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    Remove hardware to reduce pain?

    My son suffered a T12 SCI on 1/31/03. In April his pain level was briefly down to an acceptable 4 (1-10 scale). Since then, his pain has been increasing until he says it is worse than right after the accident. Recently, he spent 9 days in the hospital - admitted through ER because of his increasing pain and inadequate pain control. While hospitalized, he was kept on a morphine IV - 120mgs/hr. He was a zombie but his pain level was down to a 5 from a 9.5-10. They did several X-rays, an MRI, and a nuclear medicine study (with dye) to determine if there was some infection or inflamation caused by the hardware - rod, pins, & screws. No infection or inflamation was found. Upon discharge, the ortho surgeon who put the hardware in said that he wanted to see him in 4-6 weeks and if he was still having the same pain, he would remove the hardware. Has anyone heard of this procedure helping? Not helping? The neurology dept was cautionary about any additional back surgery. We want to get a second opinion, but aren't sure where to go or how to go about it. Any advice would be greatly appreciated

    #2
    Hi MomDonna~

    I'm so sorry about your son's injury. My daughter is a T11/T12, since March of 99. She had her rods removed in May of 2001 because she was feeling increased pain and discomfort. In our situation, she did some research about the procedure (and if you search "rod removal" on this site, you might find more info.) and went back to her neurosurgeon for the operation. I wasn't really thrilled with the idea, but it's her body...

    She does believe the removal of the hardware helped with her pain. She feels more "limber" without them. I think any operation is a concern, of course; but with hardware removal, I suspect the number one concern is making sure the fusion is solid and healed. A good friend of mine had his rods out nine months after his accident; he too had a smooth time of it. The recovery was about six weeks (as far as getting back to the same level of exercise, etc.) Neither my daughter or my friend have any regrets about having the procedure done. If you have any more questions, please don't hesitate! You can ask me here, or email me at vickyjo1221@hotmail.com

    Hang in there...
    Vicky
    ____________________________
    "God warns us not to love any earthly thing above Himself, and yet He sets in a mother's heart such a fierce passion for her babes that I do not comprehend how He can test us so."
    ~Geraldine Brooks, "Year of Wonders"


    "Be kind...for everyone you meet is fighting a great battle."
    ~Philo of Alexandria

    Comment


      #3
      Hi, this is definitely NOT medical advice, but it sounds like the first thing you need to establish is whether or not this pain is neuropathic (ie, from nerve injury) or whether it has a mechanical cause. Neuropathic pain is fairly easy to identify because the quality of it is different from anything felt by normal pain nerves. If it is mechanical, you still have the problem of whether there is loading on some disc, or whether some irritation or whatever, and on this later matter surely only an expert would venture a guess. No surgery is likely to help neuropathic pain. You can review the features of neuropathic pain at painonline.org, sorry I don't remember the name of the webpage, but David surely knows. In other words, the real question is WHAT KIND of pain is your son having. Central Pain can delay its onset after cord injury to as long as two years, but your son probably knows if the pain is bizarre or not. Never hurts to get a second opinion at a top spine place, and these are often big university medical centers. Sounds like you already go to one, but unless both departments agree, use caution. There are radiologists, sometimes called interventional radiologists who can inject local anesthetic under xray and see where the pain is relieved, which can guide surgery for pain, and perhaps avoid surgery that does not help. the joints of the spine are very complex and pinpointing pain source can be helpful. No one except an expert could actually give meaningful advice though, so I'm just giving you some educational info.

