I am in need of all the suggestions I can
possibly get at this point. I will give
you my history, current MRI reading, and
treatments. I would appreciate and I am
open to any suggestions.
34 year old male. with the above diagnosis
on MRI performed in 1/2008
Four years ago I had my first real back
injury and MRI showed "slight bulging"
disc and the treatment that finally
worked was an injection of L4-L5.
From time to time I would have trouble
giving my children a bath, bending over of
extended periods of time. I would
describe the pain as tightness and would
get some radiation into my right buttocks,
but would eventually subside.
Then towards the end of December I slipped
(one of those quick slips and then you
catch yourself) and instantly had sharp
shooting pain down my right leg. It
actually brought me to my knees the pain
was so bad. I was able to get back into
my car get myself home and stated the
rest, ice and ibuprofen treatment. I
limped around over the Holidays and
finally had enough as the pain was not
subsiding. My FP doctor (knowing my
history) ordered a MRI and it showed the
above (title post) but I will read exactly
what it states.
Findings:
L4-L5: Mild DD, central/right paracentral
disc herniation with caudal extrusion on
the right abutting with displacement of
the adjacent right L5 ventral nerve root.
L5-S1: Mild DDD
Treatments as of 2/12/2006
Two epidural injections (corticosteroids,
short acting numbing agent)
The first epidural was on Friday, January
18th. The day after I felt awful and
really felt I a made a bad decision.
However, when I awakened on Sunday I felt
great. I still had intermittent pains
shooting down my leg when I made certain
moves, but overall I felt really well.
Then on Monday it was back to same almost
constant pain shooting down my right leg
and then after awhile my lower back goes
into spasms. I forgot to mention spasms
are very predictable for me. After I have
the shooting pain for an extensive period
of time, the spasms always appear. I have
tried several medications for the spasms
and Valium 10mg and a TENS unit is about
the only way to get the spasms to
subside.
The second epidural was on February 1 and
I had about the same result. However,
this time I was pain free for two days vs.
the one day I received from the first
epidural. Needless to say, the epidurals
are not working and the side effects I get
from the steroids are not worth the
trouble.
I am scheduled to see a neurosurgeon on
Thursday at the Indiana Back Center in
Carmel, IN. What can I expect? What
would be my next step? I fell like I have
taken all the conservative steps and I
want to get my life back to normal.
Here is the problem. I finally had to go
on short term due to the medications I am
taking to make me "comfortable". Valium
and Vicoden is what my doctor prescribed
to me for the pain and the
anesthesiologist said to continue on the
meds after the epidural. However, my job
requires driving and mixing the meds and
driving is no different then drinking and
driving. In addition, the position I sit
while driving is by far the most
uncomfortable position to be in. If I am
stuck in this position for over 10-15
minutes it will instantly trigger a back
spasm associated with the pain shooting
down my leg.
I would appreciate any advice, suggestion
that you could provide.
Best Regards,
mac
|
algosdoc
Experienced User , Rather EHEALTHy
Joined: 23 Mar 2004 Posts: 186
Posted: 02-13-08 06:24am
The surgeon you are to see is not a
neurosurgeon but an orthopedic surgeon.
Most current orthopedic surgeons
performing back surgery also have a
fellowship in orthopedic spine surgery but
this doctor probably graduated long before
their existence, therefore the training
may be limited. However sometimes
experience makes up for lack of training.
As for your situation, sometimes
discectomy is the best choice. If the
disc herniation were larger, it would
statistically resolve on its own, but
given the description, it may be contained
by the ligaments of the back and will not
resolve soon. After two courses of
epidural steroids without success, no more
are indicated unless the physician does
injections onto the nerve roots leading to
the disc herniation...this would be done
under fluoroscopy x-ray. If you had
epidural injections without the use of
fluoroscopy x-ray, there is a 40-60%
chance the medication never made it to the
correct location. Pain physicians, but
not anesthesiologists, routinely use
fluoroscopy x-ray for guidance of
injections and appropriate administration
would be with you lying down, not sitting.
Other options include inversion tables,
chiropractic, use of "natural" drugs such
as fish oil and methyl sulfonyl methane
(MSM). The type of discectomies vary from
open discectomy (usually performed by
orthopedic surgeons involving an incision,
removal of some of the bone of the back,
then removal of the disc), microdiscectomy
(same thing but through a portal using an
operating microscope...usually not used by
orthopedic surgeons), endoscopic
discectomy (usually not used by orthopedic
surgeons) in which no bone is removed, and
disc decompression (through a needle or
small portal removal of some of the center
of the herniated disc to decompress it but
leaving the herniation alone to gradually
resorb).
|
trumanpocket
New User, Becoming EHEALTHy
Joined: 08 Jul 2005 Posts: 9 Location: Madison
Posted: 02-13-08 13:38pm
Mac,
I have the same thing you have. Two and a
half years a go I ruptured my disc at the
L4-L5 area. I could not even stand up
without help. My FP sent me to a
neurosurgeon and I had a discectomy. Got
releif from the pain. A neurosurgeon is
fine to see as oppose to a orthpedic
surgon. Both can specilaize in back and
if you are going to a back center, you
will get a doctor who is well train in
what you need.
