Monday, November 15, 2010

PT, and the Future

I started PT, and it seems largely uneventful. I stretch and move in all sorts of ways, and it is painless. I started running again, though slowly. A 10 minute mile should be reachable in the near future. While I did have a fusion I don't have disc disease in the rest of my back, so I should hopefully not have any reasons not to run. According to the docs I can do pretty much anything at this point as long as I have good body mechanics and don't do anything too stupid and traumatic. So no snowboarding or hockey for this season but most anything else is fair game. Everything else after the 1 year point if x-rays continue to be fine. Next one is in march.

My days are now almost completely pain free. I can hardly feel the hardware at all now--once it fuses it stops moving and you stop feeling it. If I lay on a hard floor I can feel it, but even that is dissipating as the swelling disappears. The scars are largely fading. There is some residual (maybe 1 or 2/10) on the worst days--mostly related to muscle fatigue from not being used to being upright. However this likely is not very different then those who never had surgery. Other than that there is no leg pain, no aches or twinges. I really did not expect it to be this good, though I did hope!

I will update this blog if anything changes, and will keep it alive so that others can see a "happy ending" to a back surgery instead of only the horror stories so plentiful online. (Not to say they are not justified).

If you want to know where I ended up going you can contact me through the blog, however the biggest piece of advice I can give is do all of your OWN research, don't listen to what just one doc has to say. Like anything else in life their professional opinion is still just that--an opinion. Also while there are many great community hospitals, a major surgery will usually have a better outcome in a bigger city hospital that does hundreds of these per year versus a small handful. Not always, but I would recommend getting opinions at both if you can afford it. Don't buy into any new wonderful technology if it is unproven. There are just as many snake oil salesmen in healthcare as there are everywhere else.

So for those who have yet to travel this road--I wish you luck. With each passing year the technology and outcomes on these procedures are only getting better, and I hope that soon it will be as routine as some others. For me, while I won't go so far as to say this journey was a "lost" 18 months, because I did so much despite the pain, I will admit I am quite glad and incredibly grateful that this painful chapter is over.

Sunday, October 31, 2010

It is fusing!

Radiographic evidence of fusion is there, the PT starts next week.

Monday, October 18, 2010

3 months, Already?

Yes, 3 months! The big milestone for spinal fusion!

I am now back at work, and would you believe it back to almost a fully normal existence. I can bend and lift, but do sparingly until cleared with an x-ray (in a week or so).

Why is this possible so soon? It is because of the surgical approach and age, but also largely due to allograft use.

Sometime about a month ago, all of a sudden I noticed a change. When taking a misstep (i.e. stepping in a pothole during my walk) I no longer felt the twinge of pain. When getting in and out of a car, bed, chair; I felt like I could actually move my lower back without that familiar feeling of things being pulled and moved. It felt like it was solid again. Now it wasn't completely perfect, but it was a drastic change for the better. I gave it a couple of weeks to make sure it was going to stay that way, and then filed to go back to work.

I am going to guess that that is when it fused, but I will hold off that judgment until I have radiographic proof. Otherwise I feel great. I did one of my usual shifts last week--46 hours upright in two days with 6 hours of sleep in between--and I was much better than before surgery. There was still some back pain as the days wore on, maybe a 2/10, however I think most people would have some by hour 20 surgery or not. Before surgery I was at a 6-7 and hardly able to think by then. Legs feel great, no weakness or tingling, but definitely fatigued. Hamstrings still are playing a role in the limited endurance, but I am almost back to a pre-op level of flexibility there, about 45 degrees. Since those stretches can be done without a solid fusion I have been doing them regularly and that is the result.

One thing I want to highlight here is the allograft. What is allograft? It is a piece of donated tissue (in this case, bone) from a deceased donor. Doctors will refer to this as bone from a bone bank, DBM (deminirelized bone matrix), and many other terms that fail to convey exactly what it is, but it is essentially a small 3/4" thick section of someone's femur, processed and sterilized with a hole in the middle to put the BMP sponge in. It is serrated at the top and bottom so it stays in, and once your own bone grows down the middle it will eventually be absorbed and replaced by your own bone.

Typical bone graft for spinal fusion
In the old days the way to go was to use a piece of your crushed up pelvis with other substances to fill that void the disk used to take up, and while great for fusion, it made it take significantly longer to become solid since the mush has no structural value. You can try to get around that with various metal implants, but they never last long and tend to work loose or cause other issues. Using the allograft gives structural support (the femur crush strength is significantly stronger than your own vertebrae), helps the long term outcome since there is nothing to work loose, and reduced the 6 months of instability and significant pain, to just three weeks of pain and two months of being limited. Combined with using BMP it is the reason I am back at work and having this high of a quality of life so soon. To the family who agreed to donate, and all families that do so--thanks.

I will update this again once I have the x-ray results, but I continue to stay optimistic.

Friday, August 13, 2010

4 week update

So here we are, a month just about after this journey of mine began.

I wanted to start this blog from the beginning for a reason: honest and unbiased feedback. As many of us know the majority of those who choose to be vocal are so because they are unhappy--which leads to many more negative experiences than positive around the web. This is especially true about back surgery since a happy customer rarely takes the time to tell since they are back living their lives, while those scarred by it have a lifetime of misery and pain to share with the world. So in this spirit I started this blog from the point where I knew I would likely be going under the knife and not from some point more distant in the future where I would come in with a bias. Hopefully I will join those in the former and not the latter as the years roll through.

