GP Issues/ Spinal Problems

[bluediva]

Dear all,

 

This is my first time here and a colleague suggested your forum for advise. I am in need of some impartiality if I am honest, so I hope someone can help. Just your opinion would be great

 

About 15 months ago, I started having severe lumbar back pain. I initially treated it for a number of weeks with exercise as normal, nurofen and putting a hot water bottle on my back (I am allergic to deep heat and cold sprays so I don't use those). Instead of getting better, my back seemed to be getting worse, in 2 specific areas.

 

I sought the opinion of my GP, she felt it was inflammation from pregnancy and spinal anaesthestic from delivery, my baby is 18 months old now so the pain was already 3-4 months in before this was suggested. She suggested treating with a short course of amitripyline and co-codamol. I asked for a physio referral but I was told that it is not appropriate for short term back pain.

 

I actually then went to see a private physio and had 6 sessions, in the end the physio referred me back to my GP as she felt I had underlying issues with the discs and wrote me a letter to give to my GP.

 

Since March, I have been back and forward almost every week with this, worsening pain. I have been treated with diazepam, amintripyline, tramadol, naproxen, etodolac, co-codamol, high strenghth ibuprofen with little effect. I have been told that the pain is:

* Imagined

* Caused by the epidural

* Temporary inflammation

* Constipation

* Kidney infection

* Caused by my 'work shyness', I am not work shy, I am self employed and lucky to work flexible hours

* Caused by my mattress/car/ too much exercise

 

4 weeks ago, I demanded an x-ray as I had been feeling for some time that the two areas where I was experiencing pain were 'crushing down' together. The GP agreed but told me the x-ray would not show anything.

 

I had my x-ray and today went for the results:

I have severe narrowing of the disc space between L2 & L3 & slight narrowing between L4 & L5

 

The GP seemed very arrogant about this and said it shouldn't be causing me the amount of pain I say I am in and gave me 4 days of diazepam and said that should make it better.

 

Unfortunately for him, I don't believe him!

 

He suggested I try a year of physio, unfortunately being in as much pain as I am and having already tried physio, I want to seek a specialist opinion from a spinal specialist who works in private practice but the GP says I need to try physio and there is nothing a spinal specialist can do to help me.

 

I am only 27 and just started out on my career as a construction manager, I have a young son and really, I cannot bear to get any worse. Even if the spinal surgeon says no they cannot help me, I would rather hear it from the specialists.

 

I am desperate and in a lot of pain, I am seeing another GP in the practice on Thursday to ask for a referral but I am not confident I will get it but, if anyone can advise on my rights to a specialist opinion before then, I would be so grateful, I cannot imagine having to live with worsening pain for the rest of my life.

 

Thank you all,

Liz

[zippygbr]

before dashing for surgical options remember there is a not insignificant risk of spinal cord injury from any intervention ...

 

specific physio may be benefical to work on core strength ,posture etc

 

that said there is little reason for your GP not to write a private referal for a specialist opinion, it is not as if the GP is suggesting exposing you to any more radiation or any invasive procedures ... the question is what would your reaction be if the spinal specialist said come back after a year of specialist physio input ?

[dragonkeeper]

Hi bluediva

 

Instead of getting better, my back seemed to be getting worse, in 2 specific areas.

I have been treated with diazepam, amintripyline, tramadol, naproxen, etodolac, co-codamol, high strenghth ibuprofen with little effect.

 

mattress/car

 

I have severe narrowing of the disc space between L2 & L3 & slight narrowing between L4 & L5

 

I cannot imagine having to live with worsening pain for the rest of my life.

 

2 areas of pain lower back approx 50mm either side of spine?

seems right for disc locations

possible cause of pain could be pinced/damaged nerve due to narrowing of discs.

 

mattress and/or driving position could inflame area.

 

medication (through personal experience) Tramadol/Dramadol SR 100mg 1 twice daily, Diclofenic 50mg 2 twice daily,

(and poss Diazepam tried the other meds mentioned to no avail)

Needs at least 1 month course for appraisal

away from medication you could try TENs machine (Boots and Lloyds sell them)

 

:idea: This is NOT based on Medical training only through personal experience

Always Seek GP's Advice

 

 

 

In most cases Orthopedic Surgeons carry out the proceedure

Ask yor GP for hospital referal

 

I have two operations on Discs 1990 and 1995 still suffering but glad I had 'ops' also had Epidural to no relief

 

You adapt to your limitations (varies day to day)

Keep smiling

 

 

dk

[bluediva]

Thanks both, I value both of your opinions and thanks for sharing.

 

I would try physio certainly but I would rather a specialist would tell me that and indeed point me in the direction of someone who specialises in this field, don't even mind paying privately if I am honest.

 

My only reticence on that front is I did go to a physio privately first and she felt that I had fundamental disc problems that wouldn't effectively respond to physio but I am open and willing to a second opinion on that front too.

 

What I have come to conclude is that my GP practice is not particular good at managing chronic conditions, my husband has quite bad asthma and he feels there isn't a lot of support for him.

 

Having spoken to a friend who is a nurse and a friend who is a junior dr in a hospital both have recommended surgeons and both have said if it was them, they would seek a specialist opinion.

 

I will certainly insist on this tomorrow, it us not that I don't have faith in my GP, I do, but in limited contexts! I just feel my back is so important to me, I need the specialist opinion of someone working with backs to get me back to pain free or pain limited.

