A parasagittal thecal sac indentation is a finding on spinal imaging—most often MRI—where the protective membrane around the spinal cord (the thecal sac) is pressed inward at a point just off the midline (parasagittal region). This indentation can be caused by many processes (such as a bulging disc, bone spur, or ligament thickening) that push on the thecal sac from one side. Although often seen incidentally, significant indentations can narrow the space for spinal nerves or even the spinal cord itself, potentially leading to pain, nerve symptoms, or more serious neurologic issues.
Anatomy of the Thecal Sac
Structure & Location
The thecal sac is a tubular sheath formed by the dura mater (the tough outer membrane of the meninges) that extends from the base of the skull (foramen magnum) down to the second sacral vertebra (S2).
Origin & “Insertion”
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Origin: Continuous with the cranial dura mater at the foramen magnum.
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“Insertion”: Anchored inferiorly by the filum terminale at S2.
Blood Supply
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Arterial: Branches of the vertebral arteries supply the upper cervical dura; spinal branches of the aorta (segmental medullary arteries) supply the lower dura.
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Venous: Internal vertebral venous plexus drains blood from the dura into segmental veins.
Nerve Supply
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The recurrent meningeal (sinuvertebral) nerves provide pain fibers to the dura and posterior longitudinal ligament.
Key Functions
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Protection: Encases the spinal cord and nerve roots in a durable membrane.
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CSF Containment: Holds cerebrospinal fluid, which cushions the cord and nerves.
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Shock Absorption: Fluid pressure within the sac helps dampen sudden forces on the spine.
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Anchor Point: The filum terminale within the sac stabilizes the spinal cord’s position.
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Nutrient Transport: CSF carries nutrients and removes waste for spinal cord health.
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Barrier to Infection: Dural layers form a barrier against pathogens entering the subarachnoid space.
Types of Parasagittal Thecal Sac Indentation
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Disc-Related Indentation: Caused by a herniated or bulging disc pressing laterally.
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Facet Joint Hypertrophy: Overgrown facet joints on one side indent the sac.
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Ligamentum Flavum Buckling: Thickened ligament folds into the canal off-midline.
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Osteophytic (Bone Spur) Indentation: Bony outgrowths push into the thecal sac.
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Epidural Mass Lesions: Tumors or cysts adjacent to the sac create focal indentations.
Common Causes
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Lumbar disc herniation
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Disc bulge or protrusion
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Facet joint hypertrophy
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Ligamentum flavum thickening
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Posterior longitudinal ligament ossification
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Osteophyte (bone spur) formation
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Synovial cysts of facet joints
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Epidural lipomatosis (fat overgrowth)
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Epidural abscess or infection
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Spinal tumors (meningioma, schwannoma)
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Metastatic cancer deposits
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Hematoma after trauma or anticoagulation
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Arachnoiditis with adhesions
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Disc space narrowing from degeneration
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Spondylolisthesis (vertebral slippage)
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Paget’s disease–related bone changes
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Rheumatoid pannus formation
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Congenital canal narrowing
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Traumatic bone fragments
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Post-surgical scar tissue (fibrosis)
Possible Symptoms
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Localized back or neck pain (depending on level)
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Side-specific (unilateral) radiating pain
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Numbness/tingling in a specific dermatome
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Muscle weakness on one side
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Sciatica (leg pain) if in lumbar region
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Claudication (leg cramping with walking)
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Loss of reflexes (knee or ankle)
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Gait instability or shuffling
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Bowel or bladder difficulty (if severe)
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Sexual dysfunction (rare)
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Muscle spasms or cramping
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Stiffness or reduced range of motion
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Pain that worsens with standing or extension
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Relief of pain when bending forward
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Pain at night or at rest
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Hypersensitivity to touch (allodynia)
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Muscle atrophy from chronic denervation
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Balance problems
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Falls due to leg weakness
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Low-grade fever or weight loss (if infection or tumor)
Diagnostic Tests
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MRI (Magnetic Resonance Imaging): Gold standard for thecal sac visualization.
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CT Scan: Shows bony structures and calcifications clearly.
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X-Rays (Plain Films): Reveal alignment, osteoporosis, or spondylolisthesis.
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CT Myelogram: CT after injecting dye into CSF to outline sac indentations.
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Flexion/Extension X-Rays: Assess dynamic instability.
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Ultrasound: Limited use, but can detect epidural lipomatosis.
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EMG (Electromyography): Evaluates nerve root function.
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Nerve Conduction Studies: Checks electrical conduction in peripheral nerves.
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CSF Analysis: Via lumbar puncture if infection or inflammation is suspected.
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Blood Tests: ESR & CRP for inflammation or infection.
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Bone Scan: Detects active bone disease (e.g., Paget’s).
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PET Scan: Finds metabolically active tumors.
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SSEP (Somatosensory Evoked Potentials): Tests spinal cord pathway integrity.
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Discography: Dye injection into disc to reproduce pain (controversial).
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Diagnostic Nerve Blocks: Determines which nerve root causes symptoms.
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Biopsy (Image-Guided): For suspected tumors or infections.
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DEXA Scan: Bone density test if osteoporosis or Paget’s is considered.
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Angiography: If vascular malformation suspected.
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Myelo-CT with Dynamic Postures: To see changes under stress.
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CT with 3D Reconstruction: Detailed bone anatomy for surgical planning.
