS in a female or ULTRASOUND of the PECTORAL MUSCLES which is considered an INAPPROPRIATE use of ULTRASOUND for diagnostic purposes. There is no evidence that ultrasound studies have any capability of detecting musculoskeletal spasms or inflammation. In fact, the evidence is quite the contrary which shows ultrasound is of no value when making such diagnoses.
Also, the documentation of an FT4 level of 17.73 is HIGHLY ELEVATED (though you've not provided the laboratory norms) and in the face of a normal set of vital signs, sounding as if she were not in any ACUTE DISTRESS physically speaking (blood pressure, heart rate) and a normal TSH....this number is highly unlikely. The condition she would have if anything would be HYPERTHYROIDISM of a significant degree NOT Hashimoto's thyroiditis which would require a HYPOTHYROID state to be present where the TSH is very HIGH and the FT4 is very low...or possibly normal.....but not with the numbers you've presented.
Therefore, either the numbers are mistyped on your end, the lab values reported are in error, or something else is up, etc. If I were the physician ordering the study I would repeat it and see how it compares. If it still turns out to be that high with everything else being normal or apparently normal....I would definitely get an endocrinologist involved because then, there's a really odd case of something that may need to be published. At any rate, now to the bottom line of what may be causing your fiancee's problems.
You have stated that an MRI of the lumbar spine shows disc HERNIATION at L2 and L3. I don't know if you mean there are 2 consecutive disks herniated or whether there is a disc herniation at the L2/L3 level. In either case, the symptoms produced from such a condition (PRESSURE BY DISK MATERIAL ON SPINAL NERVES EXITING THE CORD) would be exactly likely to produce the symptoms you are referring in your fiancee which are those of pain and tingling (I'd even expect some numbness in the trajectory of the affected nerve(s)) which goes down the back, wraps around to the front of the thigh through the inguinal or crural region and then, end up still in the leg and sometimes perhaps a little farther down. But your fiancee's fit the description of a herniated disk syndrome. Now, what is causing that compression seems to be (from the description of the scan) an condition of arthritic degeneration such as either narrowing of her lumbar canal, narrowing of the spaces through which the nerves themselves travel, or things such as osteophytes or other calcifications that can develop over time due to amount of exertion of the back, heavy lifting, repetitive standing, bending,etc. There certainly could be a tumor but the MRI doesn't seem to have picked up on anything like that so I wouldn't be concerned about it.
Now, CAUTION. The EMG/NCV study you are presenting doesn't seem to correlate with what the MRI is showing and again, here is where one needs to make a decision. I believe that an EMG/NCV done by a good electromyographer should easily pick up what this would be referred to as a RADICULOPATHY...as opposed to a mild polyneuropathy....So again, either the EMG/NCV study is not being read entirely accurately or the amount of electrical change in nerve function at this point is so minimal that it can't be detected. I doubt the latter is true since she's had the problem for a long time. I might consider either repeating the study or looking for another electromyographer who is a NEUROLOGIST with a subspecialty in electrical musculoskeletal problems because the MRI reading and the symptoms she has, for my tastes are right on.
Another word of caution. The use of surgery in this case PRIOR to trying conservative measures of aggressive physical therapy, aquatherapy, medication, TENS units, possibly TRACTION of the back is not suggested. Surgery should only be reserved for cases where muscle atrophy, muscle weakness, or EXCRUCIATING PAIN that cannot be tolerated any longer (after all other methods have been tried) are present. Since the diagnosis of the herniated disk syndrome (HDS) has not even yet been recognized then, she should undergo a good program of conservative therapy that would include the appropriate use of NEUROPATHIC TYPES of pain medication (NOT narcotics or simple analgesics), PHYSICAL THERAPY, and AQUATHERAPY.
PLEASE BE AWARE THAT WHAT YOU'VE WRITTEN ABOUT SCHMORL HERNIAS L2 AND L3 could be interpreted as her having SCHMORL NODES and HERNIAS....or are you mistakenly calling a SCHMORL NODE a HERNIA because those are not the same thing....it could be a translation phenomenon.......
No need to worry about tumor or paraneoplastic disease
Detailed Answer:
Thank you for reaching out with your concerns having to do with your fiancee's condition.
I've reviewed all the lab results you've presented and can tell you that in my opinion, there is a STRAIGHT FORWARD and even COMMON explanation to her condition sitting right in the labs and tests you provided. I'll get to that in a second but I also want to make a couple of comments regarding some of the results you've included for review.
I'm not sure I understand why some of these tests were obtained if her PRIMARY COMPLAINT has always been pain and tingling going down her back and legs. I'm not sure who was the first to suggest a possible tumorous growth that hasn't been able to be detected yet but my first instinct with a presentation such as your fiancee has would be to obtain MRI studies and X-RAYS of the lumbosacral spine. The first thing that should be thought of in such a situation is some type of architectural anomaly affecting spinal nerve roots at this level.
I don't understand why full metabolic panels have been obtained to include things such as TESTOSTERONE LEVELS in a female or ULTRASOUND of the PECTORAL MUSCLES which is considered an INAPPROPRIATE use of ULTRASOUND for diagnostic purposes. There is no evidence that ultrasound studies have any capability of detecting musculoskeletal spasms or inflammation. In fact, the evidence is quite the contrary which shows ultrasound is of no value when making such diagnoses.
Also, the documentation of an FT4 level of 17.73 is HIGHLY ELEVATED (though you've not provided the laboratory norms) and in the face of a normal set of vital signs, sounding as if she were not in any ACUTE DISTRESS physically speaking (blood pressure, heart rate) and a normal TSH....this number is highly unlikely. The condition she would have if anything would be HYPERTHYROIDISM of a significant degree NOT Hashimoto's thyroiditis which would require a HYPOTHYROID state to be present where the TSH is very HIGH and the FT4 is very low...or possibly normal.....but not with the numbers you've presented.
Therefore, either the numbers are mistyped on your end, the lab values reported are in error, or something else is up, etc. If I were the physician ordering the study I would repeat it and see how it compares. If it still turns out to be that high with everything else being normal or apparently normal....I would definitely get an endocrinologist involved because then, there's a really odd case of something that may need to be published. At any rate, now to the bottom line of what may be causing your fiancee's problems.
You have stated that an MRI of the lumbar spine shows disc HERNIATION at L2 and L3. I don't know if you mean there are 2 consecutive disks herniated or whether there is a disc herniation at the L2/L3 level. In either case, the symptoms produced from such a condition (PRESSURE BY DISK MATERIAL ON SPINAL NERVES EXITING THE CORD) would be exactly likely to produce the symptoms you are referring in your fiancee which are those of pain and tingling (I'd even expect some numbness in the trajectory of the affected nerve(s)) which goes down the back, wraps around to the front of the thigh through the inguinal or crural region and then, end up still in the leg and sometimes perhaps a little farther down. But your fiancee's fit the description of a herniated disk syndrome. Now, what is causing that compression seems to be (from the description of the scan) an condition of arthritic degeneration such as either narrowing of her lumbar canal, narrowing of the spaces through which the nerves themselves travel, or things such as osteophytes or other calcifications that can develop over time due to amount of exertion of the back, heavy lifting, repetitive standing, bending,etc. There certainly could be a tumor but the MRI doesn't seem to have picked up on anything like that so I wouldn't be concerned about it.
