Residual Cauda Equina, Chronic Radiculopathy and Possible Fibromyalgia

[Donna]

I had a large, central to right severely herniated disc at L4-L5 due to slipping on ice in January 98. I had surgery for (CES)in June 98 of Miscrodiscectomy, Laminectomy, Forimaectomy (sp), and Spinal Decompression.  The thecal sac was almost severed at myelogram and was this way for about 5 months before surgery.

I had a new MRI in June 99 which shows residual Cauda Equina Syndrome and Chronic Radiculopathy, due to scar tissue/fibrosis/granulation compressing the nerve root and disc space. My Neurosurgeon does not want to treat it surgically as the scar tissue will just return.

My family physician has been treating me for the severe back and leg pain with 4/Darvocet a day, 300mg Celebrex a day, 900 mg Neurontin, and Fexeril 3-10mg/day for about 15 months. My Neurosurgeon has deemed me perm. disabled and I have begun receiving Social Security Disability.

The medication my family Dr. has prescribed does not do much for pain control.  He recommended seeing a Pain Center Mgmt in my area.  When I contacted the Pain Center, I was told I would receive the same meds (nothing stronger), I could have shots of cortizone in my spine (My Neurosurgeon said that would help the leg pain but not the back pain) also, I could have accupuncture, and more PT.

I am in a support group in which many of the members are taking opiates to manage their painand are seeing a Pain Specialist.  My family Dr. is wonderful but obviously, he is not a Pain Specialist.  Not only do I have the severe back and leg pain, but my whole body hurts to the touch. (I am sedentary due to pain)My sister was diagnosed with Fibromyalgia and said her Dr. said it tends runs in families, and is often brought on by an injury.

My questions are: 1) Do you agree that opiates are proper, long term treatment? (providing the condition and medical documentation warrant it) 2) I have a greatly diminished quality of life due to this injury (basically housebound)and I am hopeful that opiates will allow me to do more physically, do you agree? 3) Is it possible that I also have Fibromyalgia as a result of the injury?  

I am 43 year old female and I am SO tired of this pain.  I had done PT for 3 months which helped my leg, but did nothing for my back (I was told due to the severity of the injury).  My Neurosurgeon told me I will be on pain meds, arthitis med and muscle relaxants for life and will require and annual exam, however he is not treating me, my family Dr. is, and my NS did say he did not want me on Narcotics. We tried Ultram but it upset my stomach

I want to know if you would also believe in treatment with Opiates long term if the condition warranted it?  And if so, what treatment would it be for symptoms like mine?  Should I seek treatment for Fibro seperate of the nerve damage and back pain?  If I am treated with Opiates, will I require stronger doses over time, is this normal?

[CCF Neuro[P] MD, RPS]

thanks for the comments.

CCF Neuro MD

[madeline]

Hi Donna:  My situation is similar to yours.  I have had two surgeries at L5-S1 and am diagnosed with radiculopathy.  Severe pain, sciatica no ankle reflex numbness in left leg.  I have been on Vicodin for a number of years and it is the only medication that gives me relief.  Sometimes I take Motrin as well.  I take an anti-depressant (Serzone) and Klonipin for anxiety which results from the chronic pain.  I went through a ten week class on chronic pain management and although I learned alot about different tools such as limit setting, time out, relaxation techniques, accuppresure, I still rely on the Vicodin for my relief of pain.  My doctor and I have a written contract concerning my use of the Vicodin and he monitors my refills closely.  Hope this info helps a bit.

[CCF Neuro[P] MD, RPS]

Dear Donna:

Thanks for your answer.  No patient should live in pain when it is possible to relieve the pain.  But quality of life issues are important also.  You will need to find the balance, and as you say, your the only one who can make that decision.  I hope and wish the best for you.

CCF Neuro MD

[nancy]

For many years I have suffered with low back pain. A MRI taken about 5 years ago showed DDG with a spondylolithesis Grade 1 at L4-5, S1.  I have taken Soma and Celebrix to help reduce some of the pain.  Recently I have been switched to Vioxx and Skelaxin which has seemed to help somewhat with the pain.  About 2 weeks ago I woke up and felt an unusual pain in my lower back.  Not typical of the LBP I have experienced for many years.  By the next morning my pain was so severe, I couldn't even get out of bed.  I was told to try complete bed rest for at least 5 days and was prescribed Vicodin to help relieve the pain.  By the 5th day I could get out of bed, but stading in one place for any period of time would make the pain worse.  I was finally able to get in to see a Orthopaedic Surgeon who said my spondy was now a grade 2.  He fit me with a corsette and over time my pain has subsided considerably.  It has been recommended to me that I have surgery (a fusion) to stabilize the vertebra.  

I don't know if this is coincidental, but at the exact time my back went out, I noticed that whenever I lay my left elbow on ANYTHING, I get a stabbing, pins and needles pain in my elbow, at the very tip.  I am wondering if this is related to the current change in my back problem. Upon examination by the Ortho Doctor, he said he didn't see any fractures in my lower back and that at this time my neuro exam was normal. Also, an x-ray of my left elbow revealed nothing, no fracture was seen.

Considering the above, do you think surgery is indicated to stabilize my vertebra??  And what do think is wrong with my elbow?? I certainly don't want my spondy to move to a grade 3 & 4!  I am worried about permanent nerve damage.  The Ortho doctor said my spondylolithesis moved considerably in less than 2 years from a grade 1 to a grade 2. I don't really want back surgery, but I also don't want to risk nerve damage.  What do you think??
Looking forward to hearing from you.
Nancy
e-mail: ***@****

[Donna]

Thank you Dr.

It is very apparent in my letter that I am not sure what is the right path, isn't it?

Take opiates or suffer?!?  I thank you for saying it is up to a Pain Specialist and myself to determine whether opiates are the right course of action (based on medical findings)and not any one else's opinion.

Thank you so much for the common sense answer and returning the power to me, to make the ultimate decision.

[CCF Neuro[P] MD, RPS]

Dear Donna:

Sorry that you are in such pain.  Whether opiates are the correct medication is individual and dependent on the injury.  Most of the time, pain can be managed without long term opiates.  However, in specific cases it might be warranted.  That decision needs to be arrived at by the physician, patient, and rehab team.  When pain is uncontrolled, the patient suffers and when pain relief is masked by changing the patients cognitive abilities by altered mental status the condition may not be that different.  This is why pain management together with rehab physicians is a must.

Whether you can contract fibromyalgia from an injury, I am not sure of the answer.  If you meet the criteria of fibromyalgia then you have the disease.  I guess that is the bottom line.  

Please, see you pain management specialist and make a decision concerning pain medications based on your individual case and not what others think you might need.

Sincerely,

CCF Neuro MD