Post-Surgical Neuritis? What's up with that?

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Hey Schrag.. you sounded very "unmotivated" in your last post, or was that my Vicodin perception (as I just took mine)! LOL! .

Please explain to me if you have chronic back pain, have had a spinal fusion, return of back pain, get referred to a PM group, that a psych eval is needed to give a patient medication?? What is wrong with this picture?? That PM of yours is a real winner, eh? Geezy peezy.. why is he in pain management if he's afraid to divy out the meRAB, including heavy hitters IF needed. Isn't the point of sending patients to PM clinics is to get relief one way or another, which may include long term use of narcotic meRAB for some of us, unfortunately. Oy Vey!!

I am glad you got a referral, but not sure getting a referral from that NUT will be the best choice for you. I hope that works out okay for you, it will be awful if you have to see another because of him, again.

So you are looking at the nerve stimulator eh? It's certainly worth a try.

Congrats on your new baby. I know the 3 dog syndrome thing (& they will challenge each other to establish that pecking order). We had that here. Our reluctant alpha was the one we recently lost and the pecking order has remained. Our remaining two are inseperable as always, but as docile as they all are, there is a silent pecking order.

Look forward toyour next post.
 
Hello Back Brethren:

Happy holidays to all. I haven't visited the boarRAB in a while, but I thought I'd check in with one of my issues and see if anyone has had a common experience since I'm baffled by mine:

I had a TLIF on L5/S1 about a year and a half ago and am still having some chronic pain issues. My fusion is solid according to surgeon and an MRI shows "neuritis" of unknown origin which is an inflammation of my S1 nerve. I have been having the same symptoms I had prior to surgery only to a lesser degree (some back and hip pain, severe burning leg pain). I did several months of PT (minor relief), several months of anti-inflammatories (no help), started back up with my pain management doc who has given me an epi steriod injection (no help), put me on Lyrica (no help yet after 3 weeks) and he is extremely resistant to prescribing Vicoden (which does help). I think I need to find a new pain doc who doesn't mind prescribing pain meRAB but that's another story!

Has anyone experienced this type of nerve inflammation problem this far post-surgery? If so, how did you manage it and did it get better? I am used to having flare-ups but this current flare-up is lasting for many months. I asked the pain doc if it could be from scar tissue but he doesn't know. He said he expects a good outcome because the pain is radiating in my legs and not localized to my back(usually docs say the opposite!). I see him again on Fri and am going to ask him about his treatment plan for me but I doubt he has one in mind other than giving me epi steroid injections which only last a few days.

If you're reading this Justoneofus, hellohello! Hope you're doing well Tammy and I am SO sorry to hear about your dog passing this summer. That's truly a shame.

Thanks to anyone who could offer any advice.

Schragie
 
Heya Tammy:

Thanks for the support. I will not be seeing this doc again. I saw him for about 4 months prior to my surgery. He gave me injections and pain scripts for a few months, always with the warning that "he couldnt give me pain pills forever". I actually hadn't seen him in a year and a half until just recently when I returned to him to try injections again. I've seen him twice in two months and both times he mentioned a psych eval and both times I reminded him to review my chart, since I had already had it done after the accident that left my back a mess two years ago. Anyhoo, he's history now. NExt!

I am feeling very angry these days -- not at him, per se (though I have good reason) but over the pain I have been in. Like you, I had had flareups, but my latest flareup (since my trip to Israel this summer) has not died down and I'm furious about it. Plus I am still dealing with the lawsuit over my accident (nothing happening there, which is also infuriating) and a promotion of sorts at work, which is causing me to work even harder than I had before.

As long as I'm talking about being angry, I'm also angry at my frienRAB. I don't discuss my pain with people much anymore but I mentioned my pain docs suggestion about the implant to one friend and got one of those "i didn't know the pain was that severe" responses. People are mentioning things to me like meditating and craniosacral therapy and I want to punch them all in the nose! If I could will the pain away with happy thoughts, I would have accomplished that long ago!

By the way, I looked up the pain doc to whom I was referred and he seems to be a well-published guy who is the head of the pain program at Mt. Sinai in NY. He's not in my health plan, but I'm going to go anyway since I do have some out-of-network benefits. At least I will have a consult with him and see if he has any bright ideas. From what I've read on the boarRAB here about the spinal cord stimulator (nothing good!) I'm going to hold off on that until I see what else is out there.