So at 4 weeks, if I was asked "Would I do it" the answer would be a resounding YES. Would I go posterior approach? NO! The ALIF/PLIF combined fusion is the gold standard for a reason: Highest chance of success, and most durable fusion for those wanting to return to an active life, along with the most muscle sparing. Yes there are more initial risks, but if you ask me that was the best decision I made in recent years.

As for where I am in my recovery, it seems that I am an exception rather than the norm when it comes to this, because at 4 weeks out I think I am actually better already then before the surgery. I have not taken a single narcotic in nearly 3 weeks (only acetaminophen now), walk between 2-4 miles/day, and have less back pain then before the surgery. The crippling hip pain is gone entirely, all there is now is some residual soreness in the left leg, but in the last three weeks it has gone from horrible to mildly nagging. Hopefully in the next month or two it will dissipate entirely. The biggest problem now is just the back brace and flexibility. As my endurance continues to improve I hope to be back to work before the 3 months are up. As it turns out the last year of being sedentary and hardly walking really took a toll on my legs and feet--my body is not used to being upright. Considering the changes to anatomy from the reduction as well as the pelvic angle its taking me a good bit of time to get used to walking and standing again, but it continues to improve slowly but steadily. The biggest thing this surgery has done is give me hope--the idea that I can again one day again go hiking in the Rockies or Sierras is something to look forward to if it comes true.

On the subject of narcotics--I'm glad I stopped them when I did. While everyone is different in their tolerance for pain, after the first few days of agony the leg pain started to subside as my threshold and sensitivity figured itself back out. I really think 75% of the pain when I stopped the oxycodone was from the withdrawl and had little to do with the back surgery. The heightened pain sensitivity when stopping can be a hurdle, but now I can drive, go places, and get back to work much sooner since I won't have that hanging over my head. With only a PLIF or without instrumentation this might not be possible due to the additional trauma, or the instability, but since there's nothing moving the only pain I should have is incisional or inflammation, and that should go away within a week or two or something is wrong.

So that is it for now, hopefully all will continue as it has been, and by this time next month I will be getting ready to go back to work a couple of weeks earlier than expected.

Wednesday, August 4, 2010

Preparing for Spine Surgery

Before embarking on this journey I had spent a great deal of time learning as to what is the best way to prepare for spine surgery, spondy or not. I should be more specific and point out that this is in regards to fusion surgery, where prolonged immobilization is required. Some of these are from my own experiences, while some are from when I worked with post-op patients and seeing their struggles.

While I did not implement all of these, I did many, and it has helped greatly so far (while others I wish I did). The following is a list that I will continue to update as I learn from this experience, and in no specific order. Please also note that this is based and specific for MY experience, and should not be misconstrued as medical advice or the like; consult your doctor for what YOU should do for YOUR procedure.

  1. Strengthen core muscles in the abs and back. They will atrophy during the brace wearing, but having a good set to start with along with good motion will help. Sit ups, pelvic tilts, leg lifts....if you're in PT for spondy you are already doing them most likely.
  2. Leg exercises and stretches. Squats: You will not be able to bend for 3-6 months. Being able to do a full squat repeatedly will allow you to pick up objects and remain functional. Hamstrings: They will be much tighter when you get fixed if its spondy. Having additional room will help big time with walking and sleeping/laying flat.
  3. Lose weight. My favorite is Atkins, with no artificial sweetners. I dropped almost 40 lbs in the 3-4 months prior to surgery. This makes those squats much easier, reduces scarring, lessens the chance of infection, dehissance, less load on new surgical hardware, less chance of complications during and after surgery. This will also give you room to "grow" as you are sedentary for a good while afterwards. However, the week before surgery, eat some good nutritious meals to have plenty of reserves, don't be in a losing mode that final week leading up to it.
  4. Lose the narcotics if you can, or at least cut down. Yes your resistance will build back up fairly quickly once you get back to the hospital, but it will make the immediate post-op experience much less painful. This varies with everyone based on how much you are taking.
  5. Have help. Make sure to have a phone on you at all times. Walking is the immediate treatment, if you don't have a treadmill, have the name of a local cab company or a friend programmed in in case you walked too far. Laps around blocks are good, but quite boring.
  6. Plan to sleep in a recliner and not a bed. It helps spread the weight away from the back incision, and keeps you in a position where the ligaments/tendons in your legs are not as stretched out (reduction will do so greatly). Find a good one and sleep in it a few times before surgery so you know for sure you have a good one. A reclining couch is best so you can shift between laying flat and reclined.
  7. Stock up on Tylenol (acetaminophen), benadryl (diphenhydramine), and ask for a benzo if you're prone to spasm. One of the issues (especially for me) is back spasm, and being immobile along with the inflammation it can be a miserable experience. Valium will help keep them at bay, and also give you some better sleep, not to mention will be beneficial when you're ready to come off the narcotics if you've been on them for a long time. Talk to your doc about it, every case is different and serious withdrawal requires an inpatient hospital stay. Be very careful mixing opiates and benzos--it can lead to respiratory arrest very quickly. The Benadryl will help you sleep when you're down to just nagging pains like I have now. Its very mild--but constant. Making it quite hard to sleep. Tylenol PM is a good mix of the two, but remember, no more than 4 grams/day of Tylenol (including that which is in your percocet) or you'll need a liver transplant.
  8. If you drink, STOP a few weeks ahead of time. This way your body can replenish lost minerals/vitamins that alcohol causes you to lose, and if you are a heavy drinker you won't find yoruself in DTs while inpatient. This happens much more often than people think and is a huge cause of lengthy inpatient stays. Do not drink until fusion is confirmed.
  9. If you're having a fusion and you're going to smoke (cigarettes, cigars, marijuana, chew/snuff), don't even bother going in for the surgery. The odds are good the graft won't take. The biggest contributor to pseudoarthrtis (non fusion) is smoking. It stops the cells that grow bone from "turning on", and you are left with an unfused back for the rest of your life. Quit. There are some great new meds out there that have been quite effective. And yes California residents, marijuana has the same effects as cigarettes on impairing bone regrowth.
  10. Don't take Advil, Motrin, Aleve, or ANY NSAID. Check with your doctor. Common ones are Naproxen and Ibuprofen, Aspirin in high doses also will significantly impair bone regrowth. 81mg childrens aspirin post-op is fine though, since at that dose it only thins the blood and prevents clots, but does not impair bone growth.

