8 Months Post Op Lumbar Fusion

[Tomorrow447]

I am 8 months post op of a lumbar fusion surgery on levels L4, L5 & S1. I still have so much pain in my back, buttock and both legs. I have great difficulty in walking. I also have burning pain in both archilles tendons. Most recent MRI showed the following:
There is a small extrathecal fluid collection at the L4 level which does not appear to communicate with the thecal sac, consistent with post operative change. (Is this Normal?)

At the L4-5 interspace, there is encasement of the thecal sac by enhancing soft tissue dorsally and on the left, consistent with epidural fibrosis.

At the L5-S1 interspace I there is posterior displacement of the
leŁt  Sl nerve root by a 10 millimeter enhancing soft tissue density with a .nonenhancing center  Although this could be post operative epidural fibrosis, a nonehhancing center raises suspicion of a small herniated fragment surrounded with enhancing granulation tissue. Continued follow-up is recommended.

I know that epidural fibrosis means scar tissue, but I have read that when their is excessive scar tissue it can cause much pain. Could this possibly be the cause of all my pain? But does that explain all the pain in my legs as well? Thank you for your time.

[CCF-Neuro-M.D.-CS]

There are a few things to consider. First if the pain you are experiencing now is the same which you experienced before surgery then it is possible the nerves were damaged before surgery, and they simply are not recovering. However, excessive tissue scaring can be a cause for post-operative pain. Based on the MRI description provided there was no enhancement of the nerve roots to suggest arachnoiditis, which can be another cause of post-operative pain. Also, another reason for post-operative pain is a retained disc fragment or a new herniation of a disc. At the S1 level on the left there appears to be a disc fragment, based on the report. This could explain some of your symptoms in your left leg. Occasionally in the post-operative state a CT myelogram is also used to visualize the spine. This may be a technique, you can discuss this with your doctor, to try and exclude other structural problems. If you have discussed this with your surgeon already, then I would encourage you to have a second opinion at an academic spine center. They will be able to review your films and provide you with some explanations. Good luck.

[The Crusader]

REPORTS OF SEVERE COMPLICATIONS FROM USING THE INJECTABLE STEROID, DEPO-MEDROL, DURING SURGERY AND FOR EPIDURAL SPINE INJECTIONS

Some surgeons are wrongly using the depo steroid, Depo-Medrol, (Pfizer/Pharmacia), while performing spinal surgery. They sometimes soak a piece of fatty tissue from the patient with Depo-Medrol and place it over the nerve roots before they suture them up!  This is extremely dangerous, (not the tissue, but the steroid) it's not approved by the FDA and "no longer recommended" by the manufacture, Pfizer/Pharmacia because of the many thousands of reported complications!  Some doctors literally pour this stuff into the incision site before they close-up!

Another way this drug is harming people is by epidural steroid nerve block injections!  Either way, it is "not recommended" by the drug maker because of the "severe medical events" that have been reported to them and the FDA!  There are new studies that link severe chronic pain syndromes with complications of this non FDA approved procedure. (Arachnoiditis, Epidural Fibrosis, etc.)  Using the Freedom of Information act, we have discovered that there have been well over 15,000 adverse event reports and 356 deaths attributed to Depo-Medrol between 1998 and 2002.  (A very high number despite that fact that only 1.5% of all adverse events get reported to the FDA!) (A 1999 Harvard Study)

Pfizer Inc. recently purchased Pharmacia/Upjohn, the manufacturer of the most commonly used injectable steroid, Depo-Medrol!  They have recently issued a new WARNING on the use of this non-FDA approved drug for spinal surgery as well as for epidural administration.  They say that Depo-Medrol is "NO LONGER RECOMMENDED" for epidural administration in a newly published Pfizer document titled: "DEPO-MEDROL - REFORMULATION-EPIDURAL USE"  The warning covers BOTH formulations they make!  

(Another misconception is that there is a preservative-free formulation of the drug, which supposedly is safer in the opinion of the doctors who use it!  These doctors are not only wrong about this, it's incompetence if they believe this is so!

