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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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Piriformis Story

The Piriformis Syndrome seems still considered “controversial” with a small group of followers and, it seems, a far larger group of non-believers.  My own experience began in this way:

As the young doctor in the west of Wales I often encountered coalminers with back pain and sciatica.  One had a clear history – he had fallen back onto the the sharp corner of a metal scuttle used to carry coal which struck him in the buttock.  He was clear that his persisting symptoms began at that moment. It seemed that he had a focal injury in the buttock affecting the sciatic nerve trunk and the nerve was trapped in the buttock, not by a disc in the back.

The consultant surgeon was adamant that this was a nerve root entrapment by pressure from a disc.   In the early 60’s the dynasty of the disc was accelerating its momentum, but precision in diagnosis was notably poor.  All that was available was the myelogram, which like many medical endeavours could only assist by negativities.  The ” exploratory” surgery on the disc was not beneficial and I continued to think about the outcome with regret. 

In 1980 a man in his early 30’s walked into my office. “I don’t know why I am here,” he said “but I was passing, saw your name and took a chance”. 

He had had three laminectomies by a professor of neurosurgery at a teaching hospital and now was being told to “live with the pain”.  That morning he had resigned his job. “I didn’t have the energy to get up and walk across to the filing cabinet”.  He had sold his house at a  desirable beach location, because  pain prevented him climbing the stairs to the car park. 

His pain was located precisely over the piriformis in his buttock and he had a notably sensitive sciatic nerve when felt rectallyPalpating the nerve in the buttock duplicated his symptoms. His replicated the Welsh miner.

“A new machine has been installed in the city” I said “it is called a computerized tomogram”. 

He looked blank.  I welcomed the chance of testing this machine.

This was the scan, which showed an enlarged piriformis muscle in all cuts.

mcculloch-painted-compressed

The piriformis is red, the sciatic nerve blue

“I have had so many opinions”, he said “which have all been wrong.  I am sure you will understand if I take the scan and ask for a further opinion.”

He had a  contact with another professor of neurosurgery who, as it happened, was hosting an international neurosurgical conference that week.  The scan was presented at the conference.  The opinion of the meeting was universal: “This is not the cause of your problems.  We advise you to stay away from further surgery.”

He returned despondently.

“You can’t continue through life as matters are.” I said

“I suggest that I release the piriformis muscle. There is minimal downside, and the potential to make your life worth living again”.  He nodded in dumb acceptance. 

The procedure was photographed, and later that day the photographer boasted  that he had seen a man who “was going to have a big pain in his behind!”  The woman to whom he was talking responded “No he is not. He is my boyfriend and he has no pain”.

A week or so later Mac did a charity walk of some kilometers without pain for the first time in years and, as far as I am aware, he never again had pain.

As I had mainly spinal practice persons with piriformis entrapment appeared from time to time.  However precession in diagnostic accuracy was a concern, since it soon became clear that CT alone, and ultimately MRI alone, could not provide an unequivocal diagnoses.  What was helpful was to paralyze the piriformis with a local anaesthetic. Initially this was done blindly by advancing a needle a centimeter or so from the lateral edge of the sacrum.  This usually gave persuasive diagnostic information by abolishing the pain for the duration of anaesthetic effect.  But it did not give the certain anatomical precision which I would have liked.  Later  I began injecting the piriformis under CT guidance and this technique became widely adopted, and spread widely internationally.

Skepticism remained.  At that time access to literature was difficult and I could find no previous experience with the entity.  Some years later I discovered that a description from Durban, South Africa, from about 1947  by, as I remember it, a Dr Adams. A neurosurgeon once asked me where he could find the literature on Piriformis Syndrome.  I said that I did not know of any literature but I could explain to him my experiences.  He said that he was not interested in my opinion and put the phone down.

I have had three failures following piriformis release, each of which, in retrospect, could be explained as failures in selection.  Nevertheless, the procedures were relatively innocuous, and had, as far as I am aware, no downside.  Balanced against that were a great number of successes.

 [A discussion on the etiology of this syndrome will be addressed in another paper.]