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  Dr. Hassan:
67ears  lady with spondylolithesis L5-S1. She has severe pain , numbness in LT. gluteal area and lower thigh plus lateral aspect of the leg, foot. 
I gave her 4 injections of steriod+LA in Lumbar epidural space,  L3,L4,L5 facet joint, Caudal. Pain disappeared for 1 1/2 months but return back. Please advice.
Dr. Hassan

Dr. Hendler's Reply:

In response to your questions about the 67 year old lady with spondylolithesis at L5-S1, I would like to offer the following suggestions. The history that you give suggests that this lady has facet syndrome and radicular pain as well as spondylolithesis. I cannot tell if the leg pain is bilateral from your note. I cannot tell if the spondylolithesis is fixed or responds to motion, or if there is worse pain with extension or flexion, nor can I tell the location of the pain with these movements, nor if there is worse pain with a Valsalva manuever. This historical is essential to establish a diagnosis, that may involve not only the spondylolithesis and facet syndrome that you so astutely diagnosed, but to further determine if the lady has disc damage, and/or radiculopathy, or an anteriolysthesis, or retrolysthesis, in addition to your other diagnoses. 

You provided relief for her for one and a half months, with the use of epidural and facet steroids, which is wonderful. Unfortunately, there is no long term benefit to the use of epidural steroids, and the Richard North, MD, Ph.D. at Johns Hopkins Hospital in Baltimore, reports that only 40% of facet denervations provide up to 2 years of relief. 

Hampton questioned the benefit of epidurals for back pain, in a recent commentary in the Journal of the American Medical Association (Hampton, T., Epidurals’ benefit for back pain questioned, JAMA, Vol. 297 # 16, pp: 1757-1758, April 25, 2007). Hampton based the commentary on work  from Dr. Armon, who studied responses to epidural steroids in 300 patients, and found, just like your lady, most had some improvement between 2- 6 weeks after injection. However, there was no efficacy at 3 months, 6 months or 1 year after injection. Additionally there was no impact on day to day functioning, need for surgery or long term pain. (Armon, Carmelet al, Neurology, Vol. 68, pp; 723-729, 2007).

While it is an old adage, advice by Boone is still a good adage.. 95% of the time you can make a diagnosis by taking a careful history. (Boone, JA,  The value of good history-taking in medical diagnosis., South Med J. Aug;112(8):243-4. 1950). 

Unfortunately, due to the complex nature of chronic pain, 40%- 67% of patients have diagnoses overlooked. .(Hendler, N, and Kozikowski, J, Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Psychosomatics, Vol 34, #6, pp. 494-501, Nov.-Dec. 1993, Hendler, N, Bergson, C, and Morrison, C, Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Part 2, Psychosomatics, Vol 37, #6, pp. 509-517,Nov.-Dec. 1996). 

I would repsectfully suggest that some additional history be obtained from this lady, to determine the answers to the questions I posed above. She would also need some addtional testing, such as flexion-extension X-rays with obliques, of the lumbar spine to determine if the spondylolithesis is fixed or movable, a 3D-CT to see if she has neural foraminal stenosis, or spinal stenosis, a provocative discogram to determine if there is Internal Disc Disruption, (IDD)  (Bogduk, N, and McGuirk, D, Pain Research and Clinical Management, Vol. 13, pp. 119-122, Elsevier, Amsterdam, 2002) that would not show on MRI or CT, and a trial with a body jacket with a thigh spika extension, to see if stabilization helps her pain. 

Perhaps the lady would benefit from taking a comprehensive diagnostic history, that would provide 72 questions with 2008 possible answers, resulting in a narative summary, a list of diagnoses, and differential diagnoses, and then a treatment alorithm. This can be found at www.MensanaDiagnostics.com. I hope this will be of some assistance in helping your patient. 

General Questions & Answers

    What do you recommend for non-Surgical Treatment For Hip Pain: 
NSAIDs. Nonsteroidal anti-inflammatory drugs such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Anaprox), and several others may be more effective than acetaminophen, particularly during sudden flare-ups of pain, because they are superior at reducing inflammation. There are also a number of prescription NSAIDs such as nabumetone (Relafin) and oxaprozin (Daypro). 

But this relief comes at a price. Regular use of NSAIDs can produce gastrointestinal bleeding and ulcers, often without warning. Each year, these drugs contribute to more than 16,500 deaths and 100,000 hospitalizations because of gastric bleeding. Combining acetaminophen with a smaller amount of an NSAID may provide equivalent pain relief with a reduction in side effects. 

The class of prescription NSAIDs known as COX-2 inhibitors is now rarely used, following news in 2004 that these drugs significantly increase a person's risk of heart attack and stroke. The manufacturers of two popular COX-2 inhibitors, rofecoxib (Vioxx) and valdecoxib (Bextra), withdrew these drugs from the market. A third COX-2 inhibitor, celecoxib (Celebrex), remains available. Because concerns about its cardiovascular side effects remain, it should be used only in cases in which a patient does not have heart disease, has tried other pain relievers without success, and is taking blood thinners (anticoagulants such as warfarin). 

  Is arthroscopy recommended for treating arthritis?
Many doctors believe it is used too often for arthritis, where its benefits are questionable. As noted in Surgery, a 2002 study found that arthroscopy was no better than placebo surgery. However, the study did not include patients with knee pain caused by torn cartilage or ligaments and those with mechanical knee problems such as locking, catching, or giving out, including cases in which these problems stemmed from osteoarthritis. These patients make up the majority of people undergoing arthroscopy and are more likely to genuinely benefit from it. 

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Case 08 : 33 Years Old Female
Case 10 : 31 Years Old Male

Hospital Accident:3
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Surgery causes complications:4
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Soccer Accident:5
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Chronic pain develop after micro disectomy:7
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