I believed that pain was always structural–I was wrong!!

During my first five years of practice, it was my assumption that if a patient had experienced low back pain for six months, then it was my role to simply find the anatomic source of pain and surgically solve it. I was diligent in this regard. The test I relied on most heavily was the discogram. The discogram is a test where dye is injected into several discs in the lower back; if the patient’s usual pain was produced at a low injection pressure, it was considered a positive response. The only patients I did not fuse were those who did not have a positive response or had more than two levels that were positive. I performed dozens of low back fusions and felt frustrated when I could not find a way to surgically solve my patients’ low back pain.

I have a physiatrist friend, Jim Robinson, who is a strong supporter and contributor to the DOC Project. From 1986 to 1992, we both served on the Washington State Worker’s Compensation clinical advisory board and helped set standards for various orthopedic and neurosurgical procedures. Our discussions were based on this assumption that there always is an identifiable “pain generator.” That means there was always some anatomical problem generating a pain impulse and we need to discover it to save the problem. It was just a matter of figuring out what test is the best one to discern it. We did not think in terms of structural versus non-structural sources of pain. We knew about the role of stress, but did not fully appreciate how large a role it played in altering the body’s chemistry and perception of pain.

BTW, our original concept of a “pain generator” was wrong. The only place in the body where pain is felt is in the brain. Sensory input has to be first interpreted by the nervous system and if a certain threshold is exceeded, your brain sends out a pain signal that indicates danger and your body will respond with an appropriate action to keep you safe. A bone spur has no inherent capacity to generate pain.

Structural problem

I define a structural lesion as one that is distinctly identifiable on an imaging test, which correlates with the patient’s symptoms. An example would be a ruptured disc pinching a nerve that causes pain down the leg. A ruptured disc between the fourth and fifth lumbar vertebrae will cause pain down the side of the leg. This is the pathway of the fifth lumbar nerve root. A ruptured disc between the fifth lumbar and first sacral vertebra will cause pain down the back of the leg, which is the pattern for the first sacral nerve. If in either of these two examples the pain was going down the front of the leg, it would not be considered the cause of the pain because that is the path of the fourth lumbar nerve root and it does not match.

Other examples are:

• Bone spurs on one or both sides of the spinal canal with matching leg pain and/or nerve damage
• Central spinal canal constricted by bone or ligaments with one or both legs feeling weak, tired, or painful
• Isthmic spondylolithesis (slippage) with corresponding leg pain.
  • More that 3 mm of back and forth motion on X-ray if only back pain; This would be considered unstable.
• Degenerative spondylolithesis (slippage) AND canal constriction with corresponding leg pain or fatigue
  • >3mm of instability if just back pain; considered unstable.
• Acute compression fracture with fluid on the MRI (indicates bleeding).
• Acute unstable fracture/dislocation
• Tumor
• Infection
• Flatback—whole body tilted forward because the normal curvature of the lower back has been straightened – many causes.
• Scoliosis that progresses over time-just the presence a curve does not count.

Pain problem

Many of you experience pain whose source is not identifiable on any test modern medicine has to offer. When there is no identifiable structural source of your pain, we cannot surgically treat it. But we can still help you and the good news is that you don’t have to undergo the risks of spine surgery.

The only scenario that surgery should be even considered is in presence of an identifiable problem with matching symptoms. Other factors such as the severity of the pain compared to the involved risks must be taken into account. If you can’t see it you can’t fix it.

The post A – Structural Sources of Pain first appeared on Back in Control.

The post A – Structural Sources of Pain appeared first on Back in Control.

Dear Dr. Hanscom:

You may not receive these kinds of letters from nurse case managers very often.

I thought I would advise you of the above captioned patient that you performed a redo L5-S1 microdiscectomy about a year ago.  Ron got quite discouraged when he did not improve.  He was almost done with your book, Back in Control when he got off the couch, got motivated, moved forward, and we saw a dramatic change in his attitude. He worked through his pain, eventually stopped all medications, completed PT, and work conditioning programs. He was recently declared fixed and stable and was released to his job of injury as a sorter. (One of the hardest jobs around, believe me!)  He is back on the job and doing very well!!

Please thank your assistant for all of her help.

Thank you for all you have done for Ron.

Sincerely,

_____________, RN, BSN,  Medical Case Manager

Ron’s story

Ron was only in his early twenties when he ruptured his lowest disc, L5-S1, while on the job a couple of years earlier. A prior surgical attempt to remove the disc had not given him lasting relief. When I first saw him, he was experiencing ongoing severe sciatica down the back of his leg. His MRI scan showed a large ruptured disc. It had probably re-ruptured relatively soon after his first surgery.

