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    Old 07-29-2013, 09:56 AM   #1
    razztaz1991
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    Help decipher test results (Please)

    A family member had back problems in the 90s. He eventually had a laminectomy/discotomy in 1997. That was ok after a year or so of healing until 2/12. Then the pain resurfaced in his legs this time. After several doctos and a multitude of tests, he went to a larger hospital in PA to have a L4, L5, S1 back fusion in 11/2012. Pain meds have doubled and he is in worse shape than pre-surgery. Doc just maintains that the hardware is in the corrent place and looks good, however his only recommendation is a nerve stimulator implant and/or pain pump. Obviously this only masks the issue permanently, and does not address or pinpoint the problem. I have copied the results of the last test. Does anyone know what all this means?


    CT lumbar spine post-myelography.

    Clinical information: Low back pain status post lumbar fusion.

    Following intrathecal contrast and lumbar myelography, CT scanning of the lumbar spine was performed axially with

    coronal, sagittal, and 3-D reconstructions. The study was compared to lumbar spine images from 5/18/2013 as well as

    to a previous MRllumbar spine from 8/30/2012. The study is also compared to today's myelogram.

    Lordotic curve is maintained. There is mild scoliosis of the lumbar spine convex to the right. There has been previous

    posterior pedicle fusion bilaterally from L4-S1. Midline laminectomy is present at L4-5 and L5-S1. There is a few

    millimeter anterolisthesis of L5 with respect to L4.

    L5-S1: Previous posterior pedicle fusion. The right pedicle screw at S1 extends beyond the anterior cortex of the

    sacrum. There is some irregularity of the dural sac at and slightly below the disc level due to early takeoff of the right S1

    root from the thecal sac. The L5-S1 disc bulges slightly asymmetrically to the left. Degenerative facets are noted.

    L4-L5: Posterior midline laminectomy and pedicle fusion. Degenerative bulging disc which is slightly asymmetric in the

    right paramedian area. No central stenosis. Mild bilateral foraminal narrowing.

    L3-L4: Mild to moderate central spinal stenosis. Annular disc bulge. Hypertrophy of the ligamentum flavum and mild

    facet overgrowth.

    L2-L3: No herniation or stenosis. Normal L2 roots.

    L 1-L2: Normal.

    T12-L 1: Normal.

    IMPRESSION:

    Mild to moderate central spinal steno

    Previous posterior laminectomy and pedicle fusion L4-5 and L5-S1 .
    Protrusion of the right pedicle screw at L5 beyond the anterior cortex of the sacrum on the right.


    Part of additional notes:

    The patient has had a midline laminectomy at L4-S and LS-S1 . Bilateral posterior pedicle fusion is present from L4-S1
    bilaterally.
    There is concentric narrowing of the dural sac at the L3-4 level consistent with mild to moderate central spinal stenosis.
    There is slight asymmetry of nerve root takeoffs of L4-5 and L5-S1 due to asymmetric nerve root exits from the dural
    sac. Above the L3-4 level, the dural sac is normal in caliber and the nerve roots within normal limits.
    The patient tolerated the procedure well. He did experience some low back pressure and discomfort following the
    intrathecal contrast which improved over time .

    IMPRESSION:

    Mild to moderate central spinal stenosis L3-4.
    Previous laminectomy and fusion L4 to S1 .

     
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    Old 07-30-2013, 07:24 PM   #2
    teteri66
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    Re: Help decipher test results (Please)

    Welcome to the board. You are kind to be looking into this for your relative.

    Is relative presently under the care of a spine surgeon, or, who ordered the new tests? Was the surgery performed by a neurosurgeon or an orthopedic spine surgeon?

    There are varying opinions on when it is time to have a spinal cord stimulator trial. A number of years ago, they were considered a last resort, only implanted when all other options were tried and failed. Not they are becoming more common and placed sooner. I credit this change to the rise in the number of doctors who have gone into pain management. It is a big money maker for the doctor.

