| The Surgery 2-12-04 | Post Op Exam | PM 1st Exam | 1st Neuro exam | Old Treatment Plan & Theory | Current Exercise Program |
February 4, 2013: I'm happy to report that my back pain is 98% gone. That is the first time I have taken Decadron and it was almost like a miracle: by day #2 of the flare-up, my back pain was about 90% gone and so was my antalgic lean (no muscle relaxers either) and the sciatica nerve really started. It seems like, as with most medications, however, there was a big trade-off: it stirred up my IBS and GERD and I suffered over the weekend (although, we do have a stomach virus going through the office so I cannot be 100% certain what was the cause of my GI upset. Here's the really weird thing: on day #2 of the Decadron, I developed the hiccups which I haven't had since I was a kid; about three hours worth of them. On day #3, I was getting nervous as I had seven hours straight of hiccups plus stomach irritation. (I actually got startled watching a scary movie and that was the event that finally stopped them). Needless to say, I was only able to complete 3 days of the Decadron (this is a known complication of oral steroid which affects <0.5% of people). Today I have a little bit of leg pain but nothing major (3/10) and virtually no back pain at all; although, I'm not feeling well and I think its from the flu. I went over my MRI images with Dr. C, and there is really nothing that I didn't already know: my S1 nerve root on the left (the target of the discectomy in 2003) is scared and swollen with more scar tissue than what is normal for a discectomy. Therefore, my condition is not operable. There is still a little mystery over the thigh pain I'm getting-- I do have a far lateral annular tear at L3 with the small protrusion, which I was hoping was fixable. But the doc says he doubts if that is the problem given the amount of scar and swelling in my left S1 nerve root. If I get a chance, I'll post some new pictures of that MRI. Wish I could take a day or two off from work (had to work all weekend) to recover from this bug or whatever it is I have, but the NASS abstract deadline is two days away and I'm working hard with our biostatistician to get six abstracts in for consideration of making the prestigious NASS Winter convention.
January 30, 2013: the January curse has struck again:
I suffered a bad flare-up of low back pain this morning for no real apparent reason. It has been about five years since this sort of thing has happened: I bent over awkwardly in the parking garage of the hospital to look for something I had dropped and felt a "pop" right in that old spot (left L5/S1) and immediately started becoming antalgic (bent to the right).
And I really need to thank Dr. Corenman and his staff again for being so compassionate and taking such excellent care of their researcher; although, it did cost me a guitar lesson, a favor and a bottle of wine....
January 17, 2013: wow, time is flying by! I've been here in Colorado 10 months now and have learned so very much about spine surgery, research and data collection and seen some crazy complicated cases (we get failed spine surgery cases from all over the country here)--I'm still like a kid in the candy store. I have also learned that getting a manuscript published in a major peer review journal is incredibly complicated and time consuming-- they are very picky. Although my low back pain continues to be basically nonexistent (maybe a few days a month of 2-3/10 pain), I still have not regained my ability to hike--I mean, I can do it, but I pay a horrible price if I walked too far or up any type of incline--I fear there will be a lumbar decompressive surgery in my not so distant future. I am still fighting, however, and walking every day over my lunch break here in Vail--rain, shine or snow. And speaking of snow and cold weather, I have now experienced some of the coldest weather in my life. I've already endured (just last week) temperatures of -19° and one morning at -17°. The humidity here is so low, however, that it really doesn't feel as cold as it sounds – although it is still pretty damn cold. I also gave my first big powerpoint lecture last month on discogenic pain syndrome and degenerative disc disease. For whatever reason, speaking comes incredibly easy for me and I was told I did very well--at least Dr. Corenman and all our interns thought so. It was a little intimidating, for my audience was all medical doctors, physical therapists and some athletic trainers (oh yeah, there were a couple chiropractors there too). I have also rekindled another old passion from the past: the guitar. If I'm not working, or doing/preparing for coaching sessions, or talking to my wife via Skype (she still has not joined me yet for this adventure), then I'm playing my guitar and singing. In fact, some of my coworkers and I have formed a band and are slowly building our song base with the goal of doing some small gigs around Vail (maybe in the future, if I get brave, I'll post a few classic blues songs I do--I got a 8 track recorder for x-mass, and I'm having a lot of fun recording and mixing my sessions). Pretty exciting weekend: I got invited by our head radiologist to join him and his fellow in reading 35 CT scans looking for fusion status and BMP complications at a six-month follow-up after fusion. I'm also writing the paper that will follow – should be pretty interesting. That's it for now.
August 30, 2012: another damn flare-up! Been 2 weeks and think I've turned the corner--much better day at work 2-3/10--but my ability to climb is nonexistent. This one happened (almost like the last) after I climbed two very long and steep flights of stairs. I had hiked about three miles two days before. Just like the last one, there was a big delay (3-4 days) before it hit and really spiraled downward for two week. No back pain at all this time but all dermatomes hit (mainly L2 and L3). Almost positive this is neuropathic pain which you can't do a hell of a lot about--other than ESIs. Need a full work up (motion x-ray, new MRI and then some diagnostic blocks). I bet some things unstable and my DRG is getting compressed. Been over a year since this anterior thigh pain started--not a good sign. Still working on the TLIF for IDD/IDR paper and boy or boy am I surprised by Dr. Corenman's numbers! Can't say yet, but I wouldn't have believed them if I didn't collect them and see them with my own eyes! Best news: my wife is finally coming to visit me--it's been five month and I can't wait to see her!!!
August 8, 2012: have finally recovered from a two-week flare-up of leg pain much greater than back pain (98%/2%) which was set off, again, by climbing. I had forgotten my hospital ID badge and was forced to park down the road. I was forced to go down four flights of stairs and then up four flights of stairs at the end of the day. Then, I had a dinner meeting and again was forced to go down three flights of stairs at another parking structure. Luckily, I found an elevator to save me from that climb but it was too late: two days later the sciatica came and was up to a 6/10 (which is very high for me) and it was a bitch sitting to work eight hours a day and then giving a presentation on that Saturday. But, I recovered and last weekend was able to hike at beautiful Camp Hale for 90 min. up and down a very gradual incline. I have been back to my normal pattern of walking at lunch although I did flare-up my back a little bit yesterday from sitting on a short stone wall and eating my lunch for 15 min. (I knew I shouldn't have done that). Not much of a flare-up, and not constant pain – occasional twinge in my low back at about 3/10. Still having some trouble with my hands (I'm on the computer all day long) much less than it used to be. My wife is coming out in less than a month and I'm so excited! Its been over four months and not seeing her has been by far the hardest part of this job. Currently working on my second research paper which is fascinating: we have a cohort of 49 patients all in whom underwent TLIF for either discogenic pain or isolated disc resorption (this is the toughest group of patients to treat). Have about 80% of the outcome studies collected (two-year follow-up) and have two radiologists on board who will be assessing CT scans for fusion time and complications. Again, that's about all I can say (so stop e-mailing me!) And will certainly post a copy of the paper once it is been published.
June 17, 2012: my L3 and L4 radicular pain is doing much better. For the second week in a row, I have done it 1.5 hour hike that included about 800 feet of elevation. Last week I was a little sore the day after my Saturday hike, but today my leg feels close to normal--slowly but surely. Work is still going well as I am continuing to plow through, report-by-report, 500 cases of TLIF/PLF a surgery with rhBMP-2 used as an augmentation. Although I'm still not allowed to release any specifics, I can say that I'm astounded by how important the pain management doctor is; he or she must be an expert at blocking facets, SI joints, and nerve roots, as well as be an expert in discography. I also got my first abstract submitted to AAOS and am waiting to see whether or not we have won a poster or presentation. I think it is a unique and interesting paper, but we will see what happens – I should know in the fall. The entire research paper is actually finished (over 100 footnotes) and we're just waiting to see which way we are going to go with it. I'm still loving it up here at 8000 feet, but am sorely missing my family. My wife is coming to visit in August! I can't wait.