Both formulations, the single dose and the multi-dose formulation, have preservatives added, MGPC and Benzyl Alcohol respectively... both are neurotoxic and potentially damaging to neuro-tissue.  Besides, both formulations contain huge amounts of Polyethylene Glycol, a chemical cousin of automobile antifreeze and a major ingredient in DOT-3 Brake Fluid!  If this isn't bad enough, they then mix Depo-Medrol with other chemicals, such as anesthetics, like Marcaine, and ionic dyes, such as Isovue, again AGAINST THE RECOMMENDATION OF PFIZER!  PFIZER CLAIMS THAT THIS PRACTICE CAN INCREASE THE "TOXIC RISKS BECAUSE OF CHEMICAL INCOMPATIBILITIES", THEREFORE THEY HAVE WARNED DOCTORS NOT TO DO IT!

Any doctor that may be reading this should call Pfizer immediately and ask for a written copy of their newly posted Warning.

All patients should be advised that they will not be told this information unless they specifically ask their doctors for it.  Even then, there is no guarantee that their doctor will even know this latest update.

Try this Google search:  "Depo-Medrol Harm"

Kindest regards,
Dennis J. Capolongo / EDNC
Center for Pharmaceutical Safety
Washington, DC

[KimSb]

Crusader, that's very interesting. Can the Neuro MD comment on this information?

[The Crusader]

It's not only very interesting Kim, the efficacy of ESI's are now in doubt!  Please read this this very important study.  Here is the very latest results of a controlled trial evaluating the efficacy of ESI's.  It's being presented next week at the 71st Annual Meeting of the American Academy of Orthopedic Surgeons in San Francisco, Ca.  It appears that ESI's are slowing falling from grace!

Link: http://www.aaos.org/wordhtml/anmt2004/sciprog/188.htm

American Academy
of Orthopedic Surgeons
March 10-14, 2004 · San Francisco, CA
Podium Presentations

-----------------------------------------------------------------

Effects of Epidural Steroids in the Lumbar Spine: A Double Blind Randomized Control Trial
Paper No: 188
To Be Presented : Friday, March 12, 2004
11:54 AM - 2:00 PM

Location: Room 250-262

Daniel Steinitz, MD Belleville ON Canada
Edward J Harvey, MD Montreal QC Canada (*)
Max Aebi, MD Bern Switzerland (*)
Philip Lander, MD Montreal QC Canada (*)
Vincent Arlet, MD Montreal QC Canada (*)
Dante Marchesi Montreal QC Canada (*)


-----------------------------------------------------------------
Moderator(s):
Behrooz A Akbarnia, MD La Jolla CA (e - DePuy Spine)
John A Glaser, MD Charleston SC
Spine

-----------------------------------------------------------------
This paper reports the results of a randomized, blinded, control trial evaluating the efficacy of epidural and translaminar steroid injections.

Hypothesis:  The addition of steroid to epidural lumbar injection may provide a measurable functional improvement after treatment.

Method:  The high incidence of lumbar pain syndromes has driven the search for an effective strategy for dealing with these patients. Much debate over the efficacy of lumbar steroid injection exists and many studies show conflicting results. Fifty patients were randomized by the even/ odd last digit of their hospital unit number. All patients with previous spinal injection or spinal surgery were excluded. All patients received an epidural injection of Xylocaine and Marcaine and the even group received additional 12mg of betamethasone. All injections were performed by the same interventional radiologist and all injections were confirmed with fluoroscopy and 2ml Omipaque dye. Patients completed all outcome measure questionnaires preinjection, two weeks post injection and two months post injection. All testing was performed by the same blinded research assistant.
Summary of results: No differences were found between patients receiving steroids and those that did not, with reference to any outcome measure. Musculoskeletal Functional Assessment (p < 0.29, p<0.68), Bother Index (p<0.50, p,0.22), Functional Index (p<0.22, p<0.73), Oswestry Score (p<0.16, p<0.11), Visual Pain Analogue Score (p<0.50, p<0.18)

Conclusion: No significant differences could be detected between patients that did or did not receive steroid injection. This study may provide evidence against the use of steroid in epidural lumbar spinal injection.

