A member presented a medical case:
Seemingly successful lumbosacral fusion for degenerative and arthritic back disease in a 35 year-old ends up in chronic pain after a later auto accident and some falls.
35 year-old woman did ok for 3 months after lumbosacral fusion for degenerative joint and osteoarthritic disease, but ended up in chronic pain after a later auto accident, and is now looking for a therapy to get her off of pain medications.
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Patient demographics
Gender
Age
35
Ethnicity
White or Caucasian
Occupation
disabled previously sales/retail banking
Chief complaint or problem to solve
Excruciating, around the clock pain from the site of fusion, through hips, leg bones, down to toes. Tried every anti-inflammatory, included cream( 10).
Case history
Spinal fusion L5-S1 with cage/brackets. Did very well for the first three months postoperative, until car accident and several falls put me in around the clock pain. Tried cymbalta which helped a tiny bit but kicks in the anxiety from PTSD so I haven't taken in a while. I eat 600 every 6/hrs of ibuprofen and lidocaine patches. Currently, not in pain mgmt, as I was trying to do without, but the degeneration and arthritis from lower spine, hips, through to my toes, causes excruciating bone pain. I do not have any quality of life. I also don't want to be loaded up on a bunch of meds. But there has to be a happy medium. The oxycodone worked well in the past, as did the fentanyl patches, but I would prefer to not have to do both but would do whatever necessary to bring pain to tolerable level and be able to return to a productive life.

PMH: Spinal fusion. DDD, OA, SCOLIOSIS, endometriosis, ovarian cysts, interstitial cystitis, PTSD,anxiety, MDD
Meds: ibuprofen
Allergies:morphine, sulfa drugs
Other tests: White blood count presently around 11k. UA neg.
Xrays: All show degeneration of spine and the fusion taking hold.
Procedures: Exploratory laps for endometriosis, C-section in 2006, spinal fusion 2014
Purpose of case discussion
Treatment decision: "What's the best treatment?"
Supplemental Materials

Dr. John Walker
Surgery - Plastics
8 doctors agree

In brief: Psychophysical

Try meditation, physical therapy, acupuncture, cbd, biofeedback, so many other things other than giving big pharmacy your bucks!

In brief: Psychophysical

Try meditation, physical therapy, acupuncture, cbd, biofeedback, so many other things other than giving big pharmacy your bucks!
Dr. John Walker
Dr. John Walker
Thank
1 comment
Dr. Herman Hammerstead
Try THC works great for Chr. Cancer pain
Dr. Herman Hammerstead
Surgery - Trauma
7 doctors agree

In brief: Try THC

This works well for Chronic pain from Cancer.
TENS is also a good alternative

In brief: Try THC

This works well for Chronic pain from Cancer.
TENS is also a good alternative
Dr. Herman Hammerstead
Dr. Herman Hammerstead
Thank
3 comments
Dr. Mark Weston
Consider facetogenic pain adjacent to fusion or muscular strain around scar tissue tendrness vs pain with extension differential diagnostic injections and physical exam eith images
Dr. James Rochester
I am assuming imaging was done after MVA showing stable fusion?Consider Bone SPECT scan to look for active areas of inflammation/injury that might be amenable to pain management injection. On exam, if pain worse with extension, consider posterior segment etiology (think facets or pedicle injury) IF pain worse with flexion, consider anterior segment cause or paraspinal muscle as source.
Dr. Jonathan Hyde
Orthopedic Surgery - Spine
6 doctors agree

In brief: PostLaminectomySyndrome

It is concerning that for three months there was pain relief, then failure.
With/without the intervening injuries, the priority would be to understand the pain generator. The original pre-operative diagnosis and work-up that led to the original surgery should be revisited to understand initial indications and anatomic variants. The mechanical causes can include cage subsidence, failure of fusion, failure of instrumentation, adjacent segment pathology, sacroiliac dysfunction, as well as nerve scarring including epidural fibrosis or arachnoiditis. The actual surgical technique and surgeon experience could also be a factor in a mechanical failure. Imaging including MRI, as well as CT imaging with reconstructions are important to obtain. Psychosocial issues can also complicate matters, as well as potential secondary gain issues from litigation. It is concerning that narcotics are required for functionality. A multidisciplinary pain program can be of major benefit.

In brief: PostLaminectomySyndrome

It is concerning that for three months there was pain relief, then failure.
With/without the intervening injuries, the priority would be to understand the pain generator. The original pre-operative diagnosis and work-up that led to the original surgery should be revisited to understand initial indications and anatomic variants. The mechanical causes can include cage subsidence, failure of fusion, failure of instrumentation, adjacent segment pathology, sacroiliac dysfunction, as well as nerve scarring including epidural fibrosis or arachnoiditis. The actual surgical technique and surgeon experience could also be a factor in a mechanical failure. Imaging including MRI, as well as CT imaging with reconstructions are important to obtain. Psychosocial issues can also complicate matters, as well as potential secondary gain issues from litigation. It is concerning that narcotics are required for functionality. A multidisciplinary pain program can be of major benefit.
Dr. Jonathan Hyde
Dr. Jonathan Hyde
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2 comments
Dr. Steven Puccio
I completely agree, Imaging should help to bring some answers to light.
Dr. Rick Pospisil
Infection May also be a potential causative factor
Dr. Edward Hellman
Orthopedic Surgery
6 doctors agree

