My Thoracic Discography - NEGATIVE

[mmglobal]

Sorry my capacity for posting is quite low. I'm in Bogen with a client and was OK for the first few days, but yesterday was very bad and I was down from 3pm.. could not even go out to eat. (Thanks Tim for bringing the Pizza!) If I can get through today, I'll be OK.

Was scheduled to come home on Monday, but instead I'll drive (6+ hours) to Holland. Tuesday, I'll go to the BetaKlink for discography. I had a wonderful conversation with Dr. Reul last night. When I was lamenting the fact that if discography was positive, thoracic fusion was indicated, he disagreed. It was great the way he put it:

"You look too much through orthopedical goggles!"

He suggested that fusion is not necessarily the next step. Perhaps PLDD (percutaneous laser disc decompression) or other MISS procedure would have an impact on my pain syndrome. We'll see. I'm glad that I get to continue the investigation there.

I have some clients with similar situations. I really love it that I have experience that may help them with their problems, but do not wish to acquire this experience by going through it myself!

I'll keep everyone posted. Wish me luck.

Mark

[Hooch]

Good luck. You'd think this has to stop for u sometime. Hopefully stem cells kick on a bit and give some options too.

[Keano16]

Well said by dr. Reul.

Depending on tear size, PLDD or endoscopic treatment should indeed be a first line of treatment for annular tears.

Good luck Mark!

[Maria]

Mark,
You are amazing! Or should I say your repaired spine is! Hope your t-spine allows you to resume traveling for further diagnostic purposes for yourself and although you are going thru it I do hope there will be good options for you (that unfortunately you are discovering re your own spine) and others as well! Hoping you have as safe and pain free travels as possible!

[newhere]

good luck Mark

[jsewell]

Mark i am glad you are having the discography , it should show the painful discs as mine did . You are the best person to be helping clients, they are all very lucky. good luck
judy

[mmglobal]

I just posted article on PLDD here:

Percutaneous laser disc decompression for thoracic disc disease: report of 10 cases

7 of 10 sounds too good to be true. (My clients all know that I don't believe much in the literature... even from the doctors that I know and love.)

I had a lengthy discussion today with one of the pro-spine surgeons who's opinion I respect VERY highly. Her opinion was that while intradiscal treatment does not come with great results, the likelihood of it making things worse is very, very low and that trying it (even at end of discography, since they are already there) was a very reasonable step to take. (Not using names here because I paraphrase and may have it wrong… just relying on my unreliable memory.) “Even if the results are less than 50%, if you are one of the lucky 30%, you’ve improved things substantially.” I did call her on the jump from 50 to 30%... that was good for a laugh, but I’ll bet dollars to donuts that 30% is much closer to reality than MicroSpine’s 70%.

More as I know it. All the best,

Mark

PS, I think we need a new phrase here. When a donut costs a dollar, our slang expression doesn’t make much sense!

[Gil Denis]

HI Mark

I wish you the best You have been through the ringer

Lets catch up when you return.

Gil

[dshobbies]

Mark,

I'm so sorry you have to go through all of this, yet again. Good luck - I'm sending you my angels.

Dale

[mmglobal]

Postponed till Thursday.

I had a long discussion with Dr. Rosenthall while I was driving from Bogen to Maastricht on Monday. He practices near Frankfurt and is a leader in thoracic spine. He developed something similar to VATS at the same time that Regan was developing VATS in the US. He's also done many XLIF procedures and is working on some alternatives to VATS and XLIF. I look forward to meeting him and learning more.

Counting down the hours till my wonderful discography!

Mark

[steve55]

Well, Mark, .... it looks like we both had our procedures today. I had facet injections at c4 and t1. It's the first diagnostic step for me that might ultimately lead to a thoracic discography myself. I'll be interested in seeing your next update.

[mmglobal]

Discography is done. I can't say enough good things about Dr. Reul. I have heard so much about how difficult and risky thoracic discography is. Some of the doctors I know who do discography warned me against it. When they found out that I was having it with a doctor with a great deal of experience with CT guided discography, they were more relaxed.

Having been in the procedure room observing more than 50 discographies, I have seen many that were very well done, and some that were not so well done. This was my fifth discography and my 11th level tested. As with all the two other needle procedures I had with Dr. Reul there was no sedation. However none of the past procedures were discographiy.

