dckatz2001
05-26-2005, 05:31 PM
I had a two-level TLIF fusion at L4-L5, L5-S1 on January 5, 2005. I have
been at home recovering since. Unfortunately, I am still experiencing a lot
of pain. Specifically at night. The pain is in my lower right back and
runs from my spine along my waist. It wakes me up at night and when I get
up in the morning it is so bad I have a hard time getting out of bed. The pain I have at night is worse than anything I ever had before surgery but luckily it generally gets better within a few hours.
I still have pain during the day as well but it's not as bad as at night. I
have brought up the night pains to my doctor on many occasions and he always claims it is normal. My physical therapist has always told me she thinks there is something wrong.
I had x-rays a few weeks ago at my 4 month follow-up and everything looked
ok although the x-rays were very fuzzy and it was really difficult to see if
any bones were broken or anything. Luckily the doctor has allowed me to
continue on pain medication. I'm not sure what I would do without it right
now.
I am thinking of seeking a second opinion for the continued pain I've been
having. I don't want to create any problems with my current surgeon but I
also don't want to take any chances with my health. I would just like to
hear other people's opinions on this situation. Also, if anyone who has had
a similar surgery as me has had the same problem with continued pain for so
long. I really trust the opinions of the people here at the Pain Management board.
Thank you.
been at home recovering since. Unfortunately, I am still experiencing a lot
of pain. Specifically at night. The pain is in my lower right back and
runs from my spine along my waist. It wakes me up at night and when I get
up in the morning it is so bad I have a hard time getting out of bed. The pain I have at night is worse than anything I ever had before surgery but luckily it generally gets better within a few hours.
I still have pain during the day as well but it's not as bad as at night. I
have brought up the night pains to my doctor on many occasions and he always claims it is normal. My physical therapist has always told me she thinks there is something wrong.
I had x-rays a few weeks ago at my 4 month follow-up and everything looked
ok although the x-rays were very fuzzy and it was really difficult to see if
any bones were broken or anything. Luckily the doctor has allowed me to
continue on pain medication. I'm not sure what I would do without it right
now.
I am thinking of seeking a second opinion for the continued pain I've been
having. I don't want to create any problems with my current surgeon but I
also don't want to take any chances with my health. I would just like to
hear other people's opinions on this situation. Also, if anyone who has had
a similar surgery as me has had the same problem with continued pain for so
long. I really trust the opinions of the people here at the Pain Management board.
Thank you.
Sponsor
Shoreline
05-27-2005, 09:45 AM
Hey Dc, been there and done that, It really is to early to deem your fusin a succes or failure by fuzzy Xrays. Yuou had a ransforminall lumbar interbody fusion which is considerd minimally invasive discectomy and fusion with minamal access rod and screw placement. It all sounds great ss far as not having open surgery with a lamnectomy, But what's missing is crosslinking devices to support the axial plane at L5-S1, the other axial plane is L1-T12, where the ribs stop and lumbar vertabrea begin. These two points are major load bearing joints and the more excepted fusion for an axial plane levels involve crosslinking devices, meanng you need more than vertical placement and stabilization but also horiszontal stabilization with horizontal bars or crosslinking systems.
Without the horizontal bars you put the sacrum under added stress from rotation and twisting, crosslinking prevents this movement and allows the fusion to heal without excessive movement.
There are obvious advantages to TLIF where the muscle isn't completely stripped away and isn't an open surgery where a laminectomy has been performed. Using the same holes they use for a micro discectomy, "aproach from the side rather than midline" limts the types of hardware that can be placed through those small holes. The 3 systems used for TLIF are the CD Horizons sextant, the METRx system and the paramatrix plus, and none of them use crosslinking systems designed to prevent twisting and undue stress on the screws and screw holes at the crucial axial planes.
I've had back surgery 3 times, the last 2 were PLIFs , the last used cosslinking at every level and both have faled. The bones in the sacrum are much softer than the vertabrea and don't hld screws as well, the more torque you puton them the more mvement and likelyhod of crating a problem at L5_S1.
A good Xray would show screw toggling at S1 where the screw is inserted if the fusion fails. With non union the hardware is bareing all the weight, screws can toggle back and forth in the holes and the bone pulls away from the screw to the point that a good Xray will actualy show the teeth marks in the screw hole where the threads of the screws used to be. The screws in my sacrum pull in and out if I cross my legs and when I walk. I crunch and grind from non union and squeek from loose togling and broken hardware from the shiftin of the rig they built, It pretty much loks like aladder with 2 broken rungs from L1-S1.