 

Will keep this updated

Liz

[honeybee13]

Hello. For what it's worth, I would also seek a second opinion. GPs are just that, generalists. I have a back problem and made very little progress until I had specialist advice.

 

I hope you get what you want tomorrow.

 

HB x

[Allwood]

If it were me I would go to the hospital causality department and they will have to deal with it for you.

 

Hope you feel better soon

[dragonkeeper]

 

I had my x-ray and today went for the results:

I have severe narrowing of the disc space between L2 & L3 & slight narrowing between L4 & L5

 

 

you have stated that is disc related

that is what needs exploring

 

 

dk

[feefofum]

I may be able to help as my ongoing PhD is in the area of back pain. Before I waffle on though:

 

Have you been pointed in the direction of any patient groups? These are a great source of information (evidence based) as well as empathy/sympathy and empowerment. There are also many forums on the internet for people with back pain and they are useful to read through, especially if you think you are receiving substandard care from your GP. Have you been referred to any pain clinics? These are great for helping you to manage your pain and continue to live a full life. Its true that many people with long term back pain are never fully recovered, but with the help of pain clinics and perhaps some CBT (cognitive behavioural therapy) their quality of live improves dramatically – to the extent that they refuse surgery when it is finally offered.

 

 

Here’s the long bit – hope it helps and doesn’t bore you too much.

 

First of all I am not defending your GP, but the truth is even 'experts' do not know the definitive reasons for low back pain. There are 'red flag' signs which alert the practitioner to signs of serious pathology, but in the absence of these red flags it then becomes a bit of a 'try and see' approach in terms of therapy. No one knows why some people respond to some kinds of treatments and others do not - though effort to 'subgroup' by such things as ' pattern of symptoms' 'duration' 'type of pain' etc have some success - BUT there is no clear distinction between these groups. That's when you may end up with a label of 'non specific low back pain (NSLBP)' which basically means the causes (and therefore the best treatment) is not known.

 

Up to 40% of the population who DO NOT HAVE BACK PAIN have degenerate discs and disc space narrowing. This means that essentially disc space narrowing and degeneration are treated in the medical community in much the same way as wrinkles are. i.e. they are a normal process of aging. It also means that tests such as x-rays are pretty useless as they may identify degenerate spines, but they won't say if this is causing your pain or not. Why some people suffer pain from this normal aging process of the spine, whilst others do not, is still unknown.

 

Interestingly, sub-grouping people with NSLBP by their psycho-social status seems to have more effect in predicting outcome to treatment than sub-grouping by symptoms etc. This basically means that if you are anxious, depressed, involved in litigation or live in poor social circumstance etc etc, you are less likely to recover from your NSLBP regardless of the cause and treatment used. This is known as the 'psychosocial model' and was a major shift in thinking in the late 1990's. Whilst this paradigm shift was great in that it moved back pain away from the 'medical model (which believes all pain and dysfunction comes from anatomical abnormalities and pathology) and thus allowed the person as a whole to be treated, it does also have the unfortunate outcome of some practitioners applying the psycho-social model in the absence of any other diagnosis and this is when you, as a patient' believe you are being told it is all in your head.

 

NICE recently published guidelines on the management of NSLBP (May 2009) http://www.nice.org.uk/CG88fullguideline which basically states that for NSLBP greater than 6 weeks duration but less than a year, the GP should offer either Spinal manipulation (can be undertaken by a Physio, Chiropractor or Osteopath - depends on who your PCT contracts out to), Exercise therapy with cognitive behavioural therapy, or Acupuncture. The choice of which therapy to try should be made with the patient's input and if one doesn't work then the patient is entitled to try another one of these therapies. In reality GP's have not consulted patients on the choice of therapy but it is important that you have a say - so BULLY your GP and perhaps try acupuncture if you haven't already? (the guidelines are based on 'evidence' and there's a great trial that shows acupuncture can help). These guidelines also say x-ray and MRI ARE NOT to be offered, for the reasons I gave above, and they state the evidence for nerve blocks and epidurals for back pain is not there to recommend it as a treatment (much to the anger of the anaesthetists who see otherwise in their day to day clinics).

 

If your back pain has persisted for more than 1 year then you fall outside of these guidelines and the GP can refer you to a surgeon (does not mean your GP can’t continue to offer these other treatments – BULLY them to do so whilst you wait for a referral).

 

However here’s the catch. Even with surgery the recovery rates are not great. There is no consensus on which surgery works for which conditions. Some surgeons will perform a micro-discectomy whilst others will go for a full blown decompression with fusion. The latter has a ‘success’ rate of just 60% (success in terms of the patient feeling fully recovered at 5 years) and more recently evidence is showing that those who continued with conservative care have pretty much the same outcome as those who opted for surgery 5 years down the line.

 

The decision is yours obviously, just make sure its an informed decision.

 

Oh and PLEASE don't go to A&E with this, you will only serve to take up the time of busy profesisonals who are already understaffed and overstretched. You may end up being treated by a 'junior doc' who will admit you purely because they do not know what else to do with you. You will then be taking up a valuable bed, and the junior will get very short shrift in his ear the next morning when his consultant realises he's admitted inappropriately. Alternatively you'll wait for 3hrs 50 mins (10 mns before the 'breach time') before a nurse practitioner who knows the recent guidelines will give you painkillers and a letter for your GP. Waste of both your times.

 

Good luck!