This procedure may have been the easiest of all the needle procedures I've experienced. Dr. Reul's caring, skill and experience are amazing. The pain I experienced on needle placement was very minor. He would get the needle close to where he wanted and take an image. He'd adjust the needle placement and repeat the process. There was not an intense pain when he penetrated the annulus as I have felt on other discographies. I was surprised to learn when he was all the way into the disc.

When he pressurized the disc, I felt a low-level pressure. At times I felt a very momentary sharp pain that shot horizontal across my ribs. People with thoracic problems will know that pain. However, none of what I felt was "my pain". My notes say 5 - 6 out of 10 NON concordant pain. Negative test.

I didn't know whether to be happy or sad. I'm glad that I'm not looking at thoracic fusion. I'm sorry that we still don't know what the problem is. Dr. Reul suggests going back to the facets. I'll write more later. I don't want to type a lot now.

Here are some of the images from today. The post-disco CT shows a pretty typical degenerated disc's distrubution of the contrast. The red arrows point to an accumulation in the 'sub ligamentous' space. The disc is herniated with an open annular tear. However the herniation is 100% contained by the posterior longitudinal ligament.



Note how narrow and curved the space where he needs to get the needle through is. This is why this should only be done with CT guidance and by someone with a great deal of experience. You may ask, "how can a doctor gain the experience?" The answer is, ON SOMEONE ELSE!

Mark

[Maria]

Hey Mark,
Was reading what you wrote and sent a chill up my spine just at the thought of neede placement at that level. Glad you got it done by this experienced practitioner, glad to hear it's negative and you can avoid fusion. Hope if it's the facets this will be determined and you can get a treatment plan that works for you.

Nice films. Thanks for explaining them. Hope if you're traveling back home soon that all goes smoothly and comfortably.

[dshobbies]

Damned if you do, damned if you don't - sounds like your back. What comes next?

I'm sorry you're suffering so. It's simply not fair


Dale

[jsewell]

Mark i am sorry this was negative and you need to further search for your problem. Glad it was a low pain procedure though , especially if it did not show your problem.
My back fusion kind of acts up only a little bit now. But NONE of that horrible pain . So i am glad i did it.
judy

[newhere]

Mark i am sorry for discogram...at least you know you will not need thoracic fusion,so thats good. I'm wishing you that dr. can set some proper diagnose for your thoracic pain. I will go also to Bonn to see some options for my thoracic because the pain must have the main source. I will open in a few days a new thread about understanding relations between my friends,environment etc... & me. It's very hard to live like this...not even my family understands me.
So thats why i look at you Mark as my other father who is willing to help me. Thanks alot
hear u soon

[steve55]

At least that is one step closer to proper diagnosis. I've been doing quite a bit of research on thoracic discography and everything I've read seems to say it's safe and effective as part of the diagnoses process.

"When performed by a skilled and experienced technician, thoracic discography has been shown as quite safe with a very low rate of complications"

Over and over I see studies that say that MRI's can and often do miss tears and many other painful pathologic disc conditions.

So far my injections haven't helped at all. I'll be pushing for my thoracic discography as soon as possible.

Anyways, good luck Mark. It will be interesting to see what other tests you will be undertaking as I may be following suit.

[mmglobal]

I met with my pain management doc last week. We talked about a lot of things, but mostly it as about being out of ideas. He suggested that perhaps I should begin to accept the fact that this is how I'm going to be.

I'm not ready for that, but I am ready to take a step back for a while. I'll try lifestyle changes, more PT... all the things that haven't worked in the past... Basically, this is just taking a break.

I brought up the idea that a large component may be a 'chronic pain disorder.' In many long-term chronic pain cases, the underlying pathology becomes minimal, but the years of chronic pain essentially rewire your brain and the way you percieve pain. This is a possibility.

I do have such certain pain responses to many activities that makes me think I do have a structural problem that may be fixed if it could be identified.

[mmglobal]

That last post was last week's news.

I just got a call from Fabien Bitan. He was on a long drive, so I could take my time and lay out the particulars of my case, the investigation we've done, the ablations, discography, etc... all in great detail.

I was not expecting anything new... I've discussed this with so many doctors. I was shocked with the simplicity of his reply:

"Why don't you try an epidural injection?"

He's had great success with thoracic epicurals and accupuncture with electrical stimulation. I don't know anything about the accupuncture, but will start to look into it. I'll also start working on the ESI right away.

