Question: I had a laminectomy December 2017. In mid 2018, L4 and L5 essentially collapsed and are pinching my sciatic nerve. I have been through several rounds of epidural steroid injections, with no relief. They are now recommending major back surgery, which I would like to avoid. If I could just figure out a way to control the pain a little bit that would allow me to walk and stand for longer than 5 minutes, I would feel blessed. — Steve
Before discussing ways to avoid surgery, Steve, I would like to first go over reasons that might make a major spine surgery be needed urgently, or even emergently. If a patient is developing major neurological deficits such as sudden severe leg weakness, foot drop, bowel or bladder incontinence or urinary retention, these could be signs of compression of the spinal cord or the cauda equina. That is the collection of nerve roots in the low back region of the spine below the end of the spinal cord. Emergency medical care should be sought if any of these occur.
Of course the information that patients can glean from a newspaper column such as this or from other sources like the internet can be helpful, but you should of course discuss further with your own physician to decide what’s best for you. In general there are several things that seem to be helpful to alleviate pain to allow a major surgery to be delayed. I’m sure, Steve, that you have already done several of these already, as you mention the epidural injections in your question, but I’ll include them for other readers who may have different experiences.
Physical therapy is often used as well as chiropractic treatments unless there’s instability of the spine. Less common are treatments such as massage therapy and acupuncture and biofeedback therapy. In addition to medications that your physician may prescribe, there are a number of over-the-counter medicines.
It is now commonly believed that chronic use of narcotics is counterproductive to pain control, and fewer physicians are willing to prescribe these on an ongoing basis. Referral to a pain clinic can be helpful and some of their treatments include nerve blocks, which I’ll describe briefly.
An epidural injection is usually used with steroids. The needle tip goes into the spinal canal but outside of the lining that holds the nerve roots and spinal fluid. That lining is called the dura, so if the needle is outside of that it’s called epidural. Epidural injections are also used to control the pain of labor for women; however, that’s usually a different medication given into the same anatomic space.
Another type of pain injection used for chronic back pain is called a facet nerve block. Again this is often done in a pain clinic setting and the tip of the needle is guided to be adjacent to the facet joints. The facet joints are the joints in the back where two vertebra touch each other. If this type of injection is successful then, often, the pain clinic physician will suggest a procedure called facet rhizotomies and that’s the procedure were the tiny nerves to the facet joints are burned with electric current. Often this will help for a number of months or perhaps even a year or two.
Attention to one’s general health can also help the back pain including such things as weight loss, keeping the core muscles well toned and quitting smoking.
Another treatment that is often used is a TENS unit. This is an electrical device that is applied externally with pads over the painful portion of the back and connected to a battery pack. This puts small electric current that helps keep your spinal cord from detecting the normal chronic pain messages. There are also surgical procedures that put a similar type device, called a spinal cord stimulator, and that’s implanted with the electrodes next to the spinal cord. But, of course, that is a surgical procedure.
Well, Steve, the above is just a brief overview and may give you some talking points to discuss at your next meeting with your physician. I wish you well in relieving your pain and avoiding major spine surgery.
David A. Cooley, MD, Neurosurgeon & Spine Surgeon with Cooley Neurosurgical Clinic, Lima, and St. Marys