I was good for a year after the surgery,
but then started having trouble again. My
neurosurgeon sent me to a Pain Management
Doctor, which is an anesthesiologists
trained in pain management. I get
injections with a fluoroscopy x-ray and
the work great for several months.
I would go to your neurosurgeon and see
what they say. Usually they will try oral
steroid meds, which also work great but
don't last long, and physical therapy
before any surgery.
I hope everything works out for you. I
know how back the pain can be.
Linda
|
mac43rn
New User, Becoming EHEALTHy
Joined: 12 Feb 2008 Posts: 4
just some points I left out Posted: 02-13-08 16:05pm
I did try a small dose of a steroid dose
pak my doctor prescribed to me in late
december (i failed to mention that)
Also, both epidurals were performed while
lying on a table (face down) and then they
let the table portion below my waist down
(so I am essentially I am lying on my
stomach and they drop the bottom half of
the table out from under me). I hope that
makes sense.
|
algosdoc
Experienced User , Rather EHEALTHy
Joined: 23 Mar 2004 Posts: 186
Posted: 02-13-08 19:38pm
It appears your surgeon to see has been in
practice 23 years. That is too long ago
in residency for doing a orthopedic spine
surgery fellowship. So, he has general
orthopedic training unless he managed to
do a spine fellowship somewhere along the
way.
As for the epidural injections: if they
used fluoroscopy with dye (radio-opaque
contrast), then you probably had a good
block. If it did not work under those
circumstances, it will not work under any
circumstances assuming the guy doing the
block was aware of the need for the
contrast dye to spread to the area of
pathology. If no fluoro or no contrast,
then consider repeating the epidural via a
transforaminal route performed by a pain
physician.
|
mac43rn
New User, Becoming EHEALTHy
Joined: 12 Feb 2008 Posts: 4
I have some more information for you Posted: 02-13-08 22:52pm
algosdoc
wrote:
It appears your surgeon to
see has been in practice 23 years. That
is too long ago in residency for doing a
orthopedic spine surgery fellowship. So,
he has general orthopedic training unless
he managed to do a spine fellowship
somewhere along the way.
As for the epidural injections: if they
used fluoroscopy with dye (radio-opaque
contrast), then you probably had a good
block. If it did not work under those
circumstances, it will not work under any
circumstances assuming the guy doing the
block was aware of the need for the
contrast dye to spread to the area of
pathology. If no fluoro or no contrast,
then consider repeating the epidural via a
transforaminal route performed by a pain
physician.
First of all thanks so much for your
reply. This physician came highly
recommended from others in the area and my
FP. I am literally driving (I am not
driving, my father is going to drive me) 3
1/2 hours from my house to see him. I
have the epidural reports so I will give
you some of the details.
Epidural number 1:
pt. was placed in prone position on chemo
table. Under fluoroscopic guidance, L4-L5
was visualized. One-percent lidocaine
infiltration. An 18-guage Husted was
advanced until loss of resistance on first
approach. No CSF or heme was seen. No
paresthesia was elicited. After a
negative aspiration, I injected Isovue 300
M 3 mL and obtained a lateral and AP
epidurogram that showed excellent
dispersion with enveloping the entire
dural sac at at least 2 different levels.
After a negative aspiration, we injected
DepoMedrol 120mg and 3 mL of 0.5% Naropin.
He tolerated this fine. We will plan on
a second injection in two weeks.
Epidural number 2:
patient was placed in the prone position.
His back was washed, and local anesthesia
was injected in the skin. With
fluoroscopy we identified the optimal spot
for entrance into the caudal canal. An
epidural needle was placed and with a good
loss of resistance, we verified the
optimal positioning with a fluoroscopy. A
120mg of methylprednisolone was injected
together with 6 mL of 0.25% bupivacaine
and saline up to a total volume of 16mL.
Anyhow there are the procedure notes from
both epidurals just so you have all the
details.
Do you think having a orthopedic surgeon
work on my back is the best choice, or
should I be looking for a neurosurgeon?
Also, what is causing the spasms. The
pain (what would call a pretty much
constant shock sensation) is there most of
the time, and the spasms usually occur
when the pain is at its peak. Is this
just due to my back muscles compensating
for whatever is going on???
And finally, I am feeling pressure from my
employer to get back to work. Believe me,
I NEED to get back to work, but I am not
going to risk further injury, and more
importantly driving while taking these
meds.
Again, I appreciate everyone's help and
advice
|
antigone
Supporter
Joined: 27 Jan 2008 Posts: 912 Location: IL
Thanks: 45
Thanked:16
Posted: 02-14-08 01:45am
I always feel a second opinion is valid.
