Reading My Own Low Back MRI: What the Findings Meant

Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, everyone. It's Dr. Sebastian Gonzales again. Performance Place Sports Care Podcast is where you're at. And today, we have a really, really special podcast. And I am using myself as a subject. There's no write-in. There's no review of any questions that anyone sent in. But, you know, I've realized over the past, you know, year or so, that people really, really freak out when they get an image report. And whether it be x-ray or MRI or ultrasound or bone scan or whatever it is, they freak out because of the complexity of the words.

So, because of that, I'm going to go through a MRI that I had done back when I hurt my back in high school. And I actually hadn't looked at this in a while. But it's kind of interesting to see that. I remember that we didn't have any idea of what this stuff was. You know, I was only 16 at the time. You know, my mom didn't have a background in medical at all. You know, my dad knows some stuff, but it's not really his expertise. But we really had no idea what was going to help me because I felt like it was really, really bad. And I mean, I was in a lot of pain. And we got this imaging done. And it's, we had no idea what it said. And I see, I hear that a lot from people. And especially when I do ultrasounds at work, I remember that there was quite a few people where I said, look, the image shows, you know, X, Y, and Z. It's, I explained it in very, very easy terminology. I assured them it's not a big deal. You know, it's relatively negative, but here's some stuff that we found. Just nice to know. So I said, I'm going to send you the report a little bit later when we get it all done.

Because it might have some jargon on it that you don't understand. But unless I say otherwise on the email, just assume it's all the same. So naturally, a lot of them, I mean, pretty much everybody reads the report. And they're looking at it. And they're like, you know, I really want to ask you some questions. So, you know, the questions come flying. And, you know, rightly so, because they, they're looking at this report. They have no idea what it says. You know, and they ask about, they're asking about actually very basic terminology. And stuff on imaging, there really isn't that big of a deal. I mean, sure, there's, there's findings there. But is it correlated to your actual condition at all? Because it might not be.

Sorry, I'm going to clear my throat a little bit on this podcast. I believe I have a little bit of a congestion. So I apologize at events. Okay, so I'm just going to go through this. This is some notes that my mom took. She took them. She was a really good note taker of my medical history. So I have a bunch of stuff in there. I should probably go over the other stuff in a different podcast to come. But this was in regards to the back anyways. So this had been, I'm just going to read this verbatim. So Sebastian had been seen, or Sebastian is seen in follow-up. Actually, sorry, this is the doctor's notes. His, he notes that he's been in, he notes he has had a four to five months history of severe low back pain.

It has got, it started when he was playing baseball and it has continued. It got better for a while. It has gotten worse. Yesterday was the final straw when he swung a bat, felt a pop and couldn't move. The pain is localized around the low back. Does not go into the buttocks, thighs, legs, or feet. He has no numbness or tingling. By the way, I will go back and redigest some of these words with you guys to make sure you understand them as well. So here we go again. The exam reveals that he has localized tenderness over the sacroiliac area on both sides, as well as in the lumbar transverse process on both sides, increase with flexion and extension of the spine.

Plain radiographs, which are experts, by the way, are unremarkable. I am concerned he has a possible fracture of the pars or of the spinous process. Recommended that he will be evaluated with a bone scan. We will obtain this and proceed accordingly depending upon what it shows. He will go on Motrin 800 mg. He may also obtain a lumbar MRI. So, before we go too much into the actual MRI findings, and by the way, I'm not going to go to the bone scan because the bone scan is, it won't really prove the point that I want to make sure that you guys get today. But for the most part, I know the bone scan was negative.

But when we go through this history right here, so first just realize how bad this hurt. It's a severe discomfort. And I don't even, I remember it hurting really bad, but I don't remember that it hurt with flexion and extension, which is bending forward and bending backwards. But apparently it did. And I know now that if I were to see someone like this, of this age, I too would be suspicious of a fracture. And I'm really glad that the MD that I saw for this was looking for that. Because I've actually found people in my clinic who, they're of this age, they're of the same sport, they play baseball or they're a rotational athlete, and they have not been checked for a fracture.

