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Medical Malady Mystery Question For Dr. Joe


Bill

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My wife has yet another medical malady mystery that hopefully Dr. Joe can solve. Any readers that have had this experience please offer your opinion, as well.

My wife has two ( 2 ) surgical incisions from anterior and posterior spinal surgery to resect a large tumor mass. One of those surgical incisions ( ~ 11 inches in length ) runs directly down her lower spine. That same area was also irradiated. The surgeries were performed in May ' 04 and the radiation occurred during June ' 04. A large portion of that surgical incision, as well as the immediate surrounding area, that was exposed to radiation is inflammed and VERY sensitive and painful to this day. That area has become my wife's # 1 source of pain. ( BTW, her other surgical incision, located on her side, has healed just fine ) Her radiation oncologist, medical oncologist and neurosurgeon have absolutely no idea what's causing this persistent inflammation and pain. The area has been X-rayed and everything, including the instrumentation, looks fine. There's no evidence of infection but just to cover that base she was run thru two courses of antibiotic therapy with no improvement. The radiation oncologist says that he can't even blame the radiation at this point in time because, in his opinion, any radiation-induced inflammation would have subsided long ago. He can only say that something is causing a hypersensitivity of the nerve endings in that area BUT he has no clue as to what the cause is. He doubts that even high-dose Neurontin will cure the problem. He's never seen this before. Thanks in advance for your opinions on this very painful condition.

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Bill,

It may be the nerves with the radiation retarding the healing process. My surgery was in February of '03, the surgical site was not in the radiation field and the nerves still are not healed. According to my "team", nerves can take years to heal and still not be in the same form as they were before surgery.

It sure does sound like an infection (minus the fact that the antibiotic courses didn't do anything, nothing has been detected, etc.), my question is does ALL of her skin hurt or just the site around the incision scar? I have noticed that I have a cycle of ALL the skin of my body aching and hurting to the touch and then it's "better".

Also, is there a possibility that maybe the fine hairs on her back are now growing inside the incision? They wouldn't show as a "big thing", but could definitely cause some irritation (my mother cuts hair, when it embeds in a barefoot, it's sometimes really hard to find where the hair is sticking in).

I hope you find out what it is so it can be dealt with.

Becky

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Is it possible that between the surgery, the radiation, the cancer, the chemo, etc., that this is an area of Shingles that has flared? The reason I ask is that my Mom had a small incision on her back (4 inches long) and received radiation in that area as well. She developed shingles, but only in the area of the incision.

The other two things which come to mind are Cellulitis (I've known a number of people who had that, and it doesn't always respond to the first antibiotics prescribed, depending upon the organism causing the problem. I had Hosptial Aquired Pseudomonas in my thoracoscopy and mediastinoscopy incision for months before it was identified and properly treated), and Herpes. You don't have to be unclean to develop these things....you just have to have a compromised immune system, an opening for the infection to enter, and the bad luck to encounter the virus or germ.

No matter what the cause I certainly hope that someone can determine what it is, and more importantly how to make it go away.

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Hmmm, hard to say. When you say it is inflammed, do you mean the whole area looks red? Infection is always a possibility but if it has been going on this long it should have "declared" itself, either gotten better or worse. Is she on chemotherapy? You can get something called radiation recall when on chemo where an area that has previously been radiated will become red and painful just like it did at the end of radiation. Shingles would be very unlikely, it almost always involves a single nerve tract (dermatome) which would wrap around the opposite direction of what you are describing.

I guess the nerve injury theory is as good as anything (the default diagnosis you get from any doctor when there is unexplained pain :wink: ).

Joe

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Thanks to all for the helpful advice. If you look at my wife's back you can clearly see her radiation window or field. A rectangular area of slight discoloration that includes ~ 2/3 of that surgical incision and immediate surrounding area. The uppermost portion of that incision, ~ 3 inches , is ABOVE this radiation field. That portion of the incision looks fine and is causing my wife no problems. Very interesting. It's pretty clear to me that the radiation played a role in the development of this condition. The pain is severe to the point that she can't lay on her back and even clothing touching the area causes pain. To make matters worse, her apparent recent drug reaction ( which I posted about and suspect Aloxi ) has caused several skin related symptoms including an exacerbation of her inflammed incision. We are in wait and see mode on this apparent drug reaction. Chemo has been suspended. Aloxi is still thought to be the culprit but only time and the process of elimination will finally determine that. Thanks again.

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oncodoc

Is she on any other medications, especially seizure drugs like tegretol or dilantin?

Joe

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Vicodin ES, senna, Gemzar, carboplatin, Kytril or Aloxi, decadron, zometa and procrit. BTW, radiation recall sounds suspicious. Can you provide a bit more detail about this phenomenon ? Additionally, I tend to agree that some of these surgical incisions ( whether radiated or not ) may simply take much longer to heal than expected. This particular incision, directly over the backbone, is in a vulnerable location.

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Was the Gemzar given after the radiation? Radiation recall is a phenomenon where areas that have previously been exposed to radiation may become very inflammed and painful, typically becomes reddened right in the radiation field. It's usually seen when people who have had radiation are exposed to drugs that can sensitize the radiated tissues, usually chemotherapy. Has been seen in drugs like anti-seizure drugs too. Usually happens with really potent radiosensitizing chemo drugs. Adriamycin in breast cancer is classic. Gemzar is one of the most potent radiosensitizing drugs which is why its almost never used in combination with radiation and when it is, only at very reduced doses.

I have seen this only a couple of times, can be treated with steroids, sometimes just topical although systemic steroids are probably more effective.

Might ask your radiation doctor if this could be a possibility, I don't want to try to diagnose anything over the internet :)

Joe

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