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Old 07-15-2011, 01:15 PM   #1
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Steroids and/or NSAIDs after fusion

It's been a little less than 4 weeks since my fusion and things seem to be progressing nicely except for the relatively minor foot drop problem (left calf and foot) and some numbness in my right calf and foot (different area than left foot and no foot drop). Both my surgeon and my pain doctor seem to think that the weakness and numbness in my left foot might be the product of post-operative swelling.

My surgeon prescribed Naproxen 500 mg twice daily for a month (I haven't started taking it yet) and my pain doctor has suggested that I have a steroid injection as well. While I'm willing to try almost anything, I do worry some about the effects of these medicines on successful fusion. The surgeon said that since I wouldn't be taking the Nsaid for too long it wouldn't pose a problem, while the pain doctor said the possible benefit heavilt outweighed any risk from the injection.

I know many folks here have had fusions. What have your doctors told you? Has anyone taken NSAIDs or steroids prior to successful fusion?

 
Old 07-15-2011, 01:19 PM   #2
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Re: Steroids and/or NSAIDs after fusion

I took Naproxen after my cervical fusion with no ill effects. I fused easily.
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Old 07-15-2011, 03:12 PM   #3
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Re: Steroids and/or NSAIDs after fusion

Thanks for responding to my question so quickly! Do you remember the dosage and how far into the fusion you took the naproxyn? Did your doctor express any concerns about giving it to you?

Last edited by bracer; 07-15-2011 at 03:13 PM.

 
Old 07-15-2011, 07:05 PM   #4
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Re: Steroids and/or NSAIDs after fusion

Is your surgeon aware you are going to a pain management doc post-surgery? It sounds like they may be giving you conflicting advice. Usually just the surgeon manages your care up until he discharges you, unless he brings some other specialist in on consult.

Regarding the steroids, it is quite common to give an injection or a Medrol pak to reduce inflammation after fusion.

One or two Medrol paks are usually tried first. If the steroid isn't going to have any effect, it is doubtful that a NSAID is going to be strong enough to reduce inflammation.

Many spine surgeons tell their patients to avoid any NSAID until they are showing good bone growth, usually for three or six months. The research done specifically on NSAIDS and fusion are a bit vague -- some statistics are deduced from studies on bone fracture healing rather than fusion -- and another study that is frequently cited was done using rabbits...so I think surgeons could justify their position for or against the use.

I say, why chance it?? If there is even a remote chance that NSAIDS slow down bone growth, and you have other options for reducing inflammation, why take the risk??

You're bound to find patients who say they fused and took NSAIDS...and yet, many surgeons tell their patients not to take any. I'd just be curious why your surgeon wants you to take Naproxin rather than a steroid, which is usually more effective.

Last edited by teteri66; 07-15-2011 at 07:06 PM.

 
Old 07-15-2011, 07:59 PM   #5
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Re: Steroids and/or NSAIDs after fusion

Teri:

My pain management doctor is a good friend of my surgeon, who is well aware that I am seeing both of them. After a debacle at the hospital involving a PA in the group of which my surgeon is a member, I insisted that my pain doctor, who I've known for several years, be a major participant in my care. In fact, I saw my surgeon last Monday and he called the pain doc that evening, before my appointment the next day. They are working together and would do nothing major in my case without informing the other. I do think they have differing opinions on the severity of my foot drop, though not by a great degree. My pain doctor told me he expects that I'll want an epidural within a week or so, and he would be happy to do it -- and I'd be very pleased with the results. I asked about side effects, and he said that everything came with risk, but the results would be worth it. I'm waiting until after the EMG results to make a decision. Do you have any knowledge about EMGs? If I post my results, would you (or someone else) be able to help me interpret it? I know the surgeon will, but I'm getting the feeling he's an incurable optimist. My pain doctor will give his opinion also, and I expect him to be a bit more objective. I hope he still feels that a shot to reduce the inflammation will do the job. If the EMG shows other damage, I guess my wait could be much longer, though that would directly contradict the findings of my sugeon after he performed a physical on Monday.