      Comment


        #4
        Rod removal

        Thank you both for your thoughtful and informative responses. I read the decriptions of central pain on painonline.com and then asked my son (for the hundredth time) to describe his worst pain. He says that it feels like someone keeps hitting him in the middle of his back at the injury site with a baseball bat - very bruised, throbbing and sore - and this painful feeling is increasing rather than decreasing over time. He said he can tell the difference between this pain and the nerve pain which sends firey, tingling, shooting pain signals and is helped by the 1200mg of Neurontin that he takes 3X day. Has anyone else experienced this increasing "ball bat" pain 4 to 8 months after their injury? As far as getting another opinion, we live way out in the country and are very limited by my son's ability to ride in the car while enduring the pain. The medical center we go to is an hour away and that is about as far as the limited pain relief (narcotics) the doctors will give him allows. We are further limited by what the state medical assistance will pay - and it pays more than the very limited private health insurance he had at the time of his accident. In addition to possible rod removal, his medical center suggested he try a multidisciplinary pain management program (they don't have one). The closest one I've found is about 2hrs away and is outpatient only, as are most of the Pennsylvania pain centers. Johns Hopkins in Baltimore sounds like they have an excellent inpatient pain mangement program, but they do not accept out of state medical assistance. Does anyone have any experience with these or any pain management programs? Right now, my son is too drugged and in too much pain (average daily pain level-7) to do much of anything for himself and neither he nor I are willing to continue living like this. Once again, any and all responses are more than welcome. I/we are so grateful to have found a place where we can share and compare notes with others in the same tragic circumstances.

        Comment


          #5
          MomDonna, management of his pain by an experienced pain specialist is critical until the cause of the pain can be identified. It sounds as if he does have noxious pain as well as neuropathic pain. The former may be associated with mechanical causes, including the hardware used to stabilize spinal column. Although the "baseball bat" quality of his pain is unusual, I do know many people who have had localized pain due to rods and other instrumentation. Removal of the hardware may reduce the pain. It has been nearly 9 months since his injury. The fracture site should have healed. If so, the rod, pins, and screws are no longer necessary. If the CT scan shows adequate fusion of the fracture site and the orthopedic surgeon indicates that he is willing to take the instrumentation out, I think that it is a good idea to remove the rod, pins, and screws. Wise.

          Comment


            #6
            Another question

            Dr Young, thank you for your input on my son's possible hardware removal. With regard to a good pain management program, I am diligently searching for one but am not having much luck. His primary care doctor will handle his pain management only on a minimal interim basis (same scripts which are not doing it). The pain management specialists that he went to from April-September (referred by PC doc)were not managing his pain. They had him on a low dose of three different narcotics (a dangerous narcotic cocktail) with Lidoderm patches as a supplement - no counseling - no PT - and they were belittling him for his increasing pain that they said he should not be having (according to the textbook SCI T12 definition). They are why he ended up in the medical center ER - and they are supposed to be the best ones in the area! The medical center did not find any definitive cause for his increasing pain in his 9 day stay there and they do not do ongoing pain management. You mentioned in an old post that the University of Pitsburgh has a good pain clinic. I surfed their web site for awhile but couldn't find anything on pain management. Do you (or anyone else) know of a link? Pittsburgh is 5-6 hrs away but at least it's in our home state. Thanks for any help in finding a PA based pain management program

            Comment


              #7
              MomDonna,

              I just did a google search and came up with

              http://www.pain.pitt.edu/index.html

              Wise.

              Comment


                #8
                Do they also remove the hardware in cervical injuries? My husband is a little over 2 years post(titanium plate, 4 screws in the front and wire in the back C7/T1). How do you know if this could be causing the pain, or if it's neurological pain? Is it something you can't be sure of until it's done?

                Comment


                  #9
                  hope2, Generally, they do not remove hardware from the cervical spine because the hardware is smaller and should not cause pain. However, if it is clear that the screws and the plates are causing pain, they can also be removed. Wise.

                  Comment


                    #10
                    More ??? for Dr Young or...

                    So we went back to the ortho docs for follow-up after my son's recent 9 days in hospital for intractable pain. The consensus is that they do not know what's causing his pain. They agreed that although there is nothing to indicate that removing the hardware will reduce his pain, they know subjectively that it does reduce pain in about 50% of the cases similar to his. I asked about decompression and they said there is nothing to decompress. I asked about untethering of the cord and they said that there is too much artifact on the MRI to tell if that may be an issue. I asked about a myelogram and was brushed off with a comment about that being in the realm of neurology. When pressed, I was told that if it was their son they would get a second opinion and agreed that the neurology perspective was a way to go.

