Hello to the forum

[Eskimo]

I just thought I'd properly introduce myself as I have been reading the forum for awhile. I have a bit of a unique perspective as I am both a physician and now an ADR patient. I am not entirely sure my background in medicine has been a help or a hindrance. It's been a hindrance in that I sometimes have a hard time being the patient and a help in that I am able to access services much more quickly than the general public (although you Americans will probably find the process I went through slow).

My problems began back in 1990 when I was 18 and putting down a very light weight when suddenly I got the worst pain of my life in the lower back. I couldn't hardly walk or sit and embarassingly had my mom call an ambulance to take me to emergency. After a shot of something and some T3's I went home that night and it gradually settled. However, over the next 3 years it would occasionally return for a few days when one day when I was 22 I was out chopping wood for a few hours and a dull ache came on. Little did I realize at the time that it would never go away. From about 1995-2008 I had really bad pain most days but still good range of motion and function and got by with little more than Amitryptiline for sleep problems. I had seen a few specialists who gave me various incorrect diagnoses. In the meantime I had gone enough to medical school and finished my residency and still really had no idea what the cause of my back pain was. I had stopped getting xrayed back in 2001 as they always came back normal and noone had ever referred me on for anything more as I was still very functional overall.

In January 2008 I reached over to pick up my son and that began the excruciating phase of my journey. I had this horrific back and buttock pain, could only sit for about 15-30 minutes, couldn't lift up objects anymore and had a hard time bending over. I went to massage and got worse. I then went to physio and got a lot worse and started to get some numbness in my left foot. At that point, I'd finally had enough and finally got an MRI - 18 years later.

I didn't necessarily expect to see a lot of damage as until the last 3 months I had normal strength and range of motion. I was still only 36 years old. However, the MRI showed severe dessication at L5/S1 with onset of facet osteoarthritis, moderate broad based disc bulge at L4/5 with an acute annular tear and very minor disc changes at L3/4. I was in shock when I heard this and cried uncontrollably for the next half hour. The amount of times I had given bad (and arguably much worse) news to patients didn't prepare me for what I saw on the report. I was too young, I had a 1.5 year old and a stay at home wife to support. I had oodles of medical school debt to deal with.

I went on to have an epidural which was helpful for awhile but I then started to have this severe ache on the left side. I went to one of my colleagues who was a spinal interventionalist and he tried a couple of medial bundle branch blocks to the facet joint and they provided about 50% pain relief on the left side. We decided to proceed in October 2008 and again I was better for awhile. However, in December 2008, one of my stroke patients fell on me and my back really acted up after that.

At this point I knew most of the remainder of my pain was the disc. I talked to another interventionalist colleague who was conducting one of the trials on intradiscal thermal biacculaplasty and he agreed to do the procedure on me after a discogram but not as part of the study he was doing. In March 2009 I went for the discogram with somewhat unusual results:

L5/S1: no pain even though radiographically the worst disc by far

L4/5: concordant pain to my deep buttock ache

L3/4: severe sharp pain that radiated into my lower back area and my thoracic paraspinals.

The followup CT did confirm significant annular tears at both L4/5 and L3/4.

I hunted down only guy in Western Canada who did multi-level disc replacements and got my appointment May 2009 (only a four week wait for the appointment and very likely influenced by one of my residency colleagues who worked in the same complex as Dr. Bouchard). When I saw Dr. Bouchard I wasn't sure if he would consider me for the procedure because of my facet arthritis and the fact that I have bit of an unusual S1 which is mildly lumbarized. However, he thought ADR at L5/S1 and L4/5 was the best choice for me given my age and the tendency for fusions to cause degeneration at the transitional level which was a concern given my L3/L4 discogram. He thought he could re-operate at L3/4 later if it became symptomatic but felt discograms have too many false-positives to rely upon for a disc that looked fairly healthy on MRI. He also thought he could do artificial facets in about 5 years if they were majorly symptomatic once the ADR was completed.

My surgery was booked but the waitlist was about a year. I finally got the word that the surgery was on February 2nd, 2010.

I remember going in for the surgery and finding it so odd to be in the patient's chair. Through my training I had experience as being the anesthetist and as the surgeon but not as the patient. They were all very kind to me. I remember the anesthetist getting ready to start putting me under and I asked him not to let me wake up during the surgery under paralysis and he promised to keep a close eye out for me. The last thing I remember before being put out was a sense of peace. I also remember thinking that I might die but not in a scary way - my suffering would finally be over.

