Brief Answer:
Challenging problem which is all too common

Detailed Answer:
Good evening from the XXXXXXX Ohio region of the world. Unfortunately, I wish I had the magical answer for you because the first one of us doctors who can figure out what the definitive way to treat all patients with your type of problem is will literally out pace XXXXXXX Buffet, XXXXXXX Gates, and XXXXXXX Trump's wealth in shorter time than it took the 100 meter record at the Olympics to be shattered by Usain Bolt. That is my disclaimer.....perhaps, not what you wanted to hear....but likely what you thought you would hear.

The dilemma of chronic pain especially when it comes to postoperative pain from musculoskeletal conditions is one of the most challenging and unsatisfying realms of medical science (in my opinion) to have to deal with because the science is just so inexact at this time. We know a lot on the mechanisms of pain, the routes that pain signals take from the point of injury to the brain, and we even have a fair amount of information of how the receptor work in transmitting these signals but what we have yet to figure out is how to translate all of this knowledge into a UNIFIED CONSISTENT APPROACH THAT WORKS FOR ALL PATIENTS 100% of the time and for at least a good long period of time.

Opiate drugs are the mainstay of treatment strategies because they are simply the strongest drugs we know of in the management of pain. The problem is they tend to be the WORST CLASS OF DRUGS that we could possibly use when it comes to CHRONIC PAIN since the body usually adapts and builds tolerances to these medications in a variable amount of time from individual to individual but eventually it happens and nobody has really figured out how to top that adaptability feature of the body.

There are long acting opioids and short acting and people play around with alternating regimens along with primer medications and adjunct medications in order to either "fortify" or "prolong" mechanisms or durations of action but again, it is a highly variable and often times unsatisfactory process.

There is a very real and often unspoken complication of any type of surgery or manipulation that occurs whenever someone breaches the spinal cord coverings in order to get at compressed nerve roots, or do any kind of major construction so to speak on vertebral bodies or the column when it comes to the installation of hardward, etc. And that is the presence of a vague and poorly understood entity called TRAUMATIC ARACHNOIDITIS. This occurs every time a surgeon or some other force of an invasive type (bullet, projectile, knife) penetrates into the subcutaneous and deep tissues to perform any type of repair. What this essentially is believed to be is a SCARRING EVENT which is almost unavoidable since any type of cutting, burning, cauterizing, freezing, poking, prodding, resecting, etc. can result in swelling, inflammation, and eventual healing with SCARRING which then, seems to always cause area nerve endings (many of which are free endings in the skin) to become caught up in the healing process and become affected by the scar tissue. Does that kind of make sense?

This entity, ARACHNOIDITIS, is often felt to be at least partially responsible for at least some pain in any postoperative situation which becomes chronic and involves the spinal column, the cord, or the brain and often times becomes the basis for people (including surgeons) to go back in for a 2nd, a 3rd, a 4th, and the numbers keep going up....time to redo the surgery because patients are convinced that something wasn't done right, something is being "caught" or "squished" or jammed...perhaps something is still "rubbing, bumping, or squeezing" something else. And so surgeons (who are trying desperately to cure their patients pain go back in and start excavating some more....which simply compounds the original amount and severity of arachnoiditis because new incisions are generally made and more scarring occurs which could lead to adhesions (things sticking together), etc. and the whole process becomes a vicious cycle with no end.

I have a patient who holds the record in my practice of having asked for and consented to do 19 separate back procedures in a period of 11 years. Do you think he's improved in pain? On each successive procedure his pain and its poor response to medication got worse and worse and worse. I have literally threatened to fire him as my patient if even thought about consenting for another surgery!

I would be very wary and cynical of an MRI that continues to show cord compression if 2 cervical fusion have already been done. I think that for anything to still remain that is compressing would be very difficult indeed. Once those areas are fused then, there's absolutely no room for the cord to be compressed again because there are no disks that can herniate and nerve roots have been generally entirely unroofed...unless......the HEALING PROCESS has imposed itself once again and caused overcalcification that is grabbing at the nerve roots and microscopic twiglets that are crisscrossing beyond the reach usually of the naked eye or even the microscopes they use in the OR to perform many of these procedures.

There is also an entity referred to as COMPLEX REGIONAL PAIN SYNDROME which can give the exact symptoms you are describing of vague, severe, and electrical like shocks that travel in a distribution that follows the involved nerves. Again, this type of pain is poorly understood but is believed to occur as a result of damage done during injury or the process of traumatic cutting of nerves, sewing, and other manipulations done to nerves, nerve roots, and other elements of the spinal column and spinal cord during such surgeries. This type of pain is mediated by the autonomic nervous system as opposed to the conventional pain nerves which go through what's referred to as somatic/peripheral nervous system. Treatment protocols can vary when treating for CRPS.

The fact that gabapentin helps to some extent may point in the directon of CRPS. If Gabapentin seems to work then, I might next try either really pushing the dose of the gabapentin so long as you don't fall asleep or become "goofy" from too high a dose....or consider switching to PREGABALIN or LYRICA. That may give you some relief temporarily and then, if at some point things get refractory I would try reverting back to Gabapentin....or even some longer acting preparations such as GRALISE.

Have you also tried alternative or complementary medicine ways of dealing with pain including but not limited to TENS units, SOOTHEWAY units, (www.sootheaway.com), DEEP BREATHING EXERCISES and other relaxation techniques, Acupuncture, Acupressure, Lidocaine patches, and other local absorbable medications such as Diclofenac patches that go directly on the area of interest and another choice in that category would be PENSSAID.

If you don't have a neurologist who has forwarded an opinion along these lines that I've given to you then, my suggestion is to ask for a referral. It may be a different way to look at the same problem and from there may come some other ideas that could be added in to what your pain management docs and so forth may be focused on trying.

I would do everything possible to hold off on additional surgeries unless the surgeon is willing to put up his Porsche as collateral to you for an absolute erradication of pain with more procedures......you'd settle for his Cadillac as well probably.

All the best to you.

I hope these answers address the question sufficiently and if so would appreciate your considering rating and closing this interaction as a high star event with some brief written feedback.

If you would agree to close the query so that end of the month tallies and credits can be given; then, by all means we may renew these discussions under a separate thread at a later date if you wish.

It would be an honor to answer your questions quickly and comprehensively if you choose that route.

This query has required a total of 51 minutes of physician specific time to read, research, and compile a return envoy to the patient.


P.S. PLEASE DO NOT RACE TO FLORIDA FOR THE NEWEST AND LATEST LASER TREATMENTS THAT EVERY PAIN MANAGEMENT CENTER OR SURGICAL OUTPATIENT FACILITY IS OFFERING. I can tell you absolute horror stories from countless patients of mine who have gone looking for the magic bullet only to find the CASH EATING COW hooked into their wallets and bank accounts and then, barely having enough spare change to get on a Greyhound to get home with the same or worse pain than they had when they left....they limp back to my office and say, "I don't want to hear that YOU TOLD ME SO....DOC...."

I usually don't taunt them TOO MUCH but every time I think about the 10's of thousands of dollars that people have spent on these types of ventures...it just kills me....

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