Tag Archives: pain management

Having an infiltration anesthesia test and probable Rhyzotomy

***** 1-30-14: Update #2, I had the test last week and it worked, I was pain free for the first time in 17 years, it was injected lidocaine so it only last 24 hours but it means I can have the Rhyzotomy that has not been scheduled for February 5th.  The doctor I work for is off the 6th and 7th so if I need those days to recover I can take them easier than if she is here.  The website said it may take a week to recover and it is considered a surgical procedure.  I will have more pain for the first week at least and it will provide about 6 months relief.  I have new insurance so that if I have it done at the hospital I work for there is no copay so nothing out of pocket, so much better than last year.  I will keep you posted but the test injections were nothing to be worried about, no pain after at all.Click below for a link for the description given by the practice I go to and who will do the procedure.

http://www.southeasternspine.com/procedures-treatments/rhizotomy/

*****Update 6-27-2013 These 2 procedures have been put on hold for financial reasons.  I had no idea how expensive they were and the practice wants me to pay me entire balance even though I have been making regular payments to them and really my insurance is excellent, they have collected tens of thousands from my insurance in the last 18 months I have been there.  So I have an appt with a PA (the same one I have been seeing who really doesn’t understand pain) on July 3rd at 230pm.  I will update more on what my other options are after that appt.  I was very disappointed by having to postpone this potential for relief.

Well I am so disappointed to report that the news at my spine doctor’s appt yesterday was not at all what I was hoping to hear.  I was really hoping they would say that I still have pain because I was originally told it would take a full year to recover completely and to expect it to taper off and in the meantime we can just treat it with medication albeit lower strength medication than before which is fine with me and actually preferable. I want to avoid all of the oxy-codones at all costs.

Instead, the PA took out my MRI report and told me something I didn’t know before I had the surgery back in October.  What I knew then was that I had 3 herniated discs L3, 4 and 5 as well as some facet joint damage from these discs being herniated and that L4 also had a tear in it.  I could only have 2 discs repaired in a surgery so they replaced the worst ones, L4 to S1 with titanium implants and told me that L3 was damaged but not as severely but I could expect it to cause pain in years to come and actually it is now with pain in my left thigh.  With all this being said, apparently I also have problems from L1 all the way down.  The vertebral joints all have arthritis (most likely from the years of having the injury putting more stress on them than would be normal for my age) and she used the term Spondylolysis: “A weakness or fracture between the upper and lower facets of a vertebra. If the vertebra slips forward (spondylolisthesis), it can compress the nerve roots causing pain.”   So, this is the reason I am still having pain all these months after surgery.  I have tried so hard to will it away, stay active (those of you that know me know that sitting still is not something I am good at) and was beginning to feel that this was a weakness in my character that I couldn’t rise above the pain and was still resorting to medicating it.

rhizotomy-chart

So here is the game plan, next Wed the 19th, I am having a procedure is called infiltration anesthesia  where local anesthesia is produced by injection of the anesthetic solution in the area of terminal nerve endings.  In my case L1-3 since they can’t do anything with the ones that have had surgical intervention.  If this produces pain relief, I am supposed to call the next day and tell them, if it does relieve my pain, then I am a candidate for a Rhizotomy.  This is the scary part; if it doesn’t relieve my pain at all then I don’t know what the Plan B is.  But the following is a description and indications for Rhizotomy as found on this website: 

http://www.espalda.org/english/divulgativa/dolor/como_tratar/informacion_paciente/rizolisis.asp

“Basis, indications and risk

 

Rhizotomy

It is the destruction of the nerves in the facet joints, normally by burning them with radiofrequency current.

Objective

To improve pain in instances of facet joint degeneration.

Theoretical base

There are no nerves in the cartilage of the facet joint. These are located in the bone placed underneath. This is why joint degeneration may not cause problems until the bone is affected. When this occurs, pain nerves are activated, with the subsequent onset of pain.

Conceptually, rhizotomy aims at destroying the nerves in the facet joint to eliminate pain sensation. It is usually performed by burning the joint nerves. Obviously, this procedure is only considered in those cases in which pain is due to activation of these nerves by facet joint disorders.