I asked the surgeon about steroids and he gave the impression that would be the next step. I really think he beleives that the problem is going to resolve on its own within the next couple of weeks. While he may have a valid medical opinion, as a patient who has seen such opinions proven wrong more than once, I'll believe it when I see it.

I agree about the NSAIDs. I guess he's of the school that a little bit won't hurt -- and just might help. If the EMG shows that a steroid injection will help, I think that's the way he'll want to go. My pain doc has given me several of those over the past few years and I'd have him do any in the future as well.

Thanks for being here, Teri. It helps to vent this stuff to someone who cares. Once again, your time and efforts are valuable and always appreciated

 
Old 07-16-2011, 05:38 AM   #6
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Re: Steroids and/or NSAIDs after fusion

I am 4 months post lumbar fusion. My neurosurgeon has given me a couple medrol packs over the course of the 4 months, also has given me a 5 day higher dose taper of prednisone followed by 1 week of prescription Ibuprofen. Recently he gave me a 1 week course of diclofenac(anti-inflammitory usually used for spinal arthritis). The diclofenac has worked the best at taking down my nerve pain in my leg from inflammation. I have had huge amounts of Inflammation seen on CT scan at 3 months, the radiologist had thought it may have been an infection but my DR said it was inflammation because my bloodwork was fine, I also have problems with bulging discs below my fusion that narrow the foraminal opening where the nerves come out and osteoarthritis of the spine which I guess affects the facet joints below my fusion. My DR had told me it was ok to do steriods & anti-inflammitories in short bursts, he said I would need to wait to have steriod injections for the facets below after I am fully fused because he said the steriods are strong and would affect the rate of bone growth for the fusion and also being so close to when I had surgery I would run the risk of infection. So right now I am playing the waiting game until I am fully fused to use the anti-inflammitories and injections, he did say he does see good fusion happening so the steriod bursts have not affected my bone growth. Everyone is different so please keep that in mind with everyones comments.
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Old 07-16-2011, 05:54 AM   #7
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Re: Steroids and/or NSAIDs after fusion

Bracer, I was only taking 200 mg three times per day, which I had taken prior to surgery, and the surgeon didn't have any problem with my continuing that. My pain wasn't due to my neck fusion, but to lumbar stenosis. As I said, my fusion went smoothly.
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Old 07-16-2011, 07:20 AM   #8
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Re: Steroids and/or NSAIDs after fusion

Bracer -- I will answer you more thoroughly this evening. My aunt and I are going to a family picnic and being picked up in 15 minutes, so this will be brief...for now.

Most of your EMG report may not even go to your surgeon as it is a bunch of graphs, etc....and you won't probably want to copy them to the board...but parts of the report I can help you with and with the language. Please don't get your hopes up that the EMG will tell you anything definitive. The test is subjective and only as good as the person administering it and the person interpreting it, and then it cannot predict the future unless the nerve is completely non-functional, which is not the case with yours.

Personally, I would go ahead with the Medrol pak first, and/or prednisone, followed by an injection before I would take NSAIDS for a month. I know I've had the Medrol after my first fusion...and I think I also had an injection...I'll try to remember details as I'm riding along to the picnic!!

 
Old 07-16-2011, 01:09 PM   #9
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Re: Steroids and/or NSAIDs after fusion

Pain In Back: Thanks for sharing your experiences. It is fantastic to have that kind of information when I go to see my doctors. You've made me feel much better about taking oral steroids and perhaps using NSAIDs over the short term. I espacially appreciate the info on the steroid injections. I'll ask my pain doctor about that when I discuss the possibility of injections next week.