May 26, 2012: It must be animal week. I could not resist: I did a two mile hike today and saw a creature I've nerve encountered: It took me a bit of googling, but I discovered it is called a pronghorn antelope (very unusual for this part of the high Rockies [near 10,000 feet]). Unfortunately, I couldn't get too close, but did get this picture:
May 25, 2012: here is my monthly update: I am still meticulously working my way through case-after-case of TLIF/PLF a surgery – I still have a long way to go, but I am definitely beginning to see patterns on which patients are going to have a good outcome and which ones aren't. I've also started working on a paper which involves two fascinating cases and rhBMP-2 (I can't say much more, until it gets published). Every day at 12 o'clock noon, I go for a mile walk along the Eagle River (which dumps into the Colorado River). Its absolutely beautiful and tremendously refreshing – what a way to recharge your batteries. My back and leg are doing fantastic, and I don't have any problem sitting through the nine-hour day. My leg still gets a little cranky if I walk much over a mile (especially hills), but it continues to improve month-by-month. And finally, I would like to introduce a few of my Colorado friends:
April 21, 2012: I scrubbed in on my first surgery, and boy was it a doozy. It was a traumatic cervical facet fracture and disc herniation (explosion) in a patient who had suffered an MVA with resultant upper extremity paralysis. The procedure was a decompressive ACDF. When the doc finally got to the anterior disc space, the disc was completely destroyed – he needed no scalpel to cut into the annulus because it was like a bomb had went off inside the disc. After clearing the disc space, two large fragments of nucleus pulposus were sucked up and then the mother of all herniations came into view! it was too big to suck into his suction tube, so he worked and worked and finally was able to free it from its home against the anterolateral spinal cord (it was just smashing the spinal cord – undoubtably the cause of the paralysis). It was 23 mm x 15 mm and will be displayed in the research paper we are going to write on this case. this accident was the result of a pretty decent snowstorm on Monday which brought back my winter driving skills from 30 years past. Although the temperature has been in the 50s and 60s this week, there is still some snow in the high mountains. Here's a picture I snapped on my way back from shopping this afternoon in Silverthorne, Colorado.
April 15, 2012: More Snow Pictures [here].
April 14, 2012: okay, okay, enough with the e-mails. Here's my update: work is actually going fantastic! It's my dream job and I'm like a kid in a candy store. I was a little concerned about having to sit eight hours a day, but all in all the old sciatica is doing well. I'm controlling the beast with about 2000mg of Tylenol per day (which is half the maximum dose allowed). I also mix in an Aleve here and there for any break through pain. As I've mentioned before, our first research project will involve the success and complication rates of transforaminal lumbar interbody fusion (TLIF) with posterolateral fusion (PLF) used as an accessory procedure. We are also looking at rhBMP-2 complication rates. I'm currently pouring through hundreds of such procedures – one at a time -- and gathering data and how these patients ultimately fared. Although I'm certainly not going to spill the beans on how the investigation is progressing, lets just say that as with any procedure, there are tremendous successes stories (including a five level fusion) and some not so successful stories--I'll leave it at that, so please stop bombarding me with questions about this. Once the study is completed and published, I'll certainly put it on my research page for all to view. I will say one more thing to all you fusion patients out there: please, please, please don't over do it after an early successful fusion! Follow your doctor;s restrictions to the Tee. I've seen failures that would not have been failures if the patient would have only listened to the doctor's instructions regarding limitations.
April 4, 2012: Added pictures from the final leg of my journey through western Colorado [here].
April 3, 2012: Almost there. After about 1000 miles of driving, I'm in Grand Junction Colorado. I'll complete my journey tomorrow (only 180 miles left). I had no idea how beautiful Utah is--wow, absolutely breathtaking! here's some more pictures (these are much more easily downloadable).
March 9, 2012: Big Change of Plan--MOVING TO VAIL COLORADO! Just as I was stocking up on bug spray and gator repellent, out of the blue I received an invitation to interview for a job as the Spine Research Coordinator at a very well respected and long established research nonprofit: the Steadman Philipon Research Institute, located in Vail, Colorado--right at the base of Vail Mountain ski resort! After a wonderful and exciting four-day interview, I have accepted the position and will be starting there the first week of April, 2012. One of my first projects will be constructing a quality observational study on the long-term outcome of interbody fusion.
What was my attraction? Notwithstanding the obvious attraction to be a part of spinal research, being an X-olympic level athlete, I felt right at home here. When you walk down the long hall of the clinic, there are pro sports jerseys covering every inch of the hall way--many great pro athletes (like Mario Lemieux) have been treated here--this is my kind of place! I feel totally honored to be apart of such a prestigious organization.
Moreover, it also looks like I will be allowed to continue my patient-coaching service, so that's good news for those of you who want to talk about your spine problem(s). (Here some pictures but don't open these unless you have high speed internet--there are a lot of them! Pictures )
February 21, 2012:
February 8, 2012: Things Not to Take for Granted: I spoke to a fellow today who has been suffering from chronic discogenic pain secondary to a small contained disc herniation at two levels. This life-changing pain forced him into selling a business because it was too arduous to continue with. He initially told me that he was being treated by a chiropractor, which I reflexively brushed off--I assumed the doctor was doing some low force technique and physiotherapy. I was wrong. To my surprise and horror, this patient was being "cracked" repeatedly by this chiropractor for years, notwithstanding the fact his functional condition was going downhill and the size of his herniation growing (probably secondary to the manipulation, rather than the natural history of degenerative disc disease). So IF YOU HAVE A SMALL CONTAINED HERNIATION, DO NOT SUBMIT TO GRADE FIVE MANIPULATIONS (THE CLASSIC CHIRO CRACK!). The disc hates twisting force and that's just what some types of chiropractic treatment do--they twist the spine. It is my layperson opinion (remember I'm still retired) that such treatment only aggravates annular tears and is perhaps the cause of this patient's ongoing discogenic pain. Sorry for the rant, but I can't understand the thinking behind continuing grade 5 manipulation on a patient when the treatment is obviously not helping or not affording relief.
February 3, 2012: finally on the mend--this was a long flare-up! Although I am still getting occasional 3/10 neuropathic type pain in various locations on my left lower limb (only from hiking), I am finally well enough to survive a walking routine. That is, I have been walking a mile and a half every other day--damn does that feel good! But, I'm avoiding hills like the plague. However, all in all, life is good again (it will be better when I can go on those hilly five-mile hikes and decide how I'm going to make a living, but things will work out the way they are supposed to). A few weeks ago, I visited my MD friend who specializes in electrodiagnostic procedures. I was certain that I had suffered a new bout of L3 and/or L4 radiculopathy. But luckily that was not the case: After a very detailed EMG/NCV examination, there is not a single fibrillation or sharp-wave present anywhere in my lower extremity or lumbar paravertebral musculature. F-waves were also normal. So all that pain must have been either referred from the disc (hard to believe without any back pain) and/or just secondary to a re-injury to my scar-tissue encased S1 root, which is no doubt sensitized (I'm feeling way more pain than a normal unsensitized patient would feel) somewhere along the pain pathway to the sensory cortex (postcentral gyrus).
I still am having trouble getting over my decision to leave medical school. I know the decision was sound based on good logic, but it still hurts--especially when I get e-mails telling me what a mistake I've made (so stop it!). On the job front, things are looking good for that researchoid position over in Florida. I'm actually flying over there in two weeks for the final interview. I'm very excited about getting a chance to work at my passion--researching different treatment options for symptomatic disc disease (even a brand new one!) and becoming part of what seems to be a most excellent, multidisciplinary, huge, treatment facility that specializes in the treatment of disc disease-induced neck/back pain and all their associated horrors (i.e., myelopathy, radiculopathy, intractable pain). It really sounds like it could be my dream job!
January 20, 2012: just a rant by the chirogeek: who are the luckiest people in the world? Those who lac tumor necrosis factor alpha and interleukin one beta receptors on the nerve cells within the sciatic nerve! Why would I say such a ridiculous thing? (I mean, I'm sure there would be other more severe ramifications for patients lacking those receptors) because a new 2011 Canadian investigation (Nadeau et al) has just elucidated that messenger RNA and protein levels of interleukin one beta and tumor necrosis factor alpha are rapidly upregulated (put out into the cell) in the injured mouse sciatic nerve. We know that these two evil cytokines are inextricably involved in chronic sciatica/neuropathic type pain syndromes and now we ostensibly know (I mean this was a mouse study) that these two cytokines are being cranked out within nerve cells during bouts of sciatica/neuropathic pain syndromes. The $64,000 question is what stimulates the ramp-up and excitement of these neuron genes? That's what I want to know.