Hardware is desingned to hold things in place while a fusion grows and provides stability. Untll that happens the hardware does the job. Unfortunately there is absolutely no test that wll tell you at 4 months if the fusion has failed or is alive and thriving or if the hardware is simply holding things in place onit's own. Docs use Xrays to determine alignment and lack of movement during flexion and extension Xrays. Unless the hardware fails imm*****ly and the fusion failed, the hardware can provide stabilty that will prvent movement and appear the fusion is doing it's job when it's all hardware doing it.
There is no test to check what's happening with the fusion materaial they placed, no way to tell if it's alive or dead and just waiting for reabsorption. The hardware may hold things in place for several years but it's not designed to do much past the fusion which sis usually deemed a success if nothing shfts durng the Xrays at the 6 month to 1 year point. The hardware becomes redundent and removable if the fusion is solid.
Because it takes 6 months to a year for a solid fusion, It is too early to tell. The only way to realy tell is very close examintion of each piece of hardware and to look for toggling in softer bone material in a high quality Xray. With a fuszzy Xray it's simply impossible to tell. ON a clean X ray, you can see the screw holes and if the bone is pulled away from the screw, or you can see if the screw head has sheared off and just sitting in place, you simply need a right angle, place it across the screw head and follow it to the tip of the screw, IF the head is offset, shearing has accured where the head of the screw breaks off leaving the tip in the bone and that screw is no longer providing stability.
The only way hardware subcomes to stress is when there isn't a fusion providing the stability. The hardware can basicaly do the work even on a failed fusion for several years, right up untill the hardware fails. I've snapped two sets, the last had crosslinks at every level but bth fusion were called a succes based on poor Xrays where alignment seemed correct and visual stability. But The hardware didn't break untill betwen the first and second year after surgery, during that time I was treated like junky because the doc couldn't explain the pain I was in, after all, he had done 1300 fusions and I was the onl one complaining acording to hime, BS . statistically impossible but with a giant ego involved geting a surgeon to accept his method failed or may not have been the best way to fuse L5-S1 is pretty tough. Surgeons learn to do techniques and tend to continue touse the same ones, It's geat he's gone less invasive, but without crosslinking, he's going to have a lower succes rate.
Harware is not designed to take the brunt of your weight and walking, flexion and extenson without a succesful fusion for an indefinite perid of time. Your frtunate he's still manageing the pain, but it may take the hardware actually snapping to prove there is a problm, if there is. But it really is too soon to do anything unless emthing is grossly abnormal or unstable and they simply don't do exploratory back surgery o see fif your fusion is solid bne or cldser to dried fish.
So it's basicaly too soon to tell, the hardware may provide and show stability and everythng may reman in proper alignment deamng the fusion a succes when the only thing holding things in place is your hardware.
But basicaly it too soon to really tell or to get a second opinion, many docs won't see you untill the 6 month mark anyway but it doesn't hurt to line those up. There really is no test at all to determine if the bone grew or died.
If your interested in crosslinking systems I can show yu a couple or at least the one actually proved for failed fusionsat L5-S1.
Hang in there and try to stay positive, your at a point where your rebulding lost muscle and strength so increased pain is very normal. You loose a lot of strenght and endurance very fast in a turtle shell.
Take care, Dave
Without the horizontal bars you put the sacrum under added stress from rotation and twisting, crosslinking prevents this movement and allows the fusion to heal without excessive movement.
There are obvious advantages to TLIF where the muscle isn't completely stripped away and isn't an open surgery where a laminectomy has been performed. Using the same holes they use for a micro discectomy, "aproach from the side rather than midline" limts the types of hardware that can be placed through those small holes. The 3 systems used for TLIF are the CD Horizons sextant, the METRx system and the paramatrix plus, and none of them use crosslinking systems designed to prevent twisting and undue stress on the screws and screw holes at the crucial axial planes.
I've had back surgery 3 times, the last 2 were PLIFs , the last used cosslinking at every level and both have faled. The bones in the sacrum are much softer than the vertabrea and don't hld screws as well, the more torque you puton them the more mvement and likelyhod of crating a problem at L5_S1.