Now, CAUTION. The EMG/NCV study you are presenting doesn't seem to correlate with what the MRI is showing and again, here is where one needs to make a decision. I believe that an EMG/NCV done by a good electromyographer should easily pick up what this would be referred to as a RADICULOPATHY...as opposed to a mild polyneuropathy....So again, either the EMG/NCV study is not being read entirely accurately or the amount of electrical change in nerve function at this point is so minimal that it can't be detected. I doubt the latter is true since she's had the problem for a long time. I might consider either repeating the study or looking for another electromyographer who is a NEUROLOGIST with a subspecialty in electrical musculoskeletal problems because the MRI reading and the symptoms she has, for my tastes are right on.
Another word of caution. The use of surgery in this case PRIOR to trying conservative measures of aggressive physical therapy, aquatherapy, medication, TENS units, possibly TRACTION of the back is not suggested. Surgery should only be reserved for cases where muscle atrophy, muscle weakness, or EXCRUCIATING PAIN that cannot be tolerated any longer (after all other methods have been tried) are present. Since the diagnosis of the herniated disk syndrome (HDS) has not even yet been recognized then, she should undergo a good program of conservative therapy that would include the appropriate use of NEUROPATHIC TYPES of pain medication (NOT narcotics or simple analgesics), PHYSICAL THERAPY, and AQUATHERAPY.
PLEASE BE AWARE THAT WHAT YOU'VE WRITTEN ABOUT SCHMORL HERNIAS L2 AND L3 could be interpreted as her having SCHMORL NODES and HERNIAS....or are you mistakenly calling a SCHMORL NODE a HERNIA because those are not the same thing....it could be a translation phenomenon.......
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you for your answer, I have found it very useful and professional.
Let me follow up on some issues which we have discussed. There is a deficiency on my side regarding medical knowledge and perhaps I did translate some terms incorrectly.
I agree with You completely regarding the lack of necessity of some tests. That is precisely the reason why I have turned to your service for advice and I am very pleased that I did.
I have checked again with my fiancée regarding the thyroid tests and the numbers check out ok. The test was done on the 26th of January this year and the numbers were as I have written. My fiancée says that the numbers were within laboratory norms. The laboratory norms state that 12.0 -22.0 pmol/L is normal for (S) fT4 (ECLIA, Roche). Perhaps it is a different grading system.
Regarding the MRI: This might be a translation phenomenon. In our language the result was called Schmorl Hernia of L2 and L3 spinal cords. I will obtain the MRI scans and send them to You to be sure.
We will repeat the EMG/NCV test as You suggested. I will also send the test to You as a control mechanism in regard to our physician.
In conclusion, from what I gathered it is Your opinion that her condition is caused by a spinal defect of some sorts?
I will send You the EMG/NCV graphs and MRI pictures once I obtain them. I presume that if the MRI test shows Schmorl nodes and not hernias, the answer is quite different? In which way?
Lastly, my fiancée fears that these pains may be caused from some defect in her reproductive organs. From what I have gathered from Your answer this is not a possibility?
What would You suggest should be our next steps?
Let me follow up on some issues which we have discussed. There is a deficiency on my side regarding medical knowledge and perhaps I did translate some terms incorrectly.
I agree with You completely regarding the lack of necessity of some tests. That is precisely the reason why I have turned to your service for advice and I am very pleased that I did.
I have checked again with my fiancée regarding the thyroid tests and the numbers check out ok. The test was done on the 26th of January this year and the numbers were as I have written. My fiancée says that the numbers were within laboratory norms. The laboratory norms state that 12.0 -22.0 pmol/L is normal for (S) fT4 (ECLIA, Roche). Perhaps it is a different grading system.
Regarding the MRI: This might be a translation phenomenon. In our language the result was called Schmorl Hernia of L2 and L3 spinal cords. I will obtain the MRI scans and send them to You to be sure.
We will repeat the EMG/NCV test as You suggested. I will also send the test to You as a control mechanism in regard to our physician.
In conclusion, from what I gathered it is Your opinion that her condition is caused by a spinal defect of some sorts?
I will send You the EMG/NCV graphs and MRI pictures once I obtain them. I presume that if the MRI test shows Schmorl nodes and not hernias, the answer is quite different? In which way?
Lastly, my fiancée fears that these pains may be caused from some defect in her reproductive organs. From what I have gathered from Your answer this is not a possibility?
What would You suggest should be our next steps?
Thank you for your answer, I have found it very useful and professional.
Let me follow up on some issues which we have discussed. There is a deficiency on my side regarding medical knowledge and perhaps I did translate some terms incorrectly.
I agree with You completely regarding the lack of necessity of some tests. That is precisely the reason why I have turned to your service for advice and I am very pleased that I did.
I have checked again with my fiancée regarding the thyroid tests and the numbers check out ok. The test was done on the 26th of January this year and the numbers were as I have written. My fiancée says that the numbers were within laboratory norms. The laboratory norms state that 12.0 -22.0 pmol/L is normal for (S) fT4 (ECLIA, Roche). Perhaps it is a different grading system.
Regarding the MRI: This might be a translation phenomenon. In our language the result was called Schmorl Hernia of L2 and L3 spinal cords. I will obtain the MRI scans and send them to You to be sure.
We will repeat the EMG/NCV test as You suggested. I will also send the test to You as a control mechanism in regard to our physician.
In conclusion, from what I gathered it is Your opinion that her condition is caused by a spinal defect of some sorts?
I will send You the EMG/NCV graphs and MRI pictures once I obtain them. I presume that if the MRI test shows Schmorl nodes and not hernias, the answer is quite different? In which way?
Lastly, my fiancée fears that these pains may be caused from some defect in her reproductive organs. From what I have gathered from Your answer this is not a possibility?
What would You suggest should be our next steps?
Let me follow up on some issues which we have discussed. There is a deficiency on my side regarding medical knowledge and perhaps I did translate some terms incorrectly.
I agree with You completely regarding the lack of necessity of some tests. That is precisely the reason why I have turned to your service for advice and I am very pleased that I did.
I have checked again with my fiancée regarding the thyroid tests and the numbers check out ok. The test was done on the 26th of January this year and the numbers were as I have written. My fiancée says that the numbers were within laboratory norms. The laboratory norms state that 12.0 -22.0 pmol/L is normal for (S) fT4 (ECLIA, Roche). Perhaps it is a different grading system.
Regarding the MRI: This might be a translation phenomenon. In our language the result was called Schmorl Hernia of L2 and L3 spinal cords. I will obtain the MRI scans and send them to You to be sure.
We will repeat the EMG/NCV test as You suggested. I will also send the test to You as a control mechanism in regard to our physician.
In conclusion, from what I gathered it is Your opinion that her condition is caused by a spinal defect of some sorts?
I will send You the EMG/NCV graphs and MRI pictures once I obtain them. I presume that if the MRI test shows Schmorl nodes and not hernias, the answer is quite different? In which way?
Lastly, my fiancée fears that these pains may be caused from some defect in her reproductive organs. From what I have gathered from Your answer this is not a possibility?
What would You suggest should be our next steps?
Brief Answer:
EMG study incomplete for her symptoms and PAINFUL Schmorl Nodes
Detailed Answer:
Good morning.
