Dr. Hilliard

Well, despite him calling twice and his assistant calling once to attempt to get me to cancel this appointment (yes, I know it's the afternoon of New Year's Eve and you want to go home early!), I'm really glad I talked with Dr. Hilliard.

First, he read me Dr. Bajaj's discogram results which were the following:

• L3/L4 = non-concordant pain correlation
• L4/L5 = partial pain concordance, moderate disc degeneration
• L5/S1 = pain concordance (~90%), severe disc degeneration

Therefore, according to Dr. Hilliard, it seems apparent that my pain is discogenic.


I asked numerous questions about my condition.

I asked if he could see the MRI images of my back and discs. He said that he couldn't but that it didn't really matter anyway since the images don't necessarily mean anything. The discogram test is subjective and is entirely dependent on the reaction of the patient. Repeating what I've heard previously, Hilliard said that there are people with terrible looking backs (discs) who experience no pain. And then there are people with healthy looking backs (discs) who are in excruciating pain.

I then asked him to look at the CAT scan results which were the following:

• L3/L4 = small fissure (Dallas classification 1-2)
• L4/L5 = fissure on right side (Dallas classification 1-2)
• L5/S1 = extensive annular fissure with broad disc protrusion (Dallas classification 3-4+)

Apparently the Dallas classification is a measure of the severity of the disc fissure or tear and indicates how wide or deep or extensive it is. I'm pretty sure that 1 is the least and 5 is the worst, so my L5/S1 is clearly in pretty bad shape.


I asked Hilliard about the various surgical and non-surgical procedures available to someone in my state. He repeated what I've heard about surgery -- recommending that it is preferable to avoid it, if at all possible (i.e.: if my pain is manageable). Once you have surgery, you cannot undo what has been done and go back to where you were before. And, most importantly, surgery is no guarantee of becoming pain-free. For disc replacement or fusion, the odds of improvement are around 50/50 (or less) with only 10% of patients obtaining complete pain relief.

I asked about IDET. Hilliard said it was preferable to surgery in that there is nothing to lose and much to gain. However, I may not be a good candidate for IDET because disc height should be at least 75% of normal, with a bare minimum of 50%. From looking at my MRI previously, I would say that my L5/S1 was easily less than 50% the height of a normal disc. I asked if there was an alternative procedure where they could somehow inflate or increase the disc space, and Hilliard said no.

This lack of disc height creates complications for disc replacement too, should I decide to go that route. Hilliard did not recommend the procedure in any case. But apparently they cannot go in there and "jack up" the vertebrae to insert the artificial disc. You are stuck with the disc spacing you have, so doctors might have to actually shave the bone to insert a replacement. Removing bone, of course, is not encouraged as it weakens the area and increases the risk of future problems. I asked about traction or inversion being able to stretch the disc space, and Hilliard said there we no studies which showed that to be effective.

I asked if I should be limiting my activities, and he said not necessarily. Apparently my back is what it is, and I can't really do any additional damage unless something really drastic were to occur. Therefore, there is no limit on my activities, including surfing, soccer, golf, mountain biking, etc. The key will be to know my limits and don't push myself too hard to where I am in really bad pain (and if I do, then take heavier medication, such as flexiril, etc.)

In the end, that is precisely what Hilliard was recommending -- make sure I am adequately managing my pain through medication and limiting physical activity. I asked if there were any drawbacks to taking my medications over the long-term. He said that the tramadol and gabapentin were very safe (although the tramadol could react with antidepressants and antibiotics). The ibuprofen is more problematic as it can be hard on the stomach and the liver. He said to make sure to take the ibuprofen with food and to moderate my alcohol intake (1 drink per day and no heavy drinking). So, no problems with all that.

I asked what I could be doing to make things better. He said I should try to "remain strong" and I think he probably meant both physically and emotionally. He said to maintain body weight (don't get fat) and try to increase my core strength including lower back and abdominal muscles. He specifically recommended pelvic stabilization, resistance training, etc.

I asked Dr. Hilliard if he could recommend a lower back specialist in the area, and he gave me some names:

• Michael Smith (Mission Valley Pain Center)
• Michael Huntley
• _____ Todah (Alvarado Medical Center)
• Michael Verdolin

I will attempt to contact these guys next week when I'm on my new insurance. In the meantime, I need to find out if they are covered under the Blue Cross PPO plan.


That's all for now.