Need help troubleshooting new L4-L5 pain

daveinaustin · #1 02-08-2009, 09:56 AM

As some of the "old timers" on ADR Support know, I was unsuccessful in convincing insurance to cover an ADR procedure. Insurance went so far to state they would stop covering any subsequent back issues if I paid for the ADR procedure myself. Hence, I had another ALIF fusion 6 months ago in the L4-L5 region.

The good news is that the procedure was successful, the region has recently properly fused, and the framework looks good. Unfortunately, I have new level 6-7 pain in the L4-L5 region, which has me on Norcos around the clock again.

The specifics are acute pain (similar to the sensation of pinching yourself with your fingernails), centrally located behind the L4-L5 region, in a radius about the size of a marble. The only radiating pain is within this very small region.

There is no muscular pain to the left or right of the spine. Also, there is no pain in either leg or foot. Flector patches don't seem to provide relief.

My pain management doctor is speculating it is ligament irritation, that is an artifact from the two anterior surgeries. Hopefully, he is right. However, my current research has not been able to determine anything conclusively.

Any thoughts?

Thanks for your help!

-Dave

Harrison · #2 02-09-2009, 07:31 PM

Dave, you must be really bummed…though your post is very polite. Sorry about the news. As usual, I don’t have any answers – just some questions:

- What diagnostic tests have you had that might have “illuminated” the L4-L5 area? Regarding ligament irritation, what does that mean? Scar tissue? Has that shown up on any of your imaging studies? Did the spine doc(s) point those artifacts out to you on the light boxes in previous visits?

- The fact that you report the pain radius to be so small is interesting! Can you find a really good massage therapist, ideally one trained in medical massage? They may be able to provide some good feedback; e.g., if you are lucky, it could be just a darned muscle knot or trigger point that can be resolved manually.

- Are you taking any NSAIDs or any anti-inflammatories? They work a little differently on different people; maybe your pain doc will be amenable to rotating you through several different (chemical) classes, starting with ibuprofen? You are far enough out in your fusion/bone growth, hopefully, that your spine doc won’t worry about NSAID's effect on bone growth.

- How were/are your facets in the lumbar AND cervical spine?

OK, sorry about the questions…let me know if this is helpful or counter-productive.

Liz · #3 02-10-2009, 09:52 PM

Hi Dave,

i'm really sorry to hear this news... i thought you were on the path to a full recovery; i still hope you are. You've been so supportive of patients on this forum. We go through surgeries and then when we still have relentless pain and have to go back on meds it's just so draining.

it is interesting, and perhaps hopeful, that you just have this one small spot w/no radiating symptoms.

if you see a PT you could have them use ultrasound on you to see if it will either decrease inflammation, increase blood flow, decrease scar tissue (if it is that). Don't beat yourself up on not having the ADR as this could have happened w/it as well, or maybe even worse. I'm in a big mess w/my two ADRs.

i just saw your post on Cindylou's thread about pain meds and i share the same attitude... i hate meds but the pain makes you crazy and playing catch up is difficult. i was prescribed the Flector patches today... sorry they didn't help you. Some pain management docs will prescribe ointments that contain NSAIDs and other meds from compounding pharmacies... i have one that contains ketoprofen, gabapentin, bupivacaine, and ketamine. Perhaps this is worth pursuing since you have an isolated spot. To be honest this ointment did very little for me but it's worth a try (if you have clearance to be on NSAIDs).

otherwise, massage, maybe try acupuncture??

hang in there and all the best,
Liz

daveinaustin · #4 02-11-2009, 10:14 PM

Harrison and Liz, thanks for your responses. I appreciate the concern, suggestions, and questions.

So far, I have not had much along the line of diagnostic testing. My pain management doctor pulled and pushed me in various directions. Most of it was without pain, except for a particular torso rotation to the right. He strongly believes a certain ligament became irritated, which he stated is "not uncommon" following low anterior fusions. Normally, I write down the specifics to perform my research. However, I was in level 7/10 pain at the time and quickly forgot the particular ligament. I'll find out more information when I see him tomorrow.

Tomorrow, I'm having a fluoroscopic-guided steroid injection, which will relieve pain if an irritated ligament is the causal factor. Also, he might be able to determine if there's any facet issues from the fluoroscopy. However, he doesn't believe the facets are the cause. If necessary, I might need an MRI in a couple of weeks for more information.