A good Xray would show screw toggling at S1 where the screw is inserted if the fusion fails. With non union the hardware is bareing all the weight, screws can toggle back and forth in the holes and the bone pulls away from the screw to the point that a good Xray will actualy show the teeth marks in the screw hole where the threads of the screws used to be. The screws in my sacrum pull in and out if I cross my legs and when I walk. I crunch and grind from non union and squeek from loose togling and broken hardware from the shiftin of the rig they built, It pretty much loks like aladder with 2 broken rungs from L1-S1.
Hardware is desingned to hold things in place while a fusion grows and provides stability. Untll that happens the hardware does the job. Unfortunately there is absolutely no test that wll tell you at 4 months if the fusion has failed or is alive and thriving or if the hardware is simply holding things in place onit's own. Docs use Xrays to determine alignment and lack of movement during flexion and extension Xrays. Unless the hardware fails imm*****ly and the fusion failed, the hardware can provide stabilty that will prvent movement and appear the fusion is doing it's job when it's all hardware doing it.
There is no test to check what's happening with the fusion materaial they placed, no way to tell if it's alive or dead and just waiting for reabsorption. The hardware may hold things in place for several years but it's not designed to do much past the fusion which sis usually deemed a success if nothing shfts durng the Xrays at the 6 month to 1 year point. The hardware becomes redundent and removable if the fusion is solid.
Because it takes 6 months to a year for a solid fusion, It is too early to tell. The only way to realy tell is very close examintion of each piece of hardware and to look for toggling in softer bone material in a high quality Xray. With a fuszzy Xray it's simply impossible to tell. ON a clean X ray, you can see the screw holes and if the bone is pulled away from the screw, or you can see if the screw head has sheared off and just sitting in place, you simply need a right angle, place it across the screw head and follow it to the tip of the screw, IF the head is offset, shearing has accured where the head of the screw breaks off leaving the tip in the bone and that screw is no longer providing stability.
The only way hardware subcomes to stress is when there isn't a fusion providing the stability. The hardware can basicaly do the work even on a failed fusion for several years, right up untill the hardware fails. I've snapped two sets, the last had crosslinks at every level but bth fusion were called a succes based on poor Xrays where alignment seemed correct and visual stability. But The hardware didn't break untill betwen the first and second year after surgery, during that time I was treated like junky because the doc couldn't explain the pain I was in, after all, he had done 1300 fusions and I was the onl one complaining acording to hime, BS . statistically impossible but with a giant ego involved geting a surgeon to accept his method failed or may not have been the best way to fuse L5-S1 is pretty tough. Surgeons learn to do techniques and tend to continue touse the same ones, It's geat he's gone less invasive, but without crosslinking, he's going to have a lower succes rate.
Harware is not designed to take the brunt of your weight and walking, flexion and extenson without a succesful fusion for an indefinite perid of time. Your frtunate he's still manageing the pain, but it may take the hardware actually snapping to prove there is a problm, if there is. But it really is too soon to do anything unless emthing is grossly abnormal or unstable and they simply don't do exploratory back surgery o see fif your fusion is solid bne or cldser to dried fish.
So it's basicaly too soon to tell, the hardware may provide and show stability and everythng may reman in proper alignment deamng the fusion a succes when the only thing holding things in place is your hardware.
But basicaly it too soon to really tell or to get a second opinion, many docs won't see you untill the 6 month mark anyway but it doesn't hurt to line those up. There really is no test at all to determine if the bone grew or died.
If your interested in crosslinking systems I can show yu a couple or at least the one actually proved for failed fusionsat L5-S1.
Hang in there and try to stay positive, your at a point where your rebulding lost muscle and strength so increased pain is very normal. You loose a lot of strenght and endurance very fast in a turtle shell.
Take care, Dave
dckatz2001
05-27-2005, 10:31 AM
Thanks for the advice, Dave. This is my second surgery. The first was in 1999 and was a discectomy.
I have recently developed a lot of tailbone pain to go along with everything else. It hurts when I walk and when I sit down. Luckily it doesn't hurt all the time but maybe 50%. Is that a sign of anything? The surgeon says that too is normal. He has a huge ego and we have had our share of disagreements but luckily he has been decent to me lately. I do appreciate that he continues to manage the pain but I worry that he will become impatient and decide that I should be healed and pull my meds. What does one do in that situation? I've been dealing with back pain for 7 years and, like everyone else, have been called a junkie before. That is the last thing I need right now.