And the rough stats are about 50% of low back pain cases for kids in high school could be fractures. And we really need to check them for that. So I'm glad that they checked this. So in case you're wondering if you have a young child or you're young, and you're being recommended to go for all this imaging, it's important. It's really important. And I've actually recommended a few kids in my clinic go get a bone scan and an MRI to evaluate something like this. And they're like, well, we've already done x-rays. Actually, the parents are. Well, they're like, well, we've already done x-rays. And I'm like, yeah, I get it.

You've done x-rays. But x-rays won't show everything. And you need to make sure that you're following through with recommendations, as I did in this case. And it was negative. It ended up being negative because I didn't have a fracture, which is great. But if I had had a fracture, the recommendation for treatment would have been completely different. Now, going through this a little bit further, I see that I do actually remember when I was swinging the bat. It was at a, I think it was a summer league game, and I was lead off batter. So I remember swinging the bat one time and felt that pop and just howled on back to the dugout.

And from what I recall is so that if you only have one strike, you can sub out a batter. So that's what they did for me. Two strikes, though, I think you have to keep going with that bat. But I couldn't move after that. It was horrible. It was horrible pain. And I've met a lot of people coming to my clinic who are in this amount of pain. And I'm really, really concerned with what they have. And when we go through the MRI, you'll see that what I had is really not that much. But it does show that people can be in pain without having positive MRI or imaging findings. So let's see. The pain was localized across the low back.

It didn't go into the butt, which is obviously the buttocks area. The thighs, which is the thighs is going to be above the knee, below the hip. The legs are below the knee, above the ankle. And the feet are obviously the feet. The reason I say that is because when we say legs, generally, when the general public says legs, they mean the entire leg. Anatomic of the leg is actually the calf shin area. So I didn't have any numbness or tingling into that area, which is a great sign. Because if I did, then we'd be looking at a possible disc injury. But it looked like they were possibly thinking of a disc injury anyways or a fracture.

So I already liked the assessment of this doc. I think it was going on the right route of it. So now, going back into what I just said, the location. So the exam reveals that I had localized tenderness over the sacroiliac area. The sacroiliac area, in case you don't know, is the area where if you see someone's back without their shirt off, and usually thinner people will have this, but they have those dimples on their back. That is actually the top part of the sacroiliac joint. And the sacroiliac joint, if we're going to break this down into parts, the sacro means sacrum. So the sacrum is kind of like the cornerstone bone that's just below where the spine ends and above the tailbone.

The iliac refers to iliac or the ilium. The ilium is a bone of the pelvis. There's two of them, one on each side. And if you're going to put your hands on your hips like you're kind of irritated, that crest you feel, that's part of the ilium. So it looks like I had tenderness over there, as well as some in the lumbar spine or low back. Transverse process area, which what they meant is basically it's on the sides of that spine, that hard spot you probably feel. The middle line of the spine is called the spinous process region. The sides would be the transverse process region, but the transverse process is actually a section of a vertebra.

And every vertebra has one. But there's the transverse process and spinous process of the spine. They're attachment points for muscles and tendons. So there's a lot that could be going on in this area. There could be the paraspinalis muscles or the muscles along the spine, which are irritated. There could be the deeper ones, the rotatories or the stabilizer groups. But there could be a lot of stuff. But I'm really, really glad that he checked out for a fracture. But the interesting thing is that I was in pain with flexion and extension. So usually, so if you've listened to one of my other podcasts on, it was on disc injuries, I believe, or low back pain and how to figure out which type of condition you are.

