Back Pain after a Road Traffic
Accident
Normal looking disc with Low Back
Pain
History
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38 year old involved in a car accident 3 years ago
Hit from behind.
Gradual onset Low Back Pain- no leg pain
Got progressively worse
Not working for 2 years – senior managment position
Tried phsyio and exercise- made it worse
Depressed
Litigation ongoing.
Pain worse on sitting. Sleep disturbed.
On regular opiate pain killers
Examination
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Tender L5-S1 segment
Flexion- limited by 50%. Extension normal.
No sacro-iliac joint tenderness
SLR normal
No neurodeficit in legs
Looks depressed
Narrowed disc height L5/S1. No
degeneration on MRI scan. Tender
L5/S1.
What is the cause of her
pain?
MRI reported as
showing a normal signal
at the L5/S1 level
Initial Rx: Facet Joint injections
Had 3 sets of lumbar facet
joint injections. Each
provided pain relief for 23 months only.
Also had physiotherapy
for 12 months.
No better. Still off work, in
pain and depressed. Job
under threat.
What should we do now?
Discogram L5/S1- painful discreproduced concordant back pain
Needle inserted into the disc under
sedation
Injected with onmipaque dye and
local anesthetic
L5/S1 Posterior Lumbar interbody
fusion 12m ago
Pain free 12m from
surgery
No more pain killers
Depression gone
Back to work full time
Claim not yet settled
Learning Points
• MRI scans do not show internal tears in disc or
small haematomas. They also do not reveal
concentration of inflammatory chemicals in
the disc space
• A normal MRI scan does not equal a normal or
‘lying’ patient
• Patients with ongoing litigation are usually
honest and in genuine pain
ANNULAR TEAR
AT L4.
MRI HERE MAY
LOOK NORMAL
Learning points
• Road traffic accidents can cause muscular
strains, sacro-iliac sprains or disc and facet
injuries
• Principle of surgery is to remove the pain
source( disc, facet joint), and restore normal
loading across the disc
• Important to chase the pain generator and
treat patients and not write them off if
investigations are ‘Normal’