1. Back Pain after a Road Traffic Accident Normal looking disc with Low Back Pain

2. History 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

3. Examination Tender L5-S1 segment Flexion- limited by 50%. Extension normal. No sacro-iliac joint tenderness SLR normal No neurodeficit in legs Looks depressed

4. 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

5. Initial Rx: Facet Joint injections Had 3 sets of lumbar facet joint injections. Each provided pain relief for 2- 3 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?

6. Discogram L5/S1- painful disc- reproduced concordant back pain Needle inserted into the disc under sedation Injected with onmipaque dye and local anesthetic

7. 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

8. 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

9. ANNULAR TEAR AT L4. MRI HERE MAY LOOK NORMAL

10. 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’