I am sorry that you are going through such a difficult period with your pain issues as well as with phsychological, emotional and family issues in your life. You have already gotten some very supportive and useful advice from other members of the exchange. As you know, this is an extremely difficult and complex problem and there are clearly no simple or easy solutions. Chronic pain is a terrible illness that devestates both the patient and their loved one. The worst part is that often there really is not a "fix" but only things that can make it better.
Unfortunately, your depression has a negative impact on your pain condition and your pain condition has a negaive impact on your depression. It is a very viscious cycle that is hard to break. This is not to imply that the "pain is in your head" but point out that the "pain gets into your head". Studies have shown that people that are under psychological or emotional distress percieve painful stimuli more intensely. In other words, if you perform something painful like a poke with a pin exactly the same way to a person under stress, they will rate the pain caused as greater than someone not under stress (a 5 of 10 intensity versus a 2 of 10 intensity. It is critical that any pain treatment that you pursue has a psychological component. This can include a person in the pain clinic or a separarte therapist like mentioned seeing or both. It is important that your pain physicians and you psychological therapist or psychiatrist work closely together to ensure you address pain and depression and that meds to not negatively interact.
Another important step moving forward is work hard on changing your daily focus from "fixing the pain" to minimizing the pain and maximizing your function. The pain is probably going to be there no matter what so you can either withdraw from everything you love and hurt or you can do the things you love and hurt. The latter would seem to be the better place. You do not have to be afraid of being active and hurting. The pain you experience is not like the pain from a burn. You are not "burning" your back if it hurts. There is no tissue damage associated with the pain from fibromyalgia and other similar conditions. There is no danger of damaging things if you try to do more.
Good luck! I hope that this was helpful in some way.
Unfortunately, it is difficult to tell from your description of your symptoms and situation as to whether your major problem is lower back or leg pain. As I have indicated before, this is a key distinction with respect to the appropriateness and potential efficacy of various treatments. All the injections that spinal specialists recommend or perform are "cortisone" injections. They are usually a combination of a local anesthetic (numbing agent) similar to Novocain and a steroid. The "success" rate of these injections varies a great deal depending on the injection type and the problem being treated. Based on the information and your comment about the recommendation to "burn the nerves", I am assuming that your major pain is back pain. I am also assuming that the recommended injections are facet injections. Facet joints are the small joints in the back of the spine that work in conjunction with the disc (also a type of joint) to allow the spine to move. While the discs and facets work in cooperation and aging of one affects the other, "slipped discs" are a different issue than facet joint pain. The facet blocks or injections are either an injection of medicine directly into the joint (like a knee injection) or of the medicine in the area of the very small nerve branches that supply the joint. If the "facet block" provides significant relief, then a facet joint nerve ablation is considered a more "permanent" way to treat facet pain. This involves using a radiofrequency "probe" or needle that heats up at the tip to "burn" the nerves. I put permanent in quotations because these small nerve endings can grow back as the treatment does not destroy the nerve cell just some if it's branches. A procedure to "burn the small nerves supplying the discs would be very different and I assume this is not the procedure being recommended. As Joy and Dave indicated the scientific evidence as to the effectiveness of injections is limited, particularly with respect to facet injections. Furthermore, no procedure is without possible risks or side effects and any patient can have significant reactions to procedures and medications. However, the risks associated with this procedure are very small and if all other treatments have failed, it may be an option. Epidural injections are also cortisone injections. They are usually used to treat leg pain. There is also limited scientific evidence supporting epidurals but there is more than that for facet injections. Approximately 75% of patients will respond positively to an epidural injection. Unfortunately, the positive effects are temporary for many patients and can last from minutes to months. It is impossible to predict if any given person will have long term or short term improvement. If the patient responds positively to an epidural with effects longer than just minutes to hours, they may be a candidate for 1-2 more injections over a period of weeks to a few months. Most physicians feel like patients should not have more than 3-4 epidural injections in a few month period. The injections can be repeated if they have been effective and a significant period of time has passed since the last injections. One study demonstrated that in patients with herniated discs and sciatica, less patients had surgery in the end if they had a special type of epidural called a transforaminal injection. While clearly the physician performing the injection is reimbursed for his or her work and there are some "injection mills" out there, the majority of physicians are very conscientious about ordering injections. Furthermore, while there are possible sided effects of injected cortisone (increased blood sugar in diabetics) the risks are much less than oral steroids or even many other oral medications. As long as the physician is not recommending numerous injections, more than 3-4, it is not an unreasonable treatment option.