Many thanks for your clarifications on your vocabulary of SCHMORL HERNIA. This is an interesting term because we actually do not directly refer to them as HERNIAS but rather nodes. They are assumed to be benign entities found in the bone and whenever a radiologist refers to them typically we don't make a big deal out of them. HOWEVER, as it turns out YOUR terminology of Hernia is not a bad description of what is going on after all. There really is and can be quite a bit of PATHOLOGY within and because of a SCHMORL node between 2 vertebral bodies so that fibers of nerve roots can be affected or compressed by way of VERTEBRAL DISC MATERIAL traveling in a vertical direction as opposed to horizontal which is how we usually envision herniated disks to operate. But when there is a SCHMORL node the direction in which disk material is extruded and flows could be up and down such that nerve roots (or at least nerve fibers emanating from the spinal cord that are forming different nerve roots COULD BE AFFECTED.
Schmorl nodes have been operated on and removed resulting in the alleviation of radicular or neuropathic symptoms when it comes to back pain that is radiating to the legs or elsewhere.
Therefore, I still maintain that your fiancee's clinical presentation of back pain with radiation through the "groin" or inguinal/crural region into the thighs and sweeping back around to the posterior aspect of the leg is in an L1, L2, and L3 distribution and with the MRI demonstrating SCHMORL nodes exactly impinging against the L2 and L3 vertebral junctions I am further convinced that radiographically we have evidence highly suggestive of the underlying cause to your fiancee's symptoms. The explanation of the Schmorl NODES/HERNIAS also gives us a rationale for why she feels the tingling sensations when she CHANGES POSITION from standing to lying since the spinal column itself may be placing more pressure and tension against nerve fibers until she moves the column a bit to get into a more comfortable status to FREE up those nerve fibers because of the SCHMORL DEFECT.
I've reread your story now with all of the other tests several times and believe that the funny sensations of tingling that she feels going to her ribcage or upward toward the extremities could be from REVERSE transmission of these spinal nerve roots that are being compressed in the lumbar spine. This is referred to as EPHAPTIC TRANSMISSION and means that electrical impulses (resulting in paresthesias and pain) can travel backward or in the case of the spinal cord UPWARD to distant spinal cord segments that are well removed from the origin of the defect at L2 and L3.
I've looked at a number of dermatomal maps and images (there are many variations of what is considered normal) and you can take a look at the following link to see whether the sensations of the pain and tingling traveling where you've described correspond to the SHADED REGIONS on the map having to do with L2 and L3 which I believe are being affected according to the MRI. I also believe she has involvement of the L1 nerve root which is 1 level above the highest SCHMORL node seen on the MRI due to your description of her symptoms traveling from the back through the hips and groin to the thigh. The hip and groin region are in the territory of L1 even though the MRI may not show anything directly. It's not a perfectly sensitive way to see EVERYTHING that may be going on.
https://classconnection.s3.amazonaws.com/371/flashcards/103371/png/dermatomes_of_lower_limb_2-140BC3E0DB80B3B543D.png
This brings me to the following point. I believe the EMG study that was done was incomplete for the symptoms that she has. I don't know why the electromyographer only seemed to choose the PERONEAL AND TIBIAL nerves to test since these nerves only carry impulses derived from L4-S2/S3 nerve roots. Her symptoms are quite a bit higher than that and don't really involve L4 or below..... Therefore, I'm not surprised that the tester did not find anything. Not only that but I just think they should've tested many more muscles and nerve root areas including the paraspinal muscles in the lower back for abnormalities that they may have found which would indicate nerve root irritation at various levels which could then, support actual pathology at the radiographic levels demonstrated.
Therefore, if you do get an ELECTRICAL STUDY done again, I would probably choose a different electromyographer than the one who did the first one because for some reason he completely missed the boat on her symptoms and tested nerves that had nothing to do with her symptoms. I actually don't even think I would say that there was any type of polyneuropathy present based on the data the tester presented. If you are close enough to an ACADEMIC CENTER of Excellence such as a large teaching hospital or Medical School I believe you will have better luck at locating a well trained and DETAIL ORIENTED person who will want to know the history of your fiancee's symptoms and tailor the exam to support both her complaints as well as the radiographic findings.
So, I want to just be clear with you that even though we say SCHMORL NODE to describe this bony defect found in the skeleton and we do not call it a hernia that for practical purposes it certainly can (under some circumstances) BEHAVE just like a TRADITIONAL HERNIA most people think of when the term is used. The difference being that a HERNIATED disk usually implies the flow or compressive forces of disk material in a HORIZONTAL direction about the vertebral body whereas a SCHMORL node (when it is misbehaving...most are benign and do not cause problems) causes its problems in a VERTICAL DIRECTION between spinal column levels....and this can be HIDDEN to the naked eye when looking at a radiograph since the compression of disk material onto nerve fibers or nerve roots is happening within the vertical substance of the vertebral body.....make sense?
Take a look at this link which demonstrates the darkened areas or defects of disk material pushing UP and into a vertebral body causing deformity in the contour of the bone itself. One could imagine how nerve fibers that are in the vicinity becoming compressed or impinged before they actually exit the vertebral canal itself to form the nerve root which then, travels to the designated dermatome. Make sense?
https://images.radiopaedia.org/images/11059/7398ac2ca766114e598fbc6d858d1d.jpg
And to put the cherry on top of this discussion as to how to TREAT what I believe to be the root of your fiancee's back and leg symptoms (and quite possibly other symptoms traveling ephaptically to the ribcage and the arms) is the conclusion from a study discussing a surgical procedure to relieve PAINFUL SCHMORL NODES.
http://www.info-radiology.com/espace-pro/espace-medecins/vertebroplastie-pro/vertebroplasty-and-schmorl-hernia/
Conclusion
The results of our study showed that painful schmorl node could be successfully treated by a percutaneous vertebroplasty under CT and fluoroscopic guidance with an excellent long-term outcome. The brief hospitalization and the speedy return to active life have very interesting economic and social consequences.
In conclusion, I am not of the opinion that your fiancee suffers from HASHIMOTO's thyroiditis in the least. I'm really not sure which lab tests or clinical symptoms somebody chose to use to come up with that potential diagnosis but I dont' think that should be a consideration in this discussion. I very much believe that the weight of the evidence of her symptoms PLUS the radiograph read are highly suggestive of her suffering from PAINFUL RADICULOPATHY which is caused by SCHMORL NODE defects at the L2 and L3 lumbar levels. The EMG that was performed was incomplete for the clinical presentation and in fact, the nerves chosen to study had very little if anything to do with her clinical presentation. I'll be courteous and professional and stop my critique of the electromyographer right there and let you draw your own conclusion as to whether you wish to return to them or not for any repeat studies.
I believe that a repeat EMG/NCV would be valuable to further support the presence of a radiculopathy which I believe not only involves L2 and L3 nerve roots but I think there is a chance L1 could also be involved though it doesn't appear to show up on the study.
I believe that a confirmatory radiographic study that could be done on your fiancee would be what's called a CT MYELOGRAM which involves the injection of XXXXXXX into the cerebrospinal fluid sac of the spinal cord and will OUTLINE the nerve roots so they can be imaged and analyzed for compression defects or other problems in the lumbar region.
I believe that your fiancee is a prime candidate for CONSERVATIVE, NONSURGICAL TREATMENT of her problem and that every effort should be made to AVOID surgery since other complications leading to chronic and difficult to treat pain may result if there are any problems. There are many useful means of exercise, massage, electrical stimulation, and effective medications that she can benefit from to at least painful sensations before having to undergo any procedures. So PLEASE do not let anybody sway you into believing that SURGERY is the best or only option to try here. I supplied you with the article on the surgical approach to this sort of problem only to let you know such a procedure exists but even the authors agree that it should be used only when other methods and approaches have failed.