A deep tissue massage sounds good. They've helped to eliminate trigger points in the past. This time, the spot that's in pain seems to be directly behind my spine. When I try to locate the source of the pain, it takes me pushing my thumb directly between L4-L5. I can't seem to get to it from either side. It is really odd!

As we all know, locating the source of back pain can be tricky and misleading. Although I "feel" the pain between L4-L5, the source could be elsewhere. Unfortunately, my physical therapist hasn't been able to pinpoint the source either. Regardless, I think a good, deep tissue massage is in order.

BTW, I have been switching between Flector patches and Voltaren 75 mg. Neither have helped the L4-L5 issue. However, they have slightly helped the other common side effect where my hip and sacral area is sore from the surrounding muscles adjusting to the fully fused L4-L5 segment.

I'll report back in a few days after the steroid injection. Hopefully, the doctor's conjecture is right!

-Dave

steelskyway · #5 02-13-2009, 01:31 PM

Dave,

I hope all goes well with the injection. I for one agree do not beat yourself for not receiving an ADR. Mine is good but I too have some nagging issue with pain just below the site. As for insurance mine paid for hospital, PT, Medical equipment. Will not pay the orthopedic surgeon or the entry surgeon or the implanted device. As far as I am concerned if you pay for something related you should pay all. Yes the world according to Paul is grand in my mind!! LOL

I will be looking for your posts!

daveinaustin · #6 02-28-2009, 08:55 AM

I had the bilateral transforaminal steroid injections two weeks ago. As expected, my back felt great for about an hour. Afterwards, the injections really ticked off my angry nerves, which lead to level 8 and 9 pain for about 80 hours. Two Norcos weren't controlling the pain, so I resorted to Percocet for a few days.

Once I had my follow-up with the Pain Management doctor, he felt positive (easy for him to say!). He wasn't surprised with the level of pain I had, but didn't want to warn me beforehand, in order to ensure that pain wouldn't be a self-fulfilling prophecy. He is convinced that my current pain is with nerve and ligament irritation, and will go away in a couple of months.

I'm still at level 5-6 pain, and he might want to repeat this procedure in another 5 weeks.

daveinaustin · #7 03-14-2009, 11:31 AM

Unfortunately, the pesky pain is getting worse. Yesterday, it was up to level 8/10 while on 1.5 Norcos. Had to miss work and take a Percocet on top of the Norcos in order to catch up to the pain.

I'm still hoping the issue pertains to irritated nerves and ligaments, which apparently can be common following two ALIF fusions. My PM follow-up is in a couple of weeks. Until then, I'll keep up the Norcos, Flector patches, and plenty of icing.

Still trying to be optimistic that the pain will begin to settle down in a couple of weeks. Also, I'm beginning to regain my flexibility thanks to P.T. and stretching.

-Dave

CindyLou · #8 03-16-2009, 12:50 PM

Dave, I'm praying for you, that your pain turns the corner soon. Hang in there,

Cindylou

daveinaustin · #9 03-17-2009, 08:31 PM

Thanks CindyLou. I deeply appreciate it.

BTW, I hope your recovery from the SI fusion goes well. From the sound of your post, the procedure was successful!

-Dave

daveinaustin · #10 04-23-2009, 05:48 PM

Unfortunately, the pain is continuing to get worse. Over the past 6 weeks, I had bilateral transforaminal injections, a series of facet joint injections, and several massages.

I'm up to 5 Norcos a day, and am having severe problems falling asleep. Besides feeling groggy, I feel fine when I first wake up and for the first 15-30 mins.

Replicating the nature of the pain (this sounds odd):

1. Pinching my palm with two fingernails,
2. Increasing pressure until it hurts (Level 7), and
3. Maintaining the pressure level for 10 seconds.

- The pain sensation during the 10 seconds exactly matches the pain I feel between L4-L5.
- After releasing the pinch, there is a pulsing, throbbing pain that correlates with the pain I feel when I lie down.

I have a follow-up next week, and have sent an e-mail on whether I should have another MRI. The doctor is considering a nerve ablation/block. However, I'd prefer a solution rather than masking the problem.

Thanks for any advice!

-Dave