It was on flexion and extension tolerance. And usually, flexion tolerance means that you can bend forward, you can tie your shoes, you can touch your toes, and all that kind of stuff makes you feel better. Even putting your knees to your chest makes you feel better. And this is usually with cases like, say, a facet syndrome or some type of what we call posterior aspect of the spine or backside of the spine, the backside of the vertebra part, which can be compressed. This is one type of rehab. So again, I didn't have, I had pain with bending forward, so possibly it's the other. And apparently, it's not because I was painful in both directions.

And usually, if you're painful in flexion, it would be a possible disc injury or some type of nerve root entrapment. Usually, these types of people would be very, very tolerant or feel better when you have them go face down and kind of push their hands on the ground and to like a cobra position. If you want to look up exercises about this, there's McKinsey Protocol, which is going to be a whole bunch of references on YouTube. I actually do have some on the P2 SportsCare site as well under low back pain on one of the, or at least it's going to be under the baseball player model. So now let's go into the MRI.

And this might take me a second because I have to find it on the computer in front of me. But here's the MRI. Cool. So this MRI was taken. It looked like they were possibly looking for a, this is possible, HNP, which is herniated nucleus propulsors, which is basically a disc injury. A disc, in case you don't know, is like a jelly donut. The jelly wants, we want the jelly to remain within the center, and if it pops out to the side, then it would be herniated. And there's different grades of disc injuries. I won't go into that too much because I don't want a tangent too much. We'll probably do a whole other podcast on it.

So here's, I'll just read parts of this verbatim. Actually, you know, I'll do sections first just to make sure you understand what these parts are before I go into the actual finding. So there's different levels of the spine. And usually within an, sorry, usually within an MRI we'd look at, so there's the exam date, which is nice to find because you know when it's done. You look at the technique or the strength of the machine, and this was a T1, or sorry, there's different strengths in the machine. I won't go into that too much, but they've gotten better machines over the years. But you want to make sure you have a good machine with a high intensity magnet because you want to make sure you get a very good image quality.

I've seen some very, very bad MRIs before, and I've seen some very, very good ones, and they look very, very different. So let's go into finding because that's the important part. So the first line says, the vertebral alignment and bone marrow signals are preserved. Basically, this looks normal. Vertebral means vertebra, which means kind of the spine. Alignment means, is it all in a line? Bone marrow is, it's almost, it's, so it's the inner portions of the bone. Bone marrow is, I mean, think about eating like a bone marrow burger. It's the inner portions of these long bones a lot of times to take them out of in, when you're eating, when you're eating the bone marrow.

But within more cubicle types of bones like this, they are, they're more condensed. So the next thing we have to see is that the, there's different levels on an MRI that we're looking at. So in a lumbar spine MRI, we're looking at the levels of the lumbar spine. So there's five of them. So there's one, two, three, four, five, six, or one, two, three, four, five. Okay. You also look at S1. But usually they're noted within sections. So there's L1, L2, L2, L3, L3, L3, L4, L4, L5, L5. Okay. So I'll read the findings. All the findings were, were the same for L1 through L5. So there's no evidence of disbolts, protrusion, or extrusion.

There's no evidence of central canal, lateral recess, or neural foraminal stenosis. And the facet joints appear normal. So the first thing that I'm seeing on this is that they've been looking for a disc injury. Bolts, protrusion, and extrusion are all different grades of disc injuries. And if they had positive on any of these, they would probably measure it, which they will when we get to the actual finding. And they would probably say the grade, whether it's bolts, protruded, or extruded, which is kind of slipping all the way out. The next is, since I was 16, a lot of this is going to be fairly normal looking, by the way.

A lot of these will be, there'll be findings all over the place on someone who's a little bit older. And I'm sure that if I had an MRI now, these would be much more significant findings. So the next part is that there's no evidence of central, lateral, recess, or neural foraminal stenosis. So stenosis is actually an interesting concept. It's a, I've explained it many times over the years, and it's a narrowing. So stenosis is, imagine, so I want you to put, put a, put your hand almost like an O shape, and look through it. Just put it all the way up to your eye, like you're looking through a scope, and you're trying to, you know, shoot an object down the way.

