Future Spine SurgeonMemberDecember 9, 2012 at 1:06 amPost count: 8
Hello Dr. Corenman,
I am a 20 year old female and I have been suffering from severe chronic thoracic spine pain since an orthopedic surgeon’s exam in April 2011. I have pain in the T7-8 region of my spine that radiates bilaterally to my ribs and sternum. I am extremely tender to touch in the area and have exacerbated pain with deep breathing and coughing. The pain is an unrelenting 10/10 and has not responded to any conservative treatments (medications, physical therapy, injections, scs trials, on-q pump trial, ect.). I have a 2mm central disc protrusion deforming the cord at T7-8, with very little myelopathy, and what my doctors believe to be DDD at the same level (as shown on MRI). There is no evidence of kyphosis or scoliosis. I have received many opinions from spine surgeons, and the latest recommends I undergo a T7-8 X-LIF. I can’t seem to find anyone who has undergone this surgery and I am worried about the risks and the recovery. If you’re familiar with this procedure, could you please tell me how you would prepare one of your patients for the surgery/recovery? I’m also wondering if you believe a discogram would be helpful in confirming the etiology of my pain? My doctors admit openly that they have never encountered a case like this with such unrelenting pain. I am trying to make the most educated decision regarding further treatment, and I would truly appreciate any help you could offer.
Thank youDonald Corenman, MD, DCModeratorDecember 9, 2012 at 10:40 pmPost count: 8468
Severe unrelenting pain in the thoracic spine that is recalcitrant to conservative care is a real problem to surgically treat. Pain can be generated from the disc, facet, rib articulation or by neuropathic means (more on that later). Cord compression typically does not cause pain as the cord does not contain pain receptors. The small herniation at T7-8 by itself is probably not causing pain but by definition, that disc is degenerative (you need to tear the disc through and through to produce a hernation).
If you have not undergone facet blocks, that would be my next step if I had a patient like you. The facets can cause pain and the “fix” is rhizolysis (see website), not a surgical procedure.
Finally, if nothing else works, I would consider discograms (see website). This test can identify the pain generator or generators. Also, if there is no pain reproduction, you have to go back to the drawing board and figure out which structure is really causing the pain.
The one caveat in this surgical discussion is the possibility of neuropathic pain (see website under “chronic radiculopathy”). That is pain caused by injury to the nerve itself and not originating from any mechanical structures. There is really no test that can identify this problem. It is a diagnosis of exclusion. That is, we surgeons do our best to identify the pain structure, perform the correct surgery and wait for the results. Thank goodness neuropathic pain is uncommon but is one source of poor surgical results.
The XLIF for the thoracic spine is a good procedure if necessary but you may not need this type of surgery. The XLIF is designed to remove the hernation but requires a portion of rib removal and an anterior approach (through the side of the spine). It is less invasive than the older approach but patients can still develop something caused intercostal neuralgia which is rib pain that can linger.
I would say that you need to identify the pain source before you consider a surgical procedure.
Dr. CorenmanFuture Spine SurgeonMemberFebruary 5, 2013 at 5:20 amPost count: 8
I am scheduled to undergo a T7-8 x-lif next Tuesday (Feb 12th). I was wondering if it is possible to use an On-Q Pump in an x-lif incision? My doctors know my post-op pain will be close to impossible to control and I suggested an anesthetic pump as an alternative to IV narcotics. But my surgeon said he has never used one before and wasn’t sure if it was possible for this approach. I’m not sure if you’re familiar with On-Q pumps or use them in your patients, but I would value any thoughts you have.
Thank you!Donald Corenman, MD, DCModeratorFebruary 5, 2013 at 8:30 pmPost count: 8468
The On-Q pump continuously infuses anesthetic in the immediate post-operative period to reduce pain. Just like any “helpful tool”, there are benefits and risks too. This pump may reduce the post-operative pain but there are some questions of having a catheter in place for a period of time that might also be a tract for bacteria.
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