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Dr. Frank
Dr. Frank, Board Certified Physician
Category: Neurology
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Experience:  Board certified general Adult Neurologist, with experience in experimental neuroimaging and neurodiagnostics.
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My question is in the field of neurosurgery and involves several

Resolved Question:

My question is in the field of neurosurgery and involves several parts to set it up. I am happy to pay for assistance. I'll start at the end to save time. I had a nasty fall about 6 years ago. I saw a chiropractor who used laser therapy, a naturopath who gave me Norco, a second naturopath who gave me prolotherapy and other naturopathic injections. None of these things worked. When the naturopath could no longer legally prescribe Norco for the rest of the year, I saw an psychiatrist/addiction specialist who put me on Suboxone as a pain treatment (he decided the pain was chronic and I needed the treatment vs. Suboxone as a withdrawal med, which is what I expected. I had an MRI that as far as I could tell didn't indicate a serious injury. At this point, I'm dependent on Suboxone, which is not a good drug to be on if one needs surgery, sedation, or full opiates for pain management. I was then referred to a pain management specialist. He took me off Suboxone CT (which was hell for 10 days) and put me back on Norco. He also started treatment with a series of cortisone shots. The first epidural seemed to help (or at least the lidocaine did). Subsequent, localized injections had little effect. The only thing he could offer was increasingly stronger opiates and stronger doses of those. I developed an allergy to Tylenol and still react to some extent to opiates with peripheral edema (although this may be related to the injury). In the meantime, the pain intensified. At this point, I cannot stand or walk for more than 10 min, the pain refers from the original location to various locations: from the original R side to the L, to the outsides of the gluts, the thigh, knees; sometimes the circulation in my legs just shuts off and my feet are subject to considerable edema, pins and needles, and numbness.

I asked for another MRI (this is the third). Clinically I've noticed significant increases in my pain levels and loci over the past 2 years, more limitations in my ADLs, weight gain (some of which is med related--I am treated with psych meds which do pack on pounds. I am 60, otherwise healthy except for having long term controlled cases of tachycardia, bipolar disorder. and lifelong migraines and IBS, which have declined as I've grown older and which are likely related. I'm as physically active as I can be -- I work with a certified trainer 3 days a week and use a recumbent bike as often as I can. My pain mgmt MD continues to give me narcotics and has not suggested any new course of action based on the 3rd MRI. I NEED another opinion. Below is the language of the radiologist who read the images. I would appreciate it if I could have

(1) an interpretation of the report in an intelligent layperson's terms,
(2) what type of treatment or treatments is/are suggested by the report
(3) a speculation of what might happen if I continue on my present palliative course of treatment
(4) possibly a recommendation of 2 or 3 neurosurgeons from whom I could get another opinion
(5) the pros and cons of any surgical options.

I am happy to pay for your time. I'm tired of taking my dope like a good girl without being given other options. The options may be risky, experimental, associated with high failure rates--whatever the case I want to at least know they exist.

Thanks so much for taking time to read this treatise. I am a PhD psychologist (I was an academic for 30 years) and know that if you're volunteering precious time to help disentangle patient(s)' medical situations, problems, questions, then your dedication is genuine. You're not being paid enough for this work--you have an altruistic nature. I'm lucky to have a chance to learn from you.
_______________________________________

MRI results: MRI without Contrast Protocol

The entire spine from T12-L4 is normal.

L4-L5 hypertrophic bilateral facet arthropathy and ligamentum flavum hypertrophy with mild central stenosis and bilateral lateral recess stenosis.

L5-S1 disc dessication only

Impression

L4-L5 facet arthropathy with small joint effusions and mild central and moderate bilateral lateral recess stenosis

thanks and best regards
Submitted: 1 year ago.
Category: Neurology
Expert:  Dr. Frank replied 1 year ago.

neuromd2012 :

Welcome to Just Answer. I am an Adult Neurologist and was contacted to answer your question.

neuromd2012 :

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.

neuromd2012 :

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.

neuromd2012 :

has received

neuromd2012 :

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.

neuromd2012 :

I realize that you have had a long history of opiate use, trials of suboxone detoxification, and find yourself back on opiates.

neuromd2012 :

You did not make mention of neuropathic meds like gabapentin, pregabalin, or duloxetine

Customer:

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?

neuromd2012 :

hi

Dr. Frank, Board Certified Physician
Category: Neurology
Satisfied Customers: 7202
Experience: Board certified general Adult Neurologist, with experience in experimental neuroimaging and neurodiagnostics.
Dr. Frank and other Neurology Specialists are ready to help you
Customer: replied 1 year ago.

Hi. No, I am here for a bit longer. I have had undesirable side effects to Neurontin and therefore have not tried its cousins.

Expert:  Dr. Frank replied 1 year ago.
Hello. When you rated me, it disconnects us, so we have to communicate on this question and answer section. (thanks for the rating though). I would ask you if you have considered just buprenophine as a patch for chronic pain, instead of dilaudid/oxycontin/oxycodone/hydromorphone, etc.? You can use a low dose in a weekly patch of buprenorphine (butrans patch). It lasts a week, and there is much less variability.
Customer: replied 1 year ago.

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.

Customer: replied 1 year ago.

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.

 

jk Innocent

Expert:  Dr. Frank replied 1 year ago.
Hello. There are procedures like RF rhizotomy for facet hypertrophy that may help to relieve the constant pain in the paravertebral muscles. This is a procedure similar to steroid epidurals, in that you advance a probe under local anesthesia, and the RF probe is like a tiny microwave oven. Using a pulsed format, you heat the nerve to the facet joint to disrupt the ascending pain fibers. You can expect up to 9 months pain free with this technique, there are also neurosurgical follow up techniques like neurolysis of the nerve, but the risk is permanent numbness on parts of your leg. Surgery to remove the facet hypertrophy and clean up the lateral recesses endoscopically are also on the menu, but the problem is that you have degenerative changes, and you are not changing that process, so the risk is a return of the abnormal state in a few years due to calcium deposition. You should consult a neurosurgeon that does endoscopic surgery (at the Mayo-Scottsdale, or Barrow Neurosurgery?). You should check your vitamin D level and calcium level as well.
RF rhizotomy is done at most higher level pain management offices, so you may have to hunt around. Please get back to me if you have questions ok? Dr Frank T
Customer: replied 1 year ago.

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?


 

Expert:  Dr. Frank replied 1 year ago.
Hello. You are describing a posterior lumbar laminectomy, discectomy and fusion with placement of lumbar hardware, pedicle screws and rods. That is the rather standard approach. Unfortunately, I do not have a source of visual aids online for lumbar surgery, I wish someone would invent this a great educational tool. Yes, the fusion will limit motion at the L4/5 level, as parts of the facet are removed, and bone graft covers the transverse processes of the vertebra. The bone cement that forms the fusion itself can take up to a year to set, so there is a recovery period. I would say based on your response to medication and steroid injection therapy, that it is a more aggressive approach that hopefully will allow you to wean off these medications. Dr Frank T
Dr. Frank, Board Certified Physician
Category: Neurology
Satisfied Customers: 7202
Experience: Board certified general Adult Neurologist, with experience in experimental neuroimaging and neurodiagnostics.
Dr. Frank and other Neurology Specialists are ready to help you

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