I do not believe there is any evidence by way of labs or imaging studies that I've seen or which you have presented which suggest the high possibility of any type of female reproductive organ problem, tumor, or cancerous lesion that is somehow not visible, detectable, or causing any of these problems.
Remember the very true saying that COMMON THINGS ARE COMMON. I don't know how that might translate into your language....but what I mean is that your fiancee is most likely going to have something having to do with the spinal column and spinal nerves causing her symptoms because this is COMMON for her presentation rather than something very UNCOMMON such as a female cancer or other structural lesion that would MIMIC that of a spinal column/nerve root defect. That sort of diagnosis (if true) would be considered VERY VERY UNCOMMON. Make sense?
Next steps?
1. Find a GOOD ELECTROMYOGRAPHER (who is a neurologist- not all are) and make sure they are well informed of her symptoms as you've presented them as well as the radiographic results that demonstrate architectural defects at the L2 and L3 levels. You may even say that at least one other neurologist (myself) has a high degree of suspicion that PAINFUL SCHMORL NODES or Hernias if that the correct term in Croatia are the underlying cause of your fiancee's symptoms.
2. Consider a CT Myelogram for further radiographic confirmation of the MRI finding to see if nerve root compression can be visualized. HOWEVER, do not be disappointed if the scan is NEGATIVE for obvious nerve root defects. It's a SCHMORL node....Many people have the impression that it is NEVER a problem (that's not true) but more than that the anatomic setup of one of these things makes it difficult to fully appreciate the irritation it can cause to nerve fibers running in proximity to where it is breaking the intervertebral disk barrier.
3. The other thing I would also highly recommend (PRIOR TO CT MYELOGRAM STUDY) is that your fiancee's RENAL CLEARANCE be checked (not just a simple BUN and creatinine because I'm sure those are normal). Rather, I'm talking about a calculated value called an eGFR (Estimated Glomerular Filtration Rate). This is something the laboratory will calculate based on information from her blood creatinine levels and other parameters in order to tell approximately how much CREATININE she clears per minute from the kidneys. I suspect she is normal. However, this is a safety test that we do for anybody who is going to receive any type of XXXXXXX injection since the contrast material used can be very toxic to the kidneys if a person is very sensitive and the people who are particularly sensitive are those whose eGFR<60 ml/min/m^2 (see my units?) LOL.....
4. Find a good neurologist who is diligent and knowledgeable about conservative treatments related to her condition of radiculopathy having to do with PAINFUL SCHMORL nodes if that becomes the FINAL DIAGNOSIS. Do not run to the surgeons just yet because there will certainly be someone who will be happy to do a procedure but I think since she's young and not sick in any other way that she should give conservative treatment a fair chance before defaulting to an invasive procedure.
If I've provided useful or helpful information to your questions could you do me the utmost of favors in not forgetting to close the query along with a few POSITIVE words of feedback and maybe even a 5 STAR rating if you feel it is deserving? I am definitely interested in getting updated information on how things are going in the next few weeks if you'd drop me a line at www.bit.ly/drdariushsaghafi
You can always reach me at that address for this or other questions. I wish you the best with everything and hope this information does help you.
This query required 236 minutes of professional time to research, assimilate, and respond in complete form.
EMG study incomplete for her symptoms and PAINFUL Schmorl Nodes
Detailed Answer:
Good morning.
Many thanks for your clarifications on your vocabulary of SCHMORL HERNIA. This is an interesting term because we actually do not directly refer to them as HERNIAS but rather nodes. They are assumed to be benign entities found in the bone and whenever a radiologist refers to them typically we don't make a big deal out of them. HOWEVER, as it turns out YOUR terminology of Hernia is not a bad description of what is going on after all. There really is and can be quite a bit of PATHOLOGY within and because of a SCHMORL node between 2 vertebral bodies so that fibers of nerve roots can be affected or compressed by way of VERTEBRAL DISC MATERIAL traveling in a vertical direction as opposed to horizontal which is how we usually envision herniated disks to operate. But when there is a SCHMORL node the direction in which disk material is extruded and flows could be up and down such that nerve roots (or at least nerve fibers emanating from the spinal cord that are forming different nerve roots COULD BE AFFECTED.
Schmorl nodes have been operated on and removed resulting in the alleviation of radicular or neuropathic symptoms when it comes to back pain that is radiating to the legs or elsewhere.
Therefore, I still maintain that your fiancee's clinical presentation of back pain with radiation through the "groin" or inguinal/crural region into the thighs and sweeping back around to the posterior aspect of the leg is in an L1, L2, and L3 distribution and with the MRI demonstrating SCHMORL nodes exactly impinging against the L2 and L3 vertebral junctions I am further convinced that radiographically we have evidence highly suggestive of the underlying cause to your fiancee's symptoms. The explanation of the Schmorl NODES/HERNIAS also gives us a rationale for why she feels the tingling sensations when she CHANGES POSITION from standing to lying since the spinal column itself may be placing more pressure and tension against nerve fibers until she moves the column a bit to get into a more comfortable status to FREE up those nerve fibers because of the SCHMORL DEFECT.
I've reread your story now with all of the other tests several times and believe that the funny sensations of tingling that she feels going to her ribcage or upward toward the extremities could be from REVERSE transmission of these spinal nerve roots that are being compressed in the lumbar spine. This is referred to as EPHAPTIC TRANSMISSION and means that electrical impulses (resulting in paresthesias and pain) can travel backward or in the case of the spinal cord UPWARD to distant spinal cord segments that are well removed from the origin of the defect at L2 and L3.
I've looked at a number of dermatomal maps and images (there are many variations of what is considered normal) and you can take a look at the following link to see whether the sensations of the pain and tingling traveling where you've described correspond to the SHADED REGIONS on the map having to do with L2 and L3 which I believe are being affected according to the MRI. I also believe she has involvement of the L1 nerve root which is 1 level above the highest SCHMORL node seen on the MRI due to your description of her symptoms traveling from the back through the hips and groin to the thigh. The hip and groin region are in the territory of L1 even though the MRI may not show anything directly. It's not a perfectly sensitive way to see EVERYTHING that may be going on.
https://classconnection.s3.amazonaws.com/371/flashcards/103371/png/dermatomes_of_lower_limb_2-140BC3E0DB80B3B543D.png
This brings me to the following point. I believe the EMG study that was done was incomplete for the symptoms that she has. I don't know why the electromyographer only seemed to choose the PERONEAL AND TIBIAL nerves to test since these nerves only carry impulses derived from L4-S2/S3 nerve roots. Her symptoms are quite a bit higher than that and don't really involve L4 or below..... Therefore, I'm not surprised that the tester did not find anything. Not only that but I just think they should've tested many more muscles and nerve root areas including the paraspinal muscles in the lower back for abnormalities that they may have found which would indicate nerve root irritation at various levels which could then, support actual pathology at the radiographic levels demonstrated.