I woke up post-op and had a morphine pump on (I had been on long-acting narcotics leading up to the operation) in one arm, nasal prongs for oxygen, catheter in my bladder. My back was sore, my stomach was sore but mostly my elbows were killing me - probably something funny to do with the positioning for the surgery. It took a herculean effort to get myself up to the sitting position as I refused help from the nursing staff. Over the next few days I came to loathe one nurse who was particularly aggressive with her spinal nerve assessments.

Finally I was released on post-op day 3.

My course after that went pretty smoothly. I was back to work for 2 visits after one week, part-time work at 2 weeks, regular work week at 4 weeks and full-duties at 6 weeks. I was off all medications by 4 weeks. I took my first flight in 2.5 years two months post-surgery. At 3 months my spine function was coming along good - I could lift my son, play some soccer in the back yard with him, sit on couches, sit through conferences.... My pain was about 80% diminished and I was so happy.

However, come mid-May that all changed again unfortunately. I was putting together a push mower my wife bought when I felt an ache in low lumbar area. The next day I started to feel deep central pain in the low lumbar area and sharp pain the thoracic paraspinals extending up to the lower aspect of my shoulder blades. I was worried that the discs may have become loose, started to subside or the L3-4 level had become symptomatic or perhaps those facets were acting up from distention from being bent over to put together the lawn mower.

Followup xrays have looked okay. Still not sure if L3/4 or the L4/5 or L5/S1 facets might be acting up. It has still been improving slowly over the last 4 weeks but not nearly as good as before the lawn mower problem. I will soon be starting some PT/pilates to see if some core strengthening will settle it down. This is what my surgeon is hoping for right now.

Alas, that takes us up to the present day. It is hard to stay positive after all of this but I will keep hoping for better things in the future even if it means another surgery(s). I've been through a lot and I suppose I'll get through this, too.

It is good to hear some of your guys' stories both good and bad as I know that I am far from alone.

[Harrison]

Eskimo,

What an eloquent introduction – thank you for sharing your struggles. I have a few questions for you, when you get some time:

- What have you taken for pain meds this year? And in the past few months, have you tried – and cycled through – any anti-inflammatories? Various classes of NSAIDs? Natural anti-inflammatories? Have you noticed if any are more effective than others?

- What are your pain levels? Does it vary in accordance to your circadian rhythms? Better or worse in the morning?

Of course, as you know, these pains could be your spine’s way of adjusting to the new biomechanical stresses introduced by your new hardware. I hope that’s the case!

In the meantime, can you treat yourself to some warm baths and massages?

[annapurna]

One thought: were you in flexion or extension when your back flared? Even when Laura was regularly fighting the facet pain little changes helped like being hunched forward on her handlebars when riding a bike. If you weren't loading the facets, it sounds more like really pissed off and spasmy muscles. Have you thought about a short-term pulse of antispasmodic or muscle relaxant as a diagnostic?

[Eskimo]

Originally Posted by Harrison

Eskimo,

What an eloquent introduction – thank you for sharing your struggles. I have a few questions for you, when you get some time:

- What have you taken for pain meds this year? And in the past few months, have you tried – and cycled through – any anti-inflammatories? Various classes of NSAIDs? Natural anti-inflammatories? Have you noticed if any are more effective than others?

- What are your pain levels? Does it vary in accordance to your circadian rhythms? Better or worse in the morning?

Of course, as you know, these pains could be your spine’s way of adjusting to the new biomechanical stresses introduced by your new hardware. I hope that’s the case!

In the meantime, can you treat yourself to some warm baths and massages?

Hi Harrison,

I haven't been using NSAIDs except for the two weeks after the flare in May. I guess I'm one of the people who feels inflammation is the way the body tries to repair itself so long as it has gone to an extreme. I was off all pain meds about a month after surgery. Right now I'm taking Lyrica 150 mg at night to help with sleep.

The pain is at its best in the morning and probably at its worst at the end of my clinics. It tends to improve a bit again in the evening. Mechanically, it is at its worst when flexing, especially from a standing position. I find I need to brace myself with my hands when I bend forward on my thigh - makes me wonder if it is weak core and biomechanical adapation sometimes.

It will tend to flare up if I've been sitting for awhile (30 mins or longer). I do find sitting in seats with good lumbar support helps alot and can tolerate this much better. If I slouch while sitting it hurts quickly. Ditto for couches.

I just got some oblique views done today to get a glimpse of the facets: L4/L5 looks good to my eyes but L5/S1 is quite hazy unfortunately. I'll have to see what the radiologist thinks. I might go on to have a SPECT CT done just to have a better look at the facets and what is happening metabolically. I also have colleagues who are spinal interventionalists who can do medial bundle branch blocks of the facets. If the facets aren't the problem and core strengthening doesn't solve it I think I'll have to have the L3/4 disc looked at again. I'm not sure how much signal void the Mavericks will cause - I'll have to speak to one of the MRI radiologists about it. If it can't be visualized, I'll probably have to go on to discogram again at L3/4.