Tuesday, August 3, 2010

Drugs are Bad

When I first saw the orthopedist, despite the pain they did not want to prescribe any narcotics. I understand why and I did not want nor ask for them. Having worked in a facility catering to many opiate addicts I have seen a good deal of back pain sufferers to know better. So I stuck with it until I received the cortisol shot. After it wore off at only two weeks, and I saw the orthopedist again at the 4 week followup, then he recommended Ultram (Tramadol). Supposedly so weak its not even considered a narcotic. I remember taking it after my shoulder surgery 10 years ago and knew I was ok with it (I took for 2 weeks then). The choice then is either to medicate until surgery or go out of work early since I could hardly stand it any more due to the hip/leg pain. So I took the pills for the short term.

Tramadol is considered so weak that in many countries it is not considered prescription--you can get it next to Tylenol on the shelf. The potential for abuse is low according to the literature, and dependence did not seem to be an issue in my brief search online prior to filling the script. Taking it I can't say it took away the pain, but it did make it just bearable enough so I could function until surgery when combining with some ibuprofen. This was in March. I figured surgery was going to be in a month or so, but the doc did not want to do it until July. Followup in May revealed some details that made me seek a second opinion, however getting in took a month. Then it was another 6 weeks to surgery. By then I had been on the Tramadol for nearly 3 months or so, on a regular basis. I In my pre-op testing, I inquired whether I should detox myself from it or not, and they said why put yourself in pain for 3 weeks unnecessarily.

As you might have read in my posts below, when I awoke from surgery they had no idea why I barely responded from narcotics. They looked at me like I was hiding an opiate problem from them--and I would have done the same given the amount of oxycodone it took to get the pain under control. I was asked more than once, that I should be upfront about everything I was taking since that's what determines what I need--I told them, "Advil and Ultram, 200-300/day on average" (400/day is max dose, gave me relief from a 8 to a 5 or 6 maybe.) Strange, I thought.

Fast forward to a week after surgery. I'm trying to cut my dose of narcotics down. First 30mg oxycodone every 4, down to 15 every 4, down to 15 every 6, then 8. In that first week I was able to walk miles, no leg pain some back pain, overall controlled well enough so I could recover and do my walking. But as I tapered to the 8 hour window after hour 6 the leg pain became atrocious, and I started shivering and profusely sweating. Mentally I was all over the place. What the hell...I was incredibly worried, did the surgery go bad, did the nerves get messed up or a screw went through one? The pain in the left leg was horrendous, far worse than before surgery. Christ, I thought, I go to one of the best surgeons in the country and this is what happens...So I stopped tapering for a day, got the pain under control, and hit the internet. Not an hour later it all clicked.

First off, lets discuss Ultram (Tramadol). Is it a narcotic? YES! It is an opiate agonist. Done. Narcotic. Why is it considered weak? In your body and brain there are several receptors that opiate agonists affect. Lets say 1, 2, and 3. 1 is the pleasure center that gives you that opiate high, 2 and 3 are pain sensors, and there are a few others that we won't mention. What makes Tramadol unique is that it acts very little on 1, but still a good amount on 2 and 3, the pain ones. So it can give pain relief without so much of the high, which is why my doc felt it was a good option since I can then still have a sound mind and still work. But nothing is free. Apparently this drug also contains some anti-depressant like effects, and strong ones, to the point where the company that initially made it actually tried to say that their narcotic is good for depressives. Yeah, real good...

So what's the problem? Well the problem is that the pain receptors in my brain have been so used to the opiod activity of Tramadol that by the time I was hit with real pain killers I had the tolerance of a long time user without even knowing it. Further research revealed that withdrawl symptoms from Ultram can be no better than from any other opiod pain killer. So now I was out of surgery, with lots of pain, and on tons of narcs. Since I'm taking this I have no way to know what is a real symptom of a surgery gone bad, or hypersensitivity to pain due to narcotic withdrawl. From what I remember working with all the addicts is that while symptoms vary, one cardinal symptom is indeed hypersensitivity to any pain, excruciating leg pain, and diarrhea etc....

This left me with two choices, taper slow, or quit and suffer. I have no intentions of being on these drugs, I want nothing other than my life back. However I also know it can't be immediate since so fresh from surgery the pain magnified is beyond tolerance. So I did a gradual taper. 7.5mg oxycodone, every 6 hours, then 8, then none, over 36 hours. The pain--terrible. But by day two it got a little better. The left buttock, thigh, calf all hurt like no tomorrow, but it was a sacral rather than lumbar pattern so I knew it was just inflammation from surgery and the remodeling from the reduction, magnified by the opiate withdrawl. The diarrhea, sweating, emotional fragility all came as well. I was in full blown withdrawl. Damn, who would have thought.

