Case of the Month #16: Persistent Pain Following Spinal Surgery by Dr Lorraine de Gray

Mrs X, aged 52 years old, was referred to the pain clinic by her GP with a history of chronic spinal pain, polypharmacy, and marked disability. Her GP reported that attempts had been made to reduce her current medication intake without any success.

She arrived in the pain clinic accompanied by her husband.  She reported that at the age of 28 she had an acute disc prolapse at L5/S1 for which she underwent a microdiscectomy.  Post-surgery her symptoms improved for a short period of time, but by a year later, she had severe back and radicular leg pain once again, also reporting issues with saddle anaesthesia and urgency of micturition.  A repeat MRI scan of the lumbar spine at the time, revealed a recurrent large disc prolapse at the same level and following lack of improvement with conservative treatment including medication, physiotherapy and a nerve root block, she went on to have a second discectomy at 30 years of age.  

Following this second operation, her pain levels remained high. She became increasingly depressed and anxious about the future.  Further attempts at engaging her with physiotherapy failed.  She was on a cocktail of medications including Amitriptyline, Gabapentin, Codeine and Paracetamol as well as intermittently taking Diazepam.

Eight years later following several visits to see more than one spinal surgeon, with both her and her husband seeking a medical cure, she went on to have an instrumental fusion involving the L4, L5, S1 level. Sadly, but perhaps not unexpectedly, her pain levels never improved, and over the next few years her level of function worsened, social isolation and depression started to take its toll, and despite attempts by her GP to adjust her medications, her pain levels remained high.  Because of her previous failure to respond to pain management prior to her second operation, she had been reluctant to revisit pain management therapy, but now fourteen years after her third spinal operation, she was advised that she had to accept being referred as the GP surgery could no longer continue to prescribe her current regime of analgesic medication.

When she arrived in the pain clinic, she was understandably upset, and made it clear she did not want to be there. Moreover, her husband who accompanied her, was angry and aggressive on her behalf.

She could only walk with the aid of two walking sticks, and reported that she could only manage around 50 metres before needing to sit down.  She required assistance to sit up from a chair. She reported back pain affecting her from the neck to the coccyx, with particular hypersensitivity around three incisions (one midline and two paraspinal) that she had over the site of previous surgery. She reported feeling fatigued all the time, and slept very poorly.

Mrs X agreed to fill in two questionnaires, including a Pain Self Efficacy score and Oswestry Back Pain disability questionnaire. The outcomes indicated complete lack of confidence in Mrs X’s ability to perform daily tasks with a very high level of disability.

By now she was taking Tramadol 100mg up to three times per day, Diazepam 5mg tds, Pregabalin 300mg bd, Oramorph as needed (generally up to 40mg per day in total), Naproxen 500mg bd, Venlafaxine 300mg, apart from medication for hypertension and high cholesterol and a proton pump inhibitor.  She also suffered from poorly controlled type two diabetes and was in the process of having her oral hypoglycaemic medications adjusted as her last glycosylated Haemoglobin was over 100mmol/mol. She also had a long-standing iron deficiency anaemia. 

Mrs X had self-referred to the Well Being Service three years previously just prior to the COVID pandemic starting.  She had been offered some remotely provided support (via telephone) for a few months, but found it difficult to engage and had discontinued contact.