Spinal Specialist in Chiang Mai

[Sheryl]

1 hour ago, ThaiPauly said:

Yes Sheryl,

She has both , although the Gabapentin is 300mg, which is to strong, she only wants 100mg or she is spaced out.

She does not panic or hyperventilate.

We are going to see the pain doctor now and see what she recommends to contain the pain and discomfort.

 

I agree with what you say about the doctor saying its all in the mind, I have had this happen to me with my ongoing stomach issues, it's an easy "get out of jail free" card IMO.

 

There is a good neurologist at Bangkok Hospital who used to work at Ram and helped me a lot when I had my TIA, her name is Dr. Kanitta, but I don't know if she specialzes in Neuropathy, so a recommendation from you would be very useful.

Do you have full name for Dr. Kanitta? She isn't listed on the hospital website.

 

Are you saying your wife is on both Gabapentin and Lyrica? Does not make sebse.

 

Also besides Prozac what orher medications is she on?

[Sheryl]

Prof.  Surat Tanprawate at Sripat seems to be the best choice. in ters of a neurologist. I am also thinking a rheumatologist might be useful, at least to exclude causes like lupus and rheumatomid arthritis, but start with neuorologist. She should have nerve conduction studies with accompanying electromyogram. 

 

I am assuming she is not diabetic as that would surely have been excluded before surgery. I also assume anemia was excluded (pernicious anemia can cause this sort of neuropathy).

 

A high potency V Complex supplement that includes all the B vitamins (inc. B12) plus folate would be worth trying. Deficiencies of several of the B vitamins will cause this sort of neuropathy though why such deficiency would exist is a question. Anyhow not likely to hurt. Dr may already have prescribed, they usually do.

 

The following blood tests may add diagnosis and can be gotten at a lab such as Bria (https://www.brianet.com/) before seeing a doctor:

 

Complete Blood Count with ESR

C-reactive protein

ANA

B12 level

Rheumatoid Factor

[saengd]

Prof. Surat Tanprawate is an excellent choice for a neurologist, very professional and thorough with good English.

[uhuh]

Sheryl's recommendation of more diagnostics has been stated in this thread before (even before the operation) and is still valid. 

 

It is not completely impossible to have pain or weakness in the legs just from cervical stenosis (that would be compression of the spine as opposed to radiculopathy). I know of a case like this that Dr Wicharn operated quite successfully with cervical fusion of several vertebra from C4 downwards. But I definitely would look for other reasons, like outlined by Sheryl.

 

NB Gabapentin 300mg is much too low. Even if your wife weighs only 40kg, don't expect results at less than 1800mg total dose per day. Patients of 70kg need 3600mg! Unfortunately,  many patients cannot tolerate such a high dose. 

It does not make sense to give her Lyrica (=pregabalin) and gabapentin at the same time. Pregabalin alone would be better.  Starting at low doses,  increasing it over about 2 weeks to at least 150mg twice daily for patients of 70kg. Again,  many patients do not tolerate this. 

 

The word "fibromyalgia" has been popping up in this thread. Google it: "Widespread...blablabla". Widespread symptoms do not originate from the spine. Impossible to confuse. 

(But some doctors use the word in a completely different sense,  meaning just musculoskeletal pain.)

[ThaiPauly]

Prof Surat it is then.

Just got back from seeing the Pain Specialist Doctor at CMR.

 

She says we should leave things as they are as the nerves will calm down in about 3 months.

Sheryl

The meds she is on now are

Clorazepate

Methycobal 500

Lyrica 75mg (twice a day) She had only been on 25mg

Lorazepam 2mg

Fluxetine

Added Today were

Ultracet

Arcoxia

Plus the increased dose of Lyrica.

 

 

 

[ThaiPauly]

7 minutes ago, uhuh said:

Sheryl's recommendation of more diagnostics has been stated in this thread before (even before the operation) and is still valid. 

 

It is not completely impossible to have pain or weakness in the legs just from cervical stenosis (that would be compression of the spine as opposed to radiculopathy). I know of a case like this that Dr Wicharn operated quite successfully with cervical fusion of several vertebra from C4 downwards. But I definitely would look for other reasons, like outlined by Sheryl.

 

NB Gabapentin 300mg is much too low. Even if your wife weighs only 40kg, don't expect results at less than 1800mg total dose per day. Patients of 70kg need 3600mg! Unfortunately,  many patients cannot tolerate such a high dose. 

It does not make sense to give her Lyrica (=pregabalin) and gabapentin at the same time. Pregabalin alone would be better.  Starting at low doses,  increasing it over about 2 weeks to at least 150mg twice daily for patients of 70kg. Again,  many patients do not tolerate this. 

 

The word "fibromyalgia" has been popping up in this thread. Google it: "Widespread...blablabla". Widespread symptoms do not originate from the spine. Impossible to confuse. 

(But some doctors use the word in a completely different sense,  meaning just musculoskeletal pain.)

The Pain Doc does not want her to use Gabapentin so that's not an issue now, but she is on a higher does of Lyrica

[uhuh]

19 minutes ago, ThaiPauly said:

The Pain Doc does not want her to use Gabapentin so that's not an issue now, but she is on a higher does of Lyrica

Sounds good. 

