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    Old 08-03-2008, 01:49 PM   #1
    ChickieLou
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    Question Educate me on the usual next steps - I'm sick of back pain

    Hi Back Boardies,

    Here is my story, as briefly as I can tell it and with apologies because it's so long!

    I am a woman in my 40s, always a daily walker, active type. I have never been overweight, 5'2", 110 lbs.

    I suddenly developed back pain about 4 or 5 years ago. The main symptom I have is horrible (!) lower back and hip pain in the morning which is only alleviated by 30 minutes on a heating pad, which has become my morning routine. Once I do that, I am pain-free for the rest of the day. The morning pain used to come on at 3 am, but in the past year and a half, through my many alternative, palliative measures (which I list below), I have shifted that time to 6 am, allowing me about 6 hours of sleep. (Hallelujah!) Since my problems did not start due to any known injury, I was put in the all too-typical "woman comes into doctor's office with subjective pain" treatment track. I was told I had fibromyalgia and that depression was causing my pain. I was sent to physical therapy twice, which did little. I kept begging for an MRI, and was met with resistance because I "don't have pain down the legs or numbness". I begged for a year for an MRI and finally my doctor figured out I was going to self-refer through my insurance and find a doctor who would do it, so she said okay. Well, lo and behold, I have a "mild disk protrusion L5-S1 with arthritis". This was a happy day for me. I was referred to an orthopedic surgeon at OHSU (which was out of my mediocre health care system and now ostensibly in the care of one of the best health facilities in Oregon) and when I saw him, I think one of the first things out of my mouth was, when can we schedule surgery.

    Well, no not from him. He said because of my age (young) that he would not like to do surgery on me yet because the standard is still fusion and what happens in many people who have fusion is that in about 10 years or so, adjacent disks start to wear out abnormally and people find they need the surgery on these disks. The thinking is, if you start out young this obviously puts you into this situation too early and you don't have enough disks in your back to keep that up. When I asked him about injections, he said that the success rate is still about 50-50 and that I will need to weigh those odds myself as it is not without risks. Basically, he tried to instill in me the idea that while lousy sleep is nothing to trivialize, I am "lucky" because I don't have pain during the day. So, I went home completely deflated that day.

    So it put me back into a mode of dealing with something that is chronic, and toward that end, I have spent the last year since leaving his office doing anything my insurance will cover and many other things as well. I've been having weekly massages (I had no real expectations here), weekly acupuncture (gave me about 3 weeks of pain free mornings), weekly chiropractor (concurrently with acupuncture, gave me about 3 weeks of pain free mornings), take glucosamine/chondroitin (interestingly, gave me about 5 weeks of pain free mornings), physical therapy (did NOTHING), traction (did nothing). In every case, the morning pain was either untouched or it eventually returned. I bought an inversion table, but I am unthrilled about trying it because it's just going to be more of the same, or that is my expectation because nothing works for very long.

    I've gotten used to the pain now, but my god, it's not quality living. I am perfectly fine with getting a second opinion on this OHSU doctor, but part of me thinks some other doctor might be all too anxious to do surgery, and that idea bothers me too. So I know it really is my choice. I think if I insisted with this doctor, he would do it, and he's probably a great surgeon. I am looking at surgery someday, when I am "older".

    But what pray tell, can I try now? What is the next thing people typically try before they get to surgery? Injections? What kind? What should I be looking for in a doctor? A sports medicine ortho? I'm willing to try the next more radical thing, short of being prescribed drugs for chronic pain (though I will listen of course but they aren't for me).

    I am humbly "all ears". THANK YOU FOR READING THIS LONG POST!

    -Chickie

     
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    Old 08-03-2008, 02:31 PM   #2
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    Re: Educate me on the usual next steps - I'm sick of back pain

    Chickie, your doctor is absolutely right in not doing surgery, but not because of your age. It's because surgery for a mild disc protrustion that is not putting pressure on a nerve (no leg pain) is a very bad idea. Surgeries for back pain alone rarely help at all and in fact, can make things worse because then you have to fight scar tissue that forms. And, he is also right that once a disc, or part of one, is removed, there is further deterioration either of that disc (partial removal) or with the discs above. So truthfully, I have to agree with the doctor, tho I disagree with the thought that you are "too young". No one is "too young" if it is truly needed.

