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The explanations, insights and advice about pain management options on this page are provided by Peter F. Ullrich, Jr., MD, an orthopedic spine surgeon and Medical Director for Spine-health.com.
This information does not replace the physician-patient relationship, and the information is not medical advice or treatment. It should only be considered as one physician's opinion based on an extremely limited amount of information. Patients should always seek the advice of a trained health professional for back pain or any health condition. Please note that the contents of this section have not been peer reviewed.
Question: What are the options for treating facet joint that has slipped slightly forward at L-4 and L-5 (results of MRI)? I have tried Vioxx, and stretching and strengthening exercises for 3 months—the pain continues, especially after golf or tennis or sitting, occasionally in buttocks and down left leg. I regularly have slight tingling in left foot, no known instance causing injury--seems to have developed from overuse--primarily golf. I am male, age 55.
Doctor’s response: This is most likely a degenerative spondylolisthesis. Besides medication and physical therapy, other choices to treat the spondylolisthesis would include epidural steroid injections or a one level spine fusion. Epidural injections are easier to go through, but the surgery is more reliable. Basically, if the joint has slipped, then the facet joint is degenerated and is no longer competent to stabilize the spine properly. A fusion surgery should stabilize the unstable painful joint. Where there is no motion, there shouldn't be any more pain. Besides medications you may want to consider physical therapy and/or chiropractics. If this does not improve the pain, and it is limiting your normal level of functioning, you may want to consider epidural injections. If these do not work, a spinal fusion may be a reasonable option. Usually, surgery is only considered for patients with significant functional limitations.
Question: I have had two spinal operations on the S1-L5-L4-L3 area, removal of disc and bone due to a work injury lifting a heavy object. I still have burning in my legs (varying degree) and leg weakness. I have seen a spine specialist and he does not think there is anything that can be done. However, I received a second opinion from a neurosurgeon suggesting an SCS device. I need to get data on the success on the SCS (spinal cord stimulators) or TENS/IFC units. Could you cite some sources and studies on SCS and on these electrotherapy units?
Doctor’s response: The Spine Journal (published by the North American Spine Society) had a review article on the use of SCS for chronic pain. After reviewing the available literature, the authors and the members of a think tank basically had no recommendations on whether or not it is all that useful. There has been no definitive controlled and randomized study showing that SCS (spinal cord simulators) are all that efficacious. Most studies will quote less than a 50% success rate at 2 years. For this reason, they stated only that it may be a useful procedure for some patients, but no other recommendations were made.
The reason you are getting conflicting information is that no one knows if electrotherapy will work for you until it has been tried. The chance it works is only 50/50, but there is no way to know if it will work before the surgery is done. In my own opinion, SCS is a technology that should be used very sparingly. In most cases, it is a lot to go through with very little in defined potential benefit. The risk of the procedure and expense is only justified in those patients with significant pain and disability that have failed a comprehensive rehabilitation program and do not have an anatomical lesion that can be corrected with surgery.
Question: I have lost most of the use of my right arm and hand over the past 6 to 9 months. I have muscle atrophy as a result, muscle twitching/fasciculation, chronic/dull pain from my hand, right arm, right shoulder, back behind my shoulder blade, neck and up thru my neck. I get sharp pains in my neck, behind my shoulder blade, and in my shoulder. My right hand has progressively gotten colder to the touch over the last 6 months to the point now that it is VERY obviously cold to EVERYONE that touches my hand (as the weather gets colder, so does my hand, an arthrogram indicated no arterial blockage at all). I get occasional numbness in my fingers.
My most recent cervical MRI indicates a mild central protrusion or herniation of C5-6 with minimal compression of the thecal sac. There is also a mild central bulge or protrusion of C4-5 and C6-7. Unremarkable dorsal spinal canal including spinal cord is also noted on the report.