However, each facet joint enfolds nerves from two, and in some individuals three, different vertebral levels. Thus, for example, the facet joint between the fourth and fifth lumbar vertebrae may receive nerves that originate from, for example, the third, fourth and fifth lumbar level. Therefore, nerve destruction of only one of these levels may have no effect, or have a temporary effect until the remaining nerves take on its nerve field.

Also, it was traditionally believed that all pain nerves reached the medulla through the posterior root, which permitted the localization of the site where nerves had to be destroyed to eliminate the pain originated in the facet joint. However, recent studies show that, although there are individual variations, in some individuals up to 20% of pain nerves reach the medulla through the anterior root. Muscle nerves also pass through this root so it cannot be destroyed since, in doing so, it would cause paralysis of the innervated muscles.

It may only be indicated in cases that comply with the following criteria:

Indications

The existing evidence based recommendations do not recommend rhizotomy, essentially because they are focused on the treatment of acute cases and rhizotomy can only be considered in chronic cases.  It may only be indicated in cases that comply with the following criteria:

 Characteristics of pain:

    1. local pain with no radiated pain nor signs of nervous compression (such as loss of strength or reflex or sensibility alterations)
    2. Pain resistant to non-surgical treatments for more than 12 months.
  1. Pain origin:
    1. Rhizotomy should not be performed on patients whose other organic alterations of the spine may explain the pain.
    2. – It must be assured that pain results from alterations of the facet joint. This is the most important criterion to recommend rhizotomy and also the most difficult one to prove. The detection of signs of joint degeneration through radiological test is not enough, since many healthy persons have it. To verify it, a test with anesthetics is needed (see below).
  2. Test with anesthetics:
    1. – Before a rhizotomy treatment, an anesthetic infiltration test at the joint should be done. If pain is due to the activation of nerves at the joint, pain should disappear completely. Some authors recommend doing three infiltrations spaced out in time; two with anesthetics and one with a placebo (substance of similar appearance but with no effect), without letting the patient know which is which).
    2.  ***** this is what I described above and will be having the 19th (next week)
    3. – Rhizotomy should only be performed on those patients in whom pain disappears completely with the anesthetic injections and remains unchanged with the placebo shot.
  1. Patients:
    1. – An adequate selection of patients is the key criterion to assure that Rhizotomy has acceptable chances of success.
    2. – It should only be considered on patients whose pain complies with the above described characteristics, after discarding that it may be due to any alteration different from that of the facet joint and where pain disappeared with the anesthetic infiltrations.
    3. Technique:
    4. – The destruction of the root should be performed under radiologic control, to assure it is done in the right place.
    5. – The roots of, at least, two segments should be destroyed and two or three lesions should be made at each location, to accommodate personal variations in the course of the nerve.”

So knowing all of this, I am worried, I really had hoped I would have much less pain than I do at this point being 8 months post surgery and have done all I can do myself to try and alleviate and relieve it so apparently this is the next logical step and I will definitely let you all know how these tests really feel.  Of course, I was told that they were “easy” and “not any worse” than the epidural injections and the discography test that I had before surgery.  I will keep you posted 🙂  Thanks as always for reading and I hope that the information I share is helping someone out there going through similar situations with chronic back pain and injury.

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Physical Therapy is even more important than I thought!

I am amazed at how much physical therapy is helping me.  I have to admit I was skeptical about it.  I was feeling pretty good and having people tell me that they couldn’t even tell I had any surgery because my mobility is so good.  However, when the therapist evaluated me she found some problems with my gait (the way I walk) that are easily solved with stretches and exercises.  My hip flexors have shortened because I have been over-compensating when I walk from when I was in pain and now it’s a habit I have to break. 