Therefore, if you do get an ELECTRICAL STUDY done again, I would probably choose a different electromyographer than the one who did the first one because for some reason he completely missed the boat on her symptoms and tested nerves that had nothing to do with her symptoms. I actually don't even think I would say that there was any type of polyneuropathy present based on the data the tester presented. If you are close enough to an ACADEMIC CENTER of Excellence such as a large teaching hospital or Medical School I believe you will have better luck at locating a well trained and DETAIL ORIENTED person who will want to know the history of your fiancee's symptoms and tailor the exam to support both her complaints as well as the radiographic findings.
So, I want to just be clear with you that even though we say SCHMORL NODE to describe this bony defect found in the skeleton and we do not call it a hernia that for practical purposes it certainly can (under some circumstances) BEHAVE just like a TRADITIONAL HERNIA most people think of when the term is used. The difference being that a HERNIATED disk usually implies the flow or compressive forces of disk material in a HORIZONTAL direction about the vertebral body whereas a SCHMORL node (when it is misbehaving...most are benign and do not cause problems) causes its problems in a VERTICAL DIRECTION between spinal column levels....and this can be HIDDEN to the naked eye when looking at a radiograph since the compression of disk material onto nerve fibers or nerve roots is happening within the vertical substance of the vertebral body.....make sense?
Take a look at this link which demonstrates the darkened areas or defects of disk material pushing UP and into a vertebral body causing deformity in the contour of the bone itself. One could imagine how nerve fibers that are in the vicinity becoming compressed or impinged before they actually exit the vertebral canal itself to form the nerve root which then, travels to the designated dermatome. Make sense?
https://images.radiopaedia.org/images/11059/7398ac2ca766114e598fbc6d858d1d.jpg
And to put the cherry on top of this discussion as to how to TREAT what I believe to be the root of your fiancee's back and leg symptoms (and quite possibly other symptoms traveling ephaptically to the ribcage and the arms) is the conclusion from a study discussing a surgical procedure to relieve PAINFUL SCHMORL NODES.
http://www.info-radiology.com/espace-pro/espace-medecins/vertebroplastie-pro/vertebroplasty-and-schmorl-hernia/
Conclusion
The results of our study showed that painful schmorl node could be successfully treated by a percutaneous vertebroplasty under CT and fluoroscopic guidance with an excellent long-term outcome. The brief hospitalization and the speedy return to active life have very interesting economic and social consequences.
In conclusion, I am not of the opinion that your fiancee suffers from HASHIMOTO's thyroiditis in the least. I'm really not sure which lab tests or clinical symptoms somebody chose to use to come up with that potential diagnosis but I dont' think that should be a consideration in this discussion. I very much believe that the weight of the evidence of her symptoms PLUS the radiograph read are highly suggestive of her suffering from PAINFUL RADICULOPATHY which is caused by SCHMORL NODE defects at the L2 and L3 lumbar levels. The EMG that was performed was incomplete for the clinical presentation and in fact, the nerves chosen to study had very little if anything to do with her clinical presentation. I'll be courteous and professional and stop my critique of the electromyographer right there and let you draw your own conclusion as to whether you wish to return to them or not for any repeat studies.
I believe that a repeat EMG/NCV would be valuable to further support the presence of a radiculopathy which I believe not only involves L2 and L3 nerve roots but I think there is a chance L1 could also be involved though it doesn't appear to show up on the study.
I believe that a confirmatory radiographic study that could be done on your fiancee would be what's called a CT MYELOGRAM which involves the injection of XXXXXXX into the cerebrospinal fluid sac of the spinal cord and will OUTLINE the nerve roots so they can be imaged and analyzed for compression defects or other problems in the lumbar region.
I believe that your fiancee is a prime candidate for CONSERVATIVE, NONSURGICAL TREATMENT of her problem and that every effort should be made to AVOID surgery since other complications leading to chronic and difficult to treat pain may result if there are any problems. There are many useful means of exercise, massage, electrical stimulation, and effective medications that she can benefit from to at least painful sensations before having to undergo any procedures. So PLEASE do not let anybody sway you into believing that SURGERY is the best or only option to try here. I supplied you with the article on the surgical approach to this sort of problem only to let you know such a procedure exists but even the authors agree that it should be used only when other methods and approaches have failed.
I do not believe there is any evidence by way of labs or imaging studies that I've seen or which you have presented which suggest the high possibility of any type of female reproductive organ problem, tumor, or cancerous lesion that is somehow not visible, detectable, or causing any of these problems.
Remember the very true saying that COMMON THINGS ARE COMMON. I don't know how that might translate into your language....but what I mean is that your fiancee is most likely going to have something having to do with the spinal column and spinal nerves causing her symptoms because this is COMMON for her presentation rather than something very UNCOMMON such as a female cancer or other structural lesion that would MIMIC that of a spinal column/nerve root defect. That sort of diagnosis (if true) would be considered VERY VERY UNCOMMON. Make sense?
Next steps?
1. Find a GOOD ELECTROMYOGRAPHER (who is a neurologist- not all are) and make sure they are well informed of her symptoms as you've presented them as well as the radiographic results that demonstrate architectural defects at the L2 and L3 levels. You may even say that at least one other neurologist (myself) has a high degree of suspicion that PAINFUL SCHMORL NODES or Hernias if that the correct term in Croatia are the underlying cause of your fiancee's symptoms.
2. Consider a CT Myelogram for further radiographic confirmation of the MRI finding to see if nerve root compression can be visualized. HOWEVER, do not be disappointed if the scan is NEGATIVE for obvious nerve root defects. It's a SCHMORL node....Many people have the impression that it is NEVER a problem (that's not true) but more than that the anatomic setup of one of these things makes it difficult to fully appreciate the irritation it can cause to nerve fibers running in proximity to where it is breaking the intervertebral disk barrier.
3. The other thing I would also highly recommend (PRIOR TO CT MYELOGRAM STUDY) is that your fiancee's RENAL CLEARANCE be checked (not just a simple BUN and creatinine because I'm sure those are normal). Rather, I'm talking about a calculated value called an eGFR (Estimated Glomerular Filtration Rate). This is something the laboratory will calculate based on information from her blood creatinine levels and other parameters in order to tell approximately how much CREATININE she clears per minute from the kidneys. I suspect she is normal. However, this is a safety test that we do for anybody who is going to receive any type of XXXXXXX injection since the contrast material used can be very toxic to the kidneys if a person is very sensitive and the people who are particularly sensitive are those whose eGFR<60 ml/min/m^2 (see my units?) LOL.....
4. Find a good neurologist who is diligent and knowledgeable about conservative treatments related to her condition of radiculopathy having to do with PAINFUL SCHMORL nodes if that becomes the FINAL DIAGNOSIS. Do not run to the surgeons just yet because there will certainly be someone who will be happy to do a procedure but I think since she's young and not sick in any other way that she should give conservative treatment a fair chance before defaulting to an invasive procedure.
If I've provided useful or helpful information to your questions could you do me the utmost of favors in not forgetting to close the query along with a few POSITIVE words of feedback and maybe even a 5 STAR rating if you feel it is deserving? I am definitely interested in getting updated information on how things are going in the next few weeks if you'd drop me a line at www.bit.ly/drdariushsaghafi
You can always reach me at that address for this or other questions. I wish you the best with everything and hope this information does help you.
This query required 236 minutes of professional time to research, assimilate, and respond in complete form.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Brief Answer:
EMG study incomplete for her symptoms and PAINFUL Schmorl Nodes
Detailed Answer:
Good morning.
