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  • SpinelessWench
    Member
    Post count: 38

    Dr. Corenman,

    HX: I am a white female, late 40’s, 5’6, 170, college professor, with standing diagnosis of DDJD since onset at age 18. I’ve undergone 21 orthopedic surgeries, 9 of which were performed on my cervical and lumbar spine. Procedures have ranged from discectomies, to laminectomies, to multi-level fusions. Latest surgical procedures included a posterior fusion at C2-T2 w/ dynamic stabilization instrumentation and BMP, as well as a posterior fusion at L3-S1 w/ dynamic stabilization instrumentation and BMP. Both fusions were conducted in 2008.

    Total Spine surgeries: 5 Lumbar and 4 Cervical

    Given my extensive surgical history, I’ve navigated acute episodes of pain fairly well. For the past 3 years, I’ve been under the care of a PM anesthesiologist, and my current pain management program primarily involves the use of opioids and other pharmaceutical modalities to control pain. Pharmaceutical management is preferred at this juncture given the failure of other conservative modalities such as ultrasound, therapeutic massage, intrathecal injections, PT, and so on.

    During the past 12 months, I have experienced worsening pain in the lumbar spine, with a rapid onset of severe pain and other symptoms in the past 6 months. These symptoms include severe, debilitating pain originating midline around L-2, radiating bilaterally across the lower back, then down both thighs laterally and anteriorly. The pain then “wraps” around the thighs and migrates downward to the lateral calf area. In the past 3 weeks, the pain has migrated further into the ankles. This is the worst pain I’ve experienced since my first ruptured disk at age 18, which I can only describe as violent, stabbing, throbbing, and intensely spasmodic. I am awakened at night by a “jolt” of these sensations, and find myself unable to turn over, sit up, or stand. In the mornings, I need assistance getting out of bed, and ambulating without help takes almost an hour. My pain levels in the mornings are a 10+, and never reach below a 7 or 8 during the day. I am unable to stand completely upright, and have needed the use of a cane to walk. Standing and walking become intolerable after 10 minutes.

    Current Distribution and Proportion of Pain: 70% isolated lumbar & sacral, 30% in legs.

    While acute in nature, relief is sometimes achieved by forward flexion while standing (shopping cart position), or lying in a fetal position with knees drawn to my chest. This is difficult, however, due to the extensive instrumentation in my low back. I’ve researched these symptoms extensively, referring largely to peer-reviewed medical and orthopedic journals. Having had experienced similar symptoms, either central canal or foraminal stenosis seemed a likely suspect.

    Recently, I made an appt with my attending orthopedic surgeon because I’m miserable. Upon hearing and observing my symptoms, he ordered an MRI with contrast to verify or rule out nerve root compression. The radiologist’s impression, aside from the usual degenerative changes / instrumentation at post-operative levels, read: “There is mild disk bulge and diffusion at the L2-3 level, more prominently to the patient’s right than left, with no central cord compression. There is moderate foraminal stenosis to the left, with moderate to severe foraminal stenosis to the right.”

    My surgeon declined further surgery, indicating his “lack of confidence in his skill set” to enter my lumbar spine for a 6th time. The perplexing part of this is that he admitted only reading the radiologiy REPORT… My surgeon never looked at the images themselves. I have no idea why. He then ordered a transforaminal injection, and offered to send me to yet a 2nd surgeon for reassessment. I accepted, and was scheduled accordingly. The 2nd surgeon walked in the exam room, and bluntly asked why I was there. When I told him what my attending surgeon said, he informed me that upon viewing my MRI, “there was absolutely NO evidence of stenosis anywhere”, and that he was “very disappointed that a surgeon would order a transforaminal injection without viewing images, and only reading the written impressions of a radiologist.” Lastly, he (loudly) declared that this “so-called foraminal stenosis” was actually the titanium instrumentation mistakenly identified by the radiologist.