Thanks again.
DC
I have recently developed a lot of tailbone pain to go along with everything else. It hurts when I walk and when I sit down. Luckily it doesn't hurt all the time but maybe 50%. Is that a sign of anything? The surgeon says that too is normal. He has a huge ego and we have had our share of disagreements but luckily he has been decent to me lately. I do appreciate that he continues to manage the pain but I worry that he will become impatient and decide that I should be healed and pull my meds. What does one do in that situation? I've been dealing with back pain for 7 years and, like everyone else, have been called a junkie before. That is the last thing I need right now.
Thanks again.
DC
Shoreline
05-27-2005, 10:59 AM
Hey DC, Most likely when he yanks the meds, which surgeons eventually do. He will refer you to a pain management doc or a Physical med and rehab doc, most physiatrst "physical med" docs also practie PM. They may or may not use opiates but there are some meds out there that may help and lkely they will continue with your rehab and PT. After 2 surgeries, expect alot of PT, aside from the basic feel good stuff, there is myofacial release which can be helpful when adhesions have tacked your skin down to the muscle layer or scar management to break loose some of the scar tissue.
They have alot of options for pain mnagement and if it's simply a matter of taking longer to recover because it's your second surgery, you may be a little older now and we don't heal as fast as kids do. If PM has a plan and believe yo will continue to improve with PT and the right modalities they may also continue the pan meds to allow you to really work in PT without the fear of causing more pain.
Some Pm docs are quick to say your pain is intractable and will start patients on long acting opiates lke OxyContin, MSContin, duregesic, methadone etc, but it's still a bit early to say your not going to get better and never will. If you believe it, it will likely come true. If you contnue to work on your recovery, do everything your supposed to and you still can't regain function or manage your pain, these meds will be available down the road.
Persoannly I wouldn't want to go the LA opiate route untill I was sure that this is my only option. Although we get desperate for pain relief, usng these meds certainly has a price, more docs will disagree with opiate use, more addict coments, even family and friends like to form opinions of where you should be as far as recovery, how much pain you should be in and what your motives for med use are. If you haven't experienced that kind of pain, or had succesful surgery that went smoth, it's hard for people to understand what your going through.
I've been in the same spot, a few months post op wondering when the last refill will be. Things are little different now than 10 or 15 years ago, and pain is certainly treated more agressively by PM docs, but you have to decide for yourself how much discomfort you can manage and what your needs are.
Pm is trial and error, most go few alot of steps before someone says opiates are the only answer. When A doesn't work, try B, when B doesn't work try C when c doesn't and that doc runs out of things to try you ind a new doc that uses different methods. Eventually you may find that the only thing that works is pain meds or you find something else along the trail of trial and error.
But 4 months post op, you should just now be weaning off the brace and getting used to suporting yourself without the brace. It takes time, we lose strength amazingly fast when in a turtle shell. I wouldn't look at worst case scenarios yet, and you don't have any reason to believe things haven't worked other than the pain, which may simply be part of rebuilding the strength you lost. Hopefuly as you get stronger the pain will deminsih and you find that the fusion has worked and the pain slwly subsides. Extra pain at night is pretty nomal, your just paying for the activity of the day, as you become reconditioned, that will hopfuly improve too. Is most of it back pain or do you still have leg pain?
Talk with ya later, Dave
They have alot of options for pain mnagement and if it's simply a matter of taking longer to recover because it's your second surgery, you may be a little older now and we don't heal as fast as kids do. If PM has a plan and believe yo will continue to improve with PT and the right modalities they may also continue the pan meds to allow you to really work in PT without the fear of causing more pain.
Some Pm docs are quick to say your pain is intractable and will start patients on long acting opiates lke OxyContin, MSContin, duregesic, methadone etc, but it's still a bit early to say your not going to get better and never will. If you believe it, it will likely come true. If you contnue to work on your recovery, do everything your supposed to and you still can't regain function or manage your pain, these meds will be available down the road.
Persoannly I wouldn't want to go the LA opiate route untill I was sure that this is my only option. Although we get desperate for pain relief, usng these meds certainly has a price, more docs will disagree with opiate use, more addict coments, even family and friends like to form opinions of where you should be as far as recovery, how much pain you should be in and what your motives for med use are. If you haven't experienced that kind of pain, or had succesful surgery that went smoth, it's hard for people to understand what your going through.