    I would suspect that arthritis is causing more of your pain than the disc is. Perhaps a regimen of motrin daily (if you can take it), maybe small dose, might get the inflammation under control. I have arthritis in my spine, too, but I have a whole host of other problems so motrin is of no use to me. Your doctor really should have talked to you about the arthritis and how the pain and stiffness can be alleviated. Maybe your family doctor will help.

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    Old 08-03-2008, 04:58 PM   #3
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    Re: Educate me on the usual next steps - I'm sick of back pain

    Hi Chickie,

    I agree with Carol, who agrees with your doctor. A mild disc protrusion with arthritis is certainly not what should lead to a spinal fusion. Generally there needs to be far more disc degeneration then that before a fusion is considered, and although I know your morning pain is bad, you would need to be in more and more constant pain for a fusion to be considered.

    You don't need to have leg pain for a fusion (I didn't have much) but a fusion is a last resort in order to completely immobilize a section of the spine because nothing else will work and the constant pain is intolerable. A fusion is very painful surgery and the recovery time is long.

    With a mild bulge a more reasonable consideration is a discectomy or laminectomy - which are less serious surgeries - but I'm still not certain it would be the right approach.

    I agree with Carol, focus on the arthritis, which may be what is actually causing you your morning pain. A great deal (but unfortunately not all) of my back pain is caused by arthritis, and medications such as Celebrex have virtually eliminated pain from that source.

    Good luck

    Paula

    Last edited by paula456; 08-03-2008 at 05:00 PM.

     
    Old 08-03-2008, 05:44 PM   #4
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    Re: Educate me on the usual next steps - I'm sick of back pain

    Wow!

    This is really interesting. Maybe this is why I responded so well to the glucosamine/chondroitin even though the results weren't long lived. It was the arthritis that responded.

    Here's another thing I was told. Some people have horribly herniated disks and never have a single symptom (I guess they are found coincidentally of autopsies). Other people have the mildest herniation and they are in agony. So is the hunch that, because I don't have sciatica or numbness, the herniation is not the cause of my pain, but rather the arthritis is?

    Are steroid injections the standard of care for arthritis? I had been offered these by a different doctor, but this was before I had the MRI and it just didn't make sense to go injecting when we didn't even know what the cause was.

    You guys are angels for me, you know? When a person decides in their mind that something is "chronic", it can also turn into an unconscious decision to be isolated with it. That's where I have been with this.

    Thank you so much.

    Last edited by ChickieLou; 08-03-2008 at 05:46 PM.

     
    Old 08-03-2008, 06:58 PM   #5
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    Re: Educate me on the usual next steps - I'm sick of back pain

    Hi Chickie. Glad we were able to help.

    Did your MRI say anything about arthritis in the sacroiliac joints? One of the places I have severe arthritis is there, and the pain sounds very much like yours. It can get so severe you'd think both your back and hip were falling apart, I'd have major spasms across my lower back and through my hip. It may very well be that.

    To answer your other question, when my doctor first diagnosed the arthritis in the SI Joints he gave me a steroid injection (it was an intramuscular injection, not into the joints) and had me taking prednasone (also a steroid) for the typical course. The first time he tried it, it worked beautifully to relieve the inflammation of arthritis. Yes, that's what it's used for, to try to subdue the arthritis. A year later when it flared again it didn't help, and that's when we ordered further tests and that's when it was discovered I had severe spinal problems as well.

    Paula

    Last edited by paula456; 08-03-2008 at 07:05 PM.

     
    Old 08-03-2008, 07:05 PM   #6
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    Re: Educate me on the usual next steps - I'm sick of back pain

    your dr and the three previous posters are correct, surgery for a mild disc protrusion is not warranted. If you look hard enough you might find a surgeon who will do it, but surgery is done to preserve neurological function, NOT for pain. In many cases, it makes pain worse.

    I realize 30 minutes on a heating pad is an inconvenience for you, but I would give anything for that to be my only problem. I had severe pain for 4 years, took morphine, fentanyl patches and vicodin, which are, in case you dont know, very strong narcotics and opiates.