That is one hole. Okay? Make the other hand do the same thing, put it around the top of it so you can see through both of them. So that is two sections of a hole, let's just say the central canal, that are nicely lined up, and they're not narrowed at all. Now if you squeeze your fingers, squeeze your hands together like you're, you're, like you're increasing the strength of the fist, the hole gets narrower. And it doesn't matter which one you narrow, or it doesn't matter which one you squeeze and contract, the, the overall canal decreases its size. And this is what happens in stenosis. So stenosis can happen from a few things.

It could be from a ligament increasing in size. It could be from bones increasing in size. It could be from a space occupying lesion or a tumor. It could be from a lot of things. So stenosis is mainly the, it is the decrease in size of the hole, because there are things that go through this hole, through these holes, which is the important part. And, uh, so, uh, neural, or sorry, uh, foraminal stenosis is the holes in the sides of the spine, which the little nerves come out of central canals, where the major spinal cord goes through. So both of these, you kind of want to have free of stenosis or narrowing, but, you know, if you do have stenosis, there's different grades of it as well.

There's, I mean, mild, moderate, severe. These aren't always significant. And you're going to find them all over the place on people who feel awesome. They might not have any pain whatsoever, but it's important to realize that these could be incidental findings because they're very scary, um, terms. And, uh, also arthritis is a scary term for a lot of people as well, but you're going to find arthritis all over the place in these images that are not pain generators. So now getting down to the actual finding, um, there's an L5, the L5 S1 is, is the level. So there's a two millimeter central disc protrusion.

The disc space is well maintained. There's no evidence of central or foraminal stenosis. Okay. So two millimeters, number one, it sounds like it's a good size, but it's really kind of small. Um, two millimeters, it's, it's interesting. I have a guy that's been coming in to see me who has two millimeters all up and down his spine here, um, in this region, in the low back. And he feels terrible, feels absolutely terrible. And he's had it for many, many years and he's about my age, surprisingly, actually about 35. So this two millimeter central disc protrusion, I'm sure I still have it. I haven't been pain, been pain in like 18 years now.

I mean, there's been minor incidences here and there, like, you know, the back feeling a little tight and so on, but I've done a lot of things too. You know, I can clean 200 pounds. I can deadlift 300 easily. Um, there's a lot of things I can squat a bunch of weight as well. I play baseball every weekend. I've run triathlons. I still run. I mean, I, I don't shy away from doing housework or even putting in home improvement projects. All this stuff is okay on this two millimeter herniation. But at this point, do, do you think that this herniation was my pain generator or not? Cause I probably still have it.

Okay. So I don't know the answer either, but the, I know the two millimeter, two millimeter herniation or small size herniations, even medium sized ones. I've seen a lot of people who do not have pain. So I still wonder this day is this, was this two millimeter herniation, my pain generator or not? Cause perhaps it was other things. Perhaps it was the muscles that got irritated around it because I remember how I did it. I was running the first base, my lead leg, I was between steps and I was trying to beat out a ball. And I just impacted the base on the front edge and it jolted all the way up into my back.

And for all we know, it was a muscle, but perhaps it created this disc herniation. Who knows? Cause I didn't have an image beforehand. But one thing is for sure though, it's, it's nice to see that the, um, there's no evidence of stenosis or impingement on a nerve root. And I've seen a couple of interesting MRIs over the years. And it always surprised me when this happens and someone has like, say they have right side of the leg pain, um, you know, into their foot, into their calf, all this type of jazz. And so we said right sided. We look at an MRI and look, we see there's a disc herniation, but there is impingement on the left nerve root.

So it's clearly the other side. So is it important to really address that? Probably not. You know, I don't see, if it was on the right side, I'd say is correlated to their condition. Possibly. And that's why in a lot of times on these images, you'll see at the very end of the impression, they'll tell you what's going on. And they'll say, how do you correlate with, uh, with, uh, with how, how they're presenting in the clinical setting? You know, if they don't complain of it, or if they don't complain of a condition, which looks like it can be correlated to this finding, then does it matter? Or does it matter immediately anyways?