1-14-12: It was a hard decision, but I have decided to withdraw from medical school. It was a combination of things: I was flared-up again from my CPR training a few days ago; our youngest daughter continues to be ill; but most of all, I just couldn't stand to leave my wife and family again! We (my wife and I) actually drove all the way to SFO airport, as we had done several times in the past, but this time it was really, really painful to say good by: we both wept and wept, I tried to get out of the car, but just couldn't--I just couldn't do it. Then I told her I loved her, and with that, we drove off into the sunset (literally--the sun was setting behind the mountains and made that teary-eyed drive very difficult)--it was one of those moments! The journey is over. There was an interesting lesson--with regard to pain--during this pivotal moment of my life. As we happily made the 80 minute drive home, I suddenly noticed that almost all of my leg pain was strangely absent (it had been a constant 5/10 for the past two days) and now it was 0 to 1/5. What' the lesson? There is no doubt that stress plays an intensifying role in chronic pain (that of course is strongly supported in the medical research). So it's on to plan B--what ever that is???? I'd love to work for that neurosurgeon in Florida--he's a big believer in discogenic radiculopathy and has pioneered a new surgical procedure for its treatment--but that would involve another painful separation. Maybe it's time to write a book, do some lecturing, beef up this site... any ideas?
1-3-12: "Sometimes I go about in pity for myself, and all the while, a great wind is bearing me across the sky." Ojibwe Saying. Something to think about when your suffing chronic pain....
Hi Clay. Thanks for the donation!
During that recent aggravation, I didn't use much medication at all. If the pain got above 5/10, then I would take 600 mg of ibuprofen (i.e. three Advil) in the morning and usually that was it. There may have been one or two days where I did 600 mg of ibuprofen in the morning and then again in the evening. I probably would've taken more; however, I was having stomach troubles and didn't want to stir that up with taking too many NSAIDs.
1-1-12: Doing much better. Back to walking a little (2 miles a few days ago with the grandchild to eat lunch) and got through the x-mas dinner just fine, which required me lifing some 40 pound gas containers from the car to the grill as well as being on my feet most of the day. No flare-up from that. Back to the island in a few weeks to give medial school one last try. Hopefully I'll stay healthy this time. I'm not going to eat anything from that island that I don't make myself! Also, I got an interesting offer to work for a fairly well know neurosurgeon in Florida; I would be heading up his research--amoung other things. That would be something I would love to do, but I'm still not ready to give up "the dream" just yet--although it certainly has me thinking....
12-17-11: yesterday was a 12 hour off-the-recliner day including four hours of on-my-feet study in the AM, then Christmas shopping with the wife. Ended the day with mopping all the floors. Little worried I would be sore today but not. Four hours of walk-around study and then three in the chair. Then two-hour slow walk in the woods with the three grand children.
12-14-11: weird little flare-up. Was at the end of my 4 hour study-walk around and was feeling so good I decided to do one set of bird-dogs and one set of girly push-ups. After this five-minute routine, I got immediate recreation of my anterior thigh pain with little lateral calf burning pain (3-4/10).
12-11-11: knock on wood, I think I'm out of the woods. for the past three days, I've been up and on my feet studying for 4-6 hours per day and then out for lunch with the wife, and today I'm completely pain-free. I was only getting into my chair after 6:00 PM. One interesting note: Last Tuesday, my left thigh & lateral calf was a little flared-up (5/10) from a 5 hour on-my-feet studyfest on Monday. So I decided to only stay on my feet for 3 hours and the rest of the day I was in my recliner. I thought the extra rest would be wise. However, to my surprise, the next day (Wednesday) I had a surprising amount of thigh and lateral leg pain during my morning on-my-feet studyfest. So I did an experiment: First, I took a hot shower (it's been cold here in Nor Cal) to see if the pain was just hypersensitivity to the cold I had been walking/standing around in, and lo and behold, this warmth immediately took the pain away for a few hours--until it got cold again from my continued study (we're not running our heater during the day). It was one of those days I told my pain to F***-off and just pushed through the pain. We got home about 8:00 PM; so after a good six hours of studying on my feet-or-seat; lunch; and a long movie (J. Edgar was really good), my leg pain was--surprisingly--only about 2/10. It was a 6/10 in the morning. So in this case, the extra off-my-feet time was not curative at all--it only caused a false irritation of my pain. My experiment also told me that this pain of mine (at this point) is more of a neuropathic type pain--the acute phase of this flare-up is over. The next step in recovery: lets get walking again before my lower back starts acting up--it historically needs at least a few miles per week to keep it pain free.
11-30-11: Got a new MRI today. Was worried about the shift of my usual leg pain (now, since the hiking flare-up of July 2011, I'm getting that damn sun-burn-like pain on the top and side of my thigh with only minor pain below the knee). Was worried it might be an L3 disc herniation. Results: Happily, there was no herniation, but there was a fairly large, new circumferential tear in the periphery of L3, which means I'm probably suffering discogenic pain (i.e., referred pain from the disc into the leg), which we know can happen notwithstanding a lack of lower back pain--sure seems weird though; I mean, no low back pain from the disc that refers pain down the leg. But I guess there are heart attach patients who only get the referred left arm pain, so maybe it does make sense. I don't think this will stop me from returning to medical school (unless it gets worse), so that's good--I think??? Now my only worry is whether or not that disc is leaking biochemical like TNF-alpha upon my L3 root, which (like before) might have caused an L3 real radiculopathy. I'll give it a few more weeks; if I don't pull out of this leg pain funk, I hit up my DO friend for an EMG/NCV to see what's up. 12/01/11: just got the radiology report. I hit the nail on the head--maybe I should go into radiology. At least that way, I can work from home if I need to. Back to biochem and memorizing clotting cascades--why they give this stuff to first year medial students, I'll never know (we have got enough to learn).
11-26-11: Hum.... not really getting better. In fact, it got much worse (6/10) on 11-23-11, when I did a six hour morning of writing my biochem cycles on the white board. Then a lot of up-and-down our steep stairs on 11-24-11, really pissed it off (6/10), which also caused the pain to spread down to the left lateral calf, as well as the anterior thigh. So I've been grounded to my recliner--this sure get old real fast. Little better today (1/10 in the chair). Probably going see if I talk the LG-MRI owner into shooting another MRI just to see what's doing on in my lumbar spine. This type of chronic sciatic really suck and makes life miserable. Another interesting note: a good hot shower really seemed to greatly help that 6/10 leg pain a few days ago. It's been colder here in California and we keep the house pretty cold. I'm definitely suffering from causalgia (way to sensitive to the cold) and hypersensitivity.
11-19-11: another damn flare-up of my old nemesis -- sciatica (radicular pain). Not sure what's going on with me. This is the same pain I got August, which involves mostly the anterolateral left thigh--not much past the knee. This time all I did was have two back-to-back, long, 6 hour days of on-my-feet-white-board study of biochemistry pathways. That's all it took and I'm back to 5/10 radicular pain without any lower back pain! The $64,000 question is this: is this referred pain from the L3 disc (it was bulging before without annular tear), or is this from a new protrusion at L3 or grade V tear [you would think I'd have back pain though]? Or is it just my sensitized dorsal horn and/or sensory cortex acting out-- i.e., over reacting to some minor annular tearing? When can we get some definitive research on this problem that many of us have (I know there are others who suffer this, for I consult / coach with them all the time). This is really making me think hard about returning to that island's medical school. I know I can make it through the first four years--although I'm going to be broke and homeless (my wife still can't find a job in the optometry field)! I'm worried about residency, which will force me to suffer during those long 10+ hour days--most of which will be on my feet. What happens when/if Mr. sciatica rears it's head then? I smell a lot of suffering in my future if continue down this path. Maybe I should just go to that 12 hour seminar tomorrow and get my license reactivated and try and put my chiropractic practice back together (that just sound horrible to me, but as the Stones said, "You can't always get what you what.... You get what you need." [or something like that]. Let's see how long this bout takes to pass--I predict about one week--and then re-think this with a clear head. BTW: here's a nice, free, paper that Mayo put out on our understanding of this damn chronic, recurring, burning, radicular type pain--although it's a few year old and geared for PCP. Very instructive read for those of you who can understand this stuff! Here it is.