Now, it has been nearly a week since I stopped. I am able to walk again, miles instead of just a couple of blocks. The leg/glut pain is still there a bit, and is nagging that's for sure, but believe it or not, two weeks out of surgery and I'm actually feeling better than pre-op (though I can't bend/lift). I take Tylenol a few times a day, and while I can't honestly say its doing anything I suppose it can't hurt since I'm not drinking and it doesn't affect bone regeneration.

I had my followup appointment with some x-rays, everything looks good and on track. I'm able to sit for a good while now (and type this long entry), I can walk, I can stand, I can sit in the car and even drive. Wow.

If this leg pain goes away entirely I will be truly amazed. When it first hit as I was detoxing I read all the horror stories, and while I won't know the true result for months (successful fusion, no nerve scarring) for being a little more than two weeks out I remain optimistic.

But the moral here is this: Don't stop your search after page 1 of Google, and don't believe a single damn thing the drug information from the manufacturer says. The other pages contained the horror stories that I myself will  have ended up experiencing. That is not to say it doesn't have uses. Perhaps if I was only on it for a few weeks it would have been ok, but it certainly left me with a bad taste.

Friday, July 30, 2010

The US healthcare insurance scam strikes

First off, let me get my perspective on the healthcare system in the US out of the way: it is abysmal. It is a pity that so many in this country are misinformed, and think that a for profit system can ever benefit the patient. It is an impossibility, a paradox. In its very essence that company which does what is best for the patient will go out of business as their customers will be healthy and not need service. It really is that simple. So I am completely not surprised the following happens...

I have full insurance for this, probably some of the best plans left in the country since it is one of the few remaining benefits of a quickly declining union. However, there has yet been a single visit, claim, or procedure that did not produce a mountain of paperwork, or require lengthy menu navigations to get to a human being who fails to fix the problem the 5th time you speak with them (or so it seems that way). Horizon BC/BS- F YOU. And that is my professional opinion.

Apparently because the hospital did not submit some progress notes in a timely manner they are denying the claim, and they will have to submit again. Being an RN I know people who work in the insurance side, and there is one thing I know for certain--this like many other letters that get sent, are done so on purpose and without real merit. ALL initial claims are ALWAYS denied. Studies show that is the first line of defense against payment and guarantees more profit. While there maybe one or two companies out there that do not practice this, this has been my experience. While they will eventually pay since everything was cleared, my bet is it will take the better part of a year for things to be settled. I mean really, do you need a progress note to justify a 3 day hospital stay for a patient who had two surgeries on the same day of this magnitude...there is 0 justification here, just profit motives.

Wednesday, July 28, 2010

Sciatic Nerve--what the heck is it?

I'm going to spare much of the scientific jargon here and make this one simple. The sciatic nerve (hence sciatica-associated pain) is formed from smaller nerves running from the lumbar to the sacral nerves, and is composed in the leg and then further branches off into smaller sections. It is responsible for a lot of the pain in those with bad disks, spondy, or other similar conditions. Irritation is typically pain, sometimes numbness/pins needles, however if major or in cases of sudden onset sensory deprivation or extremity paralysis it indicates acute damage and should be treated emergently.

Different location of pain differentiates spinal level
However the nerve itself does not just jump out of the spine. It is actually several nerves emerging from the lumbar vertebrae and sacral openings that merge into a big bundle that becomes the sciatic nerve. What is important here is that the location of the pain is critical to determining the level that is injured in the spine. Here is one diagram to the right that shows an approximation of which nerve is responsible for which pain. The one on the right is very broad, whereas the one below is much more specific.

This diagram demonstrates a "map" of the nerve origination vs the location of pain felt.

Why am I spending so much time on this? Because the pattern of pain I have been experiencing is the s2/s3 variety. That means it is just inflammatory pain from the surgery, perhaps the radical reduction, or just too much walking. The MD's office agrees, slow it the heck down. 4 miles is too long to walk less than a week post-op (ok ok I was excited to be able to walk again...)

So today it has been better. Today is also my first full day off all narcs--and that will get its own post, but let me tell you it is not pleasant. However I've seen far too many patients go down the path of not stopping soon enough, and I'd rather stop a little too soon and play it safe. So what, what's a little pain now compared to the last year. Actually with the fixation there is very little back pain, and I forget I even had abdominal surgery unless I sneeze or cough. Not bad for less than two weeks out. Now the legs--that will remain for the next post.

Tuesday, July 27, 2010

No road is without bumps

As expected not everything is perfect. This weekend as I was tapering the meds down the left leg has been protesting with new found vigor. It started as a gentle calf pain after a day of some serious walking. Initially thinking a sore muscle I dismissed it, then when the next day came I worried it was a DVT. However as any floor nurse will tell you, if it is aggravated by walking and relieved by rest, then likely DVT. However that is not the case. It is actually relieved (not entirely) by walking, and is worst when I wake up. As the next two days proceeded it went through the whole leg and left hip, not just the calf, so it is definitely nerve pain (sciatic).

This is very disappointing since that is the one thing the surgery was supposed to be damn good at relieving. I am assuming it is inflammation, and likely stemming from too much walking, or the new anatomy from the reduction pulling at the nerve. My hamstrings are tighter than I ever imagined; I only have about 20 degrees of upward motion. I can only assume the nerve is as well so that is likely the cause. Nonetheless the office is getting a call so I can figure out what to do--or not do. The appointment isn't until a week away, so that's a lot of time to damage it. I'm not terribly concerned though. Since there is no sensory deficit there is likely no damage, just irritation. And it is relieved by the current pain management regimen so I can live with it for now.

Friday, July 23, 2010

It has been a week!