What's her body weight?

 

The rest of the medication sounds about reasonable with the caveat about Lorazepam and Clorazepate mentioned by Sheryl. Some doctors do this,  but is this really intended?

Don't drink,  don't drive. This medication will make her tired. 

Edited December 2, 2019 by uhuh

[erymax]

Hi ThaiPauly. If your wife's MRI shows a clear disc prolaps with nerve compression than your wife needs to see a neurosurgeon who would perform the operation. They are different operation techniques. From dorsal (back) with hemilaminectomie and discectomie or from ventral (front of neck) in that case ususally the disc space will be filled with piece of bone taken from pelvic bone.  All sounds dangerous but anything else is more dangerous

because the prolapsed disc can move and compress the spinal cord. 

[Sheryl]

I asked about her meds in case the neuropathy was due to a medications.

 

She is on quite a collection of pyschotropics there,  some with same mode of action. It makes no sense for someone to be on both Clorazepate  and Lorazepam (and please note that both are addictive).

 

How often does she take these? And for how long has she been taken these? Are you sure she takes both? If so likely not intended by  the prescribing doctors.

 

The  Methycobal  is a form of Vitamin B12.

 

I still recommend nerve conduction studies/ EMG and also the blood tests previously mentioned.

 

For her spinal issue to have causes painful numbness in feet there would have had to have been cord compression which at cervical level would have had major other symptoms (weakness, difficulty walking, loss of bladder control etc etc) - in other words very, very unlikely. I rather suspect that the neuropathy has an altogether other cause separate from her spine related back pain.  And that the reason you aren't getting anywhere with doctors is the typical specialist tunnel vision, they are viewing everything in terms of her spinal; problems rather than considering other causes.

[Sheryl]

7 minutes ago, erymax said:

Hi ThaiPauly. If your wife's MRI shows a clear disc prolaps with nerve compression than your wife needs to see a neurosurgeon who would perform the operation. They are different operation techniques. From dorsal (back) with hemilaminectomie and discectomie or from ventral (front of neck) in that case ususally the disc space will be filled with piece of bone taken from pelvic bone.  All sounds dangerous but anything else is more dangerous

because the prolapsed disc can move and compress the spinal cord. 

 

She already had the surgery.

[erymax]

2 minutes ago, Sheryl said:

 

She already had the surgery.

sorry I missed that. 

[erymax]

I jumped few pages without reading

[ThaiPauly]

20 minutes ago, uhuh said:

Sounds good. 

What's her body weight?

 

The rest of the medication sounds about reasonable with the caveat about Lorazepam and Clorazepate mentioned by Sheryl. Some doctors do this,  but is this really intended?

Don't drink,  don't drive. This medication will make her tired. 

She currently weighs in at 47.3. She was around the 52kg before the operation, so that's quite a loss of weight loss without any activity, although she does not eat anywhere near as much as before.

The Doctor was aware that she was taking Lorazepam and Clorazepate.

 

 

[ThaiPauly]

15 minutes ago, Sheryl said:

I asked about her meds in case the neuropathy was due to a medications.

 

She is on quite a collection of pyschotropics there,  some with same mode of action. It makes no sense for someone to be on both Clorazepate  and Lorazepam (and please note that both are addictive).

 

How often does she take these? And for how long has she been taken these? Are you sure she takes both? If so likely not intended by  the prescribing doctors.

 

 

Uhuh said the same thing.

 

These meds were prescribed at the same time by the doctor at Suan Prong (Phsyciatric Hospital) on Friday last week.

 

She struggles badly with sleep issues, has done for may years, there are threads attesting to it on this forum. Normally she gets around 4 hours, the meds are giving her at least an hour more, but is it worth it?

Now I know why she is sleeping longer.

She has agreed to come off the Clorazepate We will see what the result is

[Sheryl]

Well if she started on them just last week they don't explain her neuropathy.

 

  Not a good idea though.

 

Is she menopausal? That is a common factor in insomnia in women and better handled hormonally.

 

It is also possible that menopause is part or all of the cause of the neuropathy....though it would not usually cause such very extreme severity as you describe. 

 

 The incidence of peripheral neuropathy increases in menopausal/post menopausal women and those with it have been found to have lower estrogen levels than same aged women without such symptoms.

 

[ThaiPauly]

12 minutes ago, Sheryl said:

Well if she started on them just last week they don't explain her neuropathy.

 

  Not a good idea though.

 

Is she menopausal? That is a common factor in insomnia in women and better handled hormonally

 

She went through the menopause 5 years ago Sheryl.

[Sheryl]

Please see my edits to my last post.  She is post menopausal and this likely explains a lot.

[Sheryl]

Can get bioidentical HRT here https://www.bangkokhospital-chiangmai.com/en/center/anti-aging-clinic/

 

Will likely do a lot more for her depression and insomnia than the psych meds she has been given.

[ThaiPauly]

The Neurologist you recommended Sheryl has no appointments available until 4th January, that's how popular he is.

 

We have booked in for that date.