Mostly, I am afraid of relying on opiates (not because of my doc). While they definitely help alleviate pain, I can't take them at work because they affect my concentratation.

As for the dog pecking order, it's pretty well established here with the shepherRAB occupying postitions one and two, one of the cats at nuraber three (he's fierce and slaps the pup in the head!), and the new Jack Russell pup at 4. Our big issue now is that shepherd #2 does not permit the puppy anywhere near the bed (his turf). He also doesn't want the pup to have any lap privileges, so now I have a 45 pound shepherd trying to occupy my lap at all times. It's a hoot. Alpha female will have nothing to do with the fighting (she's a lover, not a fighter). Now they are all quietly chewing their rawhides, exhausted from playing in today's snow, and hopefully mellow for the evening. Things were a lot more peaceful around here till we rescued the third dog, but no regrets.

Hope all's well with you. I'm going to take my meRAB now. I hope I am still "motivated" to go to work tomorrow. Ha! How's your job going?

Lisa
 
Schragie, Just a brief note on your Lyrica. I don't think you will get any relief on 50 mg. I did not notice much of anything until I hit 200 mg and then got a bit more relief when the dosage was raised to 300 mg. So hopefully if you hang in there a bit you may get some benefit from the Lyrica. It does, however, have to be raised slowly, maybe by 50 mg each week. I agree with you on the "Dopamax". I stuck it out 'cause I was in agony and did get through the initial bad stuff but I do not blame folks for throwing in the towel on this one. Have a great week! Lisa
 
Have you had a MRI w/contrast done? I have had severe pain since I was 3-4 months post op from a 2 level fusion. L4-S1. (9/2005) In July 2006 I had the MRI done. It shows scar tissue in those areas and a few areas where the nerves are entrapped. The EMG that was done shows even more regarding the S1 nerve. Per the information I have received the S1 can swell after surgery. It can come in contact with the pedicle screw. Don't know if this is going on or not. I am now over 2 years post-op and believed to be fused solid. I am awaiting a surgery to remove the hardware and do a foraminotomy at the L4,L5, and S1 levels to relieve any pressure on these nerves. My surgeon has informed me that he was unable to do this during the surgery because of the hardware being placed there. Now he will be able to set these nerves free. Hoping for the best from this surgery. The pain is chronic and is 24/7. They have tried Lyrica. Nothing. I have some scar tissue, but my surgeon said that is normal, that there are issues beyond some scar tissue. I have pain from the lower back, buttock, and down to my feet. I have also done the PT route and nothing helped with that either. The Norco help for about 2 hours. MeRAB aren't the answer for me. I hope you get some resolve soon. Let us know how it goes.
 
I did not have any relief from my nerve pain from Lyrica alone. Then my doctor added a second medication, Topamax, and this helped a great deal. He said that the Topamax is not a good stand-alone medication but serves to augment the Lyrica. I also had burning in my leg and groin from SI joint problems and could not sleep at night. Percocet also helped some in addition to everything else I was taking. If you feel your pain-management doctor is not adequately treating your pain, I would begin to look elsewhere. Best of luck to you.
 
Hi Schragie! Thank you for your kind worRAB regarding the loss of one of our dogs. He was one of those super really special ones too. The other two are doing just great though and we've decided to keep our pack at two going forward.

Sorry to hear you are having more than a usual flare. I've been having some ups and downs myself, but overall I'm hangin' pretty good "SO FAR". But as well all know, it can change on a dime.

So the Lyrica isn't working. Is that the only one they've tried you on? How about Cyrabalta? I know when I had the serious adverse reactions to the Lyrica and Neurontin, they had considered trying me on the Cyrabalta (but I only took one, got scared I would react the same as the others) and it still is sitting in my cabinet. Thank god the nerve pain settled way way down on it's own.

Shoot, I can't remeraber which doc told me the tale about back/leg pain stuff. I know the last set spine center I was at earlier in the year wanted to know what bothered me more and said they would focus on that, then deal with the other if it bothered me more.