I've exceeded I think just about everyone's expectations in my level of functioning. The visiting nurse and physical therapist stopped in and while we had a great chat it was the last time I will be seeing them since  I am walking between 2-3 miles every day now! While the pain is controlled by the percocet I am able to do the walking with minimal pain for the most part. The trick is to time the walks with the pain meds, or really to time the most painful part of your day with the pain meds. Lots of hills here mean finding flat roads to walk on gets repetitive, however the mall is a 1/2 mile away, so at least its air conditioned, and I fit in with all the geriatrics with my cane on their early morning/bad weather walks.

All the people who are helping me are indispensible--whether getting your socks on, or picking up something you dropped, or going out and getting you something that makes you feel better when no amount of meds does--it makes all the difference. My poor wife has been stuck with all the chores and house maintenance for a while, I think I might be stuck doing this stuff for a few years after this!

I've been doubling up on calcium, vitamin D, taking MVIs, lots of meat, fish, and some veggies to give my body whatever it needs. Since dropping the 40lbs in the last 3 months I have lots of room and this way by body is in a "building" mode rather than a losing mode. Pain meds are slowing down, but waking up and going to bed are the hardest. The initial wake up I am sore like I've just run a marathon while having the flu--and before bed much the same. From the surgical reduction of the spondylolisthesis the bones, muscles, tendons that have atrophied in the past are now being used in all sorts of different ways, and I can tell you they protest. Then there is the pain from the rods underneath the skin. I am definitely becoming more used to them, but the back brace or any firm back chair/bed still aggravates one in particular.

The abdominal incision is healing well and the tenderness is much less, however there is still pain at the end of urination, quite odd. I assume it is from the bladder being stretched as everything was moved around. The 4% chance of retrograde ejaculation (potential sterilizing ALIF complication from movement), while a big motivator for a surgeon to go PLIF only, in my case worked in my favor and luckily no damage was done. Abdominal strength is back with little pain, the trauma surgeon who assisted with the anterior portion was definitely quite skilled and a few days I feel very little from the abdominal part at all. Also, always a concern with abdominal surgery, all bowel function is returned with no issues thanks to early mobilization and good diet--but I'll spare the details here.

Out of so many blogs that I read, so many accounts of this type of surgery, I feel truly blessed with how well it has gone for me so far. The pain has been manageable, I am able to ambulate (with the back brace), spend the majority of my day in less pain than prior to surgery (though with meds now), and get a 2-3 month break from work! Though I'm really hoping it fuses early and I will be able to return early (what can I say, I'm committed.)

The horror stories online made me think I was in for 3-12 months of hell, and while it still "pending" as to how it will turn out, the idea of finally being able to live proper without handicap, is something that even if it was, would still be worth it.

As they say I suppose its a matter of outlook as well, but unfortunately no pain meds or surgery can ever fix that.

Wednesday, July 21, 2010

This blog is worthless without pics!

 here you go!

This is the intra-op xray showing the donor graft being placed in the level. Notice the near complete reduction of the spondy!!!

Compare it to the prior: 

I could not believe it, but when I looked in the mirror my back is straighter than it has ever been! Of course there is a likelihood that I will lose some of that reduction as everything settles and heals (maybe 10-20% at worst from what I read,) however compared to the prior x-ray, you can see the vast difference in alignment.

Having done this all the muscles, tendons, and bones have to get used to the new alignment, but even now I am able to walk without a cane mostly (though I still do since falling at this point would be VERY bad).

Tuesday, July 20, 2010

Back home at last

Having worked with many post-op patients, I know very well how different the experience is for everyone. After surgery the majority of people start to wake up, and usually after some time the anesthesia wears off and everything else does as well, and they start to require pain/sedation meds only after clearing out the those anesthetics. Anesthesia staff remain around to make sure they are always available to prescribe what is needed to keep the patient at a tolerable level as they come to.

So before I go on, let me put what happened into context: Up until this surgery my experience with narcotics was very limited. When I had my shoulder surgery 10 years ago, they gave me some ultram for two weeks. It hurt like hell but nonetheless within three weeks I had done a good deal of PT, and made it by with nothing but the ultram. After doing the damage with my last motorcycle wreck I was given a few days worth of percocet, since I did some pretty obvious damage. The other experience was more than 11 years ago, when having had my wisdom teeth pulled they gave me a small handful of vicodins. As for the back, I purposely set out to not take anything as long as possible since that's a downhill path unless another intervention was in the future. When the PT failed, and then injections failed for the spondy, only then did I take the ultram so that I can continue to work and function for the few months prior to surgery. For those who don't know, ultram (tramadol) it is such a weak narcotic (stripped of all its "feel good" properties) that most don't consider it one. So my tolerance to pain meds really ought to be next to none going into this. And as for my tolerance for pain, hell, I've been walking around (snowboarding, hiking, playing hockey...) with a broken back and a destroyed disk for two years I think I can handle it pretty good....

When they pulled the tube I started to come to, and while initially it looked like I was going to be ok, after just a couple of minutes it became obvious I was in agonizing pain. Shot after shot nothing would make it better. I have no words to describe it, other than it was without a doubt worse than any pain I can imagine. As anesthesia ramped up the dosages the agony continued. By the time it was remotely under control, the dosages I was was at terrified me because those are levels a typical person would have stopped breathing a long time ago on. They even started with Ketamine but by then the heavy doses of dilaudid were starting to have an effect and I made it without needing the drip. Wow, talk about a rude awakening. My initial though was to wonder what the hell anesthesia was thinking, but the reality is that every patient is different, and sometimes you do get a freak like me who just doesn't respond well to narcotics. Its not their fault, they tried as fast as possible to give me all they got. If I was in their shoes I would be just as concerned giving that much to an extubated patient.

