Question
QUESTION: Doctor,
I am a 40 year old female, post right mastectomy for invasive breast cancer. For the past 4 years, I've been suffering from increasingly severe, constant pain in both my lower back and both legs (initially, it was just the right leg, but now it is spreading to both - in the left, it reaches to about midthigh and in the right, it goes all the way to the foot, with accompanying numbness from my shin to the top of my big toe, and within the past few months, I'm getting episodes of weakness where my legs won't support me), and a strange numb/weak feeling where my thighs meet my groin, and increasing loss of daily functionality. I have been under the care of an orthopedist for the full 4 years and we have tried every conservative, non-invasive treatment possible (since I was so averse to having more surgery after I'd just finished cancer treatment): physical therapy, chiropractor (with both extension-distraction and inversion table, as well as gentle manipulation), walking in a pool, trigger point injections, facet injections, epidural injections (all by a pain management specialist), and acupuncture. I am now on sustained-release morphine orally 3x daily, with vicodin hp for breakthrough pain. I was put on Gabapentin at one point, but it didn't help at all. My orthopedist recently told me that he considers me totally disabled, unless surgery can help, and referred me to a surgeon. The surgeon says he doesn't see the spondylolisthesis on the x-ray and doesn't see 'any reason I should have surgery', but has ordered an EMG to see what nerve compression or damage I might have. I'm really not crazy about the thought of yet another surgery of any kind, but I've really hit the wall on how much I can take. I haven't slept through a night in years, the pain is constantly keeping me awake or waking me up, I can't even walk a few blocks without seriously aggravating the pain, and though the medication helps somewhat, it doesn't do nearly enough (put it this way - without the medication, I'd be screaming; with it, I'm just swallowing whimpers and trying not to cry). I'm desperate for relief, I really can't take much more of this. I'm fully aware that not only will surgery not 'cure' things 100%, but it very well may fail completely or even make things worse (though I don't see how that's really possible at this point). Considering how bad things are right now, I'm willing to take that chance. I am including my MRI/CT scan results below but my question is, given the above, do you agree with the surgeon or do you think I should request referral to another surgeon for a second opinion? Or is there another treatment option you might recommend? My insurance won't cover non-surgical decompression and I cannot financially afford to go out-of-pocket. Thank you in advance for your time, it is very much appreciated.

Thank you,
Christina

MRI: Desiccation of the L1-L2 and L4-L5 discs, mild desiccation of the T12-L1; disc bulge at L5-S1; broad-based disc protrusion eccentric to the right side at the L4-L5 level; mild lateral recess stenosis and contour deformities of the thecal sac L4-L5; lateral bulging of the L1-L2 disc; shallow protrusion vs a prominent disc bulge at the T12-L1 level; disc bulge at T11-T12;

CT: agreed with the above but also added the following: hypertrophic changes of the facet joints and hypertrophy of the ligamentum flavum; disc protrusion at T12-L1 level is compressing the left ventrolateral aspect of the thecal sac; disc protrusion noted at T11-T12; benign hemangioma within the left side of the L3 vertebral body.

ANSWER: Hi Christina,
I want to first say, that you are a fortunate and very special woman to have survived invasive breast cancer. I truly believe that you have a serious purpose of importance in this world. This is of course not to diminish the pain you are having.  I have carefully read your entire question and I have considered the results of both your MRI and CT scan.

Let me address your question.

Firstly, By the sounds of your question I don't believe that your pain has anything to do with your previous breast cancer, however, it is prudent to have your oncologist rule this out to be sure.  Having said that, everything that you have shared with me is consistent with discogenic pain resulting in a neuropathy.  In English this means it may very well be that your pain is coming from a damaged disc irritating specific spinal nerves which travel along the thigh and leg.

I am curious, are you having any trouble controlling your bladder?  


You commented that the surgeon said "The surgeon says he doesn't see the spondylolisthesis on the x-ray and doesn't see 'any reason I should have surgery', but has ordered an EMG to see what nerve compression or damage I might have."  This is a bit confusing to me because a spondylolisthesis is not the common reason for spinal surgery, rather it is usually due to herniated discs causing pathological pressure on peripheral nerves.  I wonder if he meant that he didn't see the herniation, which would also be odd because this is not visible on x-ray.

I totally understand the conundrum you have with medication, you don't want to be reliant on it yet it affords some, although little help, some relief. I have spent some time thinking about your need for sleep. I totally understand the feeling of desperation of this need, in light of your constant pain.

I strongly, strongly encourage that you look into some form of meditation to help calm your mind, help control your pain and increase your relaxation.  I have a link which may be a good start for you:   http://www.yogabasics.com/practice/meditation-basics/

You asked me if I think it is wise to get a second surgical opinion. If you are asking me do I think that a surgeon may consider you a candidate for surgery - I  think you will likely find one BUT, that does NOT mean, necessarily that you should have surgery, unless you have exercised every reasonable option. Remember that surgery comes with risks and is not regarded as terribly successful in many cases.

I would have your orthopedist clarify the significance of the spinal hemangioma to you.  you should know that most hemangiomas are completely asymptomatic and are only found accidentally. In only a very small percentage of cases are they findings which account for symptoms.

Did you find even slight benefit in the extention distraction treatment the chiropractor gave you? This is often referred to as the Cox technique. I wouldn't think that inversion therapy would be helpful for the kind of problems you have.

I saw that you we felt that non-surgical spinal decompression was not an option for you because it was not covered by your insurance.  So,... here it is, with all that you have shared with me I believe that, pending a proper the results of a proper and thorough consultation, history, a complete review of all contra-indications and a complete orthopedic, neurological and muscular assessment you owe it to yourself to seriously consider non-surgical spinal decompression in conjunction with class 4 laser.  If you check around you will likely find a clinic which may offer you financing to assist with repayment.  I have experienced first hand tremendous success with the vast majority of patients I see that share almost the identical story as you have.  

I wish you were in my town/country so I could at least offer you a trial of a few session for free to experience the care first hand.  Perhaps you can find a clinic which may do so.

I truly pray that you will consider this, and if appropriate will undergo this care with the best doctor you can find and will emerge pain free, happy and vibrant and functional again.  Feel free to go to my website to learn more at www.backclinics.ca

Please let me know how things progress. Can you please take a moment to rate my answer and also consider nominating me as expert of the month.

Please get back to me and let me know how you are doing.

Dr. Ron Nusbaum



---------- FOLLOW-UP ----------

QUESTION: Thank you for your response, Dr. Nusbaum, I greatly appreciate it and apologize for not replying sooner. Recent tests have shown worsening stenosis and degenerative disc disease, so after a great deal of thought and research, I've decided to go ahead with surgery on 4/5. Sadly, I've had no luck with non-invasive treatments and have hit the wall on how much constant pain I can take. Hopefully, the surgery will be a success and I'll finally get some relief. Thank you again, for your time and expertise - it has been very much appreciated.

Answer
My Dear Christina,
My heart goes out to you. I wish truly I could come up to you and "remove your pain". You are truly an amazing woman, stoic, sensitive, intelligent. I totally understand your decision. May I encourage you to get a second opinion so that if and when you should decide to go ahead and have the surgery then you will never look back and second guess your decision.  Also please make sure that your oncologist is on board.

As usual, please keep me posted, your friend in Canada,
Also, can you please rate my answer and consider to nominate me expert of the month.

Dr. Ron Nusbaum