Many thanks for your clarifications on your vocabulary of SCHMORL HERNIA. This is an interesting term because we actually do not directly refer to them as HERNIAS but rather nodes. They are assumed to be benign entities found in the bone and whenever a radiologist refers to them typically we don't make a big deal out of them. HOWEVER, as it turns out YOUR terminology of Hernia is not a bad description of what is going on after all. There really is and can be quite a bit of PATHOLOGY within and because of a SCHMORL node between 2 vertebral bodies so that fibers of nerve roots can be affected or compressed by way of VERTEBRAL DISC MATERIAL traveling in a vertical direction as opposed to horizontal which is how we usually envision herniated disks to operate. But when there is a SCHMORL node the direction in which disk material is extruded and flows could be up and down such that nerve roots (or at least nerve fibers emanating from the spinal cord that are forming different nerve roots COULD BE AFFECTED.
Schmorl nodes have been operated on and removed resulting in the alleviation of radicular or neuropathic symptoms when it comes to back pain that is radiating to the legs or elsewhere.
Therefore, I still maintain that your fiancee's clinical presentation of back pain with radiation through the "groin" or inguinal/crural region into the thighs and sweeping back around to the posterior aspect of the leg is in an L1, L2, and L3 distribution and with the MRI demonstrating SCHMORL nodes exactly impinging against the L2 and L3 vertebral junctions I am further convinced that radiographically we have evidence highly suggestive of the underlying cause to your fiancee's symptoms. The explanation of the Schmorl NODES/HERNIAS also gives us a rationale for why she feels the tingling sensations when she CHANGES POSITION from standing to lying since the spinal column itself may be placing more pressure and tension against nerve fibers until she moves the column a bit to get into a more comfortable status to FREE up those nerve fibers because of the SCHMORL DEFECT.
I've reread your story now with all of the other tests several times and believe that the funny sensations of tingling that she feels going to her ribcage or upward toward the extremities could be from REVERSE transmission of these spinal nerve roots that are being compressed in the lumbar spine. This is referred to as EPHAPTIC TRANSMISSION and means that electrical impulses (resulting in paresthesias and pain) can travel backward or in the case of the spinal cord UPWARD to distant spinal cord segments that are well removed from the origin of the defect at L2 and L3.
I've looked at a number of dermatomal maps and images (there are many variations of what is considered normal) and you can take a look at the following link to see whether the sensations of the pain and tingling traveling where you've described correspond to the SHADED REGIONS on the map having to do with L2 and L3 which I believe are being affected according to the MRI. I also believe she has involvement of the L1 nerve root which is 1 level above the highest SCHMORL node seen on the MRI due to your description of her symptoms traveling from the back through the hips and groin to the thigh. The hip and groin region are in the territory of L1 even though the MRI may not show anything directly. It's not a perfectly sensitive way to see EVERYTHING that may be going on.
https://classconnection.s3.amazonaws.com/371/flashcards/103371/png/dermatomes_of_lower_limb_2-140BC3E0DB80B3B543D.png
This brings me to the following point. I believe the EMG study that was done was incomplete for the symptoms that she has. I don't know why the electromyographer only seemed to choose the PERONEAL AND TIBIAL nerves to test since these nerves only carry impulses derived from L4-S2/S3 nerve roots. Her symptoms are quite a bit higher than that and don't really involve L4 or below..... Therefore, I'm not surprised that the tester did not find anything. Not only that but I just think they should've tested many more muscles and nerve root areas including the paraspinal muscles in the lower back for abnormalities that they may have found which would indicate nerve root irritation at various levels which could then, support actual pathology at the radiographic levels demonstrated.
Therefore, if you do get an ELECTRICAL STUDY done again, I would probably choose a different electromyographer than the one who did the first one because for some reason he completely missed the boat on her symptoms and tested nerves that had nothing to do with her symptoms. I actually don't even think I would say that there was any type of polyneuropathy present based on the data the tester presented. If you are close enough to an ACADEMIC CENTER of Excellence such as a large teaching hospital or Medical School I believe you will have better luck at locating a well trained and DETAIL ORIENTED person who will want to know the history of your fiancee's symptoms and tailor the exam to support both her complaints as well as the radiographic findings.
So, I want to just be clear with you that even though we say SCHMORL NODE to describe this bony defect found in the skeleton and we do not call it a hernia that for practical purposes it certainly can (under some circumstances) BEHAVE just like a TRADITIONAL HERNIA most people think of when the term is used. The difference being that a HERNIATED disk usually implies the flow or compressive forces of disk material in a HORIZONTAL direction about the vertebral body whereas a SCHMORL node (when it is misbehaving...most are benign and do not cause problems) causes its problems in a VERTICAL DIRECTION between spinal column levels....and this can be HIDDEN to the naked eye when looking at a radiograph since the compression of disk material onto nerve fibers or nerve roots is happening within the vertical substance of the vertebral body.....make sense?
Take a look at this link which demonstrates the darkened areas or defects of disk material pushing UP and into a vertebral body causing deformity in the contour of the bone itself. One could imagine how nerve fibers that are in the vicinity becoming compressed or impinged before they actually exit the vertebral canal itself to form the nerve root which then, travels to the designated dermatome. Make sense?
https://images.radiopaedia.org/images/11059/7398ac2ca766114e598fbc6d858d1d.jpg
And to put the cherry on top of this discussion as to how to TREAT what I believe to be the root of your fiancee's back and leg symptoms (and quite possibly other symptoms traveling ephaptically to the ribcage and the arms) is the conclusion from a study discussing a surgical procedure to relieve PAINFUL SCHMORL NODES.
http://www.info-radiology.com/espace-pro/espace-medecins/vertebroplastie-pro/vertebroplasty-and-schmorl-hernia/
Conclusion
The results of our study showed that painful schmorl node could be successfully treated by a percutaneous vertebroplasty under CT and fluoroscopic guidance with an excellent long-term outcome. The brief hospitalization and the speedy return to active life have very interesting economic and social consequences.
In conclusion, I am not of the opinion that your fiancee suffers from HASHIMOTO's thyroiditis in the least. I'm really not sure which lab tests or clinical symptoms somebody chose to use to come up with that potential diagnosis but I dont' think that should be a consideration in this discussion. I very much believe that the weight of the evidence of her symptoms PLUS the radiograph read are highly suggestive of her suffering from PAINFUL RADICULOPATHY which is caused by SCHMORL NODE defects at the L2 and L3 lumbar levels. The EMG that was performed was incomplete for the clinical presentation and in fact, the nerves chosen to study had very little if anything to do with her clinical presentation. I'll be courteous and professional and stop my critique of the electromyographer right there and let you draw your own conclusion as to whether you wish to return to them or not for any repeat studies.
I believe that a repeat EMG/NCV would be valuable to further support the presence of a radiculopathy which I believe not only involves L2 and L3 nerve roots but I think there is a chance L1 could also be involved though it doesn't appear to show up on the study.
I believe that a confirmatory radiographic study that could be done on your fiancee would be what's called a CT MYELOGRAM which involves the injection of XXXXXXX into the cerebrospinal fluid sac of the spinal cord and will OUTLINE the nerve roots so they can be imaged and analyzed for compression defects or other problems in the lumbar region.