So that was the day 1 nightmare. Oddly enough all these drugs did not knock me out until later on in the evening, and then I would wake up, push the PCA button a bunch of times, nap, wake up in terrible pain, push button repeat...this went on for the next 24 hours or so. I was able to get out of bed and move around a bit that first day at least, so the optimism started to come back. Oddly enough being upright was the least painful part of that day. However having two incisions made it twice as difficult, since not only must my back be straight but using the abdominals was pretty much a no-no since they were cut as well. Luckily I had help.

The second day presented another challenge. While the pain was now mostly controlled on the PCA (where you push the button,) to get discharged I would have to go 24 hours or so on oral pain medications. The choices were either dilaudid or percocet. I decided to try the percocet since it should be an easier one to kick when all is said and done. I hit the dilaudid PCA button a couple of more times and took 20 mg oxycodone (this is about  4 percocets worth less the tylenol). It lasted a couple of hours, and then I had to wait...and wait...the next dose was scheduled for 4 hours later. Unfortunately the meds lasted 2 1/2 at best. After an hour and half of being back in terrible pain they gave me an additional 10mg. I can understand their fear in giving so much since having to reintubate or give narcan is quite a step back, however I was decompensating to pain levels that were not conducive with recovery since I essentially could not move. Eventually they bumped me to 30mg oxycodone q4 with tylenol and some valium to relax the tense muscles.

The pain managment NP then made another suggestions--I could try oxycontin since that's even stronger. However having worked in rehab for the time that I did, that is one I would rather pass on. While I know the arguments for it, and I have no doubt synthetic heroin would do wonders for my pain, I decided to pass on that one. The decision was then made to just continue the 30 mg of oxycodone with 650 tylenol added in, every 4 until it settled a bit. That way the acetominiophen dose remained consistent while I could taper off the oxy as tolerated. That worked fairly well. Now that I am home I am getting by with 15mg every 6 hours now along with some tylenol, and still able to take my walks and move around and not get too groggy. So improvement seems to be going quickly. I actually managed a 45 minute walk today just this AM, I plan to continue and hopefully exceed recovery expectations.

So the question on my mind as it must be on others' as well: Is it worth it? We shall see. Having looked at the x-ray the spondy is reduced almost completely - wow. Doing the combined ALIF/PLIF allowed the large reduction with minimal manipulation, and the pars is still intact and no decompression was needed. All statistics point to what should be a back to 100% recovery. The nerve issues are definitely gone. My left leg is not tingling, my hip is not aching severely, and the incisional pain is starting to dissipate. Once I get used to the rods that should make it even better. Right now seeing everything I am VERY optimistic, and hopefully all will go well and in 6 months I can answer this question with a resounding YES!

Saturday, July 17, 2010

And so ends day 2

I remember when having a back spasm that taking 2 percocet was enough to stop debilitating pain, and made me enjoy the least humerous of SNL episodes.

After stopping the dilaudid pca, the equivalent of 6 is barely enough to hold you more than 3 hours. Despite the intense pain, I made it out of bed three times to walk around. While I suppose pain management could be better, this is the quickest path to recovery.

I cannot imagine how much worse this must be for those who do plif only; while the combination alif/plif has additional risks, if the lower back musculature was disturbed further I doubt I would be able to type this.

Till day 3....

Day 1 is almost over

What a rude awakening it was. Finding out that your tolerance to narcs is much higher than most, right after surgery, is far from pleasant. Luckily they were fairly quick about it, and within an hour I was better and remained extubated. This was puzzling since I so rarely take anything other than ultram.

So day 1, like expected, was rather unpleasant, though having gotten up and walked 15 feet I feel better about the whole thing.

Friday, June 11, 2010

Taking the Next Step

Almost a year to the date after this all started, hopefully this is a step towards the end. In early July I will be undergoing a combination ALIF/PLIF procedure to set things back into place. The requirement on the first week of recovery is to walk 30 minutes a day. I cannot remember the last time I went for a 30 minute walk. Painful or not I look forward to it.

So why ALIF/PLIF? There are tons of options for getting this fixed. The initial thought from the first surgeon I saw was to do a PLIF only. First off since I am male and fertility is a concern he did not want to do an ALIF. I understand their concerns. While the risk of of that complication is low (4% of total, only 1% of which does not resolve within two years,) they still hate to tell the news to one out of every 25 they do. However I want to get back to being active, and the less muscular disruption the better. Having seen many people in my career with failed back I am willing to take some additional risk to assure a better life in the future. While I have full confidence in the skill of the surgeons and all of their research, the less they do the better, and with the ALIF/PLIF combination they do the least manipulating, cutting, grinding, and drilling. Yes there's an additional incision, but skin heals quicker than bones. As for the infertility, I'll take my chances. There's always the option of banking some for future use.

I will update this blog as my recovery continues.

Tuesday, May 11, 2010

Second Opinion and the Chiropractor

While I really have full confidence in my current physician, at this age I do not want to take any chances and potentially have more issues down the road. In the next two weeks I should be getting a second opinion on the best course of action and surgical approach. I am concerned about some of the issues of stabilization vs reduction, decompression vs not decompressing, and doing a posterior vs an anterior approach.

Also I finally got the standing x-ray, and here you can see the difference between standing vs laying down, and the obvious difference in grade.

The good news is today marks 30 lbs of weight loss since I went back on atkins. While this has not relieved any symptoms, it most likely buys me just a little extra time each day upright and will certainly help for recovery and pain after the surgery since there will be much less tissue to go through. The bad news is that the pain continues to get worse.

