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Rehabilitation

Spondylolisthesis pain management

11/21/2011

Question:

Hello! I have two questions about spondylolisthesis and chronic knee pain. For the past four months I have been going to an orthopedic surgeon for treatment of my chronically painful knees, which he says are in distress from Chondromalacia Patella. Treatment to date has been unsuccessful (rehab exercises, NSAIDS, cortisone shots, icing, stretching). My lower back and hips had also been aching for a few months and my toes felt numb & tingly, so the doctor took an x-ray of my lumbar and found I had spondy in the last two vertebrae. They`re bent around 15 degrees or so, which, he said, is probably the cause of my numb toes. I am having an MRI this week of my lumbar. After combing the Internet for treatment options and reading Arthritis magazines, I came across the medication Cymbalta.

My first question: is long-term use of Cymbalta good for management of chronic lower back pain and irritation in the hips? I`ve been taking NSAIDS for months and want to stop taking them before they do any damage to my stomach.

My second question: do you think it is possible for spondylolisthesis to be the cause of my chronic knee pain? The knee pain is mostly in the inner knees and the backs of the knees with occasional stabbing pain in the kneecaps.

X-rays of my knees were clean, and an MRI of my right knee did not show a torn meniscus, which was what my doctor though I had. As I said, my knees have not responded to standard treatment and the doctor said he wants me to consider lubrication injections.

I have not decided on that yet because if my knee pain is being caused by spondy I would not want to take the shots. Any advice you can offer me about my situation would be deeply appreciated.

I am almost 50 years old and have been active all of my life (running, bicycling, gardening). These knee problems and sore lower back have made me stop everything, and as you can imagine it makes me sad. I`m not used to being a couch potato and I really want to get outside and become active again! Thank you in advance for your reply. I look forward to hearing from you.

Answer:

This sounds like a frustrating set of symptoms.

For further information RE: your questions about your knee symptoms, using the Search window on the homepage of the NetWellness website, typing "chondromalacia" currently yields 54 results, and typing in "chondromalacia patella" currently yields 37 results.

A physical examination should be able to determine whether your knee pain is due to a knee problem vs. due to "referred pain." Normal knee imaging studies certainly do not rule out the possibility that your knee pain is due to "chondromalacia patella".
The lack of benefit from knee steroid injection does not necessarily mean you won't benefit from knee "viscosupplement" injection(s).

You are right to be concerned about possible adverse effects from ongoing use of nonsteroidal anti-inflammatory drugs (NSAIDs): although stomach ulcers are one potential complication, NSAIDs may additionally increase the risk of kidney, liver, and/or cardiovascular problems.

If an NSAID has not provided significant benefit in terms of reduced pain and/or improved function after a couple weeks' use, switching from one NSAID to another NSAID, and/or adding another type of medication, may be helpful.

Cymbalta (Duloxetine) may help reduce musculoskeletal pain symptoms, but if trial use does not provide sufficient benefit despite adequate dosing, continued use would not be necessary. If, on the other hand, Duloxetine was tried and helped, long term use would not have the same risks as NSAIDs, but as is the case for any medication, continued use would not be free of potential problems.

The presence of spondylolisthesis ("slippage" of one vertebra upon another) by itself doesn't necessarily mean a person's symptoms are due to this. And, a lumbar spine MRI scan won't necessarily reveal the cause of pain or numbness symptoms: MRI scans reveal structure, but the significance of any structural abnormalities demonstrated by MRI needs to be interpreted by your physician.
 
The basis for your toe numbness and tingling symptoms could be further evaluated by electrodiagnostic studies (electromyography and nerve conduction studies = EMG/NCS) - if those results would change your management.

In the meantime, rather than being a "couch potato", in most cases some form of exercise - low-impact or no-impact - can be found which does not exacerbate symptoms, and which if performed regularly will help maintain or improve overall physical conditioning as well as a positive mental outlook.

For more information:

Go to the Rehabilitation health topic, where you can:

Response by:

Brian L Bowyer, MD Brian L Bowyer, MD
Clinical Associate Professor
Physical Medicine & Rehabilitation
College of Medicine
The Ohio State University