None of the MDs I am seeing think this is the cause of my problems on my right side. They are defaulting to an Amyotrophic Lateral Sclerosis (ALS) diagnosis, even though none of them can explain the pain or coldness which ARE NOT ALS symptoms. The MRIs have all been done lying down with my neck in a slight traction position (this is the most comfortable position for me by far). Could the problem be much worse when not in this traction position, and hence, the doctors are underestimating the affect it has on my spinal cord? What are your thoughts? I am trying to stay hopeful, as the doctors are giving me no hope. Also, I am a 39-year-old, very active male who used to be a very active runner until the last 4 months. The back and neck pain got very bad after digging out 3 very large tree stumps by hand last fall. Your help would be greatly appreciated. Please excuse my typing as my right hand is almost paralyzed now.
Doctor’s response: The problem is not from your neck. Nerve pinching also does not make the hand cold, as this is a vascular phenomenon.
It sounds to me as though this is some variant of Reflex Sympathetic Dystrophy. This is an unusual syndrome that can come on after any kind of hand/arm trauma. It seems to be a cyclical problem in the sympathetic nervous system that leads to spasming of the vasculature and coldness. It also leads to widespread pain. If you already have atrophy, it is probably fairly advanced.
Usually, the treatment consists of stellate ganglion blocks in the neck to block the sympathetic system and an alpha blocker medication (such as Hytrin). The stellate ganglion block is diagnostic, as about the only thing it would help is a RSD syndrome (some people now call this Complex Regional Pain Syndrome). If the block does work, then aggressive physical therapy is the next step.
Avoid any operations or other trauma, as this is likely to make the pain and syndrome worse. Your best treatment option would a multidisciplinary pain clinic that is familiar with this syndrome.
Question: My husband has had 4 lower back surgeries, 3 herniated discs removed (the last three - L3-4 & 5), a hardware fusion (bone from hip) with pedicle screws, 2 1/2 years ago. The hardware was removed July 2001. He still has chronic back pain, sees a pain management doctor, and has had nerve blocks and epidurals. Nothing helps the pain and the neurosurgeon and the pain management doctor both agree that he has scar tissue, nerve damage and arthritis causing the chronic pain now. Is there anything left that anyone can do for him? I just believe that with all the research, there is someone 'out there' that can help him. His only relief at the present is pain medications. My husband is only 57 years old. Please let me know if you can help.
Doctor’s response: Failed back surgery syndrome is a very difficult problem to treat largely because it is often difficult to find what is generating the pain. The more levels that are fused and the more surgeries that are done, the less likely any further aggressive surgical intervention is going to be successful. There are salvage procedures such as spinal cord stimulators or morphine pain pumps, but these are often a lot to go through with very little benefit.
Rehabilitation in the form of an active exercise program is generally the most reasonable course of action. He should be under the care of a physiatrist (rehab doctor).
Question: I have suffered from chronic back pain always in the lower lumbar area since 1996. I have had 3 MRI's that have all come out negative (i.e.; back is 'normal'). I had 3 injections in the L4 and 5 region in 1997 that alleviated the pain somewhat, but now the pain has returned. I always feel relief after lying recumbent for several hours so I think that the pain is axial. The pain feels like a pushing, pressure sometimes stabbing pain usually directly over the L4-L5 spine area. I liken it to someone wrapping a towel around my back and pulling it really tight. When I bend over and return upright if feels like there is a rusty hinge in my low back.
I have tried exercise, chiropractors, acupuncture, a million NSAIDs, and muscle relaxants. Nothing helps except for massage and very hot baths, sometimes with Tiger Balm applied to the lumbar region and afterwards bed rest.
I still do not know what is wrong with my back, but I wish I knew. At times, I find it difficult to participate in sexual activities with my wife because my back is so bad. To this end, I typically initiate intercourse in the morning before I get out of bed as my back usually feels good then.
Can you give me any recommendations about what I can do to ease the pain? And, can you possibly give me some clues as to what is causing my chronic back pain? I recently heard the comedian Jerry Lewis had some kind of operation that helped him immensely with his back pain which he had for over twenty years. Do you know what his operation was and would it be suitable for me? Should I have a myelogram, CT-scan, bone scan or some other test performed? Please provide me with some concrete answers as I am very tired.
Doctor’s response: If you have had three MRI scans that are all normal it is doubtful that your pain is due to any anatomic problem. Therefore, it is also doubtful that surgery will be an option for you. Surgery can only correct an anatomic condition. There are some types of arthritic conditions that affect the muscles. I would recommend being evaluated by a rheumatologist. Also, even though exercise has not relieved your pain, it may keep it from getting worse. You should at least be stretching you hamstrings every day and doing some type of low impact aerobic program (i.e. walking).
