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Unresolved pain s/p laminectomy
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Unresolved pain s/p laminectomy - December 12, 2004 12:06:00 PM
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cneup
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I'm hoping for some thoughts on treatment for a severely deconditioned 72 yo female s/p laminectomy L3-5 (no fusion) 2 mo ago. On xray she has a fixed scoliosis and pelvic obliquity (confirmed by physical exam)- SIJ look pretty sclerotic to me. Severe R radicular pain resolved since surgery but is continuing with aching buttock pain (along R SIJ)- worse with prolonged positioning (sitting, standing, or lying). Have tried SI mobilization with relief of pain following tx but does not last; have also tried a lot of flexiblity, nerve flossing, core strengthening, and gentle mobility -- all as tolerated (pretty low level ex in all of the above). I feel like I'm beating my head against a wall with this one - any thoughts??
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Re: Unresolved pain s/p laminectomy - December 13, 2004 3:32:00 AM
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PTupdate.com
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Certainly could be focal inflammation at that site, but at her age, I think the site is pretty much fused. I have had luck with iontophoresis at that spot in these patients. If palpation finds "nodules", or mobile soft tissue lumps that reproduce the pain when compressed, accupressure techniques (and perhaps even prolotherapy) are options.
Also, make sure this is not a referred pain from T-12-L1 junction on down, a likely scenario considering her previous history and current condition.
Have you tried your neural flossing techniques and evaluation over the more proximal roots and femoral nerve distribution?
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
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www.PTupdate.com
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Re: Unresolved pain s/p laminectomy - December 13, 2004 2:03:00 PM
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cneup
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John-
Thanks for your reply. I was thinking along the same lines. TPs in piriformis and obturator have been resolved with accupressure. No tenderness to palpation at SIJ or upper lumbar/lower thoracic region. Can't do much mobility testing due to pain (pt unable to differentiate b/t stretch and pain so I'm pretty conservative)
Femoral nn tension reproduces buttock pain, but I'm not sure if it's truly neural or if it is pain from movement of the SI due to hip ext (was testing in sidelying) -- If it is femoral nn tension, why would it refer to SIJ region rather than groin or ant. thigh anyway???
Excursion of painfree hip ext improved following passive nn floss of fem nn and quad stretching. I went ahead and gave her a femoral nn floss for HEP today - we'll see what happens.
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Re: Unresolved pain s/p laminectomy - December 13, 2004 2:58:00 PM
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Shill
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cneup,
How do the symptoms behave? What worsens, lessens symptoms? As these direct how I treat, the more specific info you can give, the more potential thoughts for treatment I can give you.
Sitting and standing cause increased symptoms, as does lying, but do all positions cause problems in lying?
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Steve Hill PT
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Re: Unresolved pain s/p laminectomy - December 13, 2004 3:57:00 PM
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PTupdate.com
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I am a big big big fan of rectus stretching. I used to think it was all mechanical, but realize there is some neural issues involved in some people. If pain at the SI with quad stretch, go to town and it should help, and address hip flexors also.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Unresolved pain s/p laminectomy - December 14, 2004 11:48:00 AM
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Mac
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Have you checked out her soft tissue for signs of tenderness? Palpation in the area of pain and where the pain in the leg had been pre-op may be revealing.
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Tim
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Re: Unresolved pain s/p laminectomy - December 14, 2004 2:56:00 PM
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cneup
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All --
Yes we have been stretching rectus and psoas as much as tolerated.
Incision is still swollen but non-painful; no problem with scar mobility; currently has no pain to palpation in soft tissues -- inconsistent reproduction of pain with SI provocation
Symptom behavior difficult to determine as pt is a very poor historian (She used to say buttock pain was worse with sitting and now she doesn't know). In clinic it appears that prolonged positioning in any position worsen sx -- (interestingly along those lines tried one session of gentle mobility ex and stretching only and pt actually had increased subjective stiffness with flexion following) - buttock sx aggravated with extension more than flexion; however has low-level lumbar pain with flexion (which may be due to post-op stiffness and swelling or ES hypertonicity). I have not yet found anything that consistently reduces buttock pain.
