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.

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.

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.