Dr. Roach: Surgery is a last resort for chronic back pain
Dear Dr. Roach: I am a 70-year-old man with chronic back pain. I first started having serious back pain in college after spending much of my time hunched over a drawing board. Later, as an architect, my back pain reoccurred frequently. About 20 years ago, after having terrible sciatica in my left leg, I had a surgical procedure done called a laminectomy, which successfully relieved my back pain for many years.
Now I have developed pretty serious arthritis in my lower back, and I am in pain constantly. I can no longer lie flat in bed to sleep. I started having to sleep in my recliner, which helped, and then I bought an adjustable bed, which was also helpful. I have had to rely on taking large doses of Percocet to manage my pain. Since I also have heart flutter issues, I cannot take any anti-inflammatory meds. I am having trouble getting opioids prescribed, but they seem to be the only thing that helps me. Walking and back stretching only cause more pain. Recently, my back surgeon suggested that spinal fusion might help me. What do you advise?
Dear D.A.P.: The sciatic nerve is a surprisingly large structure, roughly the size of one’s little finger. It exits the back and provides the nerve supply to the lower leg. When it is pressed on -- by a herniated disc or by bony material in people with arthritis -- it usually causes pain, and with more severe compression, numbness and weakness. Medications, physical therapy and surgery are possible options. I’m not sure whether you have given PT an adequate trial since there is a great deal more to spine PT than stretching and walking.
I consider referring patients to a back surgeon when their pain is bad enough to affect daily activities and when they are unable to get relief or require large doses of opiates. The surgeon evaluates the anatomy and provides a opinion, but the ultimate choice is the patient’s.
Back surgery is usually effective, but sometimes fails to relive pain. In a few cases, it makes things much worse. Back surgery should never be entered into lightly. However, it does sound in your case that a consultation was appropriate. I would suggest you consider getting a second surgical opinion, as it seems you are also a little reluctant. If the second surgeon also recommends a fusion procedure, that would be stronger evidence that surgery may be beneficial. It is likely that the arthritis process may cause problems to recur years from now.
Dear Dr. Roach: I give myself allergy shots with minimal reactions. My generic EpiPen expired in October 2019. When should I replace it? I wanted to buy a 1 milliliter ampule of epinephrine to draw up and inject in the event of need. Why did my pharmacy refuse to cooperate?
Dear T.R.: Drug manufacturers are required to put an expiration date on their drugs, but more than 90% of drugs sold are still effective 15 years after their expiration dates. Epinephrine in particular is a very stable compound and will almost certainly be good. However, in the case of an allergic reaction, epinephrine is literally life-saving, and you’d like to be as sure as possible it’s going to work. In general, I recommend replacing drugs within a year of expiration.
Pharmacies may dispense epinephrine only as prescribed by a physician. Your physician must agree to write you a prescription for an ampule. Epinephrine is a dangerous drug if used improperly.
Readers may email questions to ToYourGoodHealth@med.cornell.edu.