    I am not normally cynical like this, but I have come to adopt this attitude in recent years. SPS(spinal cord stimulators/neurostimulators) are now routinely recommended, and the worst part of it is that it is passed off in a way that makes it sound like a simple decision. I always suggest people do lots of research and really understand what they are getting into before agreeing to the trial. These implants are not without risk and are often only marginally helpful.

    First, relative's surgery was done less than a year ago. Sometimes it can take longer than that for nerve pain to settle down. However I see several things on the report that could be potential sources of pain.

    I should first ask if your relative's pain is the same as before surgery? Is it in a new location or have a new/different quality?

    Since you are new to the board, it is important to remember that members are not doctors, but exchange information based on our personal experiences and knowledge. I've had three lumbar surgeries including continuing pain after my first fusion followed by 18 months of serious searching for answers and visits to numerous specialists...and finally a three level fusion that resolved my pain issues....so I have some understanding of what your relative is going through. I see a couple things on the imaging that I would suggest you inquire into further.

    First, it may be necessary to get another opinion from a different spine surgeon who is not in the same practice or clinic as surgeon # 1. It sounds like surgeon # 1 has his mind made up and is not going to be looking for something that may still be causing pain. It appears to me that there is something going on with one of the pedicle screws that has the potential to cause pain. [B]Protrusion of the right pedicle screw at L5 beyond the anterior cortex of the sacrum on the right. [/B] This can cause a complication.

    Does the relative have pain that runs down the outside of the hip and leg, perhaps wrapping around toward the front of the calf and maybe even into the top of the foot and the middle toes? This would be a pattern for the L5 spinal nerve root.

    The other possible source of pain that I can identify (me, the lay woman!!) is the central canal stenosis at L3-L4. This is a narrowing that can occur in two areas of the spine -- the central canal and in the foramen, which are openings at the end of each pair of vertebrae that allow the spinal nerves to exit the spine and go out to the limbs and other parts of the body. When there is a narrowing of the central canal, it can result in nerve compression, which results or can result in pain that you feel in other parts of he body, depending on where the narrowing (or stenosis) is located...in this case at L3-L4.

    I can go into more detail but for now, I would strongly urge you to suggest to your relative to try to get to the source of the pain...rather than agreeing to try to mask it with a spinal cord stimulator.

     
    Old 08-13-2013, 08:07 PM   #3
    razztaz1991
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    Question Re: Help decipher test results (Please)

    Sorry for the delay, I totally missed that you responded...

    Welcome to the board. You are kind to be looking into this for your relative. Actually the relative is my husband, so I have a vested interest in getting his some pain relied.

    Is relative presently under the care of a spine surgeon, or, who ordered the new tests? Was the surgery performed by a neurosurgeon or an orthopedic spine surgeon?
    2007 surgery - orthopedic spine surgeon
    2012 surgery – neurosurgeon
    Tests were ordered by neurosurgeon, but we obtained a copy of the CT Myleogram since it was taken locally. We live about 4 hours from UPMC where the surgeon is.

    There are varying opinions on when it is time to have a spinal cord stimulator trial. A number of years ago, they were considered a last resort, only implanted when all other options were tried and failed. Not they are becoming more common and placed sooner. I credit this change to the rise in the number of doctors who have gone into pain management. It is a big money maker for the doctor.

    I am not normally cynical like this, but I have come to adopt this attitude in recent years. SPS(spinal cord stimulators/neurostimulators) are now routinely recommended, and the worst part of it is that it is passed off in a way that makes it sound like a simple decision. I always suggest people do lots of research and really understand what they are getting into before agreeing to the trial. These implants are not without risk and are often only marginally helpful.

    First, relative's surgery was done less than a year ago. Sometimes it can take longer than that for nerve pain to settle down. However I see several things on the report that could be potential sources of pain.
    I agree which is why I was surprised the neurosurgeon recommended this procedure. Personally I think he knows he did something wrong and is just trying to brush us off. The main reason I do think this is b/c the surgery was performed the day before Thanksgiving and he was nowhere to be found afterward even though he was supposed to stop by after I became very upset about something that happened that day.