Because I mean, it can eventually be a condition that left sided nerve root impingement. Not that I have, but someone else had. Sure. They can have an issue later, but who's to say that right sided nerve pain or shooting pain into the leg wasn't from a peripheral nerve entrapment, from maybe a piriformis syndrome. Maybe the sciatic nerve was entrapment within the hamstrings. Maybe it was actually a calf condition. Who knows? You know, but a lot of times people bank their opinion on what they find on this MRI and it's not always great. Um, so anyways, that was my MRI and, um, I remember doing that thing after, after about, I want to say about three to four months of, of physical therapy.

Um, we did a little bit of, we did foam rolling. We did stretching. We did ice, heat, um, massage. I had some chiropractic work. Um, I remember we were doing some strength training of the backside. Um, and it was, it was really interesting during that period of time that I wasn't. I mean, I wasn't in pain for, I mean, I felt good. That's why I went back to play again, but I also wasn't playing, you know, that rotational sport of baseball, the rapid swinging of the bat. It was never really challenged. And I actually don't remember doing any rotational challenges either. Cause if I'm a baseball player and I'm going to be rotating, I need to be able to protect rotation.

So, um, I need to be trained in rotation. Um, so that was probably a missing part. I'm not saying the PT didn't work, but I think there was something that was a little lacking. Um, something, what, what came on later when I eventually got, um, a treatment which stuck is I had, um, a, a tissue work called active release done. So, um, it was really, it was really, really painful at the time. Um, I had it done a couple of times a week. I felt really good actually. Decreased the muscle spasm. I was able to move without pain. Um, and I was able to start throwing again. I wasn't able to hit and play full speed, but I, I was able to really play quickly.

It was really surprising. Um, but something I've actually was reminded of today and I don't speak about a lot was the fact that I not only got, you know, treatment. I got, actually, I got STEM there or, uh, you know, like a TENS unit type of thing. Um, I got adjustments. I got active release or the deep tissue work, but man, I, I was, they were rehabbing and strength training the heck out of me. And I remember at the time I had a stick shift car, I was driving all the way out, you know, about 30 minutes away to, to go to this place. And by the time I left, I could barely get my foot off the clutch because my leg was shaking so much, you know?

Um, I mean, it'd been really nice to have an automatic car at that time, but I mean, they rehabbed the heck out of me. And at one point I actually ended up taking creatine too, um, which helped out with some of my muscular gains at the time. So I think what happened was that he got me out of pain and he was able to strength train around that area. And they were machine-based strength training protocols. I do remember that. And you can see, I wish I would have, you know, had some forethought, uh, and really documented my progress throughout with that whole thing. But I mean, I was 16, 17 at the time.

It was really hard to, you know, do it or even think it was going to be important. But I really wish I had now the way I did with that oblique strain. Um, but they strength trained the heck out of me. And it was for about three months that I did that. And I slowly started to taper off because season came and I played fine, didn't have any issues or so on. But I mean, it's been like 18 years and I still continue to lift now. I have my spurts where I go on and off, but every, about three times a week. I mean, I lift, I squat, I deadlift. I press and pull three times a week. And that's for about 30 to 45 minutes.

Ideally, sometimes I only get about 15 minutes in. But if I can do it effectively, I just do it effectively. And the reason I'm bringing this up now is because when I have people to come in, they come in and they want to feel better. They feel better. They do a little rehab, then they stop strengthening. And they go on and play their, you know, relative sport. Um, if they're not a high school or college athlete, they might be, let's just say like, you know, they like cycling on the weekend. Cool. You like cycling. Great. But it doesn't mean you're excluded from strength training for the rest of your life.