The operation Jerry Lewis had was an implantable spinal cord stimulator. This is basically a salvage operation that seems to give about 50% of patients some pain relief. It is not a cure, but can cover up the pain. Unfortunately it is also quite expensive, and even if it is successful, the effects tend to wear off with time.
Question: I suffered a severe disc herniation at L5-S1. The herniation occurred during lifting of my garage door and was catastrophic. I could actually feel the pulp extruding from the center of my disc, and I collapsed, unable to walk. I was taken to the hospital, where my condition was stabilized by injecting pain medication into my back. The doctor performed a test whereby he asked me to resist while he tried to move my foot and leg in various ways. He could detect no strength loss and told me I did not need immediate surgery, and I was discharged. But when I walked out under the influence of the pain medication, I could feel knots in the muscles of my right leg, and had difficulty pushing off due to weakness. It took a week to get an MRI. Twelve days after the herniation, I saw a neurosurgeon, who also performed the test where he tried to move my foot and leg in various ways while he instructed me to resist. He said he saw no reason for alarm, and postponed my surgery.
I finally had surgery 3 weeks and 2 days after the herniation, but by that point had suffered permanent nerve damage, manifested by permanent weakness in my right leg, and loss of the reflex when the back of the ankle is tapped. I also am now worried that I have neuropathic pain because I have pain when I stand on my right foot, but the pain goes away when I take the weight off. Sitting for long periods is unbearable.
Looking back on the tests the two physicians ran (in which they pushed and pulled my foot and leg while they instructed me to resist), I now realize I simply overpowered both of them, and they detected no problem with weakness when there really was one. I was, and am, a very fit male (currently age 51) with very strong legs.
I now have a crusade to try to tell the medical community that they can make severe misjudgments when using the qualitative test I have described. A strong man's leg muscles can overwhelm the strength in the doctor's wrists and forearms, even when the patient has a serious problem with nerve compression due to a herniated disc. A strong man can lose a considerable amount of strength and can still overpower the doctor in the test I have described.
Please take my comments seriously, as I want to spread the word, so that someone else is not hurt as I was.
I am trained as an engineer and am thinking that a simple inexpensive test could be developed to replace the qualitative test I have described. It would involve the principle of having the patient use his foot to push on a device to register force on a load cell. It would have to be configured to handle measurement of force when various muscles are used, but it should be possible to handle that. In this way the strength of one extremity could be quantitatively compared to that of the other. With some experimentation, databases could be developed to let the physicians know at what strength differential to be alarmed.
I have one additional question. Is there any possibility of nerve healing after 6 years? Recently, my pain has become almost unbearable, especially when sitting, or standing on my right foot. The physician who did the surgery has referred me to a physiatrist, but I want to heal, not learn to deal with a life of chronic pain.
Doctor’s response: You are absolutely right in that the gastroc muscles in a person's leg have to be very, very weak before a manual test can pick it up. Actually, a very sensitive way to pick up muscle weakness is to have a patient repetitively toe rise on one foot. Even very subtle weakness can be picked up with this test.
Unfortunately, even if the weakness had been picked up, it probably would not have changed your treatment or even your outcome. There is no evidence in the literature that surgery for a static nerve deficit is necessary, or that it in anyway helps the nerve heal faster. The nerve damage is probably done at the time the disc herniates, and unless it is decompressed within a couple of hours (which is not practical) early versus delayed surgery will give the same results. Your treatment sounds entirely appropriate.
The only two indications for immediate surgery for a disc herniation are progressive neurological deficit (weakness) or bowel/bladder incontinence (cauda equina syndrome).
As to your current pain, the characteristic of neuropathic pain is that it is there all the time. Pain when you step on to your foot would be more mechanical. Further conservative treatment may actually be able to help with this type of pain, so a referral to a physiatrist is appropriate.
The nerve healing usually is complete at 12-18 months, so it won't heal anymore. But, if the pain is mechanical, there may be some additional treatments that would be appropriate for you.