I should see if I can figure out how to post her plain films - they look pretty funky
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Re: Unresolved pain s/p laminectomy - December 15, 2004 3:34:00 AM
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Shill
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From: Madison WI USA
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Cneup
Poor historians dont help themselves or you with the ability to truly know what to do. The challenge, as Im sure you are aware, is wording the questions in a way that gets you clearer answers. Make her record the pain at 2 hour intervals, ON PAPER, so that some better behavior patterns emerge. Location, intensity, position at time of intensity increase, etc. If she doesnt think about how she hurts during the day, and she hurts every day, somewhere along the line, she is perpetuating her pain. Discovery of how this occurs makes your job easier, and her life more enjoyable. Insist that she do this to help you both.
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Steve Hill PT
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Re: Unresolved pain s/p laminectomy - December 17, 2004 3:42:00 AM
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cneup
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Shill-
Good idea - I forgot all about journaling. Part of the problem too is the pt's ability to differentiate "her pain" and other types of sensation (stretch, muscle activity etc) -- any thoughts on how to assist sensation description?
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Re: Unresolved pain s/p laminectomy - December 17, 2004 9:17:00 AM
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cneup
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Update -
Saw her today and she reported ionto with dex to SIJ helped so much that she walked 1 mile and irritated herself again.
Looks like the buttock symptoms could truly be focal SI inflammation -- What do you all think about cycles of inflammation and healing during the natural SI fusion process??
Shill - pt will be keeping a journal over the holidays - won't be seen again for another 2 weeks or so.
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Re: Unresolved pain s/p laminectomy - December 17, 2004 9:29:00 AM
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Shill
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From: Madison WI USA
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Cneup,
If she has trouble differentiating between pain and other sensations, give her a swift kick in the butt, and say, "that my friend, is pain". Now strech the hammies, and say, "this is stretch" . Or, to avoid lawsuits, you could use the ever popular "unpleasantness" scale. It doesnt really exist, but sometimes I just have them rate the most bothersome symptoms, depending on location.
DISCLAIMER: for anyone offended by the butt kick comment, please relax and enjoy a refreshing beverage of your choice. You need to lighten up.
_____________________________
Steve Hill PT
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Re: Unresolved pain s/p laminectomy - December 18, 2004 2:44:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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cneup,
Glad the ionto worked...weird, but has helped me in the past also. I am not sure it really is the SI joint, but rather local tissue issues. Does she have palpable nodules around the SI joint...they kind of feel like mobile blobs of gristle, that when maneuvered and pushed against the bone reproduce the pain the patient is reporting? I have yet to find out what these really are. Jan, a pain PT in the DC area, once told me they are "geloids", and seem to corespond with body hormones, thus more common in females.
I'd love to have someone get a biopsy of these and find out what the make-up is, so that the cause and treatment could be better addressed.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Unresolved pain s/p laminectomy - December 20, 2004 5:00:00 AM
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Yogi
Posts: 403
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From: San Antonio, Tx., USA
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Oh, John, somebody finally said something about those fatty nodules. It seems like if they are numerous, not all are painful. I've wondered if they relate to fibromyalgia, I don't diagnosis fibro but the people I've found them in seemed to be undiagnosed fibro folks, but I've never been able to confirm. Any other info you have or know I'd sure like to hear. Like what treatment? I've found these unilaterally in the pec, glut max, and adductors, they seem not to be in the muscle, but lie over them, is that what you find? Wondering what they are has driven me nuts for years, and no one I've queried seemed to have encountered them. All of them (three) have been women. I don't do much massage or soft tissue or ortho, so the three number is not that small, they surely are not that rare. Anyone else encountered them? Please post, John, I'll see if I can start a new thread for this.
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Re: Unresolved pain s/p laminectomy - December 21, 2004 2:30:00 PM
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cneup
Posts: 26
Joined: August 6, 2003
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Shill - LOL !
John - personally I like the term "back mice"; and no she doesn't have any. I've always thought they were benign lipomas - don't remember where I heard that so it may not be correct.
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