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Debilitating sciatica in low health literacy male - urgent advice much appeciated

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  • Michael Ray
    commented on 's reply
    Currently we have about a week wait at the most.

  • Alex Chopra
    replied
    Thankyou for the reply.

    Originally posted by Michael Ray View Post

    Alex Chopra - sorry to hear about your brother's situation. Ideally we can have a consultation with him to work through his experience, history, prior narratives/interventions, etc and then provide our recommendations for management moving forward. Curious what the surgeon is hoping to find/not find on the follow-up MRI to inform future interventions. My usual stance, generally speaking, in these scenarios is to attempt conservative management and if symptoms are not worsening then unlikely surgical intervention is necessary at this time. We'd be happy to consult on the case. If he is interested, please have him complete our intake paperwork HERE. In the meantime perhaps you can send him our podcast on this topic: https://soundcloud.com/user-344313169/lowbackpain2019
    I've sent him the podcast and he's going to listen to it, then fill out the intake form.

    Regarding the MRI: we're in the UK and I don't think NICE even recommends scanning this sort of patient. It seems that this upcoming MRI is actually to better characterise the anatomy prior to surgery, rather than for deciding which intervention is most appropriate. In all fairness, the surgeon has not been at all pushy to intervene, but he (has said that) he feels his hand has been somewhat forced due to the persistence of the symptoms and the severity of the recent episode.


    Most folks do not realize this but typically low back pain cases with or without radicular and radiculopathy symptoms are managed similarly while monitoring for improvement and symptoms not worsening (e.g. neurological) over time.
    This is reassuring to hear, thanks. I was under the impression that even minor motor weakness was a pretty stonewall indication for surgery, but I suppose there is a grey area.


    He'll send in the intake form in short order and be in contact afterwards. Assuming things are all in order, he's wondering what sort of timeframe he's looking at for a consult given the current discomfort, so that he knows what to expect.

    Best wishes,
    Alex

    Leave a comment:


  • Michael Ray
    replied
    Originally posted by Alex Chopra View Post
    Writing this on behalf of my brother, will try to keep it succinct:

    17 year old male, overweight/overfat, 1 pack year history of smoking (no longer smokes or drinks)

    - History of minor low back pain since age ~14.
    - Exacerbated this acutely during deadlift 1.5 years ago, aged ~15.5, continued to train at high RPEs through exacerbation, somewhat leading to chronic pain
    - Stopped training, became sedentary, at some point in the ensuing 1.5 years pain 'shifted' from low back to sciatica, to some degree in both legs (no acute cauda equina signs or anything like that, though)
    - Maladaptive behaviours to pain such as walking with an altered posture
    - Pain remained severe, for example preventing sleep unless he slept on a reclined sofa with legs partially flexed to limit stretch on hamstrings
    - Physio focussed on regaining some range of motion and working through discomfort bending over etc. this may have helped with some movement patterns, but pain remained severe for most of the day
    - MRI showed disc prolapses, spinal surgeon has nocebod him with the disc prolapse spiel and offered steroid injection or microdiscectomy
    - Recently, symptoms flared up and he is taking opioids for pain relief
    - Surgeon found some weakness in right side plantarflexion - I also felt this on examination. Patient also reports subjective weakness in right quad day to day. Unclear if this is actually progressive, however. Surgeon has requested another MRI with a view to assessing to see if weakness persists in a week or two and operating soon afterwards. Meanwhile, patient in severe pain, taking tramadol, rectal diclofenac regularly.

    I am a medical student, this sort of thing feels outside of my wheelhouse even if I generally subscribe to your guys' approach to pain/injury. But my conscience won't let me watch these events just unfold without at least getting your input, given that my brother seems to be your typical back pain->nocebo->strong analgesia vicious cycle case. I'm interested whether you (generally) think there is another way aside from surgery in such circumstances, as it's something the family would all prefer to avoid. My brother is willing to do anything to achieve some relief but I don't feel qualified to intervene, especially when the symptoms are so dire, and, to my family, my suggestions aren't credible compared to those of a specialist doctor. I just kinda need to know if this is the sort of thing you guys would generally leave to the surgeons (what with the motor deficit and long history etc.) or whether you think it's the sort of thing you'd work through with someone in your consults.

    Thankyou,
    Alex
    Alex Chopra - sorry to hear about your brother's situation. Ideally we can have a consultation with him to work through his experience, history, prior narratives/interventions, etc and then provide our recommendations for management moving forward. Curious what the surgeon is hoping to find/not find on the follow-up MRI to inform future interventions. My usual stance, generally speaking, in these scenarios is to attempt conservative management and if symptoms are not worsening then unlikely surgical intervention is necessary at this time. We'd be happy to consult on the case. If he is interested, please have him complete our intake paperwork HERE. In the meantime perhaps you can send him our podcast on this topic: https://soundcloud.com/user-344313169/lowbackpain2019

    Most folks do not realize this but typically low back pain cases with or without radicular and radiculopathy symptoms are managed similarly while monitoring for improvement and symptoms not worsening (e.g. neurological) over time.

    Leave a comment:


  • Debilitating sciatica in low health literacy male - urgent advice much appeciated

    Writing this on behalf of my brother, will try to keep it succinct:

    17 year old male, overweight/overfat, 1 pack year history of smoking (no longer smokes or drinks)

    - History of minor low back pain since age ~14.
    - Exacerbated this acutely during deadlift 1.5 years ago, aged ~15.5, continued to train at high RPEs through exacerbation, somewhat leading to chronic pain
    - Stopped training, became sedentary, at some point in the ensuing 1.5 years pain 'shifted' from low back to sciatica, to some degree in both legs (no acute cauda equina signs or anything like that, though)
    - Maladaptive behaviours to pain such as walking with an altered posture
    - Pain remained severe, for example preventing sleep unless he slept on a reclined sofa with legs partially flexed to limit stretch on hamstrings
    - Physio focussed on regaining some range of motion and working through discomfort bending over etc. this may have helped with some movement patterns, but pain remained severe for most of the day
    - MRI showed disc prolapses, spinal surgeon has nocebod him with the disc prolapse spiel and offered steroid injection or microdiscectomy
    - Recently, symptoms flared up and he is taking opioids for pain relief
    - Surgeon found some weakness in right side plantarflexion - I also felt this on examination. Patient also reports subjective weakness in right quad day to day. Unclear if this is actually progressive, however. Surgeon has requested another MRI with a view to assessing to see if weakness persists in a week or two and operating soon afterwards. Meanwhile, patient in severe pain, taking tramadol, rectal diclofenac regularly.

    I am a medical student, this sort of thing feels outside of my wheelhouse even if I generally subscribe to your guys' approach to pain/injury. But my conscience won't let me watch these events just unfold without at least getting your input, given that my brother seems to be your typical back pain->nocebo->strong analgesia vicious cycle case. I'm interested whether you (generally) think there is another way aside from surgery in such circumstances, as it's something the family would all prefer to avoid. My brother is willing to do anything to achieve some relief but I don't feel qualified to intervene, especially when the symptoms are so dire, and, to my family, my suggestions aren't credible compared to those of a specialist doctor. I just kinda need to know if this is the sort of thing you guys would generally leave to the surgeons (what with the motor deficit and long history etc.) or whether you think it's the sort of thing you'd work through with someone in your consults.

    Thankyou,
    Alex
    Last edited by Alex Chopra; 04-18-2021, 08:33 PM. Reason: grammar
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