Alternatives?

Davide and I spent hours and hours, days in a row, searching for anything that would reduce my TMJ pain, an alternative to the excessive use of drugs. An alternative that could give us back a little of our life prior to the arthrocentesis - no pain, no medication side-effects, no frustrations. And especially, an alternative that would allow me to follow my dream (the IODP scientific cruise in Japan) and grab the opportunities that I had been offered recently (summer internship in Norway). We found a chiropractic clinic close to where we live, offering acute and chronic pain relief through the use of neurostimulation technology (InterX therapy). We arranged an appointment for the following week (January 31st, 2012), hoping the chiropractor B. M. would be able to help me.

Usually in B. M.'s clinic, the initial consultation and examination (including X-rays) is one hour long, followed by a second appointment where the findings are reported, and a treatment plan is proposed. However, my initial consultation took almost two hours, and I still had to go back to the clinic on the following day for more physical examinations and X-rays. I was not the first patient with TMJ disorder that B. M. had seen, but I was definitely his worst case.

In chiropractic, there are three categories (I, II and III) of patients, classified according to the type of breakdown occurred to body, caused by interference to the nervous system and health deterioration. I was classified as a category II patient, having significant spine imbalance and misalignement as a result of stresses in the sacroiliac joints (pelvis and sacrum joints). The sacrum is located at the base of the spine, constituted by five fused vertebrae (vertebrae which are not separated by intervertebral discs). However, I was born with an extra disc - the top vertebra of my sacrum is not fused to the one below, having a disc in between. This abnormality combined with an excessive lumbar curvature, positions my sacrum almost horizontally, instead of the normal quasi-vertical position. As a result, my sacroiliac joints are unstable. My body tries to compensate the balance disruption of these weight-bearing joints by distortion of the shoulders and neck, which leads to instability of the joints above - my TMJs.

In chiropractics it is well established that the sacroiliac joint has a reciprocal relationship with the TMJs; in other words, TMJ equilibrium relies on the stability of the sacroiliac joint. So it is quite common that category II patients develop TMJ disorders. Having an abnormal sacrum, it is clear that I always had TMJ disorder predisposition, in agreement to what my first surgeon said back in 2005. The door accident just made me develop symptoms earlier.

B. M. proposed a treatment plan, mainly based on pelvis stabilisation and neck and shoulders alignment. He would not manipulate my lower jaw in any way, as it could cause further damage to my right TMJ. We had to wait for the results of my latest MRI scan to know the condition of my right TMJ, to be sure that it would be safe to work on it. Fortunately, the oral-maxillofacial surgery consultation with Mr. C. would be on the following day (February 3rd 2012).

As for my severe and now considered chronic pain, after a few treatment sessions B. M. would try to reduce it with InterX therapy, but he couldn't assure any improvements. All was dependent on how damaged my TMJ was.

Finally the day had come. Finally I would know the status of my right TMJ, what was causing all this pain and suffer. Finally I would have an answer. And hopefully a solution.

Davide and I entered the consultation room, both with our hearts in our throats. As I was seating, I noticed that my MRI scan report was open on the computer screen. We were alone waiting for Mr. C.. We looked at each other, took a deep breath together, and together we started reading the report.

I started breathing again only when we finished reading. As I turned to look at Davide, Mr. C.'s  assistant surgeon - Mr. A. - came in. I had met him before, as he was present during my arthrocentesis. He kindly greeted us and sat to examine the report, while we were assimilating what we had just read.

Anterior disc displacement without reduction. Anterior disc displacement withOUT reduction.

Now it was confirmed - with the arthrocentesis the disc (yellow in the image below) had been forced to be permanently positioned in front of the condyle (grey in the image below), acting like a barrier for condyle translation, preventing full mouth opening. Regarding bone structures, the condyle was described as flattened and as damaged as in the previous scan; no significant alterations since then, but in a pretty bad shape nevertheless.

