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How to manage pain better overnight

Post L4/5/S1 PLIF 16th Feb, I am having great difficulty finding a balance on my medication. I have been prescribed 4*100 mg Tramadol and 4* 1g Paracetamol daily, although my surgeon suggested I look to reduce my Tramadol over the next couple of weeks. During the day I am finding things ok, I am able to sit up for an hour at a time, am walking between 2-3 miles once or twice a day, and feel small improvements daily. However, my problems come at night, where my sleep is disturbed most nights due to excruciating pain on waking up within about 4 hours of getting to sleep. The pain feels mainly sciatic in nature, running from my lower back through my right leg to my toes. It takes around half an hour to get under control on taking my medication, irrespective of whether I take Tramadol or Paracetamol.

I have been trying various medication patterns over the last week, trying to eek out my Tramadol to reduce down to three times per day, but just can't find a way to aid sleeping / pain upon waking. Has anyone got any suggestions? I was thinking perhaps I should switch my last Tramadol to a slow release one perhaps?


  • Nick,

    I had issues sleeping after my fusion as well. As you know finding balance in medication levels / types is key. I found the magic combination was to add an anti-inflammatory, and sleep aid into my medications. Managing pain is something that we need a good doctor for.

    I am not a doctor, nor do I want to tell you what do to, but your medications seem very weak for this type of operation. I'm amazed you are not screaming in pain all day. The medications you are on are for treating minor pain, and you just had major surgery.

    I understand your doctor does not want to keep you heavily medicated, nor do you want to probably take a lot, however, I would highly recommend you make your doctor treat your pain, so you don't suffer. I was on much stronger medications for 3 months after my surgery. You are on basically nothing, and it's been a month.

    That can surely be your problem. Take care, and good luck.
    Left foramina stenosis of L3/L4 (retrolisthesis)
    L2-ilaic revision fusion ( loose screws) with a laminectomy at L3 (cage at L3-L4)
    (PLIF) -@ L4/ L/5 - S1 (cage at L4/L5)
  • I thought I was on some serious drugs already so was a bit taken aback when I first read your comment, but perhaps you are right, I will certainly discuss with my surgeon in a couple of weeks, and also may be seeing my own GP inbetween
  • dilaurodilauro ConnecticutPosts: 9,842
    Nick, finding that right balance boils down to a lot of trial and error working with your doctor. Light many others, night time seems the worst part of the day. That is why you will read about so many people having sleep problems.

    For a while, I was taking over 3/4 of my daily dosage of pain medication between 8:00pm and 3:00am. Those were the times, I just couldn't get things under control. With the worst time after I went to bed. After trying a few combinations of
    medications, my doctor decided to put me on Nortriptyline 30mg before bedtime. This drug is in the tricyclic antidepressant family, but is always frequently used to help with chronic pain.

    Now that I am taking Nortriptline, I am waking up less and generally do not need any pain medications after I go to bed.

    No two people are alike, so, you should talk this over with your doctor to see if they can come up with other suggestions in terms of medications.

    Take a look at these Spine-Health articles SLEEP
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • Nick_MurphyNNick_Murphy Posts: 171
    edited 03/17/2013 - 4:15 AM
    I will definitely take it up with him, and will look further into things, thanks
  • I'm not a doctor but sounds like you are suffering from some nerve issues with your symptoms. More than any other night time meds, my neurotin has helped me the most. It takes a long time to work, but it has really helped. I'd suggest calling the surgical nurse and describing in detail your pain to see if a nerve medication might not be right for you. And I do agree, you have had some pretty major surgery there and you need to find better pain relief so you can heal. Good luck.
    33yo mom of two. My surgical history...preadolescence scoliosis, kyphosis, and a hot mess.... 5 spine surgeries and lots of items added I wasn't born with (titanium, peek, surgical steel). Guess cremation is out. TSA loves me.
  • Thanks for your advice too, I think if I wake tomorrow and suffer the same, I will be in touch with my surgeon's assistant. Thank you all for your advice, sometimes I get so focused on wanting to feel better and see an improvement, it feels like weakness in admitting the pain is there and increasing
  • I had my 2 nd Hydrotherapy session today and asked my physio to check as my right hand scar was swollen and is where the pain starts from. She confirmed it appears to be soft tissue and not indicative of shifting hardware, and has suggested that perhaps my early morning sciatic pains are in fact due to having a firm bed mattress, suggesting I try a mattress topper that will allow me to sleep on my side yet provide better support to my body. Wondered if anyone else has found sleeping problematic and had to change their bed arrangements?