I've been in the same spot, a few months post op wondering when the last refill will be. Things are little different now than 10 or 15 years ago, and pain is certainly treated more agressively by PM docs, but you have to decide for yourself how much discomfort you can manage and what your needs are.
Pm is trial and error, most go few alot of steps before someone says opiates are the only answer. When A doesn't work, try B, when B doesn't work try C when c doesn't and that doc runs out of things to try you ind a new doc that uses different methods. Eventually you may find that the only thing that works is pain meds or you find something else along the trail of trial and error.
But 4 months post op, you should just now be weaning off the brace and getting used to suporting yourself without the brace. It takes time, we lose strength amazingly fast when in a turtle shell. I wouldn't look at worst case scenarios yet, and you don't have any reason to believe things haven't worked other than the pain, which may simply be part of rebuilding the strength you lost. Hopefuly as you get stronger the pain will deminsih and you find that the fusion has worked and the pain slwly subsides. Extra pain at night is pretty nomal, your just paying for the activity of the day, as you become reconditioned, that will hopfuly improve too. Is most of it back pain or do you still have leg pain?
Talk with ya later, Dave
dckatz2001
05-27-2005, 11:06 AM
I wanted to add that the doctor never had me wear a turtle shell type brace. I have worn an elastic brace with velcro holding it on. It offers some support but not much. Could that contribute to the problem?
Also, I am 28 years old. Before I had surgery the surgeon told me I would be recovered and back to work in 6 weeks. He seemed very optomistic because of my age. He said I was the youngest person he has ever done this surgery on. This has made me very frustrated because I always have the feeling that he thinks I am exagerating my condition and that I should be much farther along in recovery than I am. I know people heal at different rates, though.
I haven't gotten a chance to read your second reply yet, shoreline, because I have to leave for physical therapy in 2 minutes but I will read it when I get home.
Thanks again for your help.
DC
Also, I am 28 years old. Before I had surgery the surgeon told me I would be recovered and back to work in 6 weeks. He seemed very optomistic because of my age. He said I was the youngest person he has ever done this surgery on. This has made me very frustrated because I always have the feeling that he thinks I am exagerating my condition and that I should be much farther along in recovery than I am. I know people heal at different rates, though.
I haven't gotten a chance to read your second reply yet, shoreline, because I have to leave for physical therapy in 2 minutes but I will read it when I get home.
Thanks again for your help.
DC
Shoreline
05-27-2005, 01:01 PM
Hey DC, No I don't think it's good idea not to protect the fusion witha brace. best case scenario, if you have posteror hardware and cages put in from he front, this wold maintain the space between vertabrea without torking the screwss it may be safe not to protect the fusion, but It does sound odd. Maybe it's a new trend. I read where someone was returned to wrork 6 weeks post fusion and that sounds insane. It taksa good year before our spine will be right and all the muscles and nerves and scar tissue has been dealt with for fusions tobe as solid as they can get. An ellastic bvbelt doesn't protect you and if you had fallen you could have been right back under the knife. Docs are puttng way to much faith in this hardware. They used the same hardware on m that now has FDA aproval, Back then I was the guinea pig and it does fail if there isn't a solid fusion. L5-S1 junction is a tough area to fuse and even harder to do it without an anterior aproach and cages. The sacrum just won't hold screws the same as vertabrea.
Are you part of a trial to see if bracing has an impact on fusion success that you may not be aware of. If you could hav seen 6 docs about this surgery, you could have gttten 6 comletely dfferent aproaches. Some docs ue BMP, some use cages, some rods and crerws, some use both, some use an anterir aproach and sme do them posterior, some do both. Did you use a bone growth stimulator? I had no idea bracing was optinal. My last surgheon wanted to put me in a bod cast since the first fusion failed. But that's not practicle. But bracing is practicle, I don't get that and the hardware wouldn't rotect you from a fall or a car accident and you really don't want them going back in because you weren't protected while healing. Just my opinion, but It does sound stange not to have theturtle shell. Even the shells evolved between the last 2 surgeres, I liked my first one better and used it more often.
Do you know how he did your fusion> Harvested from your Hip, cadavor, plugs or crushed up paste made from your own bone, donar bone and BMP "bone morph proteins" Some docs harvest ribs for he marrow. There are just so many variations and so few studies comparing them, it would hurt the bio med product biz too much if all Orthos decided to only use one type of hardware by one manufacturer. Heck, the golf courses would be clear or docs would have to pay for their own trips and green fees.