In brief: Varies

In general, there are 5 considerations for why patients may have a poor outcome from spine surgery: 1) a problem at the surgical site such as scarring or nonunion, 2) a problem at another site in the spine, 3) a problem somewhere else, perhaps non musculoskeletal, 4) patient was not a good spine surgery candidate to begin with, and 5) non surgical issues such as drug addiction, untreated anxiety, depression, etc.
In this patient who did well for three months and recurrence after an injury; concerns would include a nonunion, a separate unrecognized injury that occurred in the accident, and non-surgical issues as mentioned above. A myelogram with a postmyelogram CT scan would allow you to do a "check up" of the surgical site to see how it looks and ensure it is solidly healed.It is much more sensitive than a simple X-ray to see if fusion has occurred. It would really be hard to move on in treating this patient until you know for sure that the surgical goals of a fusion have been met.

In brief: Varies

In general, there are 5 considerations for why patients may have a poor outcome from spine surgery: 1) a problem at the surgical site such as scarring or nonunion, 2) a problem at another site in the spine, 3) a problem somewhere else, perhaps non musculoskeletal, 4) patient was not a good spine surgery candidate to begin with, and 5) non surgical issues such as drug addiction, untreated anxiety, depression, etc.
In this patient who did well for three months and recurrence after an injury; concerns would include a nonunion, a separate unrecognized injury that occurred in the accident, and non-surgical issues as mentioned above. A myelogram with a postmyelogram CT scan would allow you to do a "check up" of the surgical site to see how it looks and ensure it is solidly healed.It is much more sensitive than a simple X-ray to see if fusion has occurred. It would really be hard to move on in treating this patient until you know for sure that the surgical goals of a fusion have been met.
Dr. Edward Hellman
Dr. Edward Hellman
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Dr. James Kayvanfar
Orthopedic Surgery
4 doctors agree

In brief: Need further eval

Physical exam to identify what is causing the pain.
An MRI and standing radiographs of the lower back would be helpful here. There may be a problem with the fusion no longer being stable , occult fracture due to the trauma, hardware loosening or break, etc. If you can, post the films here for review.

In brief: Need further eval

Physical exam to identify what is causing the pain.
An MRI and standing radiographs of the lower back would be helpful here. There may be a problem with the fusion no longer being stable , occult fracture due to the trauma, hardware loosening or break, etc. If you can, post the films here for review.
Dr. James Kayvanfar
Dr. James Kayvanfar
Thank
Dr. Merrill Reuter
Orthopedic Surgery - Spine
4 doctors agree

In brief: Lots of good advise

The multiple viewpoints expressed in the answers covers a lot of possible causes for persistent pain.
I would add that your retained hardware could also be a factor, and removal may need to be considered.

In brief: Lots of good advise

The multiple viewpoints expressed in the answers covers a lot of possible causes for persistent pain.
I would add that your retained hardware could also be a factor, and removal may need to be considered.
Dr. Merrill Reuter
Dr. Merrill Reuter
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Dr. Rick Pospisil
Orthopedic Surgery
4 doctors agree

In brief: Lumbar fusion plus pain

You should get follow up serial CT scans of fusion areas and compare with immediate postop images,

In brief: Lumbar fusion plus pain

You should get follow up serial CT scans of fusion areas and compare with immediate postop images,
Dr. Rick Pospisil
Dr. Rick Pospisil
Thank
4 doctors agree

In brief: Pain generator

As has been mentioned, many possible causes, but if you were wearing a seat belt, not uncommon to develop problems with sacroiliac joints and even a bilateral pyriformis syndrome.
I have no real problem with use of an analgesic patch, but this would only be palliative. Would suggest consultation with Physiatrist, and also, an Osteopathic specialist.

In brief: Pain generator

As has been mentioned, many possible causes, but if you were wearing a seat belt, not uncommon to develop problems with sacroiliac joints and even a bilateral pyriformis syndrome.
I have no real problem with use of an analgesic patch, but this would only be palliative. Would suggest consultation with Physiatrist, and also, an Osteopathic specialist.
Dr. Bennett Machanic
Dr. Bennett Machanic
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Dr. Jovita Anyanwu
Internal Medicine
3 doctors agree

In brief: Concern

I am doubtful that at 35 year old has significant DJD to warrant the first surgery.
Did this patient had any workers compensation or MVA claim issues ? Consider physical therapy, psychotherapy and mental health support . Avoid Opiods high potential for addition if not already present. If present refer for Subaxone treatment . Tough and interesting case

In brief: Concern

I am doubtful that at 35 year old has significant DJD to warrant the first surgery.
Did this patient had any workers compensation or MVA claim issues ? Consider physical therapy, psychotherapy and mental health support . Avoid Opiods high potential for addition if not already present. If present refer for Subaxone treatment . Tough and interesting case
Dr. Jovita Anyanwu
Dr. Jovita Anyanwu
Thank
Dr. Su Fairchild
Integrative Medicine
1 doctor agrees

In brief: Prolo?

She may be a candidate for prolotherapy.

In brief: Prolo?

She may be a candidate for prolotherapy.
Dr. Su Fairchild
Dr. Su Fairchild
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1 comment
Dr. Rick Pospisil
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