10-12-11: Bad news: got sick again (just like last term) back in mid September, and it has gotten worse. Was living on bread, butter and eggs and have lost another 15 pounds (30 pounds in total since I've been on this island). Not sure if it's a parasite, virus or an ulcer. Had to fly home on Saturday--just couldn't take not being able to eat and the stomach pain, which peaked during mid-term week. My Kaiser doc has strongly recommended testing and meds and no more school this term. So, that's it for me for this term and maybe for good. Time to get healthy and then rethink this whole journey. Perhaps it's time for plan b (try to get into PA school). The good new is my back and leg are completely normal and didn't hurt at all on that long journey home. A little advice to any 50-year olds contemplating medical school in the Caribbean: DON'T DO IT! Just to hard on the old body.
9-15-11: Flare-up is over. What a painful experience that was. The flight to Grenada ended up being 22 hours because of delays. Leg burned the whole way there (5/10 VAS), which sucked. Never got past a 5/10 though, so it was manageable. Now, however, I'm sitting through 4 to 8 hours of class a day without a problem. Weird that the lower back nerve bothered me at all. Somehow, I aggravated that nerve from all the exercising. Was it a metabolic thing (circulation at the injury site was over taxed which resulted in acid build up and pain), or physical irritation from too much movement? Need some research into these questions.
08-04-11: First Flare-up in quite some time! On 7-24-11, I over-did it and Mr. Sciatic and his friends have arisen from the dead—although the pain level and duration is nothing like it had been in the past--thank god! Here's the story: the week before it started, I had ramped up my hiking to a record 20 hilly miles in about a week. Needless to say, this was just too much “firing” for the old sciatic nerve to handle! On Sunday, with a sore leg (2/10), my wife and I went on a short two mile hike over a big mountain. The "last straw" was going up a 12-15% grade, which continued for a good mile--that really flared up my leg. The next day I was down on the couch with leg pain and burning (6/10)—no lower back pain at all. By 7-29-11, I had recovered enough to spend the day at the Gilroy Garlic festival, and then the following day it was the Three Dog Night Concert--the wine really helped! I thought I was out of the woods, but yesterday I over-did-it again: I hiked 3 miles and then had to drive about 6 hours. Today, the sciatic is back (4/10), but I bet it will be better by the weekend--it better be, for I leave for Grenada on Monday, and its going to be a twenty-hour trip. But here’s the weird thing: the weird burning pain (feels like a sun burn) is back over both forearms--it's the strangest thing. It’s got to be a prime example of central sensitization (my sensory cortex is all worked up and is now hypersensitive to even the slightest of stimuli). For example, when I was studying this afternoon, my leg was hurting/burning a little. But even more bothersome was the fact that both my forearms were stinging like crazy--seemingly just from the fan blowing on them. I put on a long sleeve soft shirt and the problem was mostly resolved. Once I hit the recliner, everything was back to zero pain. Anyway, I'll take it easy tomorrow and this weekend in preparation for the long flight to come. It’s just amazing to me that these types of nerve injuries are truly forever, and I would love to do research into this area in the later years of medical school. The nervous system is absolutely facinately!
What were the result of my studies? Not only did I meet the required 3.3 gpa, but I ended up with a 3.8 gpa, which was in the upper 10% of the class--the old brain's still got it!
With regard to my back and leg, they are doing fantastic. During the six months I was in Grenada, I only had one little flare-up of back pain (no leg pain), which lasted for three days and didn't stop me from doing anything--it only required some Advil. I easily sat on the those 3.5 and 6 hour plane rides without a problem. It seems as long as I do my exercises and don't lift things much over 70 pounds, I do fantastic.
03-02-09: Almost back to normal: back pain is completely gone (off all medication) and so is the left sciatica--as long as I don't walk too much that is. I was able to sit though 14 hours of Chiropractic re licensing last week without to much residual leg pain the next day. But, I'm only walking 1/2 mile every other or every third day, for I tried three miles last week and suffered a two day flare-up of leg pain / burning (more in the anterior thigh). So, I've got a ways to go before I'm back running again, but it won't be long. On the MCAT front, I'm still studying 6-7 hours per day and know I'll doing better this summer. Almost through the physics II stuff and getting ready to hit the O-Chem II. I decided not to take any more classes, for I'm able to get the material myself (although I've got three texts for each subject).
02-13-09: All and all I'm doing much better and am back working about 8 hours per day. The left sciatica, however, has not ebbed much, which prompted me to get an MRI done last Friday. I was very happy that there were no new disc herniations (or even bulges for that matter). There was, however, a large circumferential annular tear at L3/4 that most likely explains the anterior thigh pain and burning that continues to plaque me. The S1 nerve was fairly well encased in scare tissue (from the 2004 microdiscectomy), which probably confirms my theory of the sacral plexus getting yanked by the acute muscle spasm of my last flare-up and in turn light up the pain in my left S1 dermatome. My biggest disappointment so far is the fact I can't walk much. I've tried to walk only twice (a 40 minute loop in the woods) and both time have resulted in a 5/10 VAS flare-up of left leg pain (i.e., sciatica) that lasted three days. With regard to medication, I'm still on 100 mg of Voltaren and no Soma. My re licensing is coming up (12 hours of confined sitting / standing) next weekend and I'm dreading it. Bottom line: still not out of the woods, but I can see the light at the forest's edge.
02-04-09: Out of the woods? Maybe. Yesterday I worked for four hours. The first hour was hell! My left leg was stinging, cramping and weak. The pain kept flipping between the S1, L5, L4 and even L3 dermatome (very weird). But after I got through that first hour, it started feeling better. I was only sore for about an hour after I got home and sleep well without need for Soma. Today, even better! Again, that first hour was tough, but I was able to work a full eight hour day; I even treated ten patients. Little stinging in my left leg tonight, but if I'm not flared-up tomorrow, then I think this whole thing was a simple flare-up of sciatic brought on by simple acute muscle spasm (like a pulled muscle of the back)--although I'm still confused on how I could experience such strong radicular symptoms (i.e., radicular pain, cramping and weakness) without real nerve root damage (via physical compression and/or cytokine-induced inflammation). The other weird thing is that I have that strange stinging pain on both forearms (I know it sounds crazy, but I always tell it like it is). It's like that it was when I first got after it after my failed surgery--although it has not appear on my stomach and face like it once did. I spoke to the head radiologist of a local MRI facility--he's also a professor at a local medical university--who I've know for years. He suggested that I may have a "sensitive dura" that over reacts when physically irritated (such an irritation may have occurred when that severe, but short-lived, lumbar muscle spasm struck me after I foolishly moved a very heavy desk). He said it's also possible that I suffered an inflammation /micro scaring of the dura following surgery and/or following that botched myelogram I had (some contrast leaked into the epidural space, which is not were it belongs) that in turn sensitized the entire dura to aggravation of any one part. (I'll have to investigate this verbiage further, for I've never heard of such a theory). I still believe that my dorsal cord and/or sensory cortex of my brain are forever "sensitized" to that old pain track and basically "remembers" the old injury and has now reacted--but the reaction will be short lived for there is no true irritant of the sciatic nerve (i.e. there's no new annular tear or herniation) . Anyway, I'm scheduled for a contrast MRI on Friday and might just do it any way to see if anything has changed. The wacky world of chronic pain! BTW: My lower back is still perfect--no pain at all.
02-02-09: Yesterday was very good (low back pain 99% gone and left leg pain and burning mostly gone too); however, I only got out of the house (out of my recliner) for about two hours and didn't walk. Today, I was in the recliner working / studying almost all day and was damn near perfect until I decided it was time to exercise a little. I went for a 40 minute walk (flat and very slow) and the left leg, almost immediately, started cramping up, twitching and burning (mostly on the front of the thigh, which is new). Although I was only up from my chair for about two hour (I also did some work at the office), my left thigh is not too happy right now (it's bed time); it's about a 3/10 in the chair and is very very sensitive to the cold. I'm afraid something is amiss (like another blow disc), for the cramping is not a good sign--it may mean the motor roots are involved. I've got to work a little tomorrow (four hours), which is probably not going to be fun. Weird how I have zero lower back pain, yet all this burning (like a sun burn) pain in my left thigh, leg and foot. I'll give it another week, then I'm off to the MRI tube to see what I've done this time. I'm also planning to get an ESI quickly this time--as I know that a lot of the nerve damage of radiculopathy happens within the first few weeks. Hopefully I'm just freaking out, but the inability to walk well makes my prognosis less favorable.