                    After this appt, I gained access to and read the reports. On the MRI right before the operation there is mention of a suspicion of bony fragments in the spinal canal at T11-T12. There is also suspicion for partial transection on the spinal cord at this level. When I spoke to the surgeon right after the operation, I asked if the cord had been severed or if spinal fluid was leaking out and he said no to both. On a CT scan report right after the operation it says that "there is evidence of bony fragments retropulsed in the spinal canal in the right paramedian region at the T11 level". Could these bony fragments be a cause of his severe pain? That is the area of his back where his pain is the worst.

                    I faxed these reports with others, along with the ortho surgeon's operative notes to a neurosurgeon who specializes in SCI at a respected PA medical center with the purpose of getting an appointment with him for a second opinion. After his nurse reviewed the reports with him, she called to say that he does not want to get involved because my son was already operated on and she put a lot of emphasis on the malpractice liability crisis in PA as the main reason. She is going to ask another neurosurgeon in that group but didn't seem too hopeful that he'd be any different. She suggested that I call the ortho docs there but cautioned that they may have the same response. I told her that we really wanted the neurology perspective on this, to no avail. I didn't see this one coming! I never imagined it would be difficult to get a second opinion or that my son's options would be so limited. Could it be soley because of the malpractice liability crisis? Or could there be something in the medical reports that would cause other docs not to want to get involved?

                    On a slightly brighter note, my son has a new pain mgt doc and a psychologist who does house calls - and the two of them are working as a team! So his pain is slowly becoming a little better controlled, with a goal of being able to get a shower and sit on the comode - and make the trip for a 2nd opinion if we ever get an appt. Right now, his movement is severely limited by his back pain with most of his day spent in his chair on a thick rojo cushion. He feels a alot of instability in his back at the T11-12 site when he moves ("I feel like my back is breaking") and the aforementioned nurse suggested a brace - first time we ever heard that one! - and a myelogram. When I aksed about the myelogram, she quickly backed off saying they can't give medical advice over the phone.

                    Sorry that this post is so long - Too many questions & not enough answers...

                    Comment


                      #11
                      MomDonna, sorry about not seeing this earlier. I got your email.

                      It is true that removing the hardware does not always relieve the pain. But, even if it is a 50% chance that it would reduce the pain, I think that it should be done. Perhaps you should focus on that problem first. Decompression and untethering can come later after the hardware is removed. If the pain is still there, you can consult a neurosurgeon. One step at a time.

                      Did they say whether the bony fragments were removed? If you want, I can refer you to a neurosurgeon in New York. Please note that most neurosurgeons probably would not want to deal with the rods (this is more orthopedic than neurosurgery) and the orthopedic doctors who put the hardware in should probably be the ones to remove it. The MRI quality will be better once the hardware is removed.

                      I hope that this is helful.

                      Wise.

                      Comment


                        #12
                        Bone fragments still there

                        Dr Young,

                        On a CT scan that was done right after the emergency back surgery (where the hardware was put in), it says that "there is evidence of bony fragments retropulsed in the spinal canal in the right paramedian region at the T11 level". What is the meaning of "retropulsed"? The report goes on to say that the alignment of the spine has significantly improved since the prior study. Could these bone fragments be a cause of pain?

                        Once again, thanks for your help. MomDonna

                        Comment


                          #13
                          I was told by one neurosurgeon that should my rods come out, there *may* be a reduction in the pain.
                          I've decided against it, as the Dr who put them in has told me they were never meant to come out.
                          The bones have grown around them, and apparently it would be quite a procedure to take them out.

                          I also had many bone fragments in the spinal canal, which took an extra 2 hours during the implantation surgery to remove.
                          All are gone.

                          http://krstofer.org
                          http://krstofer.org

                          Comment


                            #14
                            momdonna, the term "retropulsed bony fragments" means that the fragments were pushed backward into the spinal canal from the front. If so, they could be a cause of pain because they would a source of possible compression and inflammation/adhesion in the spinal canal. Wise.

                            Comment


                              #15
                              I just had Harrington Rods removed two weeks ago. They were there almost 20yrs. Pain is definately subsiding and nerve pain seems to be reduced already. Some bone fragments were removed as well. I say look into the surgery as long as your spine is stable enough without the hardware, or removing the fragments won't do more damage as mine did.

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