    I should first ask if your relative's pain is the same as before surgery? Is it in a new location or have a new/different quality?
    It is different which is why according to the surgeon, the surgery was a success. No more pain radiating to the legs. In fact no more leg pain. But he does have extreme pain above and below the surgical locations. Mostly above which points to L3-L4 where the stenosis shows up.

    Since you are new to the board, it is important to remember that members are not doctors, but exchange information based on our personal experiences and knowledge. I've had three lumbar surgeries including continuing pain after my first fusion followed by 18 months of serious searching for answers and visits to numerous specialists...and finally a three level fusion that resolved my pain issues....so I have some understanding of what your relative is going through. I see a couple things on the imaging that I would suggest you inquire into further.
    I understand. I was in and out of hospitals until I was 24 or so, but I was able to research items on the internet back in 1998 (before the internet is what it is today) to find the best solution to my issues at the time. 

    First, it may be necessary to get another opinion from a different spine surgeon who is not in the same practice or clinic as surgeon # 1. It sounds like surgeon # 1 has his mind made up and is not going to be looking for something that may still be causing pain. It appears to me that there is something going on with one of the pedicle screws that has the potential to cause pain. Protrusion of the right pedicle screw at L5 beyond the anterior cortex of the sacrum on the right. This can cause a complication.
    There are a few things I specifically asked about and this was one of them. The surgeon indicated the screw was supposed to extend beyond the bone so it was stable. Never really answered the question, but he assured me this is what we wanted and this would not cause his pain.

    Does the relative have pain that runs down the outside of the hip and leg, perhaps wrapping around toward the front of the calf and maybe even into the top of the foot and the middle toes? This would be a pattern for the L5 spinal nerve root. This is the pain he had pre-surgery. Pain in legs gone = successful surgery according to the surgeon.

    The other possible source of pain that I can identify (me, the lay woman!!) is the central canal stenosis at L3-L4. This is a narrowing that can occur in two areas of the spine -- the central canal and in the foramen, which are openings at the end of each pair of vertebrae that allow the spinal nerves to exit the spine and go out to the limbs and other parts of the body. When there is a narrowing of the central canal, it can result in nerve compression, which results or can result in pain that you feel in other parts of he body, depending on where the narrowing (or stenosis) is located...in this case at L3-L4.
    And yet again, I pointed this out to the surgeon to which he responded was very minimal. And I ask, if he was in there already, why wouldn’t he address this? Keeping in mind this is what caused the pain pre-2007 surgery. When he had his first pain injection, the doctor noticed how small the canal was and recommended surgery. Something all other specialists ignored and just did not understand why he was in so much pain.

    I can go into more detail but for now, I would strongly urge you to suggest to your relative to try to get to the source of the pain...rather than agreeing to try to mask it with a spinal cord stimulator.
    He agrees.

    Any other suggestions or things to consider would be greatly appreciated. I have another appointment with a different surgeon who was recommended from a co-worked. This surgeon fixed her failed fusion from a few years back. The appointment was just rescheduled so my light at the end of the tunnel just dimmed again. We have to wait to November now.

     
    Old 08-13-2013, 08:24 PM   #4
    razztaz1991
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    Re: Help decipher test results (Please)

    Welcome to the board. You are kind to be looking into this for your relative. Actually the relative is my husband, so I have a vested interest in getting his some pain relied.

    Is relative presently under the care of a spine surgeon, or, who ordered the new tests? Was the surgery performed by a neurosurgeon or an orthopedic spine surgeon?
    2007 surgery - orthopedic spine surgeon
    2012 surgery – neurosurgeon
    Tests were ordered by neurosurgeon, but we obtained a copy of the CT Myleogram since it was taken locally. We live about 4 hours from UPMC where the surgeon is.

    There are varying opinions on when it is time to have a spinal cord stimulator trial. A number of years ago, they were considered a last resort, only implanted when all other options were tried and failed. Not they are becoming more common and placed sooner. I credit this change to the rise in the number of doctors who have gone into pain management. It is a big money maker for the doctor.