BTW: thanks for all the e-mail and well-wishing! I do read all my mail! :-)
01-31-09: Surprisingly, the lower back pain is 95% gone (it was 85% gone yesterday) and I slept well--I was able to sleep on my right side. However, as I feared, the dreaded sciatica is back and in a strange pattern (basically it shifts between S1, L5 and/or L4 on the left (mostly in my foot). It's worse today and about 4/10 while up and 2/10 while in my chair. Very hard to figure this out. My educated guess is that it's a "memory" type of nerve pain that was ignited by the acute muscle spasm pulling on my lumbosacral plexus; hopefully it will settle down in a week or so. I was basically off my feet all day except to eat and a quick trip to the post office. Tomorrow, however, I'll start a little walking (20 minutes max) and pray this doesn't get worse. It's very rare to have lower limb pain (i.e., sciatica) without lower back pain; however, this is exactly how my sciatica started in 2002--and we all know what a nightmare that was. Gut feeling is, it will pass within two weeks. If not, it's off to the MRI tube. I needed no more Soma but am taking the Voltaren 3Xday (but it's starting to bug my stomach already [see what I mean about nerve memory]).
01-29-09: I was right, I didn't sleep well last night, Soma notwithstanding, but I am walking better this morning. That Soma really knocks out acute muscle spasm--I'm not "bent" to the side (antalgic listing) nearly as much this morning. The problem is, after only 15 minutes of standing, my left leg is starting to burn! I hope this isn't a bad omen. I'll be spending the day (and probably the next 3 days) in my trusty recliner catching up on a lot of work. I'll keep taking the Voltaren three times per day, but only will take the Soma at night, and prey to the gods that the sciatica does not ignite into a blaze... like last time. Keep your fingers crossed for me! Time will tell.
01-28-09 (bad aggravation) : Well, I was doing doing tremendous! In 2008 I didn't have a single bout of pain (maybe a pinch of back pain once every three months but no leg pain) and was working / studying full power--could sit all day if I wanted. Recently, I was even able to start jogging again, which I mixed in with my walks--about 10 miles per week. BUT, now I may have screwed up big-time. WHAT IS IT ABOUT THE MONTH OF JANUARY!
For the past month or so, I have been moving my office to Morgan Hill (my home town) and this time did it all by my self! I was lifting up to 100 pounds with ease, bending, twisting, stooping, and crawling. I even build three huge and heavy shelves from scratch to hold all my files; I felt as if I was a thirty-year old.
Then, today at noon, I got a strong "twang" of pain (really only a short burst of muscle spasm like blowing a hamstring while running) in that same old spot (lower back, left paravertebrals); I immediately knew I had gone too far and f*cked up. You see I had just finished pushing a 300-pound desk away from the wall (damn electric plugs went out and the electrician [who was obviously smarter than I] wouldn't move the desk) and thought all was well; however, about five minutes later, while bending over to pick up some cords, the spasm struck. I immediately broke out into a cold sweat--not because of pain, but because of fear that I had awoken the "beast" that only about 5% of us humans know of (i.e., sciatica).
I jumped on my therapy table immediately and covered my back with ice, but that only gave me enough relief to get home. By the time I got to my recliner, I was bent to the right with muscle spasm. I could, however, get fairly comfortable in my favorite recliner but am unable to walk without a belt and walking stick. I called a doctor friend of mine (thanks Dr. S.) and now have some Soma and Voltaren to start the battle. I bet this night will not go well. At least Mr. Sciatica (which is the beast I fear most) hasn't showed up... yet.
11-01-08: Doing fantastic! I can run now (well only about one mile max) and walk for as long as I like. I was sitting for 6 to 8 hours per day without problem and even could take on some hills on a three hour hike I was doing once a week (while studying MCAT CDs). The bad news is that I didn't do so well on the MCAT. Only a 17, which is a long way from the need 25ish to get into DO school and 30 needed to get into medical school. I didn't have nearly enough time to study for the thing and will take it again next summer or spring. I did, however, get accepted into two second tier off-shore schools, but at my age, I can't afford not to land a good residency program secondary to graduating from a sub par school. So back to the books! Speaking of books, I was required to do two years of Pre-Med in order to show admissions personnel that I was very series about entering medical school. I ended my last semester with a 4.0, which gave me a over-all, pure science gpa of 3.7. But now, at 48, I'm out of time and must get in very soon.
06-24-07: I continue to do well and feel like I've gained even more function with the passage of time. Most days of a month, I have no pain at all and am on no medication other than 3 to 6 advil per day, 5 days out of on month. The flexion/distraction treatment--which I can finally tolerate--also seems to be helping my recovery. I did, however, have one noteworthy flare-up about a month ago: I had my walking up to 10 miles per week including (for the first time) some rolling hills (200 feet worth). At my own pace, I was doing well; however, my wife decided to join in on a long 3 mile hike in the rolling hills. She walks much faster than I and I, foolishly, attempted to go at her pace in stead of my own. This flared-up mainly my lower back and even sparked a little bit of sciatica for about 1 week; thankfully, I completely recovered. On the school front, I finished my first year at San Jose State (3.4 gpa) but had to take off this summer to prepare our house for sale. I hope to begin school again this fall. And, I've finished up my BS in applied biology. If I only had time to give the bike a try again--I bet I could do it to some degree, but I better (at least for now) stick to what has been working: walking, the activities of daily living and the occasional flexion / distraction treatment.
10-18-06: I scored a 20 on the four year Oswestry! Too, I've been inducted into the Hall of Fame -- Ferris State College. [here] But boy what a price I paid! I definitely wouldn't encourage your children to take up Hammer Throwing! I continue to do well and have had the best year since my injury. Still preparing for the MCAT via finishing up my BS at San Jose State University. My walking is up to 5 to 7 miles per week over mostly flat ground. My ability to lift is also increasing as I have to lug heavy books around (30 pounds worth). No time for exercise and it's too cold for swimming (although it was 80 degrees here in San Jose today). Just walking and the activities of daily living for me. I've also been able to finally get on my Leander table and tolerate a little easy flexion / distraction. Now if I can just pass this damn Genetics class!
08-09-06: I've finally got some good news to report: I'm getting better. Although I'm a far cry from the man/athlete I used to be, I'm definitely continuing to improve year-by-year as this has been hands down my best year yet. And, for the first time since my injury of 2002, I've been able to exercise via swimming. In fact, I just got back from a 3 week vacation in Hawaii where I was able to swim almost every day from 20 to 30 minutes. I also had no problems sitting for the five hours required to get there (which really surprised me) and was able to go deep sea fishing for six hours on a fairly rough sea (I only needed on 50mg Voltaren afterwards). Of course, I completely avoided lifting those heavy (50 pound) suit cases (luckily my wife has a super-strong back) and walking over uneven beaches (I have a four day flare-up in late June from trying to hike a very steep mountain), but all-in-all things are going a little better. I still have minor exacerbations two or three times per month that require a few 800mg Ibuprofens or - even better - a few Voltarens (which really works well for me [thanks Dr. Soozani]), but things are going well. Now, if I can get some weight off (I'm up to 220) maybe things will even be better.
Another exciting realization is that my sciatica (an other weird wide spread pain) is basically gone. All of my last big flare-ups have been related to low back pain. In fact, my last exacerbation of leg pain was over one year ago. I still get some numbness and tingling in my left foot, and still have weakness in my left quad and calf, but other than that, the dread sciatica has disappeared.
On another front, I'm also strongly contemplating a MAJOR career chance: I've began studying for the dreaded MCAT and will be taking some classes at a local university to help me prepare. If I can pull it off and get a good grade, it's off to Osteopathic or Medical school for me... stay tune for this Odyssey.
