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DR. STEMMLER’S MONTHLY TEACHING ROUNDS

May, 2003

CLINICAL STORY

Post-operative Pain After Cervical and Lumbar Disc Surgery

(COPYRIGHT STEMMLER, 2003)

Surgical procedures to correct degenerated, bulging or ruptured discs of the neck and lower back are often the last hope for patients suffering from spinal problems. Pain, numbness, stiffness and various levels of disabilities can become intolerable for most patients, who often wander from specialist to specialist, stumbling around on combinations of anti-inflammatories, muscle relaxants, narcotics, anticonvulsants, sedatives and antidepressants, without resolving their problem. Then comes the last resort: the neurosurgeon. The patient's faith in the medical system is once more renewed, "Cut it out, doctor, I can't stand this pain anymore." The surgery, although risky, usually goes well in skilled hands. But the long term results are too often disappointing. The so called "failed back surgery syndrome" has been reported to have an incidence between 5% and 50% for surgery of the lumbar spine. Outcomes are usually better when surgical procedures are performed on the cervical spine. In some situations, patients experience either no relief at all, or a difference in their pain level so small, that it may not have been worth the surgery. In other cases, a new pain emerges that can be more disconcerting than the original complaint. Or yet, initial relief may be followed by a recurrence of the pain within weeks, months or a few years. Many of the patients with neck and low back pain I see in my practice are actually suffering from such "failed back surgery syndrome." And although I often wish they had consulted me before considering surgery, in a vast majority of cases this syndrome will still respond well to acupuncture treatments. I will illustrate the treatment of post-spinal surgery with two clinical stories.

I) Failed Back Surgery Syndrome

Julie Kinsley was in her early 70's when she came to see me late last year, one and a half years after her lumbar laminectomy. She had done well for about one year after surgery, but started to experience increasing low back and hip pain thereafter. Her neurosurgeon suspected she had a recurring problem, but the patient did not want to submit to repeat surgery. Although very needle-shy, she had built up the courage to try acupuncture, and decided to "give it a try." On her first visit she was limping and in severe pain. Because of her fear of needles and her advanced age, I chose my points very carefully, inserting the smallest needles and performing the procedure with an extra gentle touch. Even with all these precautions, I was faced with an impatient, somewhat challenging, scared person. But I knew that her attitude stemmed mostly from her fear and that, as soon as she felt better, she would probably smile again. I estimated she would need one treatment twice a week, for a total of 10 -12 treatments or perhaps less. On her second visit she had very little improvement and she made sure to let me know how skeptical she really was "about this acupuncture." Laughter has always been my most trusted antidote to fear, and so we laughed from the first to the very last needle. It worked. The following week she came in walking significantly better. She shook her head in disbelief, "I have actually felt much better for the last three days." After that day, she required only five more visits towards complete resolution of her pain. At each visit she would tease me, "I can go home now," only to turn over on the examining table, ready to be treated. By then she was even negotiating which points she would allow me to treat! Within just eight treatments she was a totally changed woman, smiling from ear to ear, telling stories and determined to enjoy her next 30 years. She was discharged pain-free, finally accomplishing the expected outcome for her back surgery, 18 months earlier.

II) Cervical Spine Surgery with Sub-optimal Results

Rosetta Stone's cervical laminectomy had taken place six months prior to her visit. Although she had obtained significant relief from her pre-operative symptoms, she was still struggling with pain in her neck and shoulder, as well as a limited range of motion. Of course this seemed like a great improvement, considering her severe, intolerable pre-operative pain, radiating into her ears, jaw, back and arms, as well as the torture of constantly feeling pins and needles along her upper extremities. I schedule Rosetta for twice a week treatments with an estimated total of 10 - 15 treatments. Her improvement was steady and gradual, increasing from visit to visit, regaining her mobility and essentially being pain free by her tenth visit with only minimal discomfort when overusing her affected side. Rosetta could not have avoided surgery, considering the seriousness of her initial symptoms, but being only in her early 40's and, together with her husband, an avid traveler, she also needed better surgical results. Although the surgery had released the compressed nerves, it had failed to return her neck and shoulder function to normal. Most of our patients go through an acupuncture series before such surgeries, whenever it is neurologically safe to wait, a decision I responsibly help them make. Often acupuncture alone will reverse the inflammation and spasm of degenerative disc conditions, allowing the disk to reposition itself as a result. In such cases, surgery can be avoided altogether. In other cases acupuncture should be the first line of treatment and surgery can still be reserved as the last resort. Post-operatively, the patient's anatomy is modified and it does not always complement the patient's body weight, shape or posture. The spine functions as a whole unit, and post-operative anatomical changes at one level can lead to functional problems in that area as well as at other levels. Therefore, a few acupuncture treatments immediately after surgery can greatly enhance the surgical outcome, by reorganizing the energy (electric, electromagnetic) fields disturbed by the patient's condition and the subsequent surgical intervention. In the above examples, "failed back surgery syndromes" as well as sub-optimal surgical outcomes can also be resolved at a later time with an acupuncture program, but prompt post-operative treatment can eliminate months and years of suffering. Incidentally, both patients in these clinical stories had something in common: they both happened to have their procedures done by the same neurosurgeon. This is not to say that their results would have been better had they consulted another surgeon. Back surgeries, in general, are not the most effective surgical procedures. Eager surgeons often hope for and promise better results than they are eventually able to deliver. Combining pre-operative and post-operative acupuncture with spinal surgery may greatly improve the outcome of such interventions. Here is another excellent opportunity for Eastern and Western medicine to join forces, and provide a better quality of life for the patients we serve.

Christina Stemmler, M.D.


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