 
Old 07-16-2011, 01:22 PM   #10
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Re: Steroids and/or NSAIDs after fusion

[QUOTE=tetonteri66;4801202]Bracer -- I will answer you more thoroughly this evening. My aunt and I are going to a family picnic and being picked up in 15 minutes, so this will be brief...for now.

Most of your EMG report may not even go to your surgeon as it is a bunch of graphs, etc....and you won't probably want to copy them to the board...but parts of the report I can help you with and with the language. Please don't get your hopes up that the EMG will tell you anything definitive. The test is subjective and only as good as the person administering it and the person interpreting it, and then it cannot predict the future unless the nerve is completely non-functional, which is not the case with yours.

Personally, I would go ahead with the Medrol pak first, and/or prednisone, followed by an injection before I would take NSAIDS for a month. I know I've had the Medrol after my first fusion...and I think I also had an injection...I'll try to remember details as I'm riding along to the picnic!![/QUOTE]

Teri: I guess the EMG is somewhat of a subjective instrument. I know it can help in determining whether a nerve is completely non-functional, but can it tell you how much and/or what kind of damage a nerve has sustained? I was led to believe that it would be able to differentiate between the types of nerve damage and compression as well as whether or not damage is permenent. Do you think it is able to let us know whether my problems are caused by just inflammation, bruising during surgery, and/or real and long-lasting damage to the nerves? It would go a long way towards relieving my anxiety if I had something other than my surgeon's word for it that my impairment will not get worse and will, without a doubt, disappear within a few weeks.

I like the idea of trying the Medrol pack. As for the injection, will the EMG give my doctor an idea of where to inject or will I need to have an MRI done? I had a CT of my lumbar back just a week or so ago to make sure the hardware placement wasn't causing my leg issues-- maybe that could help.

I hope you enjoyed your picnic. My wife and I went to see the new Harry Potter movie. It was good, though sitting for two hours was kind of tough. I spent most of the time raising my left forefoot off the ground as best I could, trying to give those muscles some exercise. My foot was really singing by the end of the movie.

 
Old 07-16-2011, 06:13 PM   #11
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Re: Steroids and/or NSAIDs after fusion

I don't feel comfortable trying to say whether the Emg and Nerve conduction study will be able to tell you all the things you mentioned. From the studies I've had through the years, they could not tell me how a nerve was damaged, whether the damage was permanent, or whether it might improve.

They could tell me which nerve was affected and that it was chronic. I'm sure there was some technical information found on all the graphs that was not shared with me...but I felt the results were most unsatisfactory.

I really do not believe that anyone knows specifically the extent to which a particular nerve is damaged. They know if no signal is getting through, but, for example, they can't tell from the test what is causing the disruption of the signal...there could be compression that is not seen on MRI or other imaging,there could be compression stemming from the formation of scar tissue, or the nerve itself could develop a scar that causes it to misfire.

I don't know enough about the technical stuff to tell you whether your surgeon can tell you the pereneal nerve will soon begin to function normally, or any of the other things he has suggested either. I'm sure in some cases, it is probably possible to assess the damage using the EMG...but not too many docs are willing to go out on a limb and speculate.

The EMG will indicate which nerve is damaged and then the doctor will use fluoroscopy to find the exact location for the insertion of the needle. If they suspect inflammation, sometimes they will use a caudal which is less specific...it places the steroid over a wider area and bathes a larger tissue area in the steroid.

I'm afraid you'll just have to be patient until you visit your surgeon for the report.

We did have an enjoyable ride up to the lake -- 2 hours on very winding roads...then I stood for hours talking with second cousins once removed....or whatever they were...and being amazed that I could stand without any discomfort whatsoever. A year ago I couldn't stand long enough to quickly chop an onion, so it feels like a miracle to me!

Last edited by teteri66; 07-16-2011 at 06:15 PM.