01-07-06: THE CURSE OF MONTEREY AND JANUARY? It's been three years since my three-level radiculopathy (sciatica) started that, Ironically, originally occurred the day before a scheduled vacation to Monterey in January 2003, and one year since my last big flare-up of back pain, which again occurred the day of a scheduled vacation to Monterey in January 2005! January 2006, amazingly, again brought a huge aggravation of back pain that started on X-mas day when I slipped and fell down three stairs on our wet deck stairs. I cracked a rib and got that dreaded delayed pain reaction. Although the sciatica rose to a level 4/10, my lower back completely flared-up (four days later) to a 8/10 for a couple days. In fact, strangely, the worst of the back pain and right antalgia (bent to the right secondary to muscle spasm) occurred the day of my first mini-vacation to Monterey in a year. New Years eve sucked as I suffered though our party at the Aquarium (which was wonderful!), with 8/10 pain that even margaritas couldn't cure. Thank god for Soma, which worked miraculous for breaking my spasm on 01-02-06 (I allowed the severe muscle spasm to stay for one day to protect whatever was inflamed) and allowing me to have a relaxing four days with the wife. I didn't miss any work, and am only taking 600mg of ibuprofen per day at this point as the back pain is down to a 4/10 and I successfully treated three days in a row (45 patients) and made it through my 4 hour CPR re-licensing class yesterday and a birthday dinner last night (12 hours on the feet).
All in all, however, the last 5 months has went pretty well, although I haven't tried anything physical and stopped walking. I have been able to take the wife out dancing a few times without major flare-up, which was very nice. I would have to say that it was the best five months I've had since this whole pain syndrome started back in 2002; I even made it though the 3 hour + King Kong movie without incident and all that incredibly weird extra-territorial pain (upper limbs, tummy, and face) is long gone. Over 2005, I've had more trouble with my lower back than my sciatica (which is a good thing... I guess), which seems to be a typical post-discectomy phenomenon. To combat the lower back pain, I returned to my basis core exercise program, which has worked great at keeping the lower back pain in check. I may start some weight lifting and try an elliptical trainer, for I gained back all that weight I lost biking (now 210) and long to sweet again! Unfortunately, my 3-year Oswestry continues to demonstrate a Moderate Functional Disabillity as I continue to be in the low 30s. [Oswestry @ 3 years] "I can Work (with limitations), but still can't play."
08-26-05: All in all, the last two months have went pretty well; however, the swimming attempts have just plain failed. More explicitly, I attempted a two week, every-other-day, course of swimming (without even using my left leg [I just dragged it]) once in July and again in August. Although I only swam for 10 to 15 minutes at a time, by the end of two weeks, the sciatica and low back pain flared-up and forced me to begrudgingly halt. The last flare-up of back pain only, lasted one week and the pain got up to about a 5/10. It seems that as long as I don't do any form of exercise (swimming, walking, biking), I do pretty good; however, heaven forbid I try and get some aerobic exercise! I hate flaring up!! On the drug front, it's been over a year since I've need percocet and rarely need anything other than an occasional (once per month) 600mg of Ibuprofen. [I haven't needed Soma since January 2005] I still enjoy our biweekly margarita outings; this seems to help keep the edge off the pain. My ability to treat patients is also rising: although I must confess that I've changed my technique to prevent any lateral forces from being inflicted upon my back... I keep all my traction and myofascial release working "centered" and absolutely love my new Leander table - as do my patients. I'm treating about 60 patients per week (evenings only) and writing disability reports in the AM. The number one problem now, is my weight! I'm back to 210, which seems to be my natural weight... hopefully... I love to eat, it's one of the few pleasures I have left (I can't throw the hammer, I can't lift weights, I can't run, I can't ride bikes, I can't hike, I can't play hockey, and I can't surf). Ironically, I remember when I first started my journey into the land of pain and disability. I met a female RPT who was 'cursed' with the same physical limitations as me: she would work as a physical therapist, but couldn't do anything remotely physical. I remember thinking that it would be impossible to be so handicapped and thought she must have a psychological problems of some kind, for if I were her, I WOULD OVER COME . Little did I know that I was in for the same fate as her. I can working in a limited manner, but I can't play at all. What's next? I think I will go back to my core exercise program for a few weeks (I haven't did my core for months) and then start walking again. My goal will be to walk for 90 minutes and complete the rolling hill course that I 'blew-up' on back in January. I've got to keep fighting. One thing strange about the swimming flare-ups: it (the swimming) seemed to 'stir-up' my centralized pain and that arm, tummy, and even face pain slowly returned ever so slightly. How very strange is the nervous system of a chronic pain patient who's sensitized.
06-26-05: I've pretty much made it though that 'crazy' period and things have settled back down. I've started some swimming (instead of walking) and seem to be doing pretty good thus far, although I'm only able to go for about 10 - 15 minutes and I must drag my left leg though the water. I still get some faint hypersensitivity to the cold (air condition especially) on all the extraterritorial regions mentioned below, but this is really (currently) not at all irritating. Chronic pain is a strange beast! I've been able to modified my flexion/distraction treatment so it doesn't 'kill me' and can now see about 50 to 60 patients per week.
05-13-05: Well, I guess it's not over and I'm really losing it now!: Honestly, I'm hesitant to even post this latest development, but since I'm already let 'it all hang out' here goes: I've suffered another flare-up of strong left limb sciatica for god knows what reason. The best I can figure, is that I had a 12 hour day Monday that included a 3 hour evaluation, climbing three flights of stairs with my 20 pound brief case (elevator was broken), treating 12 patients, and a 1 mile walk. The next day my f*ucking left lower limb burned all the way down to the foot. The other bizarre arm burning also came to visits on that day and continues- but not so strong this time; however, on day three the left side of my face (that's right, the left side of my face) began to get that same cold-burning and hypersensitivity to the cold (I could barely stand the air conditioning hitting my face today at work)! WTF!
I guess I officially have 'wide spread pain' (which I don't even believe in) with thermoallodynia on top of my chronic sciatica! Strangely, I have no sensitivity to touch or heat that is often classic of CRPS (RSD); it's only the cold that hurts, although I am sensitive to even the sun light hitting these areas when activated. I should add (I'm not sure if this has anything to do with this latest incorporation) that I also burned the heck out of the left roof of my mouth on some pizza the day before this happened. My roof is still super sensitive as well.
BTW: My 3 tesla MRI of the spinal cord was normal (no sign of lesions), although I passed on the brain MRI.
All I can figure is that my brain is super sensitized and every time it gets hit with another dose of incoming pain signals from the original - undiagnosed, un-understood - injury, that area in my brain grows and incorporates more and more territory that becomes sensitized, hence signaling it's zones of the body to feel pain as well (even though there is nothing wrong with these areas). Ironically, the only areas of my body I haven't had this cold burning pain is my middle back, lower back, butt, back of my thighs and legs! Go figure!
Again, this is the most amazing phenomenon, for I've heard patients complain of such things over my 18 years, but never really believed them... but now... I do. I was talking to a PM doctor that I work with whose main practice is acupuncture. After telling him my story of wide pain-spread, he responded that he here's things like this all the time and is not surprised at all. [I'm still chicken to do the acupuncture but I'm considering giving it a try.]
I guess, I'm now going to have to get in to see that neurologist to get work-up for all the usual suspects, but I bet they will find nothing. I should probably get back on the meds, although I hate medication!
The only good news to report is that I've had no lower back pain in months! Probably because I've been unable to go on my mile + walks any more.
ASSESSMENT: I still believe that my nerve root(s) was/were internally damaged by a cytokine bathe as a result of grade 5 IDD (leaking discs) that resulted in some sort of immune-driven inflammatory attack against my own nerve roots. However, this crazy extra-territorial pain is really unexplainable. There is no research on extra-territorial pain to this extent. I should add, that I'm under a tremendous amount of stress right now, which I'm sure is contributing to this 'perfect storm' of pain run amuck.
I would say I must have some neurological disease except for the fact that these pains ONLY OCCUR AFTER A FLARE-UP OF MY ORIGINAL LEFT LOWER LIMB SCIATICA. In fact I never had any of these extra-territorial pains, until after the microdiscectomy... this was the first time I started getting arm pains. It's almost like chronic pain - in some - is like a cancer that slowly takes over more and more territory in the cord, thalamus, and sensory cortex, hence resulting in the patient feeling pain in many different locations that are far away from the original site of pain.
This f*cking pain and their crazy accessory pains are becoming quite f*cking annoying! I'm just wondering what the future holds?