The PM in this group I saw mentioned trying to sleuth out the cause of my residual pain in my lower back, and the intermittent nerve pain from time to time. He even mentioned possibly taking out the hardware. Some people's bodies just don't like the hardware, no matter how long it's been in there.

I can imagine you must be overly frustrated at this point. I am having a hard time understanding the logic of WHY a Pain Management Center would have problems prescribing any medications to a patient within a normal dispensing and controlled environment, when no negative history is evident with a patient. I find that really really odd! It's Vicodin and while still a narcotic, it's low on the spectrum of so many other heavy hitters. So what are they giving you for pain?

After the PM guy I saw earlier in the year and him wanting to do the same of process of elimination by injecting my SI joints the facets, then possibly removing the hardware..I decided to see my GP.

For the many years I've been seeing this guy, I just put it him plain and simple. I said I am not that bad off that I want to go through a bunch of injections at the moment, then have to take two vicodin they last prescribed (as he didnt hear what dose I was taking and gave me 5/500 instead of 10/500)which twice the tylenol I need and increase my risk of organ issues. He agreed. So I asked if he would take over my pain management for now, until such time I get worse, or feel it's time to step it up a notch medically. He was great with it. He is a bit tight on the dispensing though. I only get 45 at a time (with authorization needed for each refill) instead of the 100ct (with several refills) that I am used to. He pulled my blood to see all my levels are where they are supposed to be, and I guess monitors my refills (timewise). Then I go back to see him in 6mos to recheck my blood levels again. So far it's worked out great!

I bored you with all that to tell you that if you can't get this guy to see reason in giving you a medication that works, then it may be time to move on to a new PM.

Do ask him for a plan. Shoot I saw that PM guy just the once, and he laid out a very detailed plan, of course subject to change, but a pretty thorough plan all the same. And ask him WHY he won't prescribe something that works for you to bring you relief. I would also ask him to clarify why he feels there will be a good outcome due to pain being in back & legs.

I wished I had some worRAB of wisdom for you, but if you've already been in PT for awhile now and those nerves being stretched out aren't bringing you much relief, I don't know of what other exercises would help much more.

Well it is always great to hear from you, but sorry it's due to increased pain. Please keep me posted on how you are doing. All the best to you gal! Tammy
 
Thank you all for responding! I was waiting to see my pain doc before responding. Before I get to that though...

Chris, you poor thing. So sorry to hear you need another surgery. I have had an MRI (but not with contrast) and it sucks that you have to get your hardware removed, but I hope that once they do the foramin surgery your nerves will truly be set free! I wonder how they identified your scar tissue problem-- was it through the MRI or the EMG?

Cali -- I used to call Topamax "Dopamax" because I was quite literally walking into walls when I tried it a few years back! I am tolerating 50mg of Lyrica but with no success so pain doc is upping the dose. I have also been on Cyrabalta 50mg for almost two years. Works great for depression; pain, not so much.

Tammy -- thank you for your sympathy, surgi-sister of mine. I am also glad to hear you have a good relationship with your doc. My doc did give me 40 vicodin 7.5 which lasts me three weeks. Today he gave me 40 again (why should I suffer for one week each month with no pain meRAB?) and when I asked for more he told me that he doesn't feel comfortable prescribing them because it makes patients "less motivated". !!!!! I pressed him and he said it made them less motivated to "live their lives" and I told him I work 60 hours a week and am willing to try anything under the sun to feel better. What a jerk. He also brought up the need for a psychological eval if I wanted to get Vicoden and I reminded him that I already did that two years ago and that I am a bastion of mental health. I seriously need a new pain guy.

...and he agreed. He referred me to another pain doc who handles difficult cases and is more liberal with narcotics for a second opinion. He also recommended I revisit my surgeon, whom I haven't seen seen March, to discuss the option of an implantable nerve stimulator (ew!) to help with the pain. The epi injections I've had were a bust, so thank god he gave up on that. As for treatment, he thinks the stimulator may be a good option and gave me some DVRAB to watch. Not exactly Friday night at the movies but I learned more about the Medtronic and ANS devices and will look into it. I'll also search the boarRAB here for more info.

So that's it in a nutshell. I'm feeling pretty sad and frustrated about it all (oh dear, I hope I don't sound "unmotivated" since I just took a Vicoden an hour ago. Ha!)