    After enduring 10 more minutes of this surgeon’s unhappiness with life itself, I was informed that I had “Failed Back Syndrome”, and that my options amounted to lifelong pharmaceuticals, an implanted morphine pump, and/or retirement on disability. As I mentioned previously, I am a university professor, and my classroom obligations entail hours of standing. I’ve been forced to take medical leave this semester, given that my current pain level is uncontolled. My PM anesthesiologist is completely flustered at the degree of inconsistency between surgeon #1, radiologist, and surgeon #2. Thankfully, and until you can (hopefully) help, my PM doctor is having the radiology department re-read my films.

    My purpose in writing you is twofold: First, I would be grateful if you’d offer to assess my August 1 MRI to determine whether lateral foraminal stenosis is, indeed, present, or if there is any other problem associated with the spinal processes and structures from L1 to S1. Second, is it possible that a radiologist could see “severe” anomalies, while another physician sees absolutely nothing? That’s a HUGE discrepancy, yet the 2nd surgeon noted no stenosis or decrease in fat levels around the nerve roots in question. I’m beyond frustrated, and could use a somewhat definitive evaluation of my symptoms versus objective imaging.

    I’m sorry this post is so lengthy, but I wanted to provide you with as much HX and relevant symptoms as possible.

    S.W. in NC

    Donald Corenman, MD, DC
    Moderator
    Post count: 8468

    Your care at this point has been less than generous. At the very least, one or both of the surgeons should have gone over your MRI images with you in detail and discuss salient points on the images.

    From your report, no one has performed flexion/extension X-rays of your lower back. These are indispensable for understanding stability or instability. Even an AP (front to back) standing X-ray can yield valuable clues to the origin of your pain.

    There are disorders that cannot be surgically treated (arachnoiditis and chronic radiculopathy- see website) but no one has mentioned those to you. Has anyone mentioned a spinal cord stimulator if either of these diagnoses could be present as a form of treatment?

    I would be happy to review your films. See if your family doctor or radiologist would consider taking X-rays (AP, lateral, flexion and extension- all standing) to be included in your packet. Please call the office for delivery instructions.

    Dr. Corenman

    SpinelessWench
    Member
    Post count: 38

    Dr. Corenman,

    Much appreciated for the quick reply. I did fail to denote that I currently have standard X-rays of my lumbar spine, taken a few days prior to the MRI. I’ll send those along with the MRI materials… The X-rays are lateral and AP views, but do not include flexion images. I’ll request a few by my attending PM anesthesiologist.

    While neither surgeon mentioned arachnoiditis or other related conditions, sagittal views of the MRI seem to indicate hypertrophy of the ligamentum flavum, as well as the attendant spinous structures and processes at the L-5/S1 level. From what I can readily see, there is significant encroachment on the cauda equina at this level that doesn’t appear to be related to metallic instrumentation. The majority of operative “trauma” at this level, from numerous surgeries and fusions, has likely resulted in arthrosis and degeneration that would be expected. Given that 70% of my severe pain is located in the lumbar and sacral region, I’m somewhat surprised neither surgeon focused on this area as the culprit. Instead, both seemed scope-locked on the levels above, especially those mentioned on the radiologist’s report (L2-3). In the exact words of surgeon #2, “Look, this is all I do all day, every day. I look at MRI images. And I’m good at it. And I’m telling you, I see nothing that the radiologist claimed to see.”

    I appreciate this surgeon’s confidence in his abilities, and I also fully appreciate his extensive training and expertise (which he reiterated 14 times during the visit). Yet, while he did have the images up on the screen for me to see, he never diverted away from the sagittal views. He was adamant that, “Axial views are much less reliable, and most radiologists rely too much on them when looking for stenosis.” He never focused on the hypertrophy of other spinous elements, nor did he offer to really take a close look at the area below L-4.

    His diagnosis of Failed Back Syndrome was, I think, made in light of an absence of something else to tell me at that point. He rushed through my images, and while “this is what he does all day”, I think he likely missed the forest in the presence of the trees. I’m sure he sees a fair share of “surgery seekers”, “pill seekers”, and “doctor shoppers”, all of whom tend to challenge his opinions and assessments. I’m neither of those; instead, I’m a patient whose quality of life is diminishing, and whose career may be cut short due to a degenerative condition. I can appreciate, and accept, that yet a 6th lumbar surgery is futile and wouldn’t help. But if stenosis or arachnoiditis, or even cauda equina syndrome do exist, I’ll be a little more than angry that no one took an extra 10 minutes to look for it, and find it.