I also went to see a chiropractor and will continue to do so for a little while. They did the spondy drop and some massage last time and I definitely felt a shifting in my back--and a little relief...albeit very short lived. Perhaps this will make the next month or two while I wait to get it fixed a little more tolerable.

Wednesday, May 5, 2010

Buying Time

I am in healthcare. I see people suffer, I see people get well. Hopefully I help them with both. But as anyone who is in healthcare will tell you, doctors, nurses; everyone else involved are still people. They make mistakes, they have lapses in judgment. Whether doing a poor job of cleaning the site for a central line, forgetting or not having the time to check your circulation properly every two hours, giving the right dose of the right medication...these are all innocent mistakes that do happen every day. In 90% of cases you can fix that mistake without any harm to the patient, but it is the occasional ephedrine/epinephrine confusion, 5,000 units vs 50,000 units of hepairn, poorly cleaning the IV port prior to injecting--that can lead to fatal complications. It is only lawyers and politicians that will tell you medicine "must" be perfect, because it simply cannot be. There is a price to perfection--and in a capitalistic system with a profit driven healthcare system the bottom line is not for you to be so healthy that you do not need it.

When my wife was ill and I watched the RN inject the morphine instantly, it is not that she wanted to give her the worst headache of her life--but she did not know any better and our shoddy system did not teach her differently. Either that or it failed to instill a sense of importance to that subject.

When I see RNs clean a port with an alcohol pad for 3 seconds and immediately inject, it is not because they do not care, or want to give me endocarditis and vegetated heart valves as the bacteria from that port cling to them and eat away the tissue--but because they do not have the time to stand there for 30 seconds, and then allow it to dry. It is because that is deemed "too expensive" for hospitals to have nurses stand there doing nothing for 30 seconds every time they give IV medications. Yet they are instructed to follow this unrealistic practice (considering the patient loads.) Luckily most people's immune systems can kill those germs before they cause damage, most people's.

Physicians are also plagued with similar issues. While nearly all of whom I have had the pleasure of working with have nothing but the best of intentions, there is a point at which liability concerns trump that which is best for the patient.

This is the system I am about to enter. Anything I can do to put it off, or better yet prevent it altogether, would be imperative to pursue. Unfortunately everything so far has lead me back to the road of getting surgery. It has been months since the injection, I dropped nearly 30 lbs, increased my strength, cardiovascular capacity, and flexibility dramatically. Went down the NSAIDs road as well with some improvement but with great long term risks, reduced my upright activity to only when necessary, and many days I can get by pain free as long as I do not stand or walk more than 30 minutes cumulatively. But it is not the life I had before this. While by no means am I implying that those in wheelchairs are not able to lead fruitful and full lives, on the contrary, I think here in the US we have accommodations for an unprecedented variety of disabilities. However I think given the choice, most would rather walk.

Roid Rage

I went to see a physician in the same group who specializes in non-surgical interventions, and performs the steroid epidural injections. I will be honest, I am quite leery of this as I am of any procedure that is merely a treatment and not a cure. I spent many hours researching this subject and came to the conclusion that my best chance here is perhaps that the anti-inflammatory nature of the steroid might reduce the nerve irritation and swelling. With a smaller nerve this would then stop the vicious cycle and reduce the effects of stenosis (since its a smaller nerve now) and perhaps get rid of the pain altogether. There is definitely a chance for that. Back in the day before all of this the standard treatment was weeks of bedrest which has the same effect.

So I scheduled my visit, laid on the OR table, and took the shot. Let me tell you, that was painful beyond words. I have seen many invasive procedures in my day, and imagined that they probably hurt, but man, did this hurt. I thought maybe the novacaine injection would be the most painful part, like most visits to a dentist, however here that was not the case. The novocaine did hurt, but it wasn't quite so bad. It was when the actual epidural needle penetrated the muscle that you realize exactly how painful it is. And then they inject. If it is successful, the steroid medication encompasses the nerve root and you can actually feel it going down your leg. And what does that feel like? Something between having your leg severed and being pummeled with a baseball bat. I mean, I don't want to scare you but that's the truth. Luckily it only lasts a couple of seconds and then--nothing. A very strange experience to say the least.

So what was I expecting from this? According both docs likely a few months of improvement. While there was the hope that it could eliminate the pain altogether, I shouldn't expect it. I did not, and really I full well knew that surgery is coming. What I did not expect was how painful it would be to have, for just a couple of weeks, the ability to live a normal life again. I went for a walk--I even hiked in the park for 3 miles. I stood at work carrying on a conversation without being focused on needing to get back in a chair. I took my camera and was able to take pictures other than on the side of the road. I was able to give a talk and focus on the group, I slept with my legs straight for the first time in months--but this was short lived. I made it 2 weeks before the pain came back again. I made it a full month before I was back to the level of disability I was at before. On my followup visit to the physician it became apparent surgery was much closer than anticipated.

This experience of getting the injection I do not think I would repeat. While having that time was wonderful, and gave me my life back as I knew it before all of this started, the experience has left me in worse spirits then before. It is one thing to lose a part of yourself and begin to adjust, but it is quite another to have it back, and then go through the process of losing again. Considering the risks and long term complications involved from repeated epidural injections, my first was my last.

So What Happened?