    I have also emailed my surgeon's assistant who has passed on my question to my surgeon regarding medication, will update in due course, can't wait to get 8 hours uninterrupted sleep at some point :-)
  • I know lots of people swear by firm mattresses, but I have to have a super soft mattress. Our current mattress is about as soft as any I've come across (it isn't a sleep number, I'm sure you could make those softer), and I have a very difficult time sleeping on anything other than my bed. Let us know what the doc says.
    33yo mom of two. My surgical history...preadolescence scoliosis, kyphosis, and a hot mess.... 5 spine surgeries and lots of items added I wasn't born with (titanium, peek, surgical steel). Guess cremation is out. TSA loves me.
  • edited 03/18/2013 - 4:44 PM
    After my fusion, which happened to be my 5th back surgery:(, it took me 6 months before I could sleep through the night. I found my biggest relief in the form of a body pillow that I would hug lying on my side and between my knees. I really felt like it aligned my spine better. It made a huge difference for me.
    ALWAYS consult your health care provider before starting or stopping any form of treatment. Oh yeah, and you can't go wrong with a monkey.
  • Afraid still no progress. Have a new memory foam mattress topper which went on last night and it did feel strange but made no major difference. Having tried various combinations, it appears right now that my symptoms are that as soon as I make my first movement to getting up, ie getting out of bed, within 10 minutes of standing (shower, brushing teeth, whatever) I begin to experience sciatic pain which becomes increasingly more painful. This morning I took my Tramadol 45 minutes before getting out of bed in the hope it would have time to settle things, but again within 10 minutes the pain begun and within 45 minutes I was laid out on the sofa in excruciating pain, with my wife standing over me at a loss what to do. It took between 30 and 45 minutes for the pain to settle, and am now feeling relatively comfortable and hopeful that it won't return today. I have hydrotherapy again this afternoon, so will question my therapist again, but as of now I am still waiting to hear back from my surgeon!

    It almost feels as if my sciatic pain emanates from the fact that overnight whilst sleeping the pixies in my back have shortened my sciatic nerve, and upon getting up I am trying to stretch it out in order to move about and it is complaining! Although I experienced sciatic pain pre op, it was more so emanating from pressure building when walking, so this is very much the same pain but the circumstances are very different.
  • I just had surgery 3/13 Alif L4L5S1 doulble fusion and i was on 4 tramadol a day before the surgery. I talked to my surgeon before surgery and told him i want a strong drug to kill my pain ater surgery.I have a high tolarance to meds so he put me on morphine and tylanol every 3 hrs. I tried to strech it to 4 hrs but the pain was unbearable!!!I have to have my husband wake me up every 3 hrs or its bad.I think you should talk to your dr. Your only a mth out.You shouldnt have to suffer.We are our own advicits!!!Good luck Kathy
    Kathy B
  • Nick,

    It sounds to me like the swelling, and healing tissue is causing the sciatica. I had the same problem. I found that icing the incision site works wonders. For a good 2 months after my surgery I was convinced there was a problem, but it turned out to be internal swelling and muscle reattachment that was the cause.

    Again, I also reiterate, you need your meds adjusted. I was on a similar 2 medications, and had to go to the ER, and then a pain management doctor to really get control of my pain.

    If you can't sleep, or barely move sometimes, you really do need much stronger medications.