Floor discussion immediately follows paper presentation.
-----------------------------------------------------------------
Home 2004 Annual Meeting Education Podium Presentations Friday Presentations
-----------------------------------------------------------------

Last modified 23/February/2004

[lmroswell]

I have a relative that has had a few epidural blocks/injections for relief of pain that is located in one leg. I am not sure of the name of the procedure, but I do know that she is given some sort of anesthesia.  She is going for another procedure tomorrow.    Do you think it there is a concern here or is this topic not related to the procedure.  I wish I could be more specific.  One more question:  Is this drug used in epidurals for giving birth?  Thank you for any info you provide.

[The Crusader]

No, ESI's (Epidural Steroid Injections) are NOT what they use for birthing.  And yes, if I were you, I would tell your relative to ask if the steroid drug they intend to inject her with is Depo-Medrol.  If it is, consider yourself warned.

Sincerely,
Dennis
EDNC
Washington DC

[Tomorrow447]

Thank you for taking the time to answer my post. Unfortunately, most of my pain is a new type of pain in my back. Some of the pain that I had prior to my surgery did return as well. My doctor did order a CT Myelogram and that was just another painful experience for me. The same doctor that performed my discogram had done the myelogram. I can't understand why but with both procedures he hit a nerve that sent pain down my entire right leg and I screamed as the pain was unbearable. He told me that the myelogram was not normally painful and gave me yet another injection to numb me even more. But I pray that the pain was worth it and that when I see my doctor he will have results to find why I am in so much pain. But my worst fear is living the rest of my life this way. Again, I thank you.
Jeanne

[Tomorrow447]

The information that you have provided did scare me as well as inform me. I have received a series of 3 lumbar epidurals and 1 cervical epidural. When I first started with the lumbar epidural they never gave me any pain relief but did increase my pain. But I kept listening to my pain management doctor and was told that sometimes patient's need all three before they begin to work. They never worked for me. I have absolutely know idea if the drug that you have mentioned was in those injection's. With my cervical epidural I also got know pain relief and I finally said no more as I could not take the chance of the doctor increasing my neck pain as well. After all my lumbar epidural's and my lumbar discogram I required a quad cane as I was dragging my right leg. Till this day my husband states I was prepared for surgery. But I did have herniated and torn disc's with DDD, lordosis and stenosis. Based on my MRI report and the Neuro Doctor, I do not have Arachnoiditis and I thank God for that. But I also thank you for sharing your information.
Jeanne

[nursecarie]