Now I'm wondering what ther strange method the doc used, Do you remeber signing consent forms that included experimental methods or products. They used BMP on me 5 years before rhBMP2 got aproved, but we do what docs convince us is the best way. What I know now is to get as many consults as possible and ask them why their way is better, SHOW ME. LOL
You may want to actively pursue a consult just because your didn't wear a brace, is it too late to help? I would want to ask anther doc, Is this so far outside the standards of practice it's mal practice to experiment on you? I just have more questions the more you tell me about your surgery?
Hang in there, Hopefully you got some feel good PT today.
Dave
Are you part of a trial to see if bracing has an impact on fusion success that you may not be aware of. If you could hav seen 6 docs about this surgery, you could have gttten 6 comletely dfferent aproaches. Some docs ue BMP, some use cages, some rods and crerws, some use both, some use an anterir aproach and sme do them posterior, some do both. Did you use a bone growth stimulator? I had no idea bracing was optinal. My last surgheon wanted to put me in a bod cast since the first fusion failed. But that's not practicle. But bracing is practicle, I don't get that and the hardware wouldn't rotect you from a fall or a car accident and you really don't want them going back in because you weren't protected while healing. Just my opinion, but It does sound stange not to have theturtle shell. Even the shells evolved between the last 2 surgeres, I liked my first one better and used it more often.
Do you know how he did your fusion> Harvested from your Hip, cadavor, plugs or crushed up paste made from your own bone, donar bone and BMP "bone morph proteins" Some docs harvest ribs for he marrow. There are just so many variations and so few studies comparing them, it would hurt the bio med product biz too much if all Orthos decided to only use one type of hardware by one manufacturer. Heck, the golf courses would be clear or docs would have to pay for their own trips and green fees.
Now I'm wondering what ther strange method the doc used, Do you remeber signing consent forms that included experimental methods or products. They used BMP on me 5 years before rhBMP2 got aproved, but we do what docs convince us is the best way. What I know now is to get as many consults as possible and ask them why their way is better, SHOW ME. LOL
You may want to actively pursue a consult just because your didn't wear a brace, is it too late to help? I would want to ask anther doc, Is this so far outside the standards of practice it's mal practice to experiment on you? I just have more questions the more you tell me about your surgery?
Hang in there, Hopefully you got some feel good PT today.
Dave
Shoreline
05-27-2005, 01:15 PM
Hey DC, I did some digging to see if not bracing is a trend and only found one article off the bat, I guess it wouldn't be considered outside the standards of care not to brace acording to this small study. They usally learn within a couple of years what the outcome of a significant change in the previous standard of care is and how it effects the patient regardless of small studies.
They used to just cut peripheral nerves for radiculopothy, unfortunately the guys that had this done, had a very high percentage of recurrent and worse pain than prior to clipping a nerve.But some docs still do it and feel by placing the ends of each nerve in a position where they can't reconenect and can't connect to something they shouldn't it will be OK. I wouldn't do it no matter how much some doc thinks it's OK. I've read enough, talked to enough docs, to know it's very iffy and takng a big chance on making things worse.
Here is what I found about bracing.
Post-Operative Bracing
After spinal fusion, bracing may aid in immobilization in the early stages of fusion healing. However, due to the advances in internal fixation techniques, not every patient will require a brace post-operatively. (88)
Lumbar Braces
Lumbar braces include corsets, bi-valve thoraco-lumbo-sacral orthoses (TLSO), Boston Overlap braces, and chair-back braces. The need for bracing for thoracic procedures is less, because of the stabilizing forces of the ribs and chest cage.