    I did end up having surgery but to preserve neurological function, not for pain. The surgeon said my nerves were so compressed they were as thin as ribbons. I could not walk anymore, not just because of pain, but because the legs would buckle and not hold me up, and I was making arrangements for a wheelchair. I had gastroparesis so bad I could not poop more than once or twice a week and my bladder function was also affected.

    They told me all along surgery is to improve function, not for pain. I had surgery last month and all of my function has returned. It is truly a miracle. I can walk, sit and stand, and poop every day and urinate a normal number of times a day. My pain however is much worse than it was before. I am on about double the pain meds I was on before the surgery. Its only a month, so maybe it will get better, but I knew going in that I was doing it for the function, not the pain.

    Be grateful and do your 30 minutes on the heating pad. As time goes on it may get worse, and we will be here for you, hopefully later rather than sooner.

     
    Old 08-03-2008, 07:44 PM   #7
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    Re: Educate me on the usual next steps - I'm sick of back pain

    Hi roro,

    Well, truly I am always grateful that a heating pad helps and I understand that's what the doctor was also trying to tell me. My complaint wasn't about the inconvenience of the heating pad sessions. I threw that in as hopefully useful info as it is the only thing that helps. If I could sit on it all day, I would. The problem is the agony in the morning that destroys my sleep. If anything would help that, I would be absolutely pleased as punch. It becomes a cyclical nightmare. If I get too far behind on sleep, the next morning is worse. But the pain causes me to be behind on sleep so I am guaranteed a perpetuation of the problem. As I say though, 6 hours of sleep is certainly better than 3, but I am never really rested.

    I am sorry about your troubles and I know on a much lower scale how this darn problem starts to drive your life. I have so many pillows and cushions in my bed, my husband has to sleep in another bed. We haven't slept together since we were married 4 years ago. (It's okay, he's a horrible snorer. ) I have learned to shuffle pillows behind back and between legs in my sleep. This can't be restful.

    roro, I wish you continued improvement on your function. I have alot to learn still, because this really has been eye opening. I realize from being on these boards for a while that we've all told our stories a few times, but if you don't mind can you tell me was this a injury that you are aware of that caused this to happen to you? Was this spontaneous and/or gradual? You are right, surgery will be coming for me at some point and all the doctor said further was to be aware of sudden weakness, CES emergency, etc. and then I have a different situation on my hands.

     
    Old 08-03-2008, 08:02 PM   #8
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    Re: Educate me on the usual next steps - I'm sick of back pain

    [QUOTE=paula456;3675014]Hi Chickie. Glad we were able to help.

    Did your MRI say anything about arthritis in the sacroiliac joints? One of the places I have severe arthritis is there, and the pain sounds very much like yours. It can get so severe you'd think both your back and hip were falling apart, I'd have major spasms across my lower back and through my hip. It may very well be that.

    Paula[/QUOTE]

    Nothing was mentioned about arthritis in the hip, but I am suspicious none the less. I have had problems in that same hip since I was a teenager. It just blends into the pain in my back and I have always assumed it was referred pain from my back, but now I am starting to recollect other information about this. I saw a sports medicine ortho many years ago (before the back pain) and he said I was looking a hip replacement at some point. Maybe that point is coming. Being a young athletic person in my late twenties, I said "why wait til I'm old. I'm young and will bounce back. Let's do it now!" and he just laughed at me and explained that doctors like to forestall that one as long as possible because the technology is improving every year and "you want the best you can get when you need it since it's a joint". Maybe I'm finally apace with technology.

    Well, it sounds like steroids may be in my future if I need to try to control the arthritis.

    Back problems are a diabolical legacy, Paula. I wouldn't wish it on my worst enemy. I think my denial that this can't just be "fixed" is hurting my progress sometimes. I work in clinical research and I have quite a bit of faith in science and technology, although at the same time I am skeptical of anything a doctor says. When I walked into that doctor's office, I guess I expected that it would be like the hip replacement; technology has finally caught up. This doctor said "surprisingly, no". At least not for people in my category. That's when I turn to patients because, as is evidenced here, we know ALOT!