 

In the list of blood  tests to do you suggested ANA is that just ANA or ANA in profile?

 

Many thanks

[ThaiPauly]

I have found out that Dr. Surat has a private clinic called Chivacare, so we will be able to see him once we have the results of the blood tests which take 5 working days to complete

 

Wow, I asked them about a Nerve Conduction Study and Dr.Surat phoned me and said not to worry about that until he has done a physical exam, but to bring the blood tests in.

So we are seeing him Wednesday week.

 

Thanks everyone for your help so far, you have been brilliant, especially Sheryl and Uhuh

Edited December 2, 2019 by ThaiPauly

[Sheryl]

1 hour ago, ThaiPauly said:

The Neurologist you recommended Sheryl has no appointments available until 4th January, that's how popular he is.

 

We have booked in for that date.

 

In the list of blood  tests to do you suggested ANA is that just ANA or ANA in profile?

 

Many thanks

Just ANA to start with. Only if it is positive would it make sense to look at breakdown by specific ANAs. Odds are it will be negative and thus exclude lupus as a consideration. If by chance it is positive then you'd want to consult a rheumatologist and they would advise re further tests.

 

Serum estrogen and progesterone level test are also a good idea. As she is post-menopausal her levels will naturally be low but the question is how low. If lower than average for a post-menopausal woman then greater chance it is causing or contributing to the neuropathic pain.  If you want you could leave this until she sees HRT specialists but odds are they will order these tests and will cost a lot more at Bangkok Hospital than at Bria Labs.

[uhuh]

When you see the neurologist you can also ask to

- off one of the benzodiazepines, lorazepam or clorazepate

- and instead increase pregabalin (Lyrica) which is still too low

 

Most important is a thorough (!!!) physical examination: range of movement,  power, sensibility, pain, of all extremities and the trunk. Plus taking her detailed history. Before any technical diagnostic tools,  it must be clear what are actually the symptoms of the patient. 

[ThaiPauly]

What is the prognosis if it turns out that it is a neurology problem and not a spinal one?

 

Although I feel happy that we may be able to rule out a connection to the spine I am suddenly concerned as to how the problem can be resolved....if it can?

[uhuh]

1 hour ago, ThaiPauly said:

What is the prognosis if it turns out that it is a neurology problem and not a spinal one?

This depends on what kind of problem it is.

[ThaiPauly]

On 11/10/2019 at 10:33 AM, Sheryl said:

Re post-op, he has a pretty good team that works with him. The most important period is the 1st 24-48 hours and with luck maybe that can be before he leaves.

 

There usually isn't much by way of post op care needed, she should be fully ambulatory by discharge, but see what the doctor thinks. My sister had the same Op and just came home with me afterwards and I do not recall it taking much of anything in the way of after care.

 

Yes, if there is nerve  root impingement - which it sounds like Prof. Wicharn confirmed  -- the surgery should be soon as possible to avoid permanent nerve damage.

 

 

 

 

Hi Sheryl,

 

3 and a half months post operation and she is still in a world consumed with pain after 10am, she is not to bad until then, the same as before the operation.

 

The pain is from the area where the operation was performed, she is also very weak and has lost about 2 kilos.

She is uanable to walk very far without getting tired and when she is walking it is at about 1 klik an hour.

She is dependent on Ultracete opiod medication.

 

She is so depressed that I have to be very viligent with regard to medication, I have to hide it.

 

I know that it has been said that it can take between 6 months and a year before it is healed properly.

I would think that she has only had about 10% relief from the operation, I think I know this from the fact that we have only had to go to the hospital for a pain killing injection once wheras we were going at least once a week before.

 

I am really just looking for reassurance, she has massages from a qualified medical professional twice a week, I think these help a little.

I have taken her to every pain specialist in the City, and also tried some of the private clinics with no joy.

 

Thanks for reading

[Sheryl]

While the recovery can take months,  the pain relief (other than incisional pain) should be pretty immediate. it is strength and also relief of numbness that can take time, not pain relief.  If she is still in pain of the same type and severity and location as before the surgery, that suggests that the surgery did not correct the source of the pain.

 

What happened with the nerve conduction study and neurology consult?

 

And you has previously indicated she had different pain, neuropathic pain.But now you are saying it is the same identical back pain that she had before the back surgery? Can you clarify?

[ThaiPauly]

Hi Sheryl

 

She had a nerve conduction study and a brain MRI by Dr.Surat who you recommended.

The neurologist said there was very little nerve damage and definately  no brain damage and suggested therapy by way of massage

 

The numbness she used to get is not as frequent as it was but she constantly has sweaty feet

 

I would say that the pain was 75% back pain and 25% nerve.

Is it true that spinal fusion can take so long to heal?

 

 

The nerve pain in my opinion has reduced slightly.

 

However her brain time reactions are well down on what they were before the operation I am finding now and am concerned about this.

 

She no longer seems the same person, she never wants to go out...anywhere, we spent all the holidays alone this year, we never go out to dine any more and we used to go at least once a week.

 

 

[Sheryl]

Some of what you describe may be due to the tramadol

 

It sounds like the doctors can find no explanation for her pain in which case it might be pyschogenic