Mark

[mmglobal]

Just got a call back from the pain doc. He agrees that the ESI is a great next step. He also has had good results with the juiced up accupuncture needles.

When we discussed why this had not been brought up, he said that these treatments are good for the people with exiting nerve root impingement w/pain radiating around the chest wall. (He said this like that's not me.) I don't want anyone to think that I have the slightest problem with this doctor. He is a great listener and has been completely on board with everything we've done, including the treatments and diagnostics I get overseas. I love this doctor. But... so much still gets lost in the translation. I do have the radiating chest pain and also sternum pain when it gets worse.

In any case, he is going to start the approval process for both the ESI's and accupuncture.

Well, that was a short step backwards... my break from treatment/diagnostics has only lasted a week.

Wish me luck,

Mark

[dshobbies]

Have you ever thought of a tens unit or does your ADRs on top and bottom rule that out?

Got to tell you- this stinks!

[mmglobal]

I have a tens unit... not much help.... actually I've never seen any benefit from the tens... lumbar, cervical, or thoracic.

[Maria]

ESIs worked extremely well for me. Of course now WC won't authorize them saying they don't work for me (10 years of documentation in my WC records should show otherwise). Anyway here's hoping you get the degree of relief I did w/ESIs. Good luck w/this and keep us posted.

[newhere]

Mark...any news???

[Gil Denis]

Hi Mark

How are things?

I have a new MRI lets talk!

Gil

[mmglobal]

Newhere and Gil, thanks for asking, but no news yet. My local doctor is doing the authorization dance with the insurance company. That may take a few weeks. I look forward to what the ESI shows, but there is other news.

I'm in the Netherlands now, but just spent the weekend with Dr. Baumbach in Munich. He is amazing and every time I see him I learn a ton. Unfortunately, it was too much work and spine... not enough hiking.



Dr. Baumbach recently had an experience with a patient that made him think of my case. The patient is post single-level cervical ADR with a pain pattern similar to mine. She has similar thoracic pain, wrap-around chest pain and sternum pain. This is a common pattern of referred cervical pain. In this patient, other scans did not show relevant pathology, but a 3 tesla MRI clearly showed a substantail bulge at a level adjacent to the ADR.

Our discussion about the reasons we are only looking thoracic was very interesting. After the onset of the thoracic pain, I had a large panel of facet injections from T2 down to T8. This was positive, so we thought this isolated the operated c-spine above from the thoracic pain and narrowed it down to the the t-spine. I have no problem with the choices we've made during this process... we were methodical, only doing low-risk procedures and we only acted on clear results (as with the positive costo-vertebral joint injections, followed by more targeted injections, followed by the ablations.) However, I have since come to suspect the large panels of injections because I believe that there is a cumulative value to the injections. So much local and steriod coming from 6, 8, 10, 12 injections at once may very well generate false positives.

Note that we were also thrown by the presence of a very clear disc herniation in the area that I have the pain. (Baumbach believes that while this is not likely a pain generator, it is substantial enough to cause myelopathy.)

I will follow through with the ESI and acupuncture when I get home (unless I experience a miracle before then.) But on Baumbach's advice, I will have a 3-Tesla MRI. I'll be at the BetaKlinik on Thursday anyway and they have the most state of the art MRI equipment availalble there. (Open 3-T. When I was here a year ago, it was the only open 3-T in Germany. I don't know if that is still true.)

So the old news is not ESI yet... still in the works. But new information causes me to look cervical and have the 3T MRI.

I'll keep you all posted... All the best,

Mark

[jsewell]

Mark i hope the ESI's are approved when you get back to the US. Hope they and accupunture really help with your pain. Something has to !!!
judy

[newhere]

I want to ask you some questions...
so,your discography was negative...so why they suggest thoracic ESI??
also,in case that discography is positive,do they make some laser or some similar procedures directly after tested???(i ask for Betaklinik) tnx

[Aaron]

Mark, how many levels of your Tspine have you had tested. I would assume that there was no need to have a control tested above or below since the discogram was negative. Even under sedation I knew mine was the pain I exp. , but was suprised that I have the same or even more at the level above the herniation, a tear. But something I have not been able to explain is that when they pressured the T67 disc, herniated disc, I went to scream because it went from 0 to 100 in pain and my voice box or diaphram was locked up, I could not talk. The same thing happened when the ESI medicine hit the level of my herniation. I literally cannot get a sound out . Are you aware of any connection from Tspine nerves that may cause that?