     
    Old 08-03-2008, 08:09 PM   #9
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    Wink Re: Educate me on the usual next steps - I'm sick of back pain

    I have to add my agreement with the other posters. I too have arthritis in my spine, along with numerous other things, but it is the arthritis that keeps me crawling out of bed in the morning, in pain. As I read your original post, and you were describing your morning pain and having to use the heat on it...then you are ok for the day, I said to myself that I bet she has arthritis...before you even mentioned it. As far as I know, there isn't an injection for arthritis itself. If you have arthritis of the SI joint, then there are injections for that.

    I agree about the surgery questions. I did have 2 fusions and 2 laminectomies. I had my 2nd fusion, because after the 1st one, the level above it, blew out. This is something I will have to live with for the rest of my life. There is always going to be a chance that the level above or below my fusions will rupture and will need another fusion. Also, because of my suregeries, I now have terrible problems with scar tissue and that comes with each surgery. So, I can totally understand why your Dr. did not suggest a fusion or any surgery at this time. My 1st fusion was when I was 41 and at that time, my Surgeon 1st tried all the conservative treatments and when all else failed, he told me that when I get to the point that my life is so restrictive, that I have a low quality of life, then he would be willing to do te surgery. But if I could live with the restrictions, he'd recommend not having surgery right away.

    One thing that I find very helpful for my arthritis is aquatic therapy or even just water excercises on my own. I go to our local pool, and take a water aerobics class for those with arthritis. I highly recommend it to you, as I noticed a difference after 4 or 5 classes. I now go to the pool weekly.

    Please feel free to continue to come to the boards to ask questions and to keep us posted on your situation.

    Lorie
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    Old 08-04-2008, 02:19 AM   #10
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    Re: Educate me on the usual next steps - I'm sick of back pain

    Hi Chickie,

    The SI Joint isn't in your hip, it's the joint that connects your spine to your pelvis. Arthritis in that joint will give you lower back pain and that pain can also refer to a number of places around your pelvis. Now, to be fair, an L5/S1 problem can also mimick hip joint pain, but 30 minutes with a heating pad is more likely to resolve arthritis rather then a protrusion problem. If you have a doctor who would like to try prednisone give it a try. Generally you will be given a pack that is set up for dosages, starting high and then reducing each day. You MUST take the entire pack, following the dose instructions carefully, but you'll know within a few days if iti's helping. You don't stay on it long term.

     
    Old 08-04-2008, 06:59 AM   #11
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    Wink Re: Educate me on the usual next steps - I'm sick of back pain

    Hi Paula-Can you tell me if the prednisone is for the arthritis in SI joints, or for the spine problem. Also, if the Arthritis is in the spine, but not in the SI area...would this work for that too. I have not heard about this and maybe it is something that would work for me too. Also, is it something that if it works, it works long term?

    Thanks,
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    Old 08-04-2008, 07:42 AM   #12
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    Re: Educate me on the usual next steps - I'm sick of back pain

    Lori, now keep in mind this was done before we did any spine imaging, but my GP is an osteopath and a thorough examination was able to pin point the SI joint as being a source of pain. He did an intramuscular cortisone shot (in the butt) and then put me on prednisone. Within a few days the pain was gone and it stayed gone for over a year, even though the prednisone dosage went on only about a week.

    Btw, unless really really necessary, you do not want to stay on Prednisone long term. It has nasty side effects.

    When the pain returned a year later, and was even worse, we tried the same thing again. This time it had no effect at all, so I was sent for a CT scan (I had an IUD so that ruled out an MRI until I could have it removed.) The CT scan shocked both of us. Severe arthritis in the SI Joints, but also severe arthritis in the facet joints, bulging at L4/L5 and severe degeneration at L5/S1 - enough so that the disc was collapsed on one side and vacuum phenomena had set in. Throw in a bit of stenosis here and there, and things were much worse then had been suspected. Since we are now out of his league, off to the specialists.

    I do not know how bad my spine was the first year when the prednisone worked. I would think if your primary problem is arthritis it's worth asking your doctor.

    I have since had a 2 level fusion of L4-S1, but I still have arthritis. I now take Celebrex for the arthritis and it has done wonders for me. If you can tolerate it, that may be another thing you may ask your doctor about. I don't know how much it actually helps the facet joint arthritis, because in my case the facet joints were so arthritic they didn't move at all. No movement, no pain. Even surprised my PT office. I could bend over and that part of my spine didn't bend at all - they called over all the therapists to look at it and go "wow."

