The Patient

She sits in a chair as I enter the room.  Though I have never met her before, I know her story all too well from many who have sat in that chair before.  She suffered a motor vehicle accident 5 years ago, and ultimately required a spine surgery to decompress a nerve root in her low back.  She had shooting pain down her leg and numbness, as well as occasional weakness before the surgery.  That all improved for several months after the surgery, but then she developed a flare up that led to another surgery.  She was unable to return to her job at the grocery store after that one, and finally had her most recent surgery 6 months ago.  She comes today reporting shooting pain down her leg with numbness, as well as occasional weakness.  She wonders out loud what went wrong, and complains that no one can find out what is wrong.  Her primary care does not want to prescribe pain medicines to her any longer, and her husband is upset that she is not getting better.

We continue the conversation as I detail her history in the computerized record.  I have learned to listen, create meaningful eye contact, and yet enter a constant flow of information into the computer.  She continues to answer my questions, “the pain is 8/10 on the bad days and I can hardly stand it….I wake up 4-5 X per night in pain and sometimes run out of my medication early….Do you think this is all in my head?  My husband does.”  I pull away from the keyboard and scoot my rolling stool near to her as I reassure her that pain that lasts this long is complicated.  Depression, anxiety and anger are often interwoven in chronic pain.  They complicate the ability to cope and impair recovery.  These need to be addressed, but they don’t mean that the pain isn’t “real”.  She tears up as I give affirmation to her feelings and alleviate her fear that she is “crazy”.

The physical exam shows no surprises.  I conclude that she has undergone appropriate surgical treatments, but unfortunately has developed scar tissue at the site of the original injury that is contracting around the nerve and resulting in aggravated symptoms.  This occurs in a certain percentage of spine surgeries and is known as post-laminectomy syndrome or failed spine syndrome.

I review with her in terms easily understood what I think is her diagnosis.  She understands that there is no cure for this, but that treatment will help her improve her quality of life.  The combination therapies that we term multi-disciplinary treatment are reviewed.  Initially, the medication options I recommended included continuing her pain medication, but in a time released form.  We would also be following her closely to assure that she took these according to the directions.  She signed an opiate agreement paper and an informed consent re: this part of her treatment.  I explained to her why seizure medications help with nerve pain such as she had.  Antidepressant medications also help with nerve pain as well as the depression that often accompanies chronic pain.

Spinal injections and even the future possiblity of a spinal cord stimulator were described, but her eyes showed fear as I talked about this, so we tabled it for another day.

She cringed when I brought up physical therapy, but I persisted in the explanation of its importance.  She had a bad experience in the past, but now understands that this will help her reactivate and retrain her nervous system. 

I described the intention to involve her in counseling re: chronic pain issues, and that this would be useful for her husband to be involved in as well.

The visit ended with prayer that she had requested.  She smiled as she walked out of the office with a slight limp.  “I have hope for the first time in a long time.”

Who of us could face another day without hope.  What a privilege it has been over the years to bring hope and relief to many people’s lives.  Sometimes, the therapies don’t work, but the compassion and caring are real and make a difference.

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