Hello all...I am a new reader on this site, and have been doing nothing else the past few days.
I was in a car accident in 96 which resulted in 5 back surgeries by 1998!
At one point I was soo desperate for pain relief, i went to a local "pain doc" in the rural town in which I live.
This man, basically gave me a list of diagnoses, including failed back surgery syndrome, RLS,RSD, had BACK cage fusion L4/5-L5/S1, etc etc etc,, my toenails on my left foot (left was always my affected side for herniated discs) were starting to grow away from the nailbeds, in almost half moon shapes..he gave me a "trial" dose of fentanyl given in the epidural space..my leg, foot, that had always been numb and cold since like my 3rd surgery, were immediatley warm, no more dragging that foot.
this was to see if an "implantable pump" would work for me..
I had a problem with insurance ok'ing the 40 grand operation,and this doc had been in "trouble" for prescribing narcotics previously, so he informed me, if i wanted relief, he offered what he called a "pain cocktail"...catch was I could NEVER know what the ingredients were.
Against my better judgment being a nurse as well as a patient, but he preyed on the desperation of people like me, who would rather die than live another day in pain like this.
After passing out, having absense seizures, literally passing out so bad my cigarette burnt me between 2 fingers down to the bone..I thank God I was at my pc and went forward and didnt burn my house down, ended up in the ER where they found out the deal with the cocktail...if a week went with good results ( had to get refilled 1x a week)then he would take out any opiods in it..if a bad week, he'd have them add alittle methadone, week after week, on top of uncontrolled pain, enough to drive a person nuts.
And almost 3 yrs later this "doctor" is still in practice, he also gave spinal injections, depo medrol...which I warned him, steroids make me manic..i ended up on a 2 month road trip...point is, with only medical assistant as his assistant, he would give a dose of Diprivan IV..milk of "amnesia"...knocks ya right out...except my mom watched him one time do a "procedure" on me.
He told her he was breaking up scar tissue around where my herniated discs had been...basically my mom was nauseated, said he went in and out in much the same rough manner used in liposuction...and instilled...or forced...100 cc's of normal saline in the area of fibrosis.I woke up, sobbing uncontrollably, not knowing why...I left that office and never went back, may add, I had a very rough time walking when I left that office.
My point is I guess..that there are so many clinics that really don't care...example..i am currently on medicaid because I've just went back to work,and have no medical insurance. I called for an appointment at a pain clinic for a pump evaluation, again, and was told that "people with medicaid were low priority" ouch...that put me right in my place..
Makes me sick, I have spent 15 years of my life caring for patients, but right now...I can't get help.
A quick past 3 yrs update...found a doc locally finally whom was secure enough with prescribing the patch to someone who doesn't abuse meds, doesn't even like taking pills..I slowly started regaining my life...the depression slowly evaporated..there was suddenly hope where before there was nothing but black pain..I was not only able to go back to practicing nursing, but usually at least 2x a week i did double shifts! I was able to support my kids again, myself.How awesome that felt to feel as if I was contributing to society again..
where I spent 3 yrs basically in bed before..I had my life back.
Until a local doc in my town lost his license to practice medicine with questionable narotic prescribing practices..and my monthly appointment last week for my monthly refills..I was informed it was "time to taper off all narcotics" I had been on 50mcg/hr of duragesic for 2 yrs...and at my own request, was lowered to 25 mcg/hr about 8 months ago.
So my doc handed me my scripts...hmmm, methadone 5 mg tid around the clock for pain...I took this reluctantly for a few days, until I passed out at my pc again, this time slamming my head/face into the side of my dresser.
I looked at the pills a couple days later and realized they were not 5 mg...the pharmacist accidently gave me 10 mg...and the cumulative effect was way more than i could tolerate.
I am trying now to get the medtronic pain pump again...no more questions or looks of addiction...i could function on the duragesic....drove cross country several times...on this methadone, i cant even focus my eyes to get in my car, i won't.
I am back where i was at square one 3 yrs ago....
wow i said alot...and sorry for the jumping in sequences...but am so glad i found a pain site to post on.

I wish you all tolerable days, and nights tired enough to sleep

c

[cyndi57]

Hi...I too had a double lumbar fusion (January 19th) with titanium cages and BMP instead of bone grafts. I also am experiencing severe pain in both buttocks, legs, feet, and more on the right. The pain in my feet is severe burning as if I ran on hot pavement. This burning pain worsens with walking. I can't lay flat on my back as I feel the rods nor can I sit on a hard chair, only padded, as it too worsens the pain. I am wondering if you have heard if a person can have the rods and screw removed early after a fusion or exactly how long they have to wait for removal. I will be having a NCS and EMG to see if the nerves are pinched or if it will see any interruption and will see the surgeon a week following the tests. I could use some assistance and maybe some reasurance. I am glad that I am not the only one that feels these sensations/pain post surgery. You can also e-mail me at ***@****

[fly]

Steroids, steroids, steroids!  I have avascular necrosis.  I can't have steroids.  I wonder what would they do for me.
fly

[Never Again]

Hi;
I just underwent a universal (Posterior/anterior) L5 S1 Fusion along with the surgeon "opening up" the nerve canals for the sciatic nerves. I went home after 4 days only to return with a fever and unbearable pain in my lower back and legs.found out I had an infection in fluid build-up around the fusion area. I have since senn an infectious disease specialist ,who is still running tests. I still am in considerable pain ,especially my left leg from my lower back through my buttucks and down into my heel,worese than before the surgery. my Surgeon is "baffled as to why I am still in so much pain,when all the mri/cat scan,and x-ray shots in his words are "beautiful".
I was better off before just "toughing it out and going to pain managment.
Is there anyone else out there who has had a similar experience? if so ,please let me know,the Oxycontin ( 20 mg 4 times daily) isn't even touching the pain anymore. Is there anything else I could run past the doc to try?  
Thank You,
Bob

[K747]

A related discussion, An answer to recurrent pain after spinal fusion surgery was started.