Your symptoms do seem to be consistent with a disc herniation at C6-7. The natural history of this problem is the approximately 90% of people will improve with conservative care in a period of 3-6 months. Therefore, it is very likely that with some additional treatment that the symtpoms will improve dramatically. Conservative care usually includes medications and physical therapy. Spinal manipulation with the chiropractor includes some aspects that may be a part of physical therapy or PT but there are other parts that it does not cover. It is generally shown that active treatments such as PT are more effective in the long run than "passive" therapies like manipulation. In addition to PT, many patients will respond to an epidural injection or nerve root block. This is something that could be ordered through a spine specialist. Also, many patients respond to medications that are specific for the nerve pain. These include medications that are classically used to treat seizures or depression but taken low doses they seem to help "nerve" pain. The down side of these medications is that they can make you sleepy or drowsy though this tends to pass after you have taken them for a while.
With respect to the long term, you are at some risk for neck pain due to the degenerative disc that resulted in the disc herniation. Even if the nerve pain improves, which it should, the disc will not go back to being "normal" or young. The key to trying to avoid chronic neck pain is a regular neck range of motion and strengthening program that you would learn in PT. With respect to the "cause" of the degeneration, it is just the natural aging process of the spine. It affects everyone, albeit, with different degrees in different people. It does tend to be hereditary though not as directly as things like hair and eye color.
Hope this was helpful. Good luck and the odds are on your side for improvement if you get active in recovery.
It is great that you have had exellent results from your surgical procedures. You are wise to try to get moving and active again. Being fit and active is the best thing that you can do to prevent future problems with your back. However, it is important that you develop a progressive aerobic and strengthening regiment. I would suggest that you contact your surgeon for a referral to a spine physical therapist who can help you get started on your return to exercise. In general, you want to avoid impact type exercises so the elliptical is a reasonable option. You should also avoid any heavy weights, particularly free weights, above your head that will cause compression to the spine. I usually recommend that spine patients use the weight machines that use resistence mechanisms or weights on tracks with pulleys. These are less likey to injury you. You also need to do regular core muscle strengthening. Again a physical therapist can help you get started. Pilates is the commercial exercise course that is most similar to a core strengthening program.
Glad you are doing well and eager to be active. Good luck!
I would agree with some of the suggestions that you have already received from exchange members. It is unusual for scoliosis to cause such severe back pain, especially in someone so young. As such, the scoliosis alone may not be the whole story. I would suggest that you discuss your problem and request a referral to a an orthopaedic spine specialist that has an interest in adult scoliosis. I would suggest that you not purue any x-rays or other tests until you see that physician. They will be better able to determine what type of x-rays or other tests are most appropriate to assess your particular problem. If your primary does not know of such a physician, you can locate a scoliosis specialist in your area by searching the Scoliosis Research Society website at www.srs.org
Unfortunately, your post has limited information on your prior history. However, I assume that you had an L5-S1 fusion at some time in the past for back pain or some type of instability. It is clear that you are either having a recurrence of your pain or have continued to have pain since the time of your surgery. That is actually a critical distinction as to whether you had a period of pain improvement or not. If you had a significant period of improvement (more than 6 months), then it is possible that changes at L4-5 could causing pain. This is a described phenomenon called "adjacent segment degeneration" and is accelerated deterioration at a level above or below a prior fusion. However, it would seem that there has not been significant degeneration at L4-5 if your x-ray and MRI "came back clean" with no abnormalities for you. Having said that, it may be the case that your L4-5 level already demonstrated some degenerative changes at the time of your surgery and no apparent changes were noted on the new studies. You can develop increased mobility at a level above a fusion but this really can not be "diagnosed" with any type of physical examination maneuver or test. The "test" performed by the therapist could have placed stress on any number of structures that can cause pain including your pelvis and lumbar facet joints (small joints of the spine). It is not specific for any type of abnormal motion of the vertebra. Furthermore, the therapists' definition of "instability" or "hypermobility" is not the same as used by physicians. I have discovered this fact by participating in journal clubs (meetings to discuss scientific studies of back pain) with our therapists at Duke who teach in the PT school. If there is any instability or abnormal motion of your L4-5, this would be demonstrated on x-rays with you bending forward or backward (flexion-extension) x-rays. This may be something to discuss with your surgeon. In reality, there are a multitude of things that could cause new pain and there is no test where a flashing red light goes off at the source of the pain. I know this is frustrating for you as a patient but trust me; it is also frustrating for your doctors that would truly like to help you.
If your pain never improved after surgery, it would not be logical to attribute the pain to a new problem. Possible causes of pain after surgery include a failure of the surgery to heal, additional problems that were not addressed at the time of surgery, and simply a poor outcome that is not explainable. I assume that your surgeon has assessed you for a possible non-healing of the fusion if there is any question on the x-rays. This is most often done with a CT scan as it demonstrates the bone much better than an MRI.