 
Old 07-17-2011, 07:20 AM   #12
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Re: Steroids and/or NSAIDs after fusion

Teri:

If there is no inflammation, is there still a reason to get steroid shots? I guess I'm under the impression that if it's not inflammation, then it must be some sort of nerve damage -- anything from normal bruising after a fusion to some sort of more severe damage, either from something the surgeon did to improper handling of my leg during the surgery. It seems to me that if the problem is from the nerve root, then it may be a result of the surgeon's work. However, if the problem directly involves the peroneal nerve at or below my knee, then something else happened. Based on some of the things I've read, it seems peroneal nerve injury from surgery is very rare during back procedures (it usually occurs as a result of hip or knee surgery). Do you think the EMG will tell where the damage is -- is it in my back or in my leg?

I'm not willing to go with the "wait-and-see" approach until all the details of where and how are answered as much as possible. This is my leg and my life -- the whole reason I had this surgery was to be able to regain the ability to do most things that a 40-something should be able to do. If the peroneal nerve is damaged, do you know the treatment options? On the internet, most folks seem to do some PT, buy an AFO, and hope for the best while their muscles atrophy and they accept their role in the ranks of the permanently disabled. Will I never be able to run or even walk normally again -- both things I could do before this surgery, albeit with the help of medication? The thought of being permanently disabled is tough to swallow -- something I'm not sure I can handle, especially given the circumstances.

Perhaps I'm getting way ahead of myself, but If I go see the surgeon and he says time is going to tell the tale and come back to see him in 6 weeks, it's going to be tough not to feel like I'm being tossed aside as an unfortunate statistic. Frankly, I think he should see me every two weeks until this situation is resolved one way or the other. I see no reason that another EMG can't be done at the six week post-op mark to check for progress or an MRI be ordered to look for areas of damage. Is that being unreasonable?

Last edited by bracer; 07-17-2011 at 07:22 AM.

 
Old 07-17-2011, 04:43 PM   #13
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Re: Steroids and/or NSAIDs after fusion

I don't know of a way you would "know" there is no inflammation. Also the two (inflammation and nerve damage) are not an either/or thing. The inflammation may be causing nerve damage. Or the nerve may have been cut, knicked, stretched, or is just plain unhappy from being disturbed.

The EMG MAY indicate that one particular nerve is damaged, but I don't think that automatically rules out that something else may be going on, too. (such as inflammation). I think you just have to try to be patient until you get the results back from the guy who did the test, or from your surgeon if he is the one relaying the results to you. But I still do not believe those results will necessarily tell you what you want to know. Perhaps when your complaint is something as specific as drop foot, the EMG will provide more information than my limited knowledge is aware of. I hope so.

I just know in my case, the EMG showed that I had chronic radiculopathy at S1, right side worse than left. But it didn't provide any further information as to what was causing the radiculopathy, why I had such intense sciatic pain when there did not appear to be any compression on the nerve, etc.

[B]Perhaps I'm getting way ahead of myself, but If I go see the surgeon and he says time is going to tell the tale and come back to see him in 6 weeks, it's going to be tough not to feel like I'm being tossed aside as an unfortunate statistic. [/B]

You can feel this way but it wouldn't be fair to your surgeon. He'll tell you what he can...beyond that it would be like fortune telling or trying to predict the future. He won't be able to justify having you come back more often, because, other than offering you an option of PT or prescribing steroids or ESIs, there isn't anything more he can do for you.

Most people that have a more complete foot drop than you deal with it by prescribed exercises, stretching, perhaps wearing an AFO, and praying that time will heal the problem. If it appears that the damage is permanent and the nerve is not responding to treatment, they might look into tendon surgery, if the type of nerve damage supports that possible remedy. I believe it would have to be pereneal nerve damage for that to have any effect on the foot. From what you have described earlier, your situation doesn't seem to be severe enough to warrant a complex tendon surgery that might or might not "work"

Muscles do not need to atrophy while you are waiting to see if the nerve regenerates. You should be continuing to walk several times each day. Your PT should give you plenty of exercises to keep you busy, just as a one-footed calf-raise, etc. When your fusion is further along, I would think you could swim or ride a bike, etc. which would help keep the muscles exercised.