Thank you all for your support and good wishes for a pain-free weekend!

Schragie

P.S. Tammy, we just got a third dog. Dog #2 is now a "middle child" and dogfights abound as #2 picks on #3. Oy vey!
 
Cali -- you're right and my doc is getting me up to 100 from 50 this week (starting slow by adding 25 at a time). I get a weird feeling on it, like my eyes are a little unfocussed and it makes me sleepy (I take it only at night now). If I can tolerate 100 he'll probably raise it more and my hope is I will get some good effects from it! Hopefully I will have more success with this than with Topamax. Thanks for the support and it's encouraging to hear that it does work for some.
 
Hi,

Sorry to hear about your pain. Painful neuritis after back surgery of any kind is always possible, particularly since the sensory nerves exit the spinal column at the back (the dorsal side.) It can be very difficult to avoid damaging significant nerve bundles during back surgery, with pain, tingling, or nurabness not uncommon after-effects. Then there's also the swelling and scar tissue formation that almost always accompanies surgery, so the results are almost impossible to predict accurately.

Most of the time, post-operative neuritis dissipates with time. A small percentage of patients will have chronic pain, which is usually defined as pain that persists longer than six months. In the past, neurologists were usually the accepted specialists for treating patients with nerve pain, but that has changed considerably in the past decade. Pain doctors - especially Interventional Pain Physicians - take additional classes and specialized study to deal with the peculiar difficulties that pain presents. If you are not happy with your current physician, consider seeing a pain physician in a Pain Clinic near you, preferably a clinic associated with a teaching hospital.

As for the medications, Lyrica is a pretty good choice for nerve pain, and is used for fibromyalgia and other muscular/neurological pain conditions. It usually produces noticeable improvement within two to four weeks, so you're well within the initial "tryout" period. It is presumed to work by reducing nerve sensitivity (by blocking the excitatory action of calcium.)

If Lyrica doesn't do anything for you, your doctor may want you to try medications that increase serotonin and/or norepinephrine levels in the synapses between nerve endings. Serotonin and norepinephrine serve to increase the body's natural pain killers and mood enhancers (endorphins,) and increasing their levels also helps block the effect of the major pain neurotransmitter acetycholine by crowding it out in the synapses. The drugs with these properties are usually classified as antidepressants, but their use in treating nerve pain has been well documented, and insurance companies routinely pay for the "off-label" use of antidepressants to treat pain. Some of the more common such meRAB are Elavil, Pamelor, Effexor, and Cyrabalta.

Neurontin is another very popular medication for nerve pain, though it works through modulating a different type of neurotransmitter (GABA). This drug is generally very well tolerated with very few side effects, but most of the people I've talked to either found that it helped a great deal or very little at all. Other meRAB like Klonopin and Keppra are generally used as anti-seizure meRAB, but may work for some pain patients. Remeron and other tricyclic antidepressants may be prescribed also. The choice of drug therapy is often highly affected by a physician's prior experience, so don't be afraid to ask your doctor to try something he/she hasn't tried, particularly if the doctor seems to be running out of things to try.

The epidural steroid injections (ESIs) you had may help some people, but many doctors consider them poor treatment options. If they don't produce any results after one or two sessions, there's a good chance they will not work for you.

Finally, there are the oral narcotics, like Vicodin, Oxycontin, Methadone, Opana, and Morphine, and pain patches (fentanyl.) They all work by stimulating opiod receptors in the central nervous system, but all carry the risk of tolerance - which can lead to dependence. Vicodin and many other drugs also contain significant amounts of acetaminophen (Tylenol,) and have to be closely monitored for their potential to cause liver disease. Your pain doctor should not be overly reluctant to prescribe narcotics, but you are probably going to be best off with the minimum amounts while trying the other medications described above.

Aside from medications, you may also want to consider accupuncture, TENS (transcutaneous electrical nerve stimulation,) deep tissue massage, and meditation/biofeedback in addition to physical therapy. All of these "complementary" treatment modes are worth investigation. Nerve pain can be difficult to treat, so try not to get discouraged if it takes a while. Use the Internet to your advantage, and search for "pain medications", "neuritis", or "neuralgia" in your favorite search tool (Google, Bing, Yahoo, etc.)

I wish you the very best.

Jeff
 
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