In light of your various medical problems, your back and leg pain is most likley multifactorial in its etiology. As such, there may be no simple or single way to address the pain issues. It is unfortunate that your surgery did not provide improvement in your leg pain (sciatica). No pain surgery is guaranteed, even one as successful as spinal stenosis surgery. I assume that you have discussed the possible causes of failure with your surgeon and have determined that there is no simple solution. If not, I suggest you do discuss why your surgery "failed". It may be helpful to get a second opinion from a another surgeon to determine if the orginial problem was adequately addressed or to ensure that a "new" problem has not arisen. Having said the above, the general rule is that subsequent surgeries are less likely to be effective than original surgeries. This is particularly true in patients with a generalized pain disorder like Fibromyalgia. It would be prudent to be cautious with respect to further surgery.
With respect to your Fibromyalgia, this is not a surgically treatable problem so it is not surprising that these symptoms did not improve with spinal stenosis surgery. This is a systemic pain problem that is thought to be due to "over sensitive" pain nerve endings. The treatment is usually medical and multimodal often best administered in a comprehensive pain clinic.View Thread
It certainly sounds at though your brother is in a lot of pain and has a complex problem. Unfortunately, there is no easy or simple answer for these issues. It sounds as though more surgery is really not an option or advisable. That is not surprising as the likelihood of success decreases with each subsequent procedure. At this point, it may be useful to seek a consultation at a multidisciplinary spine center, particularly one with an active pain management component. If there is not one where your brother lives, you might research the closets medical schools or universities to see which ones may have such a center. If this is some distance from his home, it would not make sense to plan on long term treatment there. However, they may be able to recommend a plan to minimize his pain and maximize his function that either his PCP or a local pain physician could initiate. If you do seek such a consultation, make sure he takes all the records (physician and hospital) as well all of his radiographic studies (reports and films) from before and after surgery with him to the visit. The films may be on a CD but the doctors will usually want to view the images themselves.
Good luck and I hope he can find some improvement!
With respect to your particular issues, studies have shown that people with scoliosis are more likely to have back pain that people without scoliosis. Also the back pain in scoliosis tends to be worse and more difficult to get rid of compared to back pain in patients without scoliosis. At this time, it seems as though you have had a very thorough evaluation and a "fixable" problem has not been found. I know this is frustrating and disheartening but it is common. As such, your focus may need to shift from "finding out what the problem is" (because you may never have a definitive problem) to "How can I minimize the pain and maximize my function?". I am not giving medical advice over the internet but I do not think that a neurologist would have a lot to offer in your situation. You may be better served with a physiatrist and/or pain management physician as Joy recommended. If you do want a second opinion for surgery, that is very reasonable and a neurosurgeon would be okay. I agree with Joy again that I would make an appointment to speak directly to your PCP about a desire to see a neurosurgeon as a second opinion even though you have already seen an orthopaedic surgeon. This is a very reasonable request and if they will not help you, you may have to seek out another physician. You asked about what to ask to the neurosurgeon, I have posted two Tips on how to get the most out of a doctor visit that may be helpful. If you see a second surgeon that also does not feel as though surgery is the right answer, I counsel to consider putting that option behind you and moving forward, If you keep trying, you can find one of my colleagues that will agree to operate but as you will see from a lot of posts on this exchange, that is not always the right move and you can end up worse.
I know that these things may not have been what you want to hear but I hope they were helpful. Good luck!
I am going to reply in two parts because of th character limits.
Here is the first installment.
Unfortunately, back pain is a common but complicated problem. I assume that you also made the post about the myriad of treatments, diagnostic tests and opinions that you have had and the difficulty getting a referral to a neurologist or neurosurgeon.
Your situation in particular is complicated. You have a history of scoliosis as well as a history of lower back pain and some prior motor vehicle accidents. While I know that this is difficult to believe and frustrating, only about 10% of the time can we definitely identify the cause of back pain. Everything and nothing in the back can hurt. The discs, the small joints between the vertebrae (facet joints), the muscles and ligaments can all cause pain. However, there can be aging changes in all these structures and a person can have no pain. So the presence of something on an MRI, like your bulging/herniated discs, does not necessarily mean that it is the real cause of your pain. This is why it is so difficult for your doctors to "tell you what is wrong". While we are on the subject of your disc issues, there are different terms for the degree of herniation or protrusion that a disc may have. These generally range from bulging (not a true herniation) and may simply be a phenomenon of aging (your disc are getting old even though you are only thirty) to protruded (mild true herniation), to extruded (moderate true herniation) to sequestered (marked true herniation). Unfortunately, these terms are used interchangeably even when they should not, are somewhat subjective depending on the person reviewing the MRI, and may be used very differently by surgeons and non-surgeons. So to answer you question in a frustrating way, yes the disc can be bulging and "herniated" at the same time depending on the perspective of the person reviewing the pictures. To even further frustrate you (without wanting to), if your primary complaint is not leg pain, the disc bulges/herniations that you have may be what I call true-true and unrelated to your back pain. In other words, you have back pain and you have bulging discs but the two things have nothing to do with each other. Many completely asymptomatic people over the age of 25 have abnormal MRIs with bulging discs and by age 65, almost everyone has at least one bulging disc.