I know what you're going through is not what you'd planned on or hoped for, but tormenting yourself over what-ifs and what may happens are not helping you maintain the positive attitude you need for optimal healing. I think you'd be better off accepting this is where you are right now, and doing what you can to keep the foot stretched and active, walking as much as your surgeon suggests, keeping your food and liquid intake adequate and nutritious, and just trying to be as positive as you can muster. I realize it sounds kind of Pollyanna-ish but a positive attitude really does have an effect on healing.

[B]I see no reason that another EMG can't be done at the six week post-op mark to check for progress or an MRI be ordered to look for areas of damage. Is that being unreasonable? [/B] These things can be done if one of your doctors thinks it would reveal anything. There would be no point in repeating the EMG in six weeks...at least, I can't think what it would be. If the CT scan you had done post surgery didn't reveal anything, I doubt there would be any new information from a new MRI.

There is a new type of MRI you could have that might tell you if a nerve is damaged...it was developed by Dr. Aaron Filler, who has licensed a number of facilities around the U.S. to perform the MR neurography. But again, even if it were to reveal the exact cause of your drop foot, what could be done about it?? I think you would still end up in a waiting game.

I know you very much want some answers, and I apologize for being less than encouraging in that regard. I really hope I am completely wrong about what the EMG can reveal, and that the surgeon will be able to tell you what you want to hear when you see him. Then I will apologize again to you and learn from what you have to tell me about the whole process.

When do you see him?

 
Old 07-17-2011, 05:32 PM   #14
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Re: Steroids and/or NSAIDs after fusion

I see him on Wednesday. Please know that I don't think I should visit my surgeon just to check in. I want to make sure that I've done everything possible before waiting for Mother Nature to do her thing. To a great degree, this surgeon has brought my attitude about this on himself, either directly or indirectly. First off, the day before I had surgery, my wife and I went to see him to ease my fears and make certain we were doing the right thing. I took my list of questions, one of which was: "Can you guarantee 100% that if I have a spinal fusion I'll be no worse off than I am today?" Perhaps this was an unfair question, but I was interested in how he would qualify his response. However, his response to this direct question was "Yes." I repeated to make sure and he gave the same answer, even repeating the 100% guarantee back to my wife and I. This was a major factor in our decision. He also said that the only difference in having the fusion and a diskectomy was recovery time and the fact that I could eliminate back pain with the fusion, while the other surgery would only deal with leg pain.

As you know, two nights after my surgery I developed aspiration pneumonia (from something that occurred during the intubation process). I was moved to ICU and given additional doctors, who assumed a major role in my treatment. I was discharged by the neurosurgeon folks on Friday (my surgery was on Tuesday), but stayed in the hospital until Monday afternoon, when the other doctor released me. On that morning, the PA from the neusosurgeon group came to see me (they had continued to stop in and check on me every day). On this visit, I asked him to look at an apparent weakness in my left foot. As he tested me, I asked him why there was a difference in my strength level and he told me that he thought I wasn't giving the same effort to my left foot as my right. Maybe he had a bad breakfast or a tough weekend, but I have no explanation as to why he would say I was trying to mislead him. In any case, he gave this comment as a passing remark as he left my room. I was incensed and immediately called the surgeon's office to express my displeasure with this unprofessional behavior to his secretary. She apologized and made sure that I wouldn't have to deal with this young man in the future. My surgeon was on vacation at this time or he would have been the one I talked to about this. Regardless, it made me feel that my concerns weren't being taken seriously.

When I did see my surgeon last Monday, we discussed the incident and he apologized for it. He checked me and confirmed that I had foot drop, though he classified as a 4 on a scale of 5 and told me I'd make a "full recovery within a few weeks." That is an absolute accurate quote. He also said that my drop was so mild that he'd be surprised if anything showed up on the EMG.