Go to a neurosurgeon. Many neurosurgeons
specialize in back surgery. Chicago has
many great options for neurosurgeons as
does Northwest Indiana. If you are not
having to trek too far to get to any of
these locations I can name some very
reputable docs. I am an RN and worked
neuro ICU in these areas. Best of luck.
|
algosdoc
Experienced User , Rather EHEALTHy
Joined: 23 Mar 2004 Posts: 186
Posted: 02-14-08 06:40am
I agree a second opinion from a NS may be
in order. The epidural administration of
drug probably did not work because it was
not targeted to the disc level and the
massive volume used during injection
diluted out the steroid all up and down
the spine so that only a small fraction
was deposited on the affected nerve. A
transforaminal small volume approach would
have avoided this and placed the majority
of the drug directly on the nerve. Also,
the automatic planned repeat in 2 weeks of
another epidural steroid injection has no
basis in medicine or science. The
depressive effects of the steroid on the
adrenal glands from the first injection
would not have worn off by 2 weeks, and
repeated high dose steroid injection
(120mg is fairly high) can lead to shock
or severe systemic effects (short term for
about a week) after the injection.
Because of these two issues, I question
whether your steroid injection was
optimally performed, and therefore your
poor results may be due to the choices
made by the anesthesiologist. A pain
physician would probably not have used
this method. If your FP selected the
anesthesiologist and now has selected your
spine surgeon, it may be that the FP is
not sophisticated enough to know the
differences in practice, and referral
patterns may be based on who one knows
rather than what one knows. Consider a
second opinion by a neurosurgeon OF YOUR
CHOICE, not that of your FP.
Muscle spasms are not uncommon due to the
irritation of the spinal nerve....the
posterior part of the nerve courses to the
muscles of the back and the anterior
(front) part of the nerve goes to the leg.
|
mac43rn
New User, Becoming EHEALTHy
Joined: 12 Feb 2008 Posts: 4
Posted: 02-28-08 09:41am
algosdoc
wrote:
I agree a second opinion
from a NS may be in order. The epidural
administration of drug probably did not
work because it was not targeted to the
disc level and the massive volume used
during injection diluted out the steroid
all up and down the spine so that only a
small fraction was deposited on the
affected nerve. A transforaminal small
volume approach would have avoided this
and placed the majority of the drug
directly on the nerve. Also, the
automatic planned repeat in 2 weeks of
another epidural steroid injection has no
basis in medicine or science. The
depressive effects of the steroid on the
adrenal glands from the first injection
would not have worn off by 2 weeks, and
repeated high dose steroid injection
(120mg is fairly high) can lead to shock
or severe systemic effects (short term for
about a week) after the injection.
Because of these two issues, I question
whether your steroid injection was
optimally performed, and therefore your
poor results may be due to the choices
made by the anesthesiologist. A pain
physician would probably not have used
this method. If your FP selected the
anesthesiologist and now has selected your
spine surgeon, it may be that the FP is
not sophisticated enough to know the
differences in practice, and referral
patterns may be based on who one knows
rather than what one knows. Consider a
second opinion by a neurosurgeon OF YOUR
CHOICE, not that of your FP.
Muscle spasms are not uncommon due to the
irritation of the spinal nerve....the
posterior part of the nerve courses to the
muscles of the back and the anterior
(front) part of the nerve goes to the
leg.
It has been a week since my last epidural
(under fluroscopy) this time with no
steroids, only morphine. I felt great
(other then the horrible itching) for
about three days and then back to the same
thing. I can say the pain does not shoot
down to my big toe like it did before, the
lower back pain (spasms) and pain in right
buttocks is the same. It has become
frustrating beyond belief, it is effecting
my mental outlook (I wouldn't call it
depression but almost a feeling of
hopelessness). I return to my "new"
doctor on Tuesday for a follow up and I am
not sure what is left in their bag of
tricks.
Here is a prime example, I sit down in a
recliner to start typing this and I can
already feel the spasms starting. Back to
the bed I go the lay flat and stop the
spasms.
Any suggestions would be greatly
appreciated.
|
rickso
New User, Becoming EHEALTHy
Joined: 17 Aug 2008 Posts: 1
L4-5 herniation Posted: 08-17-08 11:01am
I am 63, was in great health untill I was
moving a 200 lb oxygen tanks, L4-5
heniations impringing on the L5 nerve, so
I lnow what it feels like, no fun--
My Dr gave me a Epidural whiched helped
for a short time-
Ok this is my suggestion for you, it has
been six months for me and the nerve pain
is awful at times, I take Tramadol to take
the edge off, I had a driving job, sitting
is a problem, if I was you I would just go
to a Pt and let time heal it--YOU DO NOT
WANT SURGERY of any type, I believe it
will resolve in time , could be a very
long time
I am doing this , you are much better off,
I have never heard of any type of back
surgery that was without complications of
some type and long term effects-- your
body will heal ,the back just takes
longer--be patient, some dr's are looking
for an excuse to do surgery, the goods
one's aren't, they will tell you they
believe in what they do, but if it will
heal on it's own you are better off