I believe that your fiancee is a prime candidate for CONSERVATIVE, NONSURGICAL TREATMENT of her problem and that every effort should be made to AVOID surgery since other complications leading to chronic and difficult to treat pain may result if there are any problems. There are many useful means of exercise, massage, electrical stimulation, and effective medications that she can benefit from to at least painful sensations before having to undergo any procedures. So PLEASE do not let anybody sway you into believing that SURGERY is the best or only option to try here. I supplied you with the article on the surgical approach to this sort of problem only to let you know such a procedure exists but even the authors agree that it should be used only when other methods and approaches have failed.
I do not believe there is any evidence by way of labs or imaging studies that I've seen or which you have presented which suggest the high possibility of any type of female reproductive organ problem, tumor, or cancerous lesion that is somehow not visible, detectable, or causing any of these problems.
Remember the very true saying that COMMON THINGS ARE COMMON. I don't know how that might translate into your language....but what I mean is that your fiancee is most likely going to have something having to do with the spinal column and spinal nerves causing her symptoms because this is COMMON for her presentation rather than something very UNCOMMON such as a female cancer or other structural lesion that would MIMIC that of a spinal column/nerve root defect. That sort of diagnosis (if true) would be considered VERY VERY UNCOMMON. Make sense?
Next steps?
1. Find a GOOD ELECTROMYOGRAPHER (who is a neurologist- not all are) and make sure they are well informed of her symptoms as you've presented them as well as the radiographic results that demonstrate architectural defects at the L2 and L3 levels. You may even say that at least one other neurologist (myself) has a high degree of suspicion that PAINFUL SCHMORL NODES or Hernias if that the correct term in Croatia are the underlying cause of your fiancee's symptoms.
2. Consider a CT Myelogram for further radiographic confirmation of the MRI finding to see if nerve root compression can be visualized. HOWEVER, do not be disappointed if the scan is NEGATIVE for obvious nerve root defects. It's a SCHMORL node....Many people have the impression that it is NEVER a problem (that's not true) but more than that the anatomic setup of one of these things makes it difficult to fully appreciate the irritation it can cause to nerve fibers running in proximity to where it is breaking the intervertebral disk barrier.
3. The other thing I would also highly recommend (PRIOR TO CT MYELOGRAM STUDY) is that your fiancee's RENAL CLEARANCE be checked (not just a simple BUN and creatinine because I'm sure those are normal). Rather, I'm talking about a calculated value called an eGFR (Estimated Glomerular Filtration Rate). This is something the laboratory will calculate based on information from her blood creatinine levels and other parameters in order to tell approximately how much CREATININE she clears per minute from the kidneys. I suspect she is normal. However, this is a safety test that we do for anybody who is going to receive any type of XXXXXXX injection since the contrast material used can be very toxic to the kidneys if a person is very sensitive and the people who are particularly sensitive are those whose eGFR<60 ml/min/m^2 (see my units?) LOL.....
4. Find a good neurologist who is diligent and knowledgeable about conservative treatments related to her condition of radiculopathy having to do with PAINFUL SCHMORL nodes if that becomes the FINAL DIAGNOSIS. Do not run to the surgeons just yet because there will certainly be someone who will be happy to do a procedure but I think since she's young and not sick in any other way that she should give conservative treatment a fair chance before defaulting to an invasive procedure.
If I've provided useful or helpful information to your questions could you do me the utmost of favors in not forgetting to close the query along with a few POSITIVE words of feedback and maybe even a 5 STAR rating if you feel it is deserving? I am definitely interested in getting updated information on how things are going in the next few weeks if you'd drop me a line at www.bit.ly/drdariushsaghafi
You can always reach me at that address for this or other questions. I wish you the best with everything and hope this information does help you.
This query required 236 minutes of professional time to research, assimilate, and respond in complete form.
EMG study incomplete for her symptoms and PAINFUL Schmorl Nodes
Detailed Answer:
Good morning.
Many thanks for your clarifications on your vocabulary of SCHMORL HERNIA. This is an interesting term because we actually do not directly refer to them as HERNIAS but rather nodes. They are assumed to be benign entities found in the bone and whenever a radiologist refers to them typically we don't make a big deal out of them. HOWEVER, as it turns out YOUR terminology of Hernia is not a bad description of what is going on after all. There really is and can be quite a bit of PATHOLOGY within and because of a SCHMORL node between 2 vertebral bodies so that fibers of nerve roots can be affected or compressed by way of VERTEBRAL DISC MATERIAL traveling in a vertical direction as opposed to horizontal which is how we usually envision herniated disks to operate. But when there is a SCHMORL node the direction in which disk material is extruded and flows could be up and down such that nerve roots (or at least nerve fibers emanating from the spinal cord that are forming different nerve roots COULD BE AFFECTED.
Schmorl nodes have been operated on and removed resulting in the alleviation of radicular or neuropathic symptoms when it comes to back pain that is radiating to the legs or elsewhere.
Therefore, I still maintain that your fiancee's clinical presentation of back pain with radiation through the "groin" or inguinal/crural region into the thighs and sweeping back around to the posterior aspect of the leg is in an L1, L2, and L3 distribution and with the MRI demonstrating SCHMORL nodes exactly impinging against the L2 and L3 vertebral junctions I am further convinced that radiographically we have evidence highly suggestive of the underlying cause to your fiancee's symptoms. The explanation of the Schmorl NODES/HERNIAS also gives us a rationale for why she feels the tingling sensations when she CHANGES POSITION from standing to lying since the spinal column itself may be placing more pressure and tension against nerve fibers until she moves the column a bit to get into a more comfortable status to FREE up those nerve fibers because of the SCHMORL DEFECT.
I've reread your story now with all of the other tests several times and believe that the funny sensations of tingling that she feels going to her ribcage or upward toward the extremities could be from REVERSE transmission of these spinal nerve roots that are being compressed in the lumbar spine. This is referred to as EPHAPTIC TRANSMISSION and means that electrical impulses (resulting in paresthesias and pain) can travel backward or in the case of the spinal cord UPWARD to distant spinal cord segments that are well removed from the origin of the defect at L2 and L3.
I've looked at a number of dermatomal maps and images (there are many variations of what is considered normal) and you can take a look at the following link to see whether the sensations of the pain and tingling traveling where you've described correspond to the SHADED REGIONS on the map having to do with L2 and L3 which I believe are being affected according to the MRI. I also believe she has involvement of the L1 nerve root which is 1 level above the highest SCHMORL node seen on the MRI due to your description of her symptoms traveling from the back through the hips and groin to the thigh. The hip and groin region are in the territory of L1 even though the MRI may not show anything directly. It's not a perfectly sensitive way to see EVERYTHING that may be going on.
https://classconnection.s3.amazonaws.com/371/flashcards/103371/png/dermatomes_of_lower_limb_2-140BC3E0DB80B3B543D.png
This brings me to the following point. I believe the EMG study that was done was incomplete for the symptoms that she has. I don't know why the electromyographer only seemed to choose the PERONEAL AND TIBIAL nerves to test since these nerves only carry impulses derived from L4-S2/S3 nerve roots. Her symptoms are quite a bit higher than that and don't really involve L4 or below..... Therefore, I'm not surprised that the tester did not find anything. Not only that but I just think they should've tested many more muscles and nerve root areas including the paraspinal muscles in the lower back for abnormalities that they may have found which would indicate nerve root irritation at various levels which could then, support actual pathology at the radiographic levels demonstrated.