Anterior disc displacement without reduction 

(source Kelley's Textbook of Rheumatology)

"So what can be done?" I asked. M. A. said that most likely Mr. C. would propose another surgery to correct bone structure, bringing the disc back to its original position. But we had to wait a little bit until Mr. C. was available to come and speak to us. "Meanwhile tell me Ana, how are you? How is your pain?" I complained and complained. I told him all the drugs I had been taking and all the nasty side effects I had to live with. I explained my eating frustrations - the inability to chew, my beyond-boring soft/liquid diet, much more effective than any other for weight loss. In February 2012, I had lost 17kg  (2.68 stones/37.5 pounds) since the arthrocentesis (six months before). And then he spoke.

"You can't be living like this. You have to stop taking co-codamol and the anti-inflammatory now! I don't understand how your GP (general practitioner) prescribed you naproxen knowing how much you've been suffering from your stomach! And the paracetamol present in the co-codamol is poisoning your liver - you have been taking it for far too long! There are other drugs that are far more effective for pain relief and have less side effects associated. Why haven't you been given these before? Oh well... GPs can be pretty useless..."

Finally someone with some sense. Finally. I felt like crying. Mr. C. came in and Mr. A. told him everything regarding the scan and my situation.

Mr. C. explained to us that the best way to help me was through another surgery, this time exposing the TMJ. During this procedure, he will remove/shave a small amount of bone in order to create more space inside my right TMJ, so that the disc may return to its original position. He clarified that the main goal of this surgery is to correct bone structure and not to reposition the disc - the disc may be able to be repositioned on its own, just by creating extra space inside the joint. In this way, he won't be compromising the joint and nerves so much. However, if he can have access to the disc, he will try to put it back to its proper place. He included me on his waiting list of surgeries with some urgency, which meant the waiting time would be some months instead of more than a year.

I accepted his surgery proposal. All in all, it was still the best and fastest solution. I only asked if there would be anything that he could do meanwhile to reduce my pain. Davide and I found in our researches that botox injections could be helpful, as these numb the muscles and nerves temporarily. However, he asked "Ana, where is your pain?" The entire right side of my head, my neck, my right shoulder and back... "That would require a lot of botox, don't you think? I'm sorry but botox injections are not for your case. Botox injections are good for TMJ disorders associated with muscle overactivity. Your case is much more complex. I can only offer you a surgery." What about pain management, physiotherapy? "Physiotherapy won't help, I'm afraid. Pain medication is the best way for you to cope with it. I will leave you with Mr. A. and he will arrange it for you." And then he left.

For the pain, Mr. A. prescribed me tramadol in 50mg capsules. I take two capsules (100mg) every four hours, up to a maximum of eight per day. Like other pain drugs, tramadol also causes constipation, so I still have to take laxatives. Tramadol has many other side effects, including nausea, sickness and vomiting. These affect me the most, so to prevent them and to protect my stomach, I also take an anti-acid/proton pump inhibitor (30mg lansoprazole) and anti-sickness pills (50mg cyclizine hydrochloride) every morning and whenever I start to feel sick. The other side effects that I have are: difficulty passing urine, tiredness and weakness, low energy, loss of apetite, sweating, sleep disorders and nightmares.

I feel tramadol helps me much more than co-codamol did - 100mg tramadol is more effective than 60mg codeine/1000mg paracetamol. However, in bad days of pain (which are becoming more and more frequent) I have to take three capsules in one go. Even so, I may feel some degree of pain, although tolerable.

Although there was a solution planned for my current TMJ disorder, it was still several months away. We still had to find a way to reduce my pain and drug intake, if I was to get onboard the IODP scientific cruise in the beginning of April. My hopes were now entirely on the hands of B. M., my chiropractor.

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Note to my readers: My apologies for the long time gap between some of the posts. But please understand that I put a lot of effort into writing and editing each post published here. It is quite demanding for my current health condition, and that is the reason why it may require a bit more time for a post to be finished. Thank you for reading :)