How is the pain when you are lying down? That is when I am at my best, I can feel upon standing up the knifing begin in exactly the place you would think and continue to get worse until I guess it reaches max compression and the support from the ribs kicks in.

Hope the ESI helps. IF possible request medicine next to the tear also, definite positive response when they put medicine in the spot of my tear along with the herniation. Also I don't know if some of these things are just a coincidence or not , but I had a much better result from my 2nd ESI done at the end of the day vs. the first ESI in the early morning, I had endured a full day of compression and nerve irritation .

[mmglobal]

Newhere, great questions!

If the discogram was positive, I would have had a MISS thoracic discectomy... something like PLDD (percutaneous laser disc decompression.) I had spoken to many leading thoracic spine surgeons about the options and this was considered to be low risk and potential success. Bigger VATS or XLIF procedures were to be avoided if possible.

Dr. Reul had called it and told me it would be negative. If my disco was positive, I would have had PLDD done in same session. The needle is alreay in the disc and becomes the guide for the laser. vaporize the nucleus tissue behind the herniation and it shrinks


ESI was suggested by another doctor friend of mine... Fabien Bitan in NY.

I will follow through with ESI and accupuncture with my local doctor in the US.

Regarding your question... if the disc is not the problem, why do ESI? (Also, where are injections to be done. (from skype msg)

ESI will be in the t-spine in area around the herniated disc... hoping to reduce inflammation so potential constant irritation is reduced.

[Tbackpain1]

Aaron,

I tend to think that while there's no direct correlation between a thoracic nerve and not being able to speak, there is definitely a link between high pain levels and the Vagus Nerve. This nerve is part of your Autonomic Nervous system. When I have very very bad flares with the t-spine pain, I get a classic Vagus Nerve response (rapid heartbeat, clammy skin, etc) and I have passed out a few times as well.

The vagus nerve is either one of two cranial nerves which are extremely long, extending from the brain stem all the way to the viscera. The vagus nerves carry a wide assortment of signals to and from the brain, and they are responsible for a number of instinctive responses in the body. You may also hear the vagus nerve called Cranial Nerve X, as it is the 10th cranial nerve, or the Wandering Nerve. A great deal of research has been carried out on the vagus nerve, as it is a rather fascinating cranial nerve.

Vagus is Latin for “wandering,” and it is an accurate description of this nerve, which emerges at the back of the skull and meanders in a leisurely way through the abdomen, with a number of branching nerves coming into contact with the heart, lungs, voicebox, stomach, and ears, among other body parts. The vagus nerve carries incoming information from the nervous system to the brain, providing information about what the body is doing, and it also transmits outgoing information which governs a range of reflex responses.

When the vagus nerve is stimulated, the response is often a reduction in heart-rate or breathing. In some cases, excessive stimulation can cause someone to have what is known as a vaso-vagal response, appearing to fall into a faint or coma because his or her heart rate and blood pressure drop so much. Selective stimulation of this nerve is also used in some medical treatment; vagus stimulation appears to benefit people who suffer from depression, for example, and it is also sometimes used to treat epilepsy.

[Tbackpain1]

I'm sorry to hear that you're having that horrible wrap-around pain. Any word on the ESI? Are they going to consider attempting to knock out C7-T1, or are the going to address t-spine only?

Its just crazy how closely related some of the nerves are, and the cross over of dermatomes can vary from person to person, injury to injury. I've been getting horrible high thoracic pain lately with the increase in workload (yay new clients! but man my spine is not happy about the extra computer/keyboard time).

I hope that conservative tx and lifestyle changes will help eliminate some of your pain. My chiro has been on me to make sure I am changing postion frequently...sometimes something as simple as that can make a difference. After so long dealing with these issues, Dr. Reul is right, we do look at things with "orthopedic goggles".

Be well.

Theresa

[mmglobal]

Theresa, it's great to see you here. I am soooo glad that you have improved to the point where you can work again. You were pretty far from that point when we met in NY for my 2005 patient symposium. (I just checked the photos on the GPN events site... you are there.) Great news (and hope for many of us t-spineys.)

Aaron, sorry I missed your question. We only tested one level. No need for a control disc for me. I'm very lucid in spite of the severe pain and know exactly what is happening. The clear positives and clear negatives we have gotten obviate the need for control disc. If I was hypersensitive and reporting high pain there would be need for control. Certainly with a negative discography, a control disc would add no data. In spite of the belief that discography is safe, I don't want to poke a hole in a disc unnecessarily. (Risk of damage or infection is low, but not zero.)

