Failed Back Surgery

[Nanook]

Hello,

I posted on this forum five years ago after I'd had surgery and received good advice. Unfortunately after lot of physiotherapy, hydro therapy my back isn't any better. I was finally told I had Failed Back Surgery. I have been diligent as a patient and have followed all the advice and exercises that I was given. I now suffer from chronic pain, I get injections twice a year, epidural, the last injection also included neuro thermy . The injections last anywhere from 3-7 weeks. I use a variety of painkillers and had avoided opiates so far, although I requested medication in order to sleep and was given Oramorph for night time, I try to use this no more than 3-4 times a week.

I suffer from chronic neuropathy in the left leg from thigh to foot, it never goes away,( lessened by injections) low back pain , after just a few minutes walking, muscle spasms. The muscles in the front of my thighs are very stiff, there is nearly a 1 inch discrepancy on my right side ( I use orthotics), a pronounced stoop, I've lost quite a few inches in height.

I was sent to a chronic pain clinic, however I didn't find it very helpful, I'd already tried most of the thing's they suggested, relaxation, meditation etc. I was berated for being " a permanent alternative therapy seeker", which included deep tissue massage for hamstrings, a couple of chiropratic sessions and 2 Bowen therapy sessions. I wasn't looking for a cure I'm very aware I have DDD and there is no cure.

Is there anything else I can do? This has altered my life drastically and left me quite depressed, although I have some fight left in me!

Another question if I may, when I do ask Dr's etc, I usually get a shrug of the shoulder's .... I have had problems with incontinence for a long time, I can tie it in with the start of the leg pain that took me to my GP in the first place. I have asked if my back could be the problem, again shrugged shoulder's .... I have a copy of my original scan, which I recently re read, it has the following, " anterior listhesis of L3 L4 combines with some minor posterior disc bulging and fairly florid facet joint hypertrophy to cause significant central canal narrowing and crowding of the cauda equina roots. At theL4-L5 level a posterior disc bulge causes narrowing of the canal compressing the thecal sac with some crowding of the equina roots but no frank central cauda equine compression. There is displacement CSF space amongst the roots suggesting significant central cauda equine root compression". Could this be the cause of my incontinence problems?

Thank you for taking time to read this, it has been my experience that once you have chronic pain , the medical profession wipes their hands of you and you're left to struggle on.

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[physiobob]

Hi Nanook,

Sorry about the slight delay on this response but was in Paris watching Mr Froome win the tour de France yesterday and just got back to my laptop. I think you have highlighted the issue here with the title of your thread 'Failed Back Surgery'. To say it more clearly you had an operation on your back that did not fix the issue that you were having that back surgery for. I would perhaps like to rethink this notion in that you did not have failed back surgery as much as you had a surgery and this did not help your issue. The surgery itself, as happens A LOT with back issues, was perhaps a total success, just not as a remedy for your pain.

Unfortunately it seems someone has dropped the management ball and not managed the next course of action. And so, as you post vividly summaries you are what many people would label a 'chronic pain' patient, one who should now be sent for Cognitive Behavioral Therapy (CBT). Of course I am jesting somewhat as for you I realize this is not at all humorous but we should make light of some of the 'shoulder shrug' comedy we see in health care these days.

Is there anything else I can do?

I think the first thing you need to find is a person who will take the time to look at and collate all your reports and investigations to put a type of flow chart together. This will help to highlight what has/has not assisted, in what ways and for how long. This person needs to be the continuous go to person to report back on ALL interventions and reactions. I would suggest this is not a GP or surgeon but perhaps a physio or other well education healthcare professional. Remember every intervention is important. 'Failures' are successes in the overall picture as we can say that these did not help. Think 'Dr. House' on this one.

The symptoms you report sound very much like you still have referred neurological symptoms AND perhaps some localized mechanical ones as well. In terms of additional investigation that would help to build the overall picture I would start with EMG nerve conduction studies to the lower limbs. These would help to identify if any particular level/s of the spinal nerves are implicated. Once we have a yes/no we can add that to the flow chart.

The above may also shed some light on cauda equina issues however there may well be other factors associated with that which are not related to the back and leg issues. Time will tell on that suffice to say that any combined incontinence issues that are of sudden onset (especially with numbness in a 'saddle distribution' between the legs/groin) should be assessed asap and not left for any length of time unchecked.

For the local pain due to mechanical loading of the facets you would expect facet injections to assist and assist with immediate effect. It is typical to use guided injections, first with an infiltrate of local anaesthetic to see if that reduces the localized discomfort. If so then pushing in a corticosteriod would be of use. If no local result you move to another segment and assess again. If the result helps for a few weeks and then wears off it would suggest that the facet was an issue but that perhaps the amount of mechanical loading on the spine is of a degree that 'freeing off' the musculature to allow more normal movement is not sufficient to sustain a result post injection. The note you mention on the original scan 'anterior listhesis of L3 L4' might indicate that the migration of bone in that part of the spine could be a factor in this but again many observations show false positives on MRI.

I don't know your financial position but perhaps a second opinion with a private Neurologist who specializes in back pain (not a rheumatologist or orthopod) would, in my opinion, be the a solid first person to discuss findings with. They have more of a handle on what can be managed conservatively and when it is time to consider other options such as surgery.

I remember a client I treated with all sorts of stabilization exercise in assocation with another physio just dpoing manual therapy for 18 months. She had a six pack to die for but her back was still unstable. In the end I watched a neurosurgeon and orthopaedic surgeon to combine to fuse 3 segments of her spine. 5 months later she was back skiing and 9 months later back horse riding. I suppose what I am saying is that don't rule out a different approach to widening the intervetebral spaces if further assessment and diagnosis lead to that option as well.

Lastly it is worth mentioning that back pain is normal. 80% or more people get in during their working lives no matter weather you are a blue collar worked or a native hunter gathered. Pain is the brains response to tell you that you are doing something that the body does not want you to do. I like to give an example of factory workers being annoyed with management and so they come knocking on the door of the boss to complain about the conditions they are being put through. The brain acts as a boss to decide what level or discomfort to give you to stop putting them through those conditions. If you stop, the workers are happy and the brain can reduce or remove the pain. If you do nothing then they come a knocking again and the brain tells you a little stronger. I hope this makes sense and what it is saying is that the area of degeneration is not causing the pain, it is causing a stimulus to the brain which is complaining. The brain then decides what to do about it. A facet block stops them knocking on the door for a while, then wears off and they start again if conditions are not changed.

It sounds like with the bowen, chiro etc. you have been trying to change the conditions but these have not targeted enough of the causes making the segments complain. So they were all good to try but now time to move on. It might also be worth reading a simple book on this like 'Explain Pain'. See more on this as this might help to understand the symptoms in relation to the cause/effect. That in turn would put you in a better place to give useful feedback for further investigation and intervention.

Do let us know how you get on as with this being a forum there is not much more we can add right now. Take the comments above as commentary and advice which you should take to your clinical manager to discuss and see what fits the overall picture. Best of luck with a speedy resolution.