I have had chronic back pain for many years and I have been told there is nothing wrong with my back.
The length of the time it takes a patient to be referred to a skilled interventional pain specialist, impacts the degree of success. It also increases the chronicity of the pain besides creating other problems such as drug dependency, loss of work, loss of functioning, and psychological problems such as depression. Back pain has many causes. Dr. Vengurlekar will evaluate your back pain problem by both a clinical examination and sometimes by ordering additional testing, and occasionally by performing diagnostic procedures such as selective root sleeve injection, transforaminal epidural steroid injection, facet nerve block, discography etc. Based on the cause of your pain, you still have potential for improvement or cure. Obviously, the longer patients go with the chronicity of the pain, the poorer the chances are for complete success of pain relief.
If there is paralysis in an extremity or if there is problem with incontinence, then undoubtedly spine surgery is the answer. In your situation, it appears that your pain has started recently, and if you have a herniated disk, you may benefit significantly, and almost completely, from the procedures that Dr. Vengurlekar may choose to perform on you after an evaluation. Most spine surgeons recognize the limitations of spine surgery and insist that patients undergo a minimally invasive procedure before they make the decision to go through with a surgery.
It appears from your symptoms that you indeed have a protruding disk or radiculopathy, meaning irritation of the nerve root. Although MRI imaging is useful, it does not always show the changes from the irritating disk or herniated disk. Every week, I see several patients whose MRI’s show a protruded or ruptured disk, but patients have no symptoms. On the other hand, I have patients who have symptoms of nerve pain in their neck or back, whose MRI’s are completely normal, but they do have a significant disk problem. Such disks can be identified by performing discography studies.
From your symptoms and your presentation it appears you have a condition called Reflex Sympathetic Dystrophy also now known as complex regional pain syndrome. This is a nerve disorder which can be precipitated by minimal injury or a minor surgery, as in your case, and needs to be diagnosed and treated appropriately. The sooner you get the appropriate interventional procedure for this condition, the better are your chances for a complete cure and complete restoration of function.
RSD is a result of a nerve disorder affecting specialized nerves that supply the sweat glands and blood vessels of the skin. Under certain conditions, these nerves take over abnormal functions and start shooting off abnormal pain impulses, resulting in tissue changes. If these conditions are diagnosed early, the chances of cure and prognosis are excellent. However, if they are misdiagnosed, and are prolonged, then there will be irreversible damage to the tissues and the chances of cure and prognosis are poor. In your case, if you’re proven to have RSD, then certain procedures that target the sympathetic nerve tracts will need to be performed. These may be specific nerve blockades of the sympathetic tracts or ultimately a radiofrequency ablation which permanently destroys the troublesome nerve. This is usually combined with physical therapy to restore function.
There are several factors which will determine whether or not help can be provided for your shingles pain. You now have a condition called Post Herpetic Neuralgia. The ideal thing for you when you had your shingles attack was to see a pain management physician and receive certain blocks of the nerves which could have shortened the duration and severity of the attack. Such episodes of shingles, when untreated, may result in Post Herpetic Neuralgia, as in your case. The treatment of Post Herpetic Neuralgia is very complex and involves several therapeutic options. This may include nerve blocks, and some patients may also require spinal electrodes as an ultimate therapy.
Your problem is a generalized condition and arthritis and fibromyalgia need a complex treatment plan which involves accurately diagnosing the condition and instituting medical treatment. Also bear in mind that patients with arthritis and fibromyalgia may also have spinal pain caused by other conditions. So if you have spinal pain or specific pain in certain parts of the spine, those may be amenable to interventional therapy. In the past several years, exciting medications are on the market which can control your discomfort from fibromyalgia. I have successfully diagnosed and treated fibromyalgia and chronic fatigue syndrome with SSRIs, SNRIs, DRIs, etc. restoring quality of life to the suffering individuals.
MRIs alone will not help in making a diagnosis. Pl focus on the patient’s history and a detailed examination, for e.g. Does the pain radiate down the leg or the arm? Is there numbness or paresthesia? Are any reflexes decreased or absent? Any muscle atrophy or fasciculation?
More often, history and physical exam alone are enough to establish a diagnosis. My role would be to make an accurate diagnosis, sometimes aided by a diagnostic procedure such as a selective root sleeve injection, facet nerve block or a discogram.
Unfortunately, headaches, like other medical disorders, are often misdiagnosed or mislabeled as migraine. Headaches can be caused by several conditions. Just from your history it appears that the possibility of occipital neuralgia should be considered in your diagnosis, and it is very important to establish an accurate diagnosis in headache disorders, just as it is for any medical disorder, because the treatment for all these different headaches are very different. You may benefit from a nerve block called an occipital nerve block or a block of the C2, C3 ganglion, if you are proved to have the condition of occipital neuralgia. Other differential diagnoses may include cervical facetogenic pain, greater auricular nerve entrapment, etc.
You have classical symptoms of a disc tear and I am assuming that the other possible conditions in the differential diagnoses have been ruled out such as kidney stone, rib fracture, etc. The first thing you need to do is to stop your physical therapy as all that is going to do is not heal the problem and worsen your disc pathology. After a thorough examination on you, were you to come and see me, I would review your MRIs and then consider a diagnostic discography. Depending on the appearance of the discs, you may be a candidate for Biacuplasty, which as you know is a cooled RF heating of the posterior third of the annulus of the affected disc or discs.
The key element of diagnosing a painful disc causing back pain, on discography, is pain provocation. Rarely have I had a patient who has been so uncomfortable. In my practice, judicious conscious sedation is provided and pain provocation is elicited at low threshold of pressure. This largely contributes to avoiding unnecessary pain for the patient.
With a recent onset of acute pain in a patient who has osteoporosis or any individual who is at high risk of osteoporosis, the first presumptive diagnosis is a compression fracture of the vertebra. These can occur in the thoracic, lumbar and the sacral region and cause acute unremitting pain. Of course, in an older individual, cancer metastases to the spine must also be considered in the differential diagnosis.
The only effective and rapid method of treating a compression fracture is vertebroplasty in which a medical grade of cement is injected into the collapsed vertebra and helps to bolster the fracture and relieve pain. Medical treatment of underlying osteoporosis must also begin immediately to prevent additional fractures. This includes performing DEXA scans, vit D levels, calcium and parathormone levels, etc. Treatment with vit D, calcium supplements and also salmon calcitonin or medications like boniva, etc., may need to be started.
I would like to clarify that my practice is solely limited to interventional pain procedures. If you feel that your patients have an addiction problem, then they need to see an addiction specialist. I also do not take over pain medication therapy initiated by another physician. However, I would be happy to see them and make some suggestions and give my opinions on the patients to ensure that these patients get the appropriate therapy and reach the appropriate level of functioning and productivity.