[Eskimo]

Originally Posted by annapurna

One thought: were you in flexion or extension when your back flared? Even when Laura was regularly fighting the facet pain little changes helped like being hunched forward on her handlebars when riding a bike. If you weren't loading the facets, it sounds more like really pissed off and spasmy muscles. Have you thought about a short-term pulse of antispasmodic or muscle relaxant as a diagnostic?

It was more or less flexion in 10 minute intervals for about an hour. I was crouched on the ground and bent over during the assembly. The should have been no extension at all. The problem becomes now whether the issue is pressure on the disc or distraction of my arthritic and possibly hypermobile facets post-ADR. This is especially true at the L5-S1 level on the left.

Unfortunately, there is no such thing as a "muscle relaxant" in reality. This entire class of medications all work mostly at the CNS level as global depressants. I'm not sure it would answer the question anyway as muscles often become irritable as a consequence of underlying injured joint tissue, IMO.

[CharlesinCharge]

I have two Maverick discs in my lumbar spine, and you will not get a clear MRI image with them in there---I tried. You could do a CT scan to get a look at your facet joints (with or without contrast)---that will give you a better picture than an MRI since the Maverick discs are 100% metal. But, I believe the best way to determine if the pain is coming from the L3-L4 disc is to have a discogram done on it. The original MRI showed degenerative changes there, and just because it was not symptomatic then does not mean it is not a pain generator now. As I am sure you know, discs do not have a blood supply and thus do not heal well---once the degeneration process starts, it usually continues to progress. That is what happened with my L3-L4 disc, which did not test positive for concordant pain on my first discogram but did test positive the second time a couple of years later and led to my second spine surgery.

Good luck,

[Eskimo]

Originally Posted by CharlesinCharge

I have two Maverick discs in my lumbar spine, and you will not get a clear MRI image with them in there---I tried. You could do a CT scan to get a look at your facet joints (with or without contrast)---that will give you a better picture than an MRI since the Maverick discs are 100% metal. But, I believe the best way to determine if the pain is coming from the L3-L4 disc is to have a discogram done on it. The original MRI showed degenerative changes there, and just because it was not symptomatic then does not mean it is not a pain generator now. As I am sure you know, discs do not have a blood supply and thus do not heal well---once the degeneration process starts, it usually continues to progress. That is what happened with my L3-L4 disc, which did not test positive for concordant pain on my first discogram but did test positive the second time a couple of years later and led to my second spine surgery.

Good luck,

Hi Charles,

Thanks for your advice again. It is just hard to get a discogram done up here - maybe I'll have to plead with the fellow who did the first one to try me again at L3/4 and see what happens. My own guess is that it is a combination of weakness and L3/4 disc but would like to resolve the issue of symptomatic facets first.

[CharlesinCharge]

I agree that ruling out the facet joints is a good idea, but your level of pain still sounds to me like it could be discogenic (sadly I have a lot of experience with it!). I would have facet injections (nerve blocks as you mentioned), and if the pain is coming from them, that should help. If the pain is not resolved (or at least not fully), I really think the next step is to have a discogram on L3-L4. It could be that your pain is coming from BOTH sources (facet joints and the L3-L4 disc), but the only way to know is to test both---injections in the facets and a discogram on the L3-L4 disc.

You cannot control your pain until you know where it is coming from, and sometimes that can be hard to determine. I recently had a flare-up of my back pain after a long period of doing very well, and we eventually injected the sacroiliac joints. The pain completely went away, and I was shocked! I never would have guessed that the SI joints were the cause of the pain, but it goes to show that you must leave "no stone unturned" in trying to diagnose the source of back pain.

[Eskimo]

Interesting that your SI joints flared up even though you have ADR which should provide some range of motion to allow dissipation of forces. However, the one thing to remember is that they won't provide significant shock absorption.

What flared things up?

[CharlesinCharge]

I am really not sure what flared up my SI joints. I did take a hard fall on my butt a couple of months earlier when I was walking my dog in the rain and I slipped, so that may have done it. But, my Pain Management doctor said they may have just gone out of alignment because my spine has has so much done to it (3 surgeries in 3 years). But, the injection worked really well and if they flare up again I may consider having a Rhizotomy (RF Ablation, much like Biacuplasty) on them. I have heard it works really well, they zap the nerves that transmit the pain, and you are pain free.