Non-Pharmacological Treatments
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Physical therapy (guided exercises)
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Core-strengthening routines
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Flexibility stretches (hamstrings, hip flexors)
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Posture training & ergonomics
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Heat therapy (warm packs)
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Cold therapy (ice packs)
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Manual therapy (massage, soft tissue work)
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Spinal mobilization by trained therapists
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Chiropractic adjustments (if no red flags)
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Acupuncture for pain relief
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Yoga or Pilates for flexibility & strength
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Tai Chi for balance & core control
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Aquatic therapy in a warm pool
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Transcutaneous Electrical Nerve Stimulation (TENS)
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Traction (inversion or mechanical)
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Ergonomic workstation setup
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Weight-loss programs (to reduce spinal load)
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Bracing (lumbar corset) for short-term support
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Activity modification (avoid heavy lifting)
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Post-operative rehabilitation (after surgery)
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Dry needling for trigger points
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Dietary counseling (anti-inflammatory diet)
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Smoking cessation (improves disc nutrition)
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Biofeedback for muscle control
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Cognitive-behavioral therapy for chronic pain
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Mindfulness meditation
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Laser or ultrasound therapy
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Prolotherapy (injection-based stabilization)
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Ergonomic vehicle seat adjustments
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Foot orthotics if gait contributes to back strain
Commonly Used Drugs
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NSAIDs (e.g., ibuprofen, naproxen)
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Acetaminophen (paracetamol)
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Muscle relaxants (e.g., cyclobenzaprine, tizanidine)
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Gabapentin (for nerve pain)
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Pregabalin (neuropathic agent)
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Duloxetine (SNRI for chronic pain)
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Oral corticosteroids (short course prednisone)
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Epidural steroid injections (targeted anti-inflammatory)
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Tramadol (weak opioid)
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Oxycodone (stronger opioid, short-term)
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Topical lidocaine patch
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Capsaicin cream (topical desensitizer)
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Methotrexate (for rheumatoid pannus)
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Bisphosphonates (for Paget’s or osteoporosis)
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Antibiotics (if epidural abscess)
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Anti-TNF agents (ankylosing spondylitis)
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Antiviral therapy (herpes zoster cases)
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Calcium & Vitamin D supplements
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Tricyclic antidepressants (e.g., amitriptyline)
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SNRI antidepressants (venlafaxine for pain/well-being)
Surgical Options
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Laminectomy: Remove part of vertebral arch to decompress.
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Microdiscectomy: Remove herniated disc material with minimal tissue disruption.
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Laminotomy: Small window in lamina for targeted decompression.
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Foraminotomy: Widen the nerve-root exit canal.
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Spinal fusion: Join two or more vertebrae to stabilize.
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Corpectomy: Remove part of vertebral body for severe compression.
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Facet joint excision (facetectomy): Remove overgrown facets.
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Artificial disc replacement: Swap damaged disc for prosthetic.
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Endoscopic spine surgery: Minimally invasive approach for select cases.
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Epidural decompression via interspinous spacer: Implant device to hold vertebrae apart.
Preventive Measures
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Maintain a healthy weight to reduce spinal load.
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Practice proper lifting techniques (bend knees, keep back straight).
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Strengthen core muscles regularly.
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Keep good posture when sitting and standing.
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Use ergonomic chairs and workstations.
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Avoid tobacco (smoking impairs disc nutrition).
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Stay active with low-impact exercise (walking, swimming).
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Ensure adequate calcium and vitamin D intake.
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Take regular stretch breaks if sitting ≥30 minutes.
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Wear supportive footwear to maintain spinal alignment.
When to See a Doctor
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Severe or worsening pain that limits daily activities
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New weakness or numbness in arms or legs
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Loss of bladder or bowel control
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Fever or chills with back pain (possible infection)
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Unexplained weight loss plus back pain (possible tumor)
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Night pain that wakes you from sleep
Frequently Asked Questions
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What exactly causes a parasagittal thecal sac indentation?
It happens when something off the midline—like a bulging disc or bone spur—pushes into the dural sac that surrounds your spinal cord. -
Is it the same as central canal stenosis?
Not always. Central stenosis narrows the canal in the exact middle, while parasagittal indentation is off-center, affecting one side more. -
Can small indentations resolve on their own?
Mild cases often improve with physical therapy, posture correction, and anti-inflammatory treatments. -
How is it diagnosed?
An MRI is the best test to see thecal sac shape and any indenting lesions clearly. -
Will I need surgery?
Only if you have severe, persistent symptoms that don’t respond to conservative care, or if you have new neurologic deficits. -
Can it cause permanent nerve damage?
In rare, severe cases with prolonged compression, yes—but early treatment usually prevents this. -
What role does posture play?
Poor posture can worsen the pressure on one side of your spinal canal, making indentations more symptomatic. -
Is walking or exercise safe?
Yes—low-impact exercise like walking or swimming can actually relieve pressure and strengthen supporting muscles. -
What drugs help most?
NSAIDs and targeted nerve-pain medications (gabapentin, pregabalin) are commonly effective. -
Are epidural steroid injections risky?
They’re generally safe if done by an experienced specialist, though there’s a small risk of infection or bleeding. -
How long does recovery take after surgery?
Most patients see significant relief within 6–12 weeks, though full healing can take up to a year. -
Can I prevent future indentations?
Yes—core strength, good posture, weight control, and proper ergonomics make a big difference. -
When should emergency care be sought?
If you suddenly lose control of your bladder or bowels, or have rapid leg weakness, go to the ER immediately. -
Is this common in older adults?
Yes—age-related disc degeneration and arthritis are leading causes of parasagittal indentations. -
Will physical therapy hurt?
No—therapists tailor exercises to your tolerance, gradually improving strength and flexibility without making indentations worse.
Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.
The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members
Last Updated: May 02, 2025.