“The word degeneration is very scary for me”

[Farisshd]

For this post I am discussing a lumbosacral pain patient I have been treating for a few weeks. She has been a bit atypical in her presentation, with some inconsistent responses, so finding the right approach with her was initially a bit more challenging. She originally presented with a high level of irritability and in severe pain, and unable to find a comfortable position at all, with lancinating pain in her L glute and posterolateral thigh that would peripheralize with minimal provocation.
Over the past few visits, we had established a clear trusting relationship and had begun to see progress, with centralization of pain and decreased frequency and severity of symptoms. The patient arrived with her imaging results from an x-ray that she had been reviewing with her pain management doctor. She had her doctor write the findings on it that they discussed so she could ask me about it. She arrived with them in her hand and immediately expressed concern and said she wanted to discuss the results from her x-ray, stating she wasn’t doing good.

Here is what her doctor wrote:
1- Anterolisthesis at L4-L5
2- Advanced degeneration and facet arthropathy at multiple levels
3- Mild levoscoliosis at L2

Naturally she had questions like “what does this mean”, “does degeneration mean it will keep getting worse?”, and “If it’s degenerating, can it ever improve?”.

This was the perfect opportunity to educate my patient on the frequency of many of these findings in the pain free population, and to also explain how the symptoms do and do not correlate with the report. She asked for me to show her what was going on in her body using a spine model, and of course the model in the clinic had the scary red bulging disc on it, which I was careful to disregard.

Knowing her level of anxiety regarding her situation in the first place, and the severity of her symptoms, I was careful to preface the conversation with an explanation that all of us have “degenerative changes” and that they are better understood as normal age related change. I offered her some loose statistics regarding increasing frequency of disc degeneration and even anterolisthesis (though I didn’t have the specific frequencies memorized) in different age groups, explained that I myself have multiple findings that sound similar on my imaging, and then went into a quick explanation of nerve tracks, the area of her spine involved, and how we are able to move and reposition and gap these structures to decrease symptoms. I explained that while she had several positive findings on her imaging that correlate with the pain, that they were likely there far before she began experiencing pain, and that we are working to decrease the level of irritation and improve her movement patterns and core strength in order to prevent further exacerbation. In the end, she was relieved and expressed understanding and a more positive outlook.

It was clear that this was a very big concern for my patient, and that she had a lot of trust in me as a provider to interpret and explain the findings, and to act to continue progressing her care. I felt that the overall conversation went very well. I did not have the stats perfectly memorized, but I was able to effectively get the point across. The patient was clearly relieved and satisfied with the explanation, and expressed less worry over the findings. I have had some similar conversations in the past, but in this circumstance I felt challenged to avoid worrying the patient further, and to clearly articulate my points without facilitating further rumination. In the future I will likely draw on this encounter, as I feel it went well, and was instrumental in diffusing the anxiety my patient had built up since seeing the other provider.

I would like to have more confidence in knowing the prevalence of each finding, and will be reviewing my materials in hopes of being better armed in the future for the next time I have this conversation.

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