Based on Dr. Baumbach's recommendation, I had 3-Tesla MRI of cervical and thoracic spine last Thursday. I did an extensive review with Dr. Reul... no new data, nothing interesting. No new pathology seen in c-spine.

I told him how disappointed I was with the negative costovetebral ablations, especially after such conclusive results of the diagnostics.

He said that he was being especially careful with me, using low amounts of energy in the ablation to avoid permanent wrap around numbness that is not uncommon with this ablation. See the thread linked below for more discussion.

He recommended repeating the investigation to determine painful levels. If data is reproducible, he suggests redoing the ablation, but a little more aggressively. I think that is a fine plan and will proceed with that... next time I can get back to Bonn.

I'll repost this on the costovertebral ablation thread... the story will continue there.

CT Guided Costovertebral Nerve Ablations

Mark

[Aaron]

Mark,

Have you any experience with these? I know they are weaker in strength, but I have heard in certain cases they revealed a more signifigant cord impingement than previously found. I thought that would be the case with myself since I have no pain lying down ( trad. MRI) , but the only new finding was some stenosis in the lower end of thoracic. Just wondering if the upright MRI would be of any use in your case.

[mmglobal]

Aaron, the upright MRI's may show up pathology that is not present when our spines are unloaded. Kind of like the flexion extension images, we hope that images in more realistic situations will yield more info than the static, neutral images.

In theory, I see the functional MRI's, standing or sitting MRI's being very useful. There are amazing examples of big disc herniations apparent under load, that are not present in a neurtral position. In practice, I have yet to see a smoking gun under standing MRI that is not present in prone MRI.

Nobody has suggested it for me. I'd try it if someone suggested a need for it.

That's the long answer. The short answer is no... not much experience with standing MRI here (except the dozens of clients with them... but nothing extraordinary shown.)

Mark

[Crystal33]

Mark,
Maybe decades from now they will be able to take MRI or some image that can show what the problems are down to a cellular level, and the software might even be able spit what the problem/s are. But for now I still think the technology is fairly crude, sometimes helps, but at other times leaves people as radiated pin cushions, with no real help. And the risky surgeries best avoided, unless critical, or unless failure of extensive conservative care.

It is low tech, but do you follow a daily physical regime tailored for your condition, including things to do, and things not to do or to minimise?

I blew a hole thru thoracic disc with a loose piece pressing on spinal cord 22 months ago. Operation was considered hi risk and months on back followed then a slight 'lift' in my condition every 3 or so months. Now I have very little pain, l get around ok, started light daily swimming, but still very conservative with any bending or lifting or consecutive hours on feet. I ended up taking a view that your body tries to repair problems but can only do it one cell at a time, over a long period, though not likely ever as good as before the damage. I know nothing about how a broken leg heals, but my body knows everything.

Could a combination of things like daily posture awareness, light core conditioning, minimise static sitting, lie down a few times day, or other things help? Very easy swimming with a bit of added buoyancy unloads spine, gives gentle motion, stretching, and controlled breathing ....might help thoracic area. Even add glucosamine for joint issues. So maybe a combination of modifications, and things done every day might help with the pain very slowly but surely like an extra drop of water in a glass each day compared to losing a drop from the glass each day.
Just my thoughts.
regards

[Maria]

I'm wondering if the incidence of thoracic disc problems are higher in persons that have had lumbar and/or cervical surgeries (ADR and/or fusion).

It would seem that T-spine injuries can happen for any reason and more so w/certain activities (weight lifting? jobs that require use of upper body strength?) though I do wonder if persons w/other areas of weakness and surgery w/instrumentation are higher in incidence w/t-spine probs as well, incidence higher in males vs. females?

I have slight scoliosis at T7 and have had only several incidences of a pain in that area that is piercing and literally takes my breath away demanding absolute stillness and a fear of exhaling or inhaling.

My OSS said long ago before my cervical spine started to bother me that my Tspine where bra clasps in back would be next to bother me because of DDD there. So far so good.... probably lifting one bag of kitty litter away from disaster anywhere in my spine tho I often wonder if not upsetting the status quo of my spine any further re surgery to date has kept it relatively stable (even w/DDD thru-out). This is not to say that if one area demanded surgery I'd forego it~ just pondering.