There are several types of Spondylolisthesis, and I'm going to focus on two. The first of of which is traumatic. While you would think that the motorcycle accident could have caused it, it seems unlikely that it did. Most likely it is of the isthmic variety. Approximately 4% of the population is born with a propensity for spondylolysis (not to be confused with spondylosis)--a fracture in the pars interarticularis usually caused by a genetic weakness in that particular segment. This is the bony part that connects your vertebrae to your spine. Think if it as outstretched arms that wrap around the actual spinal cord. When this is broken there is less to support the vertebrae and prevent anterior displacement. In the majority of those who are diagnosed with this, it usually an incidental finding and is not the source of pain. It is only when the vertebrae slips forward and pinches the nerve roots leading to the legs that it becomes an issue. While there are several grades, usually only grade II or above is symptomatic. When I initially had my supine lower back x-ray, it was graded as a Grade I. But there is a problem with this that later became apparent when I saw the specialist--when you stand, gravity pulls things down and forward. In my case a standing lower back lateral x-ray showed a significantly worsened listhesis, at Grade II/III. This of course correlates exactly with my symptoms as when I sit or lay down I am just fine, but when standing or walking....

So what likely happened in 2008 was that during the motorcycle wreck, landing on my left hip caused compression and further displacement of the L5/S1 junction (in my case L6) stretching whatever ligaments held the segment in place. It was this additional motion that was first responsible for the back pain, that later progressed to radiating back pain (left hip) and leg numbness (sciatic nerve root stenosis/irritation).

While I am not a radiologist (if you are correct me in the comments below if needed) here are my observations from the MRI I had done:

Here you can see that the L5/S1 disc is significantly damaged compared to the rest. This was likely the source of pain the first few months along with other nearby trauma.

As we continue to look you can see the forward slip. This is laying down on my back so it shows a Grade I (less than 25%)

Continuing down we look at it from another angle, and you can see in the enlarged crop exactly where the fracture is:

The results of this is the displacement of the nerve roots, and in the following you can see where those exiting at L5 are significantly different with accompanying stenosis causing the symptoms:

And this is when laying down...when upright this is significantly worse.

Physical therapy is a great option for many, and with the greater abdominal and back strength it is possible to prevent further slippage and maybe even to reduce the fracture. However in my case that is not enough. After seeing the surgeon he recommended to get some steroid injections and give that a 'shot'. Supposedly that can buy me some more time and put off the surgery as long as possible.

The PT starts

Going to PT was quite a strange experience at first (and maybe at last too...) I had done PT in the past when my shoulder was operated on and while painful, it was good to have made progress and regain full mobility. I had hoped for more of the same here. According to many sources it had a very high success rate in spondy cases, and I knew I wasn't nearly at my peak condition so there was certainly room for improvement. If you haven't seen spondy exercises, they are an interesting bunch. From the "pelvic tilts" to the "bridges" it trains you not only for back support but for bedroom acrobatics as well. I spent more than 3 months in physical therapy, and by the end I was back to nearly my military levels of sit-ups, with greatly improved flexibility. This was all good--except that I was still in pain, and even worse than before. Regardless of the strengthening it had continued to progress at an alarming pace.

At the initiation of PT I was standing for hours at a time with mild (but tolerable) pain, walking miles with the same. At the 3 month point I was in moderate pain after a mere 30 minutes of standing (total throughout the day) and able to walk no more than a couple of blocks before I was done. My job requries standing, lots of it. I can try to sit in the occasionally available stool every now and again, but that is a luxury and not always a given. At this point it began to affect my work. I could no longer think clearly because of the amount of pain I was in. I started making mistakes and paying less to what I was doing and more to what I was feeling. This I knew I could not keep up. After nearly four months I stopped going to PT so I could save the remainder of my allotted visits in the case I need surgery that year. I made an appointment with an orthopedic surgeon who specializes in backs.

The Spondylolisthesis Blog Begins

What is spondylolisthesis? When I first heard about it, it was nothing but a complicated word. When my X-Ray report came back and I asked as to whether they found anything they said:

"They wrote that they saw spondylo...., it's nothing major, we're not sure why your back hurts, it is very common and probably isn't causing it, but you should go to PT."

That's what my primary doctor said. After seeing it mentioned on the X-Ray report, they said they don't know what is causing the pain and I should go see a specialist as they are out of ideas, and of course go to PT as that can only help.

I went to see wikipedia instead (why didn't they?!) and wouldn't you know it spondylolisthesis has the exact symptoms of what I am experiencing. As the first treatment was still PT that is what I did.

So lets take it back a little bit in time, what the hell is going on?
For me--it all started with this:

See the skidmark? That was the rear tire of my motorcycle when I highsided. I was tossed 6 feet in the air, landed on my left hip, felt my spine compress on impact (however one can describe that sensation), and other than a broken toe and some bruises I thought I made it out OK thanks to full leathers and a helmet.

What followed was some x-rays, and with the help of some painkillers I was actually able to finish off my vacation and ride the damaged bike until the week was over. I took out the insole out of my shoe so I can fit my swollen foot in there, and the percocet did wonders for the lower back pain so I could function and ride.

6 months later the broken toe healed, and the back pain had gone away, so I thought I was fine. Fast forward to a year after the accident and I was back out enjoying life, able to run, hike, walk, lift, play hockey...anything. In 2009 I hiked to the top of half dome, 17 miles, 5,000 feet of elevation change, 14 hours on my feet with just barely any aches and pains.

However after that hike it began to deteriorate. By  6 months after that hike: If I walk more than two blocks and I have to sit. If I stand 15 minutes, back to a chair. Forget running. I can still bike, I can sit in my chair all day, I can drive anywhere, and I can ride my motorcycle. But any walking, standing, running...and I am sent rushing back to a chair so I can sit and recover. 

I am 30. I am in great shape. Nearly everything I love to do involves either walking, standing, or doing such to get there. You don't know how much you walk until you can't...