Although a few studies have been attempted to explore the need for post-operative bracing, no well-designed studies clearly show that bracing increases fusion rates in the lumbar spine. Authors of a retrospective study analyzing cases spanning 47 years suggested that more restrictive post-operative immobilization in a body cast increased fusion rates over immobilization in a TLSO, but did not control well for surgical approach (posterior only versus anterior/posterior) or use of instrumentation. (89)
In one study, 95 patients undergoing instrumented lumbar fusions were randomized to either eight weeks of external immobilization using a corset or no immobilization. After only eight weeks, the authors concluded there were no differences in post-operative outcomes measured by SF-36 scores, Dallas Pain Questionnaire, or fusion rates. (90)
One small study (n=6) measured loads across implanted, calibrated, posterior spinal fixators while patients were wearing three different types of braces. The fixators consisted of longitudinal rods and hooks placed prior to anterior interbody fusion in all but one case. The fixators were removed later. The authors concluded that none of the braces reduced loads or forces measured across the fixator. In fact, during some activities, wearing a brace tended to increase loads on the fixator. It was not clear from the study whether posterolateral arthrodesis was performed. It is important to note that this fixator did not utilize pedicle screws; the form of instrumentation most commonly used in elective lumbar fusion surgeries. The fusion rate was not an outcome measured by this study. Despite the lack of clear evidence that bracing positively affects fusion rates, many surgeons utilize some form of post-operative immobilization to help moderate pain and remind patients of their activity precautions.
They used to just cut peripheral nerves for radiculopothy, unfortunately the guys that had this done, had a very high percentage of recurrent and worse pain than prior to clipping a nerve.But some docs still do it and feel by placing the ends of each nerve in a position where they can't reconenect and can't connect to something they shouldn't it will be OK. I wouldn't do it no matter how much some doc thinks it's OK. I've read enough, talked to enough docs, to know it's very iffy and takng a big chance on making things worse.
Here is what I found about bracing.
Post-Operative Bracing
After spinal fusion, bracing may aid in immobilization in the early stages of fusion healing. However, due to the advances in internal fixation techniques, not every patient will require a brace post-operatively. (88)
Lumbar Braces
Lumbar braces include corsets, bi-valve thoraco-lumbo-sacral orthoses (TLSO), Boston Overlap braces, and chair-back braces. The need for bracing for thoracic procedures is less, because of the stabilizing forces of the ribs and chest cage.
Although a few studies have been attempted to explore the need for post-operative bracing, no well-designed studies clearly show that bracing increases fusion rates in the lumbar spine. Authors of a retrospective study analyzing cases spanning 47 years suggested that more restrictive post-operative immobilization in a body cast increased fusion rates over immobilization in a TLSO, but did not control well for surgical approach (posterior only versus anterior/posterior) or use of instrumentation. (89)
In one study, 95 patients undergoing instrumented lumbar fusions were randomized to either eight weeks of external immobilization using a corset or no immobilization. After only eight weeks, the authors concluded there were no differences in post-operative outcomes measured by SF-36 scores, Dallas Pain Questionnaire, or fusion rates. (90)
One small study (n=6) measured loads across implanted, calibrated, posterior spinal fixators while patients were wearing three different types of braces. The fixators consisted of longitudinal rods and hooks placed prior to anterior interbody fusion in all but one case. The fixators were removed later. The authors concluded that none of the braces reduced loads or forces measured across the fixator. In fact, during some activities, wearing a brace tended to increase loads on the fixator. It was not clear from the study whether posterolateral arthrodesis was performed. It is important to note that this fixator did not utilize pedicle screws; the form of instrumentation most commonly used in elective lumbar fusion surgeries. The fusion rate was not an outcome measured by this study. Despite the lack of clear evidence that bracing positively affects fusion rates, many surgeons utilize some form of post-operative immobilization to help moderate pain and remind patients of their activity precautions.
dckatz2001
05-27-2005, 02:27 PM
Shoreline, thank you so much for the research you did. It was way beyond what I even imagined I would get as a response from anyone here. But you always do go beyond what people ask for with your responses and I know I appreciate it very much.
The surgeon use BMP. He was very enthusiastic on the stuff. Claimed it was wonderful and would increase my chances of a successful fusion.
I have no idea if I was in a study regarding the outcomes of not wearing a brace. I do remember thinking it was strange when they showed me the girdle thing I got after reading about the turtle shell type that most people got.
When I was in the hospital after the surgery I had horrible muscle spasms. They were so bad that I cried many times from the pain. The spasms forced me to quickly jerk my legs up into the fetal position to relieve the pain and I remember being worried that it would hurt the fusion. The surgeon told me that there was nothing I could do that would hurt the fusion because it was so strong. He wasn't worried about it. I was in the hospital for 6 days which was longer than originally planned because of the horrible back spasms.
