Welcome to Just Answer. I am an Adult Neurologist and was contacted to answer your question.
To answer your question. Your MRI shows degenerative changes mostly within the lateral facet joints. The enlargement of these joints (facet arthropathy and small joint effusions or fluid collections within the facet joints themselves) compromise the space of the central canal. That and the ligamentum flavum, which is enlarged as it connects the spinous processes of the vertebra, contribute to the narrowing of the central canal. In addition the lateral recesses at L4/5, where the L5 nerve root runs as it exits the vertebra, is narrowed or stenosed.
So your problem anatomically is more focused at the L5 level. and this is probably the level which as received epidural steroids in the past, in an approach at pain relief.
as you are offline. I will switch this off chat to the question and answer section. Please get back to me with other questions if I can answer them.
I realize that you have had a long history of opiate use, trials of suboxone detoxification, and find yourself back on opiates.
You did not make mention of neuropathic meds like gabapentin, pregabalin, or duloxetine
Thanks for answering. The terminology makes more sense in the context in which you've presented it. I still feel I need to reach for a copy of "neurology for dummies" if such a book exists (lol). Given that the epidurals have not worked and I am now dependent on opiates to the point that my current med, Dilaudid, no longer provides any relief (the catch-22 of opioid tolerance), and I would like to spend my life doing something other than lying on the couch, are there and what are, in order of efficacy, the alternative treatments to those that I've been subjected to over the past half dozen years? I know there are various surgeries and fans and detractors of each. Do you have an opinion or preference about any one of these?
Hi. No, I am here for a bit longer. I have had undesirable side effects to Neurontin and therefore have not tried its cousins.
I'm blanking on the brand name of buprenophine--is it Subutex?
I'm actually wondering about the efficacy of spinal surgery. Do you have an opinion on that for this condition. I'd rather be pain free that drugged.
My pain mgmt doc said in no uncertain terms that he would not prescribe anything stronger than Dilaudid for my pain. The med assistants tell me that any stronger drug has to be administered in a hospital setting. That I know is false since I've seen people pick up their Fentenyl patches at the pharmacy. There is one other pain doc in town and of course anyone can Rx it. Only Suboxone is regulated with respect to who can prescribe it. Very backward thinking. But I'm in AZ and nothing makes sense here.
The fact that he descries the possible benefit of surgery bothers me. I make him no money now. All he does is write scripts, sees me every 4 months for a "consult" which covers the same topics with no change and says that only a minority of surgeries are successful. So his demeanor and approach is quite pessimistic. Also he's giving more urine tests now. The staff says he's doing this to everyone--probably he hasn't been meeting the state requirement.
There should be more text in the answer I wrote prior to this one.
It's late and I've been on all day.
Thanks for your help. If you have any thoughts about surgery, I'd be glad to hear them.
Also if you can comment on vascular problems (swelling, pins & needles, numbness) in the lower extremities) please let me know. Or perhaps send me off in the right direction.
A pleasure "chatting" with you.
Hello again, thanks for the info on surgical methods. Is there a book directed toward the advanced lay audience (with diagrams) focused on spinal surgery? I do well when I have images to go with good explanations.
I am working with Stephen Ritland, MD, in Flagstaff, AZ. He is the "go to" surgeon for minimally invasive spinal surgery. His patient pool includes numerous individual from my town (Prescott) and a number of smaller towns in northern AZ who do not have access to neurosurgical care. His patient pool also includes physicians (including neurosurgeons and other professionals as well as "regular" people) from Phoenix and from the rest of the state, We have a new top level NS in Prescott now but the referrals are still to Ritland--(Flag is about aXXXXXfrom Prescott.) My pain doc sends his staff to Ritland. I doubt there would be such unanimity if Ritland were not highly regarded.
He is currently writing a text for professionals/med students on minimally invasive spinal surgeries. The population in AZ is spread across quite a sparse, broad area and generally when you ask for a recommendation for a neurosurgeon, Steve Ritland's name comes up. He is selective about which patients he choses and conservative about whether surgery is called for in a given case. He talks in a wave of jargon for the most part so I'm seeking a translator. That's why I included the text of my most recent MRI report and a fairly detailed history.
My interpretation of what Ritland proposes is a fusion technique using screws and artificial bone. But I need other user friendly sources to complete my understanding.
He will push back the muscles in the area, saw off the ends of the vertebrae at L4 and L5 (to create some attachment hinge (?)) remove cartilage in the central canal and will form a "window" using the bone graft and screws" opening up the area at L4/L5. The muscle then is repositioned over the graft. Whereas now there is nothing holding those two joints apart (my pain varies from the R lumbar (the original injury side) to the gluts and legs on that side AND is mirrored on the L lumbar area, gluts and legs, I have no spinal stability in that area. I can't predict which nerve in which location will be painful on any given day. I know there will be pain and that it will range from some ability to walk or do minimal household things to a complete disability with shooting pain over most of the area. All HH tasks are my husband's burden which is not fair. I understand Dilaudid 4 mg is strong but it has no effect on the pain. The rest of my spine is normal. I understand this technique reduces pain without creating complete immobility at the joint; thus there is less chance for deterioration elsewhere. Also since this was due to an injury vs some other spinal problem, and I am 60, there is not a huge likelihood I'll have a recurrence before I die. Your thoughts?