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Lumbar strain with disk protrusion at 3 levels
(06-04-2016, 05:26 PM)California_Help Wrote:
(06-04-2016, 10:33 AM)Cycler Wrote:
(06-01-2016, 09:20 PM)beesgonz Wrote: I am from CA. Thank you for responding.
As a OccMed/ Rehab Dr.  for 25 yrs I just want to comment on your stated need for a fusion. In short- don't.  

There is no scientific data that bulging discs are abnormal, there is no data that bulging discs cause any symptoms. In fact three bulging discs are normal finding by age 35 in half the population and as high as 70 % of the population by age 60. 
First, be aware that lumbar surgery is only designed to relieve motor loss/ progressive peripheral neuropathy to the lower extremity ( and maybe the leg pain of you get lucky /bowel and bladder dysfunction. 

Second, there is no data that lumbar surgery relieves back pain. It might but that's not the goal of the surgery.  There IS quite a bit of good data that lumbar fusion patients rarely return to work and rarely experience the relief they were hoping for.  There is also reams of data on fusions that most of the time it should not have been done at all and wold not have been save for the financial incentives provided to the surgeons as the "distributor " of the device so double dips.  Fusion is necessary for spine instability, not back pain.

And, most importantly, chronic back pain is more often than not a mechanical problem, not a disc problem, and procedures to identify that are not the type of things surgeons generally due: i.e. medial chain branch blocks to assess the facet joint itself as the source of the pain ( most of the time), poor core stability- painful damaged soft tissues which respond to McKenzie and other Core rehab approaches.  

BTW- all studies have demonstrated that chronic opioid use actually INCREASES pain level experience by a complicated receptor and brain re-wiring mechanism.

Physiatrists with Pain Fellowship training tend to get better outcomes when there is no frank radiculopathy present.

Just my thoughts. Good luck.

Cycler, thank you SO much for your thoughts.

There are several injured workers on this site from California who are being told they need fusions and a few of them are arthrodesis 360 (front and back) fusions. I am very concerned. I am aware of what has been going on in California work comp with spinal fusions. Patients in pain who are desperately looking for someone to "fix" them can become an easy victim, especially if they have been denied alternative therapies, testings etc as the patient above and do not have a good advocate to guide them. Many of the ortho surgeons who are known to be doing unnecessary fusions are also among the most used by WC applicant attorney's and they are sending their clients there.

Can you please advise what a patient in CA work comp system should do when their doctor has stated they need a fusion? Also, where can a patient find a good, ethical doctor (within their MPN ) who can review if the proper testings were done and also where to find a good physical therapist to guide them on core rehab techniques if needed?

The only thing I would like to add is what also can happen to the spine after a fusion, the discs above and below can be affected and in time many patients end up being told they need another fusion.

I am very thankful to you for taking the time to provide a response about fusions. Hopefully this post will help other patients who are researching this and see your comments.

Thank you.

 "California help"
It really takes a change in thinking about what chronic back pain really is.  Certainly what it is not is a surgical condition in all but 2-3 % of cases.  That the US experience for surgical management of back pain is about 18% of all cases is telling. And you are correct, it is not unusual to have to extend the original fusion to adjacent segments within two years due to the transfer of forces from the fused segments- or at least that's one theory.

The fault doesn't lie with the surgeons, they are just doing what they do and as profitably as possible. Their training does not really prepare for much more than yes or no.  Primary care doesn't want to deal with back pain patients as they are ill prepared as well and the patients are an unrewarding lot to try and care for.

Best best is with the modern type of DC's who are well versed in approaches other than back cracking: i.e. McKenzie techniques, Functional Movement System (SFMA) Active Release Therapy (ART ) and non-medication.

The wise provider with an interest in chronic low back pain will enlist the consultative support of a Physical Medicine & Rehabilitation Specialist ( PM&R ) who can do injections  for a second set of eyes on with deep training in movement anatomy and physiology, kinetic chain, etc and whose primary concern is functional restoration as they have the ability to specifically block certain target structures to aid in the diagnosis and sophisticated treatment approaches  or, less desirable maybe, anesthesiologists who can do much the same intervention. Only failing the above would a surgical consultation be considered absent progressive neurologic findings.  

I'm faced with much the same in my practice when patients come to me in late in the injury and have been told they need this or that done and I'm not convinced.  My approach has alway been to obtain a second opinion consultation at a University or tertiary Spine Center by a highly  respected department head or similar credentials and that unless someone of the experience and insight of Dr. So and So says you need that surgery you should not do it. Also, at that level the financial incentives to operate first are pretty much non-existent as patient outcomes are the measure of excellence.

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