I have progressed to the point that I now have about 6 different exercises to do every day.  There is the hamstring stretch, the hip flexor stretch and pelvic tilt to strengthen my lower abs.  Two new ones are designed to strengthen my thigh muscles;  using a medium sized ball between my knees with a belt around my ankles I pull my ankles apart and squeeze my knees together at the same time and hold for a count of 10, then put the ball between my ankles and the belt around my knees and this time pull my knees apart and squeeze my ankles together.  It’s important for both of these that your ankles, knees and hips be in perfect alignment.  My thigh muscles are probably going to end up better than they were before so it’s dual purpose exercise just in time for swimsuit weather! J  The other new one is called “the clam” you lie on your side with your knees bent, do a slight pelvic tilt and while pushing the leg that is on the bottom down, you lift the other leg so you look like a clam shell opening.  This one I am supposed to work up to doing 3 sets of 10.  She also taught me a great hip stretch but you need a buddy.  You lie on your side as if you are going to do “the clam” you have someone strong stand sideways in front of you, put the upper leg around their waist so the back of your thigh is against their side, they provide resistance for you to push against, when you push against them it stretches your outer thigh, hip and glutes. 

We are also still working on thinning out my scar through massage, now I am massaging it side to side now, this is kind of graphic and I’m sorry but what I am doing is to “pick it up” and slowly move it back and forth to break up the scar tissue underneath that has been causing all the pain, I do this twice a day morning and night.  I really wish I had known about massaging the scar earlier than this, for anyone reading this who has yet to have surgery, scar massage is safe to do as soon as you are healed so about 6 weeks.  The earlier you start it the less likely it is that you will have adhesions like I did, this is a good preventative treatment for that.

All in all I am continuing to improve although am still on pain medication daily at least for now but it’s not as strong as the one I used to be on and I will continue to try and reduce that at each visit with my pain doctor, Dr. Netherton.  Thanks for reading and if anyone has any questions or comments feel free to post them I am happy to help if I can!

Coumadin/Warfarin Troubles!

I am having an extremely frustrating experience with Coumadin, generic name Warfarin.  I have been taking it since I got out of the hospital on November 8th (so nearly 2 months now) and increasing the dosage every Wednesday when I go to the Hematologist and have my INR taken.  The INR is a finger stick blood test and stands for International Normalized Ratio which tests for how fast your blood is clotting.  Normal is between 2-3  for my diagnosis and I know I had to stay in the hospital when I had the pulmonary emboli until I was within that level but as soon as I got out it went down except for 1 week when I was over 3.  The higher the number, the higher the risk of bleeding.  My number has been 1 – 1.3 all this time which means my clots are not being dissolved on this therapy so my risk for recurrence of them remains high.  I have done everything they have told me to do.  Every week there are elaborate dosage plans such as 5mg on M W F and 2.5 the other days and so on.  As of yesterday when I still measured a 1.2 I was increased to 7.5mg every day.  At the level I am at new clots can form and obviously that would be a complete disaster.  This medicine is killing my stomach much like steroids and even NSAIDs do and so I have to take protonix along with it to protect that and it finally feels better after over 2 weeks back on protonix.  I ran out and didn’t realize it was making such a big difference until my stomach felt like it was tearing in half and I was living on bananas and toast.    I had been avoiding vitamin K high foods but have recently read that I am better off to keep some in my diet maybe 3 times week.  These foods include the green leafy salads I have always loved.  I have avoided them since they can reduce my INR and it is so low anyway.  The link to info about vitamin K and Coumadin:  

http://www.clotcare.com/vitaminkandwarfarin.aspx

 I have an appointment with the doctor next week and am planning to ask if I can just go on the Xarelto at this point like he wanted to do last month.  Since it works differently I won’t have to go to their office for these blood tests every week anymore because there is no way to test for the level of it in a person’s system like you can with Coumadin (which by the way is mild rat poisoning according to my doctor).  I found a co-pay card online for it so it won’t cost the $40 as originally told to me, I pay no more than $25.  If you are in need of one yourself here is the link:  https://www.activatethecard.com/Xarelto/

Click on enroll now, answer a few questions and print it out.  I faxed it over to my pharmacy to make things easier later.

Anyway, this is the story of what it is like trying to survive pulmonary emboli.  I am still having some issues with pain after the surgery so have also been referred to a pain management doctor at Southeastern Spine Institute.  I see him January 22nd.  I am hoping we can find a way for me to have less pain on a day to day basis but also by taking fewer meds. Evenutally I am really hoping for no meds but for now I can live with fewer.  I am and will remain optimistic, thanks for reading as always!