    However, I have virtually no SI Joint pain if I take Celebrex regularly.

     
    Old 08-04-2008, 09:58 AM   #13
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    Re: Educate me on the usual next steps - I'm sick of back pain

    I am really shocked this morning after pondering this thread that several of the people here suspect right away that it is arthritis causing my pain and neither my PCP or the OHSU Ortho were clued in. I knew the heating pad business was significant.

    Lori, you asked the same question I had. It's really fascinating, but must have been extremely painful for Paula too. (Although it's always good to have answers.)

    Paula, your problem describes what my poor mother is going through RIGHT NOW. But she has had SI joint pain as far back as I can remember and responded similarly to the cortisone in the butt injection and a course of prednisone. She is having an EMG this week. Will that reveal anything of significance?

    I knew that prednisone was rough stuff and is not for long term. Paula, since cortisone is also a steroid, do you know if repeated use of it over time has the same risks associated with it as prednisone?

    What is the difference between disk degeneration and arthritis? I have heard both terms used about my case.

    Sorry about all the the questions. (I believe there should be a term coined for that moment when you have clarity on the Healthboards and now you have an insatiable curiosity about your condition! )

     
    Old 08-04-2008, 10:17 AM   #14
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    Re: Educate me on the usual next steps - I'm sick of back pain

    Chickie, I did not receive repeated cortisone injections. One injection with the regimen of prednisone was all he wanted to try before looking for other answers, and I agree.

    Disc degeneration is a loss of height and basic foundation of the intervertabral discs in your spine. Your disc protrusion is one of the symptoms of disc degeneration. It can take many forms, and as you may have noted in your research, all people at a certain age and over show some disc degeneration.

    Arthritis takes place in the skeletal structures, not the soft tissue (such as a disc.) It happens in joints when there is a breakdown in the cartilage that cushions the joints. In osteoarthritis the breakdown is caused by wear and tear, in rheumatoid arthritis the breakdown occurs because the body's immune system is attacking the joints.

    So, in facet joint arthritis there is pain when you move your spine because the facet joints have lost the cartilage cushioning, and the same if you have arthritis in the SI Joints. Because there is bone on bone contact it creates inflammation that translates into pain.

    The posters here keep focusing on the arthritis because the pain in your back disappears after 30 minutes of heat therapy, and is gone for the rest of the day. Although none of us are doctors (well, I don't think we are) generally pain from a disc gets worse as the day goes on and compression increases, and very rarely goes away after a 30 minute treatment.

    This is not to say I didn't use a heating pad as my constant companion while I was at work waiting for surgery. The heat helped sooth the constant inflammation I was feeling from my collapsed disc, but I would describe it as soothing, not pain relief. As soon as the area cooled again the pain was back as nicely as ever.

     
    Old 08-04-2008, 10:45 AM   #15
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    Re: Educate me on the usual next steps - I'm sick of back pain

    my problem in my L5 S1 was the vertebrae was broken at the pars on both sides and the vertebrae was slipped 50%. It happened slowly over 3 years. First a crack at the pars and slippage of the vertebrae, then that side broken and slipped grade 1, then both sides broken and slipped 2nd grade. (the grades are slippage of vertebrae, this is worse than a disc bulge because its the bone and it pulls all the nerves along with it and narrows the foramen, where the nerves come out)

    After reading the other posters, I agree that the arthritis is causing the pain, probably not the disc. Arthritis pain is worse in the morning or after long periods of rest, and gets better with heat and with movement. Disc pain would be pretty constant throughout the day, since it would always be pressing on the nerves. Disc pain could also get worse with certain positions.

    You are absolutely right about the sleep. Sleep is very important. I take a sleeping pill, ambien, every night, and have been for years. You may not need something this drastic. Could you put the heating pad on a timer to go off in the AM at the time you think it starts getting bad? You might need it again when you wake up, but maybe it could help you to sleep longer. Or maybe a long acting pain reliever such as mobic. (like ibuprofen but time release to last 8 hours)

     
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