    I am not normally cynical like this, but I have come to adopt this attitude in recent years. SPS(spinal cord stimulators/neurostimulators) are now routinely recommended, and the worst part of it is that it is passed off in a way that makes it sound like a simple decision. I always suggest people do lots of research and really understand what they are getting into before agreeing to the trial. These implants are not without risk and are often only marginally helpful.

    First, relative's surgery was done less than a year ago. Sometimes it can take longer than that for nerve pain to settle down. However I see several things on the report that could be potential sources of pain.
    I agree which is why I was surprised the neurosurgeon recommended this procedure. Personally I think he knows he did something wrong and is just trying to brush us off. The main reason I do think this is b/c the surgery was performed the day before Thanksgiving and he was nowhere to be found afterward even though he was supposed to stop by after I became very upset about something that happened that day.

    I should first ask if your relative's pain is the same as before surgery? Is it in a new location or have a new/different quality?
    It is different which is why according to the surgeon, the surgery was a success. No more pain radiating to the legs. In fact no more leg pain. But he does have extreme pain above and below the surgical locations. Mostly above which points to L3-L4 where the stenosis shows up.

    Since you are new to the board, it is important to remember that members are not doctors, but exchange information based on our personal experiences and knowledge. I've had three lumbar surgeries including continuing pain after my first fusion followed by 18 months of serious searching for answers and visits to numerous specialists...and finally a three level fusion that resolved my pain issues....so I have some understanding of what your relative is going through. I see a couple things on the imaging that I would suggest you inquire into further.
    I understand. I was in and out of hospitals until I was 24 or so, but I was able to research items on the internet back in 1998 (before the internet is what it is today) to find the best solution to my issues at the time. 

    First, it may be necessary to get another opinion from a different spine surgeon who is not in the same practice or clinic as surgeon # 1. It sounds like surgeon # 1 has his mind made up and is not going to be looking for something that may still be causing pain. It appears to me that there is something going on with one of the pedicle screws that has the potential to cause pain. Protrusion of the right pedicle screw at L5 beyond the anterior cortex of the sacrum on the right. This can cause a complication.
    There are a few things I specifically asked about and this was one of them. The surgeon indicated the screw was supposed to extend beyond the bone so it was stable. Never really answered the question, but he assured me this is what we wanted and this would not cause his pain.

    Does the relative have pain that runs down the outside of the hip and leg, perhaps wrapping around toward the front of the calf and maybe even into the top of the foot and the middle toes? This would be a pattern for the L5 spinal nerve root. This is the pain he had pre-surgery. Pain in legs gone = successful surgery according to the surgeon.

    The other possible source of pain that I can identify (me, the lay woman!!) is the central canal stenosis at L3-L4. This is a narrowing that can occur in two areas of the spine -- the central canal and in the foramen, which are openings at the end of each pair of vertebrae that allow the spinal nerves to exit the spine and go out to the limbs and other parts of the body. When there is a narrowing of the central canal, it can result in nerve compression, which results or can result in pain that you feel in other parts of he body, depending on where the narrowing (or stenosis) is located...in this case at L3-L4.
    And yet again, I pointed this out to the surgeon to which he responded was very minimal. And I ask, if he was in there already, why wouldn’t he address this? Keeping in mind this is what caused the pain pre-2007 surgery. When he had his first pain injection, the doctor noticed how small the canal was and recommended surgery. Something all other specialists ignored and just did not understand why he was in so much pain.

    I can go into more detail but for now, I would strongly urge you to suggest to your relative to try to get to the source of the pain...rather than agreeing to try to mask it with a spinal cord stimulator.
    He agrees.

    Any other suggestions or things to consider would be greatly appreciated. I have another appointment with a different surgeon who was recommended from a co-worked. This surgeon fixed her failed fusion from a few years back. The appointment was just rescheduled so my light at the end of the tunnel just dimmed again. We have to wait to November now.

     
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