Lower back pain

I am always clear about the goals of surgery and what I can and cannot accomplish with a given operation. He had a significant amount of lower back pain (LBP) in addition to his sciatica. There is not an operation that relieves LBP, and I explained to him that I would only address his leg pain. I also explained to him that once you have had ongoing pain for more than four to six months, the brain lays down pain pathways, which are permanent. (1) Although it was necessary to re-do his operation, my observation has been that the sciatica still will often persist. The pain is usually better, but often it is still severe enough to really destroy the quality of your life.  The back pain and residual sciatica are treated by the tools on this website.

The operation

After my operation, which was a redo of removing the disc at L5-S1, Ron did not do that well. As expected, he had ongoing back and leg pain. I had explained the DOC Project to him, but he had not really engaged. Finally, about three months after the surgery, I was extremely clear with him about where he was headed. Living the rest of your life in chronic pain when you are in your early 20’s is not an inviting prospect.

Worker’s Comp

I did not post this story right away. In the interim, I began to think about my historical view in dealing with patients on Worker’s Comp. I was taught and believed that it was my role as a physician to “set boundaries.”  It was in the patient’s best interests for me to be tough and just “shut the door.” Injured workers, I thought, are focused on gaming the system and remaining off of work. It is often repeated in seminars that injured workers have “secondary gain” issues, and that if the benefits were decreased or cut off that would be the best motivator to get people back on the job.

Thriving??

I realize that a only small percent of people are gaming the system. However, my strong observation is that given the opportunity, people want to thrive. Surviving on a fixed income when you are only in your 30’s or 40’s is not living a full life. Years ago I would have told him to “buck up and just get back to work. That would be the best thing for you to do to help your life and pain.” I would have just closed his case.

Motivation

When you have been physically and emotionally beat up by the pain and the system, you have lost the ability and motivation to become productive. Once you have the tools to reconnect with who you really are and where you want to go, there is no stopping you.

It took about six weeks for Ron to fully engage, but he did it. This whole project is about showing you the tools to heal yourself. My role is to be a coach and cheerleader.  Watching patients like Ron start smiling again as they make strides in becoming pain free is one of the most rewarding aspects of my practice. I am grateful that I have been able to help show him the way.

1. Hashmi, JA, et al. “Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits.” Brain (2013); 136: 2751–2768.

The post Ron Salvages His Own Spine Surgery first appeared on Back in Control.

The post Ron Salvages His Own Spine Surgery appeared first on Back in Control.

His tests and treatment were as follows:

• His lumbar MRI showed disc degeneration at every level but no instability.
• He had crippling anxiety including fairly frequent panic attacks.
• He was open to psychological care.
• I engaged him a structured rehab program, but essentially every request we made for biofeedback, psychological intervention, mindfulness/meditation, and back school was denied by Worker’s Comp—over and over again.
• I somewhat kept him on his feet by seeing him back every couple of weeks for about six months. We kept requesting care.  Even personal phone calls to his claims examiner were of no avail.

I referred him to a pain specialist that I have teamed up with, and he continued with a similar program but again with no support from Workers’ Comp.

• The patient still complained of severe crippling anxiety and was somewhat desperate for mental health care.
• I am not currently his treating physician but last week my colleague emailed me and asked me to re-evaluate him.
• It has been recommended to him that he have a two-level lumbar fusion for his degenerated discs.  My friend begged him not to pursue it.
• The patient is anxious, frustrated, and does not want to talk to me or anyone else.  He is now intent on pursuing surgery.

So look at this situation.

• We know that chronic pain increases anxiety and frustration, which exacerbates pain.
• Psychosocial stress is a better predictor of outcome than the surgical pathology.
• The return-to-work rate at one year from a lumbar fusion for low back pain in the State of WA is 15%.
• The patient has documented severe untreated anxiety.
• In addition to his baseline anxiety, interacting with the Worker’s Comp system has pushed him almost into a rage.
• The state still will not pay for any mental health resources
• They will pay for an operation that will cost them between 50-75 thousand dollars and has a re-operation rate between 15-20% within the first twelve months of the index operation.
• If he does not undergo surgery, his claim will be closed and he does not have the emotional capacity to compete in the work force.

I have no ability to intervene, as I am no longer his treating physician.  I realize that “this is not my problem.”  That is correct.  It is not my problem; it belongs to all of us.

Does anyone have any suggestions?

BF

The post It Really is Upside Down first appeared on Back in Control.

The post It Really is Upside Down appeared first on Back in Control.