The ALIF Recovery Begins!

The rest of my hospital stay was much improved after that first extremely uncomfortable day.  Although, most of the nurses never did get the hang of my pain management medication order.  It was a fight every time there was a shift change.  I know my doses seemed high to them however, I had been on pain medication off and on for 16 years and had built up tolerance  to the lower level medications.  My surgeon decided to consult with my primary care doc as well as a pain management doctor from his own group at Southeastern Spine Institute to determine what I should be given to manage post surgical pain.  Much thought went into that plan and it was very frustrating to see them refusing to adhere to it.  My overnight nurse, Mary Jane, was wonderful and did everything she could to make me comfortable and make sure I had everything I needed.  Brian stayed in my room with me all weekend.  We didn’t plan it in advance but I have to say that it helped a lot to have him there not only to keep me company but as an advocate.  If I had been alone, I am sure I would have been too tired and sore to try and argue with the nurses that didn’t want to follow my doctor’s medication order. He stood up for me and made sure that everything I needed was taken care of.  I highly recommend that anyone considering this or any other surgery try and find a family member or very close friend to stay in your room with you and speak for you when you can’t.

My physical therapy began the evening of surgery.  I got to my room at about 7pm from recovery and shortly after that a nurse brought me my walker and had me stand up and walk around my room.  The expression on my face in this picture should tell you how that felt! Ouch! But I understand it was important for circulation.  I also had boots on that inflated and deflated periodically so that I wouldn’t get a blood clot in my legs.  Those felt nice, like a massage and I wore them throughout my entire stay.

 

The following morning I walked down the hall with my physical therapist and walked up and down a little set of stairs at the end of the hall.  Having my family there with me helped a lot, their moral support made me want to try harder.

Primary Care Doctor Pre Surgical Appt. I trust I will be pain free now!

I am so glad I made an appointment with my primary care doctor yesterday!  I told her everything that was going on with my surgery, (she hadn’t gotten the most recent notes from my surgeon) and she reassured me that she will call him to check in and make it known that she handles my regular medical care and also to explain my pain relief regimen to him.  I guess that was the biggest cause of my anxiety.  My surgeon said he had never heard of the medication I am taking and that she prescribed and it scared me.  My primary care doc told me that it is not unusual for surgeons not to know anything about pain medicine.  This was news to me, I assumed they did.  She said all they do is “cut and do” and handle the first 24hours of pain relief in the hospital.  Their specialty is the surgery itself, beyond that, there will be a hospitalist and a pain management doctor from the surgeon’s practice that will prescribe whatever I go home taking.  The appointment was so informative and reassuring and I am very glad that I scheduled to actually see her and not just try to talk on the phone.  I have come to trust her so much that just being able to talk to her in person was enough to assuage my fears.  I was crying when I first went into her office but by the time I left I was ok, smiling even.  She assured me that she will see to it that I have “no pain” during my recovery.  I wasn’t even sure if it was possible or even a reasonable expectation to be pain free after surgery but she told me that not only is it possible but it’s a necessity.  How can I do the exercises I will need to do for rehabilitation if I am in pain?  There is also the psychological aspect; my attitude will be a lot better in general if I am not in pain. If my attitude is positive then I will recover faster.  I can’t believe the odyssey I have been on since I first injured my back.  It amazes me how many doctors do not treat pain as a condition.  I have even had doctors tell me that there was nothing else they could do for me because I was already taking the highest level pain relief there was (and I was taking 5mg vicodin which is by no means the highest level or even mid level pain relief).  There was one doctor who told me that my MRI was normal so he had no idea why I was in pain and left it at that.  Even I knew my MRI report in no way stated that it was normal, there was a whole list of highlighted items at the bottom.  For years I watched my sister battle with long term pain as well, she went through all these same things as me.  I wish I had understood more about it then but now that I have been in chronic pain, I completely understand her situation now. 

My hope is that I am nearing the end of this painful journey.  I am working with the assumption that once I heal and believe me I am going to work hard to heal well, I will have a pain free future!  That’s my story and I am sticking to it!