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...