Before the surgery I had sciatic pain in my right leg. Luckily that pain has been relieved. Unfortunately, since the surgery I have developed a pain in my left ankle area. It is numb and has a dull ache. The surgeon told me that it is normal and started me on Topamax. He recently had me stop the Topamax and the pain returned. I called the office and told him and he wanted me to stay off the med for a while but said if the pain didn't go away in a few weeks I should start the med back up again. So far it hasn't gone away so I'm guessing I will be back on the Topamax soon.
The thing that makes me nervous about this doc is that no matter what new pain I complain about he says it's normal. I have a feeling I could call and tell him that my screws have started making grinding noises and he would say that's normal, too. It's very frustrating!
I've gone to physical therapy about 5 times in the past 7 years. I went to Pain Management before the surgery. I tried Acupuncture before surgery. Nothing worked. I know the surgeons get you when you are in your most frustrated state and will believe anything they say and try anything to relieve the pain. It's just too bad it doesn't work out a lot of the time.
Thanks again for all of your advice.
DC
The surgeon use BMP. He was very enthusiastic on the stuff. Claimed it was wonderful and would increase my chances of a successful fusion.
I have no idea if I was in a study regarding the outcomes of not wearing a brace. I do remember thinking it was strange when they showed me the girdle thing I got after reading about the turtle shell type that most people got.
When I was in the hospital after the surgery I had horrible muscle spasms. They were so bad that I cried many times from the pain. The spasms forced me to quickly jerk my legs up into the fetal position to relieve the pain and I remember being worried that it would hurt the fusion. The surgeon told me that there was nothing I could do that would hurt the fusion because it was so strong. He wasn't worried about it. I was in the hospital for 6 days which was longer than originally planned because of the horrible back spasms.
Before the surgery I had sciatic pain in my right leg. Luckily that pain has been relieved. Unfortunately, since the surgery I have developed a pain in my left ankle area. It is numb and has a dull ache. The surgeon told me that it is normal and started me on Topamax. He recently had me stop the Topamax and the pain returned. I called the office and told him and he wanted me to stay off the med for a while but said if the pain didn't go away in a few weeks I should start the med back up again. So far it hasn't gone away so I'm guessing I will be back on the Topamax soon.
The thing that makes me nervous about this doc is that no matter what new pain I complain about he says it's normal. I have a feeling I could call and tell him that my screws have started making grinding noises and he would say that's normal, too. It's very frustrating!
I've gone to physical therapy about 5 times in the past 7 years. I went to Pain Management before the surgery. I tried Acupuncture before surgery. Nothing worked. I know the surgeons get you when you are in your most frustrated state and will believe anything they say and try anything to relieve the pain. It's just too bad it doesn't work out a lot of the time.
Thanks again for all of your advice.
DC
dckatz2001
06-15-2005, 08:47 AM
I have a bit of an update on this. I had an appointment with one of my surgeons PA's last week. She decided that it was time for me to start tapering off my meds despite my complaints of continued severe pain. I still can't sleep for more than a few hours at a time without being woken up from excruciating lower back pain. I am almost six months post op now and this just doesn't seem right. To top it all off I just started back to work on Monday. More out of necessity than anything else. It has been more than two months since I received my last LTD check and it doesn't seem like I'll ever be able to get any of the money I'm owed. They always claim they need more documentation and when they get it there's always something wrong with it (they claim). It's a big game so they don't have to pay me. I also think they were trying to force me back to work earlier than I wanted to go back so they would end up paying me less. Well, they won.
But, on top of my normal pain I have all of the normal increased pain due to increased activity. I have no idea how I am going to do this. I am tapering off the MS Contin first and am now down to taking only one 30mg tablet at night (rather than 3 30's 3X per day). It seems like a very rapid taper but I have no choice because they didn't give me a refill of the meds. I have no idea what to do as I am not seeing the surgeon until August. I do see the PA again in July but I don't see that it would make any difference talking to her. Does anyone have any suggestions for me?
Thank you very much.
DC
But, on top of my normal pain I have all of the normal increased pain due to increased activity. I have no idea how I am going to do this. I am tapering off the MS Contin first and am now down to taking only one 30mg tablet at night (rather than 3 30's 3X per day). It seems like a very rapid taper but I have no choice because they didn't give me a refill of the meds. I have no idea what to do as I am not seeing the surgeon until August. I do see the PA again in July but I don't see that it would make any difference talking to her. Does anyone have any suggestions for me?
Thank you very much.
DC