Dear Dr. Roach: Last November, the outside of my left leg above my ankle started hurting badly. At its worst, it felt like someone had hit me with a bat. Other times, it was just a bad ache. The pain is exacerbated by standing, walking, and exercising on a treadmill, elliptical or recumbent bike, but sitting and lying down are most comfortable.
I saw my primary care doctor in mid-December, who referred me for physical therapy. Since my pain persisted even with physical therapy exercises, and my left toe started tripping me up several weeks ago, I had an MRI. The results showed “severe spinal canal stenosis with mild bilateral lateral recess narrowing.” It also showed “mild left and moderate-to-severe right neural foraminal stenosis; moderate-to-severe bilateral facet osteoarthritis with small bilateral facet effusions at L4-5; and moderate-to-severe left and mild-to-moderate right facet osteoarthritis at L5-S1.” There were also multiple perineural cysts at L3-4 and S2.
The physical medicine doctor recommended doubling my gabapentin dosage and summarized my results: “You have several large disc bulges in your lower back, pinching the nerves around it and causing the pain. The next step is speaking with our anesthesiology team about epidural steroid injections.” What course of action would you recommend so that I can stay fit and strong without as much pain?
M.M.
When someone has multiple issues appear on their MRI, which is common, I always try to correlate the MRI findings at the level where the symptoms are. In your case, the pain is on the outside of the left ankle. That’s the distribution of the L5 and S1 nerves. The MRI shows spinal stenosis at this level. Most perineural cysts are incidentally noted by MRI and do not cause symptoms.
There are three kinds of treatments considered prior to surgery: physical therapy, medications and injections. You’ve tried physical therapy and are taking gabapentin (which is just one effective choice for pain due to nerve injury). So, now, your physiatrist is recommending injections. My experience is that some people do very well with injections, and I agree that it is a reasonable next step.
If a good trial of epidural injections is not helpful, surgery is a consideration. People who tend to do better with surgery include younger patients, those who are more active, those who have fewer medical conditions, and those who have more severe stenosis. I never recommend surgery lightly, so I refer only those who are likely to benefit and choose surgeons who are more conservative.
Dear Dr. Roach: I often grow numerous basal cell cancers during the course of a year. Many get removed with a biopsy. The problem I have is with my feet. If a basal cell is removed, it takes a long time to fully heal to the point where I am able to hike again. How long can I leave the cancer in place before I really need to get it removed? I know they are slow-growing.
F.N.
Basal cell cancers are the most common skin cancer. About half of people who get one basal cell cancer will get another. There are a few rare syndromes that lead to many basal cell cancers.
While basal cell cancers are slow-growing and very unlikely to spread, I can’t recommend leaving any cancer in place longer than necessary. Furthermore, it is easier to remove them when they are small. You’ll need to recover in any event, so recovery will be shorter if the cancer is smaller.
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