Okay. I've been strength training and eating well, or actually, sorry, I've only been strength training now for 18 years. I've been eating well, probably for the past two, three years or much better. I actually grew up on fast food. Um, but you really need to give your body the right type of food and nutrients to let it repair itself. You know, I get proper sleep. I drink a bunch of water and I'm response. I'm trying to be responsible with my body. Okay. And the way I mean that is that if I'm training for baseball, which actually I was asked to play winter season this year, um, I didn't play. And the reason is because I want this time of year to strength train myself and get myself ready for the new season.

Okay. There's on and off season. And the same thing goes for endurance sports like biking and running and triathlons and so on. Okay. If you're going to do that sport, do it responsibly and treatments are awesome. Decreasing pain is awesome. And this MRI shows that I have two millimeter bulge. Is it not my responsibility to strengthen around it and protect it? If I'm going to do baseball, if I'm going to continue playing baseball and running and biking and doing triathlons. Yeah, it is. Okay. I'm not going to be the one who goes into someone's office and say, Hey, look, you know, I felt better when I left and I've been doing a little bit of rehab and stretching, but I started biking.

I know it's been three, four months. Hey, it hurts again. No, you keep doing the things that strengthen around it. That's just the way it goes. Make it a lifestyle change. And I guess I'm getting preachy on this now, but I, I really get, I think about all the, the effort that I put in to make myself feel good over the years. And to make it so my back doesn't re-aggravate and my hamstrings don't re-tear and so on. And it takes a lot of responsibility. So I would really, really challenge you guys to be responsible with your body and strengthen around it as much as you possibly can. Thanks for listening, everybody.

I want to close out here by letting you know that you can get in contact with me at p2sportscare.com. That is where I have a button where you can actually leave me a voicemail for the podcast and you can get your question featured. I strongly suggest leave as much detail as you possibly can. You know, calling in and saying my pinky toe hurts and the hanging up is not going to let me give a lot to talk about. And it's not going to give me a lot of, give the, the listeners, the other listeners or you guys to, you're not going to give a lot of information about the case either. So, um, leave as much detail as you possibly can.

And if you're looking to take part in our online, uh, online, uh, rehab courses, ideally it's supposed to be educational because I'm not allowed to quote unquote recommend, um, for people that I haven't seen yet. But if you understand the stuff, it's, it's going to be really, really good for you. Um, or quote unquote, it's gonna be good for you to learn, uh, for your, for your actual or for an, for an actual injury. So, uh, currently we have those up on p2sportscare.com. Just find courses. Uh, it'll push you over into, uh, another platform, which we have our, uh, courses on. And I really try to update those as much as I possibly can and have the most updated research on it.

Um, I do have a lot of free videos out there and I'm not going to say those are bad. Uh, I really try to share the best information in any regard when I share information, but the, the stuff that I have in the online course is designed to organize everything well for you and to give you a little extra. Um, we're trying to make it so there's actually a online community there. So all you can also learn from each other. And I actually think that a lot of times people get frustrated with finding, you know, rehab that works for them or exercises or stretches that work for them because they don't know what they're looking for.

Number one. And second is that no one keeps them accountable. Um, I've actually had a lot of, uh, patients who have talked about their friends or family who have, uh, you know, I've like chronic conditions and I'm like, Hey, just bring them in. Let's just check them out. And they're like, no, no, no. They don't really, you know, they don't really want to deal with it right now. And I think accountability is, is a big thing. Um, you can get anything done if you really, really want to, or if you have someone else forcing you to do it. Um, just this course is a form of accountability because we really want you to finish it.

Okay. I don't know how exactly we're going to do it yet, but we actually can monitor your progress on the course. And we might just send out, send out an email and just push you on blast and just tell you, Hey, look, how bad do you want it? You know, almost tough love on it. How bad do you want to get better? Because if you want to get better, this is going to be the way. And we really want you to educate yourself about training methodology and how to rehab an injury. Cause if you don't understand it, you're not going to do it. That's the way it goes. So hope you guys enjoyed this and I will talk to you guys soon.