    Neurostimulators have been discussed. I’ve conducted extensive research (both corporate and academic) into these devices, as well as the morphine pumps, taking into consideration my job and hobbies. It seems the morphine pump is more conducive to my needs, and would allow for operation during my biggest enjoyment, which is riding my Harley-Davidson. Stimulators are not to be activated while driving, riding a motorcycle, or operating machinery. I have a consult tomorrow, in fact, to discuss the pros and cons of each. Plus, morphine pumps decrease the physio-psychological side effects of oral opioids, so teaching in a more lucid state would be welcomed as well.

    ONE QUESTION: With arachnoiditis, is bowel or bladder dysfunction a necessary symptom? I don’t have either, nor do I have tingling, pins/needles, or parasthesias in the legs. Only a throbbing pain… I do, however, have the sudden sensation of a taser gun or cattle prod hitting me in the area of the upper buttocks and hips, as well as the midline lower back.
    I’ll refer to your site for sending images… Much appreciated, again.

    S.W., NC

    Donald Corenman, MD, DC
    Moderator
    Post count: 8468

    Your symptoms sound more like instability than arachnoiditis. Do you have a solid fusion at L3-S1? Have you had a CT scan of the area to demonstrate a solid fusion?

    If you had a solid fusion at L5-S1, it would be unlikely that you would have compression of the canal at this level. The titanium instrumentation can generate artifacet that can simulate compressive situations.

    Dr. Corenman

    SpinelessWench
    Member
    Post count: 38

    Much appreciated for your input… Today’s consult with my pain management team culminated in the decision to proceed with a spinal cord stimulator first, then a morphine pump should my subjective pain relief fail to exceed >50%.

    I’ve not had a recent CT scan to assess overall fusion integrity, yet from all indications, my fusion from L3 to S1 appears solid. Both my cervical C2 to T2 revision and lumbar L3 to S1 fusion revision in 2008 were performed, however, to repair severe arthrosis and failed grafts from prior fusions in 1991 and 2006.

    Aside from being run down by a beer truck from behind, the only word I can otherwise describe the feeling in my lumbar area is “unstable”… Prior to my 1991 lumbar fusion, MRIs indicated spondylolithesis at L4/5, and L5/S1.

    And as promised, my PM anesthesiologist had a radiologist and my other PM physician view the “misbehaving” MRI that was interpreted 47 different ways last week. The consensus: Diffuse bulge of the L2/3 disk, with bilateral foraminal stenosis, more severe on the right than left…….. I’m tempted to nail-gun this trifecta RE-assessment to the gluteus maximus of grouchy surgeon #2 from last week.

    Here’s to hoping for success of the spinal cord stimulator… And thanks again for your help.

    S.W., NC

    SpinelessWench
    Member
    Post count: 38

    ADDITIONAL QUESTION REGARDING INSTABILITY:

    I’d failed to mention an additional symptom in relation to my HX above..

    1. At times, while in bed, I’ll lie on my left side, then prop myself up on my left elbow… So, my left hip downward is on the mattress, and my waist (and above) is suspended off the mattress.

    2. At times, I’ll hear a muffled, yet tenable, “crack” in my lumbar area around the fusion region. It can only be metaphorically described as an internal “knuckle cracking” sound… I apologize for the weird analogies..

    3. At the same time, there is a definite “shifting” sensation, as if the fused area subtly adjusts itself… This shifting, and muffled crack, are simultaneous, and are accompanied by a jolt of pain.

    4. There is no attendant parasthesias… Only isolated pain at the area this occurs.

    Now, I know that fusions are intended to prevent motion, stabilize an unstable area, and stop things like this… And, my surgeons have all indicated that my fusions appear solid, with no arthrosis apparent since the fusion revisions in 2008.

    These shifting and cracking sensations aren’t “all in my head”, or imagined. Any suggestions as to whether this could be evidence of some arthrosis or instability not yet noticed on imaging?

    Thanks, one more time.

    S.W., NC

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