04-23-05: Ok, it's over. But boy was that a nasty flare-up of sciatica and secondary arm pain! It drove me to get a new gadolinium enhanced MRI that showed no recurrent herniation or major scar tissue but, amazingly, demonstrated a severely "inflamed" S1 root; so inflamed that a rare MRI phenomenon occurred, one which I've never seen before: the S1 root glowed bright white (indicating inflammation/congestion/water content) all the way up (L5 through L2) through the axial views! A severely inflamed nerve root, yet no visible sign of compression? Hum, how exactly does that happen? MS, the head radiologist for LG MRI was dumbfounded as we gazed at this phenomenon. The surgery I underwent definitely had no chance for the disc at L5 was/is not the problem... All I can figure is that the root is snagged-up somewhere, probably within the sacrum (S1 foramen) or maybe it's just scared and hypovascularized internally to the point anything (like a boxing match) set it off. This is definitely a lesion that sciatica is much more complicated, in some cases, than disc-meets-nerve. I've got pictures coming... And, all the weird arm burning is completely gone. I did have to go back on percocet and neurontin for three days but that was all I needed to beat this down. This last week was great (although no exercising or walking) as I worked five 8-10 hour days without too much problem... other than sitting - which I avoid like the plague.
There is absolutely no doubt that my pain has become centralized and will manifest to secondary places (bilateral arms) if aggravated. Simply amazing... If this wouldn't have happened to me, I'd say it was impossible and I probably was nuts or had the mythical fibromyalgia. But I don't... just a case of extraterritorial pain gone amuck. [no more hot massage cream for me... my patients will get over it.]
04-01-05: It’s been many months since Mr. Sciatica has reared its ugly head, but boy did I have an ‘attack’ over the last three days:
I had been doing pretty well with my low back pain, sciatica, and strange mirror extra-territorial like arm pains so far this year, but all that changed over the last few weeks.
Believe it or not, (and I know this is going to sound like I’m loosing it) this massive attack of burning neuropathic pain, which not only struck my left foot (as usual), but also hit my whole left and right lower limbs and upper limbs as well in a completely non-dermatomal pattern, all started when I switched massage creams! I kid you not! Here's the story:
I wanted to start using some a salicylic-based hot-hot-hot massage cream (camphor) that would leave a more lasting effect on my patients (I do about 7-10 minute of massage as part of my usual treatment on each patient). Little did I know that this extra stimulation on my own skin would awaken that weird neuropathic-induced extraterritorial type pain in my arms and forearms, BIG TIME!
After a few days of using it (the hot-hot-hot massage cream) (some always got on the back of my hands), my forearms and arms began to burn long after it was removed from my skin and even lingered later and later into the night. Finally, it got to the point where it hurt more than my usually daily left foot burning did!
Stubbornly, I refused to admit that this allodynic condition in my upper limbs could be occurring so very far away from the original injury site in my lower back and continued to use the cream, much to my patients delight. But after a few more sleep-disturbed nights, do to that burning upper limb pain, I finally threw that massage cream out. AND, low and behold, the burning upper limb pains were gone within two days!
THERE IS NO QUESTION IN MY MIND (no pun intended) THAT MY SENSORY CORTEX (BRAIN) HAS UNDERGONE SOME TYPE OF BIZARRE NEUROPLASTIC CHANGE AS A RESULT OF MY UNTREATABLE L4, L5, AND S1 NEUROPATHIC PAIN SYNDROME.
Just as I was about to write of this ‘painful experiment’, I did something so stupid I’m embarrassed to post it: while under the influence of a bottle of red wine, I decided that I needed to sweat and hadn’t tested my ‘electric fence’ lately! So I proceeded to put on some boxing gloves and go more than a few rounds with my step daughter (who should have been my hammer throwing champion, for she is built and as strong as an ox!) What fun we had! For about 30 minutes I was sweating like crazy for the first time in well over a year.
BOY DID I PAY FOR THAT! The inevitable ‘delayed’ sciatic pain attacked a full two days later and took me out of work for the first time since my surgery that was well over one year ago! BUT this attack of sciatica not only ravaged my left lower limb and right medial knee (as usual), but this time burned in both lower and upper limbs as well, and I mean strongly! What have I done! Did that experiment with the hot-hot-hot massage cream now super-sensitize my upper limbs as well! This allodynic upper limb phenomenon is NOT coming from the dorsal cord, it's coming from the brain stem, or brain itself!
Luckily, I’m feeling about 70% recovered today and was able to treat four hours worth of patients this afternoon.
So, it seems that all of you e-mailers who have also experienced this bizarre extra-territorial manifestation of pains – miles away from the original pain site – maybe weren’t as crazy as I once through you were! Some of you warned that this might ‘spread’ and it appears like you were correct. Or maybe I’m just going crazy as well! LOL (sort of)
I’m now convinced that many of these cases of the mythical FIBROMYALGIA are really nothing more than the phenomenon of CENTRAL SENSITIZATION AND NEUROPLASTICITY done amuck.
It seems I’m really living in the WHACKY WORLD OF CHRONIC PAIN now! The big question is how in the hell do we stop this nonsense! Other than not piss-it-off!
As a chronic pain sufferer, medical professional, researcher, and scientist; I am both completely amazed by the manifestation of this unreported form of extraterritorial pain, but also a little terrified of its future course.
Furthermore, I’m convinced the surgery (massive afferent nociceptive attack upon my dorsal horn and sensory cortex) I had somehow trigger this widening of my symptoms. As I recall it (and I know I noted the birth of this upper extremity neuropathic pain back in my diary somewhere), it first appeared about two weeks after that fruitless attempt at alleviating my sciatica – L5 microdiscectomy; however, I did have that strange appearance of right medial knee pain (which is a closer form of mirror pain) even before the surgery.
It’s ashamed I’ve had this set back, for I was almost going to post that I’ve finally made a step forward in regard to my lower back pain, which had grabbed center-stage for well over 6 months. I simple returned to religiously doing my ‘core’ program and boy does that seem to help the lower back pain – which as been mostly in remission since my last big attach back in January. More explicitly, I would do my core program for about 30 minutes, and them walk – flat – for 30 to 60 minutes… three times per week.
01-28-05: An interesting change of symptoms has occurred over these last two months: the lower back pain is now bothering me more than the lower limb pains! The sciatica is always there but it seems to be losing some of it's bite. But the low back has definitely grabbed the stage as of late. I have had two pretty big flare-ups in early January, both from pushing my limits of walking (of all things). It seems the minute I go over about 60 minutes of walking (especially when hills are added) I pay. BUT the pain, unlike in the past, is now low back pain!! Humm.. In fact, the day of our planed Monterey vacation, I had the worst flare-up in a long time (over did it hiking), which required the usage of Soma to break back spasms and wrecked my New Years party! (Maybe I should stop going to Monterey, for my sciatica started for the first time ever the day of a Monterey trip in Jan. 2003! LOL) My Oswestry hasn't really changed much (I'll take it again at the one-year mark - post discectomy). My biggest disappointment - besides the fact I can't do anything physical - is my inability to treat patients. I'm good for about 10 per day and that's it; the lower back just can't take it. Interestingly, I met another Chiro whose wife, who is also a Chiro, had a "successful" micro-discectomy about two years ago. Coincidentally, she is also limited to about 10 patients per day (they use the same Chiro technique as I - Cox flexion/distraction) and is quite limited in her ability to treat.
The best surprise, however, was my 16 hour relicensing weekend: it when pretty damn good! Much better than last year (which was what pushed me into micro-d in the first place). Although I stood through most of the 16 hours, (and boy did I get some bewildered chiros and MDs asking me why I had to stand all the time!) I definitely handled it better than last year. My ability to be 'up' is certainly much much better than one year ago, however, sitting is definitely continues to be my nemesis, for it will set off the leg pains like clock work if I am forced to sit.
So was it the Micro-d, the passage of time or just knowing what I can and can't do that has increased my sitting and standing capacity? It's really impossible to know for sure; maybe it's a combination of all. Still, the goal of the Micro-d was to get me back to treating 30 patients + per day, and (more importantly) getting me back on my bike. In the latter respect, the Micro-d has failed miserably. Would I repeat the micro-d if I could have a do-over? Humm, ask me next year.