    Good luck - Eric
    Left foramina stenosis of L3/L4 (retrolisthesis)
    L2-ilaic revision fusion ( loose screws) with a laminectomy at L3 (cage at L3-L4)
    (PLIF) -@ L4/ L/5 - S1 (cage at L4/L5)
  • Appreciate your feedback. I spoke with my surgeon late Thursday evening, and he felt its likely my muscles first thing in the mining are not up to holding me entirely, and hence why after being upright for 10-15 minutes I end up in sciatic hell. He has suggested I try to slow down my getting up in the morning, and not try and be up and at 'em straight away. I am finding the pain during the day totally manageable, it's just this morning time issue. He said to give it some more time but if necessary he is happy to meet up and/ or change my meds ahead of my 6 week post op check up. The last 2 mornings have been much more sedate, and it has improved things, so perhaps I am just trying too hard to get back to normal. It scares me a little that I am already over a third of the way through the 12 week recovery and could be facing a return to work in around 7 weeks time! Will see how the next few days go and take it from there. Thanks everyone for your comments, much appreciated, Nick
  • I'm 7 weeks post op this morning, wow doesn't time fly when you are having fun!

    I saw my surgeon yesterday, and whilst I had reservations going into the appointment, he was overjoyed with my progress. Had some new X-rays taken for him to review, and he said he couldn't be more pleased, everything looks perfect and there has been no movement. I explained I am still suffering most with my morning pains, regardless of what time the pain is at its worse 20 minutes after getting out of bed, and takes 45 mins to an hour to settle enough to start moving, or at least lay here without spasms / pain. He said I have to take into account the severity of my operation, the fact that it was complicated by the remedial work to revise my prior surgery, and that I perhaps have had too higher expectations for a speedy recovery.

    He has prescribed me Pregabalin (Lyrica) to be taken at night, and said it will take a week or so to kick in but hopes it will help settle the nerves to stop these morning pains. He was very happy with my walking abilities, wants me to continue my Physio and when I questioned him about future golf possibilities, his response was "why not try it now, go on, it will be fine" - I will NOT be taking this up right now, there is no way I could contemplate even a modest swing for chipping in my present state, but was reassured that golf should not be off my radar and I am free to try it as and when I feel comfortable.

    I raised my concern that his predication of a return to work 12 weeks after the operation was not possible given we are at week 7 now, and he said not to loose faith and if it takes 3 or 4 weeks longer, so be it, but in his mind he thinks its closer to 12 weeks than 24!
  • I cant believe your dr is telling you you can play golf already. I had ALIF L4L5S1 surgery march 13 and I am still in a lot of pain.I just had my dr refill my 4 mil morphine because that's all that works.I also take Gabapentin for nerve pain in my legs. Like you my pain gets bad at night ,but last night I finally slept good. Did you start PT YET? Im wondering when my dr will start me.Take it slow and let it heal. Much luck and hope you are pain free today kathy
    Kathy B
  • I think he was just emphasising that its in my future and when I am ready I can give it a try, or perhaps he was trying to brighten me up as when I went in he could see from my face I was concerned. Either way, I shall not be picking up a club yet, but it's nice to think about it down the line :-)

    I started PT week 3, and attend twice weekly. It's only Hydrotherapy at the moment, but it's amazing the things you can do in the pool with no weight to impede you. I actually don't think my pain is at night now as I can get a reasonable sleep of about 5 hours uninterrupted, maybe 8 hours with only 1 or 2 interruptions for medication. My real issue is on getting out of bed, when the real pain kicks in, and it's this that I am hopeful of getting under control with the Pregabalin, although I have to wait for Monday to get as I went to collect 14 tablets today from a local pharmacy and was told it would be around £100 as its a private prescription, so will get my GP to write a regular prescription instead!

    Hope you continue to improve, all the very best, Nick
  • Thought I should post an update to the above. I have been taking my Pregabalin for the last 4 nights, and have seen a marked improvement within 48 hours to the point that I can now get up each morning, get myself ready, and not be in intense pain as previous. The last 2 days I have been able o get up, get ready and go straight to the golf course - obviously not to play but to walk holes with my friends and take in the fresh air whilst exercising :-) managed 9 holes today, measured as just over 6 km on my GPS tracker.

    I hope everyone is doing good, fingers crossed my pain is becoming more controllable, Nick
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