While that made me feel better, my pain doctor felt that something would show up (though he still considers the drop relatively mild) on the EMG. SUre enough, the doctor who performed the EMG, while not exactly loquacious, told me that there were some issues. I asked him if there were any "red flags" and he said no. He said that the test was positive overall, but there were no guarantees on any kind of recovery.

It's those incidents that have lead me to the point where it's tough to believe that everything is going to be OK. That's why it sure would be nice if something scientific, like the EMG, gave some real results and some definitive answers. If it doesn't, then I'm going to want to know what else can be done, aside from letting things slide for a few weeks. If it's steroids or increased PT or something else, that's OK. I just want to do everything possible to make certain my recovery is as complete as possible. I'm not going to wallow in my negativity to the extent that I don't walk or follow other necessary actions for recovery, but I'm going to be nervous about this until I'm sure that everything has been done and we are on the right course.

Whew! You'd never know that I'm a man of few words most of the time. However, when it comes to sticking up for myself or someone I care for (including my students at school), I'll be a thorn in someone's side, firmly believing that the squeaky wheel gets the grease. It's too easy to be ignored or forgotten in a huge practice such as my surgeon's. In that situation, you can bet they'll know exactly who I am. I'll not be a victim of a bureaucracy.

Last edited by bracer; 07-17-2011 at 07:06 PM. Reason: spelling, spelling, spelling -- and I probably missed some!

 
Old 07-17-2011, 08:29 PM   #15
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Re: Steroids and/or NSAIDs after fusion

My posts always end up being long, too. Some people write a short paragraph and apologize for the "long" post....I can't remember if you had XLIF...I should go back and look.

I had a similar situation after my first fusion, which was for L4-5. The day after surgery, while working with the PT for the first time (my surgery concluded at 9 pm), while doing a "quad set" in the bed, I got the most horrendous pain in the front of my thigh -- I'd never had anything hurt that much before or since...and it didn't let up. They finally had to get permission from my surgeon to give me something stronger, and pretty much knocked me out for awhile. The pain never completely went away until my other fusion that I had a year ago.

It was really horrendous to go into the hospital for one thing, and come out with another malady...and I know you are reacting the same way! It was suggested that "perhaps" it was femoral nerve injury due to the way I was positioned on the table. I was told that no matter how careful they try to pad the patient, sometimes something "happens" while you are lying there for 2 hours, or however long it is you're in one position. (I have a friend who fell asleep with his legs propped up on a coffee table. I think he slept a couple hours. When he woke up, his knee wouldn't support him. He had damaged the ligaments just from the way his leg was positioned...so I know these things can happen.) But I am really digressing tonight...let's see, back to you.

Your surgeon was very unwise to say what he did to you.... If this is typical of your surgeon's responses to your inquiries, I can understand why you were annoyed by the PA's response. I have a feeling that was one of those things where you had to be there...because from what you wrote, I didn't quite interpret his response the way you did. But in any case, my surgeons would not have said that to you. Come to think of it, my current surgeon doesn't answer most of my questions directly. We discuss my question and I end up getting the information I was looking for, but there is always an acknowledgement that there are no guarantees with surgery, that he doesn't have a crystal ball, and that sometimes things happen. He never tells me what he thinks I want to hear, or gives me the easy answer. If anything, he errs on the side of unpleasant reality.

When he said the drop foot was 4 out of 5 -- would 5 be "a perfectly functioning reflex?" As I've told you, I've been learning a lot about foot drop through my aunt's situation. When I can, I ask the PT a question that I think might relate to your situation...but so far, I haven't really learned anything that surprised me. It's mostly confirmed what I already thought I knew. From everything you've said about your situation, I have to believe that you will make a full recovery. It just may take awhile.

We're going again in the morning -- the last time before my aunt's surgery. Anything you want me to ask??

 
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