Therefore, if you do get an ELECTRICAL STUDY done again, I would probably choose a different electromyographer than the one who did the first one because for some reason he completely missed the boat on her symptoms and tested nerves that had nothing to do with her symptoms. I actually don't even think I would say that there was any type of polyneuropathy present based on the data the tester presented. If you are close enough to an ACADEMIC CENTER of Excellence such as a large teaching hospital or Medical School I believe you will have better luck at locating a well trained and DETAIL ORIENTED person who will want to know the history of your fiancee's symptoms and tailor the exam to support both her complaints as well as the radiographic findings.
So, I want to just be clear with you that even though we say SCHMORL NODE to describe this bony defect found in the skeleton and we do not call it a hernia that for practical purposes it certainly can (under some circumstances) BEHAVE just like a TRADITIONAL HERNIA most people think of when the term is used. The difference being that a HERNIATED disk usually implies the flow or compressive forces of disk material in a HORIZONTAL direction about the vertebral body whereas a SCHMORL node (when it is misbehaving...most are benign and do not cause problems) causes its problems in a VERTICAL DIRECTION between spinal column levels....and this can be HIDDEN to the naked eye when looking at a radiograph since the compression of disk material onto nerve fibers or nerve roots is happening within the vertical substance of the vertebral body.....make sense?
Take a look at this link which demonstrates the darkened areas or defects of disk material pushing UP and into a vertebral body causing deformity in the contour of the bone itself. One could imagine how nerve fibers that are in the vicinity becoming compressed or impinged before they actually exit the vertebral canal itself to form the nerve root which then, travels to the designated dermatome. Make sense?
https://images.radiopaedia.org/images/11059/7398ac2ca766114e598fbc6d858d1d.jpg
And to put the cherry on top of this discussion as to how to TREAT what I believe to be the root of your fiancee's back and leg symptoms (and quite possibly other symptoms traveling ephaptically to the ribcage and the arms) is the conclusion from a study discussing a surgical procedure to relieve PAINFUL SCHMORL NODES.
http://www.info-radiology.com/espace-pro/espace-medecins/vertebroplastie-pro/vertebroplasty-and-schmorl-hernia/
Conclusion
The results of our study showed that painful schmorl node could be successfully treated by a percutaneous vertebroplasty under CT and fluoroscopic guidance with an excellent long-term outcome. The brief hospitalization and the speedy return to active life have very interesting economic and social consequences.
In conclusion, I am not of the opinion that your fiancee suffers from HASHIMOTO's thyroiditis in the least. I'm really not sure which lab tests or clinical symptoms somebody chose to use to come up with that potential diagnosis but I dont' think that should be a consideration in this discussion. I very much believe that the weight of the evidence of her symptoms PLUS the radiograph read are highly suggestive of her suffering from PAINFUL RADICULOPATHY which is caused by SCHMORL NODE defects at the L2 and L3 lumbar levels. The EMG that was performed was incomplete for the clinical presentation and in fact, the nerves chosen to study had very little if anything to do with her clinical presentation. I'll be courteous and professional and stop my critique of the electromyographer right there and let you draw your own conclusion as to whether you wish to return to them or not for any repeat studies.
I believe that a repeat EMG/NCV would be valuable to further support the presence of a radiculopathy which I believe not only involves L2 and L3 nerve roots but I think there is a chance L1 could also be involved though it doesn't appear to show up on the study.
I believe that a confirmatory radiographic study that could be done on your fiancee would be what's called a CT MYELOGRAM which involves the injection of XXXXXXX into the cerebrospinal fluid sac of the spinal cord and will OUTLINE the nerve roots so they can be imaged and analyzed for compression defects or other problems in the lumbar region.
I believe that your fiancee is a prime candidate for CONSERVATIVE, NONSURGICAL TREATMENT of her problem and that every effort should be made to AVOID surgery since other complications leading to chronic and difficult to treat pain may result if there are any problems. There are many useful means of exercise, massage, electrical stimulation, and effective medications that she can benefit from to at least painful sensations before having to undergo any procedures. So PLEASE do not let anybody sway you into believing that SURGERY is the best or only option to try here. I supplied you with the article on the surgical approach to this sort of problem only to let you know such a procedure exists but even the authors agree that it should be used only when other methods and approaches have failed.
I do not believe there is any evidence by way of labs or imaging studies that I've seen or which you have presented which suggest the high possibility of any type of female reproductive organ problem, tumor, or cancerous lesion that is somehow not visible, detectable, or causing any of these problems.
Remember the very true saying that COMMON THINGS ARE COMMON. I don't know how that might translate into your language....but what I mean is that your fiancee is most likely going to have something having to do with the spinal column and spinal nerves causing her symptoms because this is COMMON for her presentation rather than something very UNCOMMON such as a female cancer or other structural lesion that would MIMIC that of a spinal column/nerve root defect. That sort of diagnosis (if true) would be considered VERY VERY UNCOMMON. Make sense?
Next steps?
1. Find a GOOD ELECTROMYOGRAPHER (who is a neurologist- not all are) and make sure they are well informed of her symptoms as you've presented them as well as the radiographic results that demonstrate architectural defects at the L2 and L3 levels. You may even say that at least one other neurologist (myself) has a high degree of suspicion that PAINFUL SCHMORL NODES or Hernias if that the correct term in Croatia are the underlying cause of your fiancee's symptoms.
2. Consider a CT Myelogram for further radiographic confirmation of the MRI finding to see if nerve root compression can be visualized. HOWEVER, do not be disappointed if the scan is NEGATIVE for obvious nerve root defects. It's a SCHMORL node....Many people have the impression that it is NEVER a problem (that's not true) but more than that the anatomic setup of one of these things makes it difficult to fully appreciate the irritation it can cause to nerve fibers running in proximity to where it is breaking the intervertebral disk barrier.
3. The other thing I would also highly recommend (PRIOR TO CT MYELOGRAM STUDY) is that your fiancee's RENAL CLEARANCE be checked (not just a simple BUN and creatinine because I'm sure those are normal). Rather, I'm talking about a calculated value called an eGFR (Estimated Glomerular Filtration Rate). This is something the laboratory will calculate based on information from her blood creatinine levels and other parameters in order to tell approximately how much CREATININE she clears per minute from the kidneys. I suspect she is normal. However, this is a safety test that we do for anybody who is going to receive any type of XXXXXXX injection since the contrast material used can be very toxic to the kidneys if a person is very sensitive and the people who are particularly sensitive are those whose eGFR<60 ml/min/m^2 (see my units?) LOL.....
4. Find a good neurologist who is diligent and knowledgeable about conservative treatments related to her condition of radiculopathy having to do with PAINFUL SCHMORL nodes if that becomes the FINAL DIAGNOSIS. Do not run to the surgeons just yet because there will certainly be someone who will be happy to do a procedure but I think since she's young and not sick in any other way that she should give conservative treatment a fair chance before defaulting to an invasive procedure.
If I've provided useful or helpful information to your questions could you do me the utmost of favors in not forgetting to close the query along with a few POSITIVE words of feedback and maybe even a 5 STAR rating if you feel it is deserving? I am definitely interested in getting updated information on how things are going in the next few weeks if you'd drop me a line at www.bit.ly/drdariushsaghafi
You can always reach me at that address for this or other questions. I wish you the best with everything and hope this information does help you.
This query required 236 minutes of professional time to research, assimilate, and respond in complete form.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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