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A wretched back

These letters exemplify many that I have received, and duplicate the complaints of many of my patients over the years.

Professor Driver Jowitt, I have found your info by accident and what I have read has confirmed some suspicions I have had about my own care for some time.

About 30 years ago I had a Takata type disc extrusion which led to laminectomy discectomy including a dural tear and weeks on my back in hospital. It was not enjoyable.

I have just had a fusion to help with awful foot and leg pain due to instability and bilateral foraminal stenosis.

I still have pain in both legs and feet and my low back feels no more stable than before. I have suspected for a long time that I have not been fully informed on my true condition-based simply on how bad I often feel- and I know that my GP is taking his lead from the latest ‘expert’ and my outpourings are largely dismissed.

After all I have been ‘fixed’ now… so what is the problem???

My insurer is taking an increasingly hard line lately on folks like me. I am about to be sent for assessment by an independent contractor to determine if I can return to my trade as a carpenter. I fully expect this to be found to be true and my exit (from benefits) put into motion. I have not worked full time since 2002 – in great pain and discomfort – and lost my latest (light)job when I agreed to the fusion. I feel let down by my health services.

Dear Patient, I have the greatest sympathy for you. Medical investigatory techniques (including the most recently developed “scans”) are relatively crude. Therefore a meticulously accurate diagnosis is often lacking. At times the view is taken that “nothing shows, therefore nothing is wrong”. This is an inferior conclusion, which I often have to counter in Court. My argument is that “absence of evidence is not evidence of absence”.

By the same token, such an absence of an anatomical diagnosis defeats accurate treatment design.

However empirically and over a lifetime of involvement in vertebral management [both surgical and (mostly) non-surgical] the least dangerous and most effective form of management is in water, as described in my website.

I imagine you are seeking responses to those who might deem you “fit to work” and so cut your grants. If I can help further, please let me know.

Dear Doctor Driver-Jowitt, I have read some of your articles on spine surgery and tried, elsewhere, to contact you.

I am doing some research on my own situation post discectomy/laminectomy for Takata type extrusion (20mm) in 1989 and L5/S1 fusion recently. I have significant ongoing issues. I am a 52 year old ex tradesman.

Can you tell me how I can establish the current status of my ligamentum flavum? After reading what you have written I think I may have instability and weakness due to its removal in 1989. But how on earth would I know??

Dear Patient, As a beginning, it is not likely to be productive to return to the past in terms of unpicking previous events. What counts is to get going on a process of improving what you have at present.

However, having said that, it might also be important to provide your source of social benefits with some reasons why you may never have been truly “cured” following the original disc prolapse.

At the date of your original surgery it was widespread practice to excise the ligamentum flavum, and to strip away the inter-spinous/supra-spinous ligaments, as well as to elevate (and so inadvertently de-nervate) the mutifidus muscles. The last mentioned is an often unrecognised cause of “instability” as well as “transfer pathology” to segments above and below the segment of primary pathology.

Therefore those who might take the stance “you have been correctly treated, nothing can be found by experts now, and therefore you are fit to work as a carpenter” might well be wrong. Add the impairments at the disc level to other (unrelated and often subliminal) changes of age, and you could well have good reasons not to be able to return to work as a carpenter. Indeed if you are expected to build and mount trusses, or work on scaffolds and ladders, you should be prevented from those activities.

Have your hips been checked? An arthritis, at times not appreciated, can often exacerbate vertebral problems.

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The spine is not so simple

Back pain, often associated with leg pain, is common. Rapid conclusions as to the cause are often made, and the unfortunate victim is told with authority by friends that “this is obviously a ‘disc'”. Even the profession was beguiled at one stage into believing in the “dynasty of the disc” for nearly half a centuary. However back pain originating is the disc is relatively rare.

The compendium of potential caused of back pain is large, and often originates from causes external to the vertebral column such as inequality of leg length and restricted (but unrecognised) limitations of hip movement. Even changes in the feet, by disturbing the fine and specific axis of balance of the vertebral colum can produce back pain. [This will be the subject of a dedicated page in the future].

Events near the vertebral column can produce back pain, such as gynaecological or bowel disease. Others include disease of the min arteries or ulceration of stomach or duodenum.

The ligaments, particularly the ilio lumbar ligament and fascia can produce intractable back pain. [Entrapment of the sciatic nerve by the piriformis muscle will be considered in a later post].

The problem is that the vertebral colum is an exceedingly complex anatomy of fine dimension, and is hidden deeply within the body. It is frequently assumed that one or other type of “scan” will be all-revelatory. Unfortunately even the most sophisticated investigatory equipment is too crude to give precise answers. Instead this equipment might show an abnormality which is no more than a “red herring”, with the regrettable outcome that  patient and therapist  alike begin to pursue this misleading cue even to the extent of attacking it surgically. Another problem is the cavalier surgeon who is determined to “explore”. Pain, however, is never found with a knife.