Dear Hubbard,

İnstability after lomber discectomy is not unusual. Modic changes represent a strong evidince of disc disease after discectomy. Normal Electrophisiologic findings are also support instability rather than nerve compession.

What is the solution? Any dynamic stabilization of L5-S1 for example Dynesys is adequet treatment  for me. But the surgeons WHO suspicious about dynamic systems, can do fuson procedure.

Ali Fahir Ozer

Dear Ali, 

Thank you for your input. The Doctors have said more surgery, nerve blocks, or Intradiscal Electrothermal Annuloplasty. All non surgical interventions that have been offered are drug therapy, massage therapy, chiropractic therapy, PT, and/or going on permanent disability. This patient would like to stay working and active as possible and try to maintain a normal life. As of now,patient has lost 20lbs. in the past three months, he is depressed and can not participate in any of his hobbies and many physical activities due to pain and decreased stamina. As for the spinal fusion, this patient would be very hesitant to doing this procedure and none the less any surgical intervention unless he knew it would 100 percent fix his problem. The patient would like to get off pain medication as well as he feels upping the dosages would create an addiction problem in the future. Thank you for your time and I appreciate everything you have presented. 

Kelly Hubbard

Reza,

This patient has not had the combination of those drugs. He did just do a trial of lyrica 75mg 1 cap BID the past month and it did not seem to help in conjunction with oxycodone and tizanadine at bedtime, so he has stopped the lyrica. He did not use it inconjunction with diazapram. What would the combination of these two medications do? Would respiratory depression occur He is a severe asthmatic, so the medications used in his treatments are limited. I don not know if a combination of these drugs are something he could try and I would have to look into that further. Thank you for your time and information you have offered. 

Kelly Hubbard

I´d interesting to know if the Modic changes were of Type I or II.In the first case I´d recommed the lecture of 1) Albert HB, Lambert P, Rollason J, Sorensen JS, Worthington T, Pedersen MB, Nørgaard HS, Vernallis A, Busch F, Manniche C, Elliott T. Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2013 Apr; 22(4):690 and 2) Muzi S et al.The role of intradiscal streroigds in treatment  of discogenic low back pain

Joan,

Regarding the modic changes, it was not specified type I or II and says minimal chronic modic endplate degenerative changes seen at L5-S1.. The only other information offered besides what I stated above is: vertebral body height alignment is maintained, few mild endplate Schmorl's nodes were noted, the conus is identified and is unremarkable, no abnormal enhancement is seen involving the conus or cauda equina. I will look into those lectures you recommended and appreciate the time you took to provide information in this case.

Kelly Hubbard

 No good surgeon could ever promise 100% solution of the problem. In spinal surgery even less than in other types of orthopaedic surgery. In this cases chances are probably 50-50 that nothing will change, and even if you get some improvement it will never be 100%, 60-80% at the best. I would not advise for surgery, and in any case not having tried some form of prediction of the result of a stabilization (external fixation, or at lest bracing etc.) To advise for a better treatment information on weight, BMI, posture, pain history (continuous, only standing etc; inflammatory or mechanic; widespread or metameric distribution, etc...) would be important. Anyway, such a long story of pharmacologic treatment makes it very difficult to find a solution. If the problem, as it seems, is originally mechanical, manual therapy and exercises along with lifestyle changes should have been offered in the first place. Now, with such a strong drug addiction profile, it will take a long time and consistency both from patients and physicians/physical therapist to restore a "normality" or at least an acceptable compromise. With so many yellow flags, cognitive behavioral approach should probably be integrated in the process. If inflammatory and/or neuropathic pain is suspected to be superimposed on the mechanical problem (likely at this stage) pharmacological support should be aimed at reducing that, and thus enabling better work for the therapists with exercises, manual therapy, occupational therapy etc. It is not going to be a quick process (at least 3-6 months to see some progress) and it will require active involvement and high motivation of the patient, as well as competent physiotherapists. Not always easy...