Treatment wise, over the last two weeks I've stopped the walking completely and went back to my core exercises again (I had stopped all exercise and just was walking) in hopes of decreasing this lower back dysfunction. I've also (gleefully) started a tiny bit of stationary bike riding again. I've got to get some sort of cardiovascular stuff going here; not only to combat my ever-growing tummy (now up to 200 pounds!) but more importantly, to keep my ticker and lungs in some form of shape. And finally, another thing I've been doing (which isn't recommended) is having two 'margarita' nights per week. About three strong margarita's really seems to help get me through the week. All that strange mirror arm pain is gone and the right inner thigh is much less bothersome as well. Naturally, besides the bi-weekly alcohol, I take no medication at gal... not even advil.
I've got a sneaking suspicion that I'm going to recover just as the patients in the Weber study did... little by little, slowly but surely, for about 7 years (barring exacerbation) and the leg pain - as in the Weber study - will finally be a thing of the past... but not the back pain. Hopefully, I wouldn't spiral into progressive degenerative disc pain and be forced into fusion. I sure hope not! Most of the Weber patients didn't.
Have I mentioned my recent bout of carpal tunnel / over-use syndrome yet? Yet another challenge for me and my aging body... although it's nothing compared to my back/leg problems... I think that's all I'll say about that latest curve-ball life has thrown at me.
11-28-04: The last six weeks has went pretty well, i.e., no major flare-ups and my no need for pain medication streak continues. I've stopped doing all exercises and have been focusing on 'walking'. I'm walking over flat ground four to five times per week (three days on, one day off) and have managed to build up to 45 minute periods. Although this is a long way from the 5 hour mountainous bike rides that I used to do, I'll take it. I believe I'm almost back to my pre-surgery levels for walking, although I still am getting cramping in my foot and solius muscles after about thirty minutes (which I didn't have before surgery), but hopefully this will pass with time.
I'm also able to work 8 to 10 hour days AS LONG AS I DON'T GO OVER MY LIMITS. It's like my world is surrounded by an 'electric fence' (did I say this before?): as long as I don't touch the metal fence (surpassing my limitations to lifting, bending, standing, walking, and especially sitting) I have a pretty good day. Sitting, in particular, just kills me! I avoid it like the plague, unless it's in my favorite recliner.
About two weeks ago, I was forced into treating all of my patients, for my associate doctor got sick. I successfully treated 32 patients (26 flexion/distraction treatments, 4 re-exams, & and did two new patients) and did not suffer much of a flare-up the following day. This is a long way from the 60 plus I used to treat in the good-old-days, but it's a record for me since my sciatica started over two years ago. Was this accomplishment the result of the microdiscectomy or the work of 'grandfather time' and 'mother nature'? If I were to believe my surgeon, who told my the surgery had failed after about 2 weeks, then the answer is 'time'.
And, finally a piece of good news (which is a rare occurrence these days since our "governor" has pulled all work comp patients, past and present, from chiros and private MDs): I did pass my test, again, and am now a QME doctor licensed to perform disability evaluation through the DWC (state of California). However, with Chiro's basically getting the boot from the Workers' Compensation System, it is doubtful that there will be many injured workers around to be Chiropractically evaluated. Time will tell, but I sure wish I was strong enough to go back to school to become a DO! Next year is going to be tough!!
10-18-04: It's been about two years since my injury and my life has been devastated! I still can't, despite the microdiscectomy of February 2004, do any of the following things: ride a bike, swim, hike, skate, dance, surf, golf, or do anything repetitive with my lower limbs. The surgery of some 8 month ago hasn't done squat, except give me a case of mild to moderate thermal allodynia and greatly worsened my ability to walk. I still can't even go down the stairs normally; I have to go one step at a time. I can't walk over a mile and that mile has got to be flat. I guess that I should be grateful that I still can work to some degree, although I've failed to be able to treat more that 12 to 15 patients without paying for it the next day.
As you've probably noticed, I'm in another fowl mood because I was forced to take a three hour seated test on saturday. I was allowed by the moderators of the test, one 5 minute stand-up break, but that really didn't do much. I'm suffering again with that same damn burning pain in my left foot (L5 and S1 dermatome), right medial knee and that strange burning sensation over the left lateral elbows (which only occurs during a flare-up). I'm still not bad enough for drugs though; however, if my pain level goes over a 5 or 6 tonight, I might have to take a percocet (I hope not, for I haven't need any meds for almost 5 months now). I've got the dreaded relicensing seminars approaching which is going to kill me! Living life in pain sure sucks SH*T!
THEORY: I've been reading a lot about the phenomenon of 'Pathological Pain' (aka: Neuropathic Pain) and have come to the conclusion that I'm one of the unlucky few that, for reasons not understood, have developed a true 'Central Sensitization' which has resulted in a increasing 'Thermal Allodynia' and hyperalgesia of my left foot and right inner knee. The strangest thing about this pain is that if, and only if, I go over my limitations and flare myself up, I will get a burning-stinging pain over both lateral elbows! This has got to be some sort of combination between 'Mirrored Pain' and Extra-Territorial Pain'... it's most bizarre and if I didn't know that these things were possible, I would swear that I was loosing my mind! I've heard a few patients complain of pain similar to mine over the years but always kind-of thought they were a little 'crazy'... but now I believe!
I believe the microdiscectomy, despite the good intentions of Dr. XX, released a tremendous nociceptive-insult upon my dorsal horn and brain stem and only worsened the hypersensitization phenomenon and caused neighboring nerve fibers ("innocent bystanders") to also become 'hyperactive' as well, hence the spreading of my pain to unrelated body parts. Why only some people react in this manor is a complete mystery. Even M. Dev or, who is one of the worlds leading researchers in this area, has noted the rarity of this condition. He used the example of Herpes Zoster (Shingles) which usually leaves its victims pain free after 6 to 12 weeks; however, in some people Herpes Zoster can also lead to chronic life long pain, sometimes so severe that the patient contemplates suicide! Why? Why do some people recover from Shingles (a condition of the A fibers within the sensory nerves) and others suffer life-long pain? The answer would probably help explain why some people also react violently to disc herniation/leak-associated radiculopathy and other don't. We just don't know why or really what to do about it. Hopefully, someday researchers will figure out just how to 'unwire' somebody with chronic pain. Sometime I think this has got to be some sort of bad dream:( I wish I could awake.
9-26-04: All in all, this has been a pretty good month, as I have had no major flare-ups and continue to need no medication - other than an occasional glass of wine. I've been working 8 -11 hours per day in preparation for the 'Arnold-induced' Loss of Workers' Compensation patients that will devastate many of the private practices of MD's and DCs here in California. I've cut my exercises down to 1 time per week and am treating between 10 and 15 patients per day but can't do much more than that.
Treatment wise, I've decided to leave things alone, i.e., no more poking or proding of my back. Dr. Carragee's final words, "I'm not sure I can justify performing a fusion on someone with no lower back pain", have confirmed my suspicions that I'm caught, once again, in Limbo-land... not bad enough for a fusion, but not good enough to resume a normal life.
Interestingly, I continues to have an apparent, real-live, case of 'Central Sensitization' with associated thermal-allodynia, extra-territorial pain, and/or a form of Mirror Image pain. I may be posting a page on this most complex and facinating subject.
8-24-04: (Eugene Carragee) Yesterday I saw the famous, Volvo-Award Winning Dr. Eugene Carragee of the University of Stanford. He was absolutely wonderful; a kind and compassionate man. He had me fill out a battery of tests, including the ZUNG, Oswestry, and MSPQ. He reviewed all my MRI's, pre and post discectomy, CT, Myelogram and examined me (as did he PA who was also great). Like all the other doctors I've been to, he is also stumped, and a little concerned that I'm getting some bilateral outer arm 'burning' that mirrors my inner knee pains. He said he has seen a few other cases of discogenic referred lower limb pain but he's still just not sure what's going on. He noted that small contained herniations do not do well with surgery (as I've known all along), especially when the patients straight leg raising was normal (as mine was and still is). He also noted that since the EMG was not even positive for 'true' S1 radiculopathy (only positive in the paravertebrals and not the calf) there was not much proof that the L5 disc disc herniation was the problem in the first place. He did say, after my wife said that I have been a tiny bit better with respect to being able to be 'up' for the whole day, that maybe I would slowly continue to improve.
THE PLAN: I'm going to one of Dr. Richard Derby's old associates, Dr. Conor O'Neill MD to have some pure diagnostic blocks (anesthetic only) of the S1, and then L5, and then L4, and then maybe some combinations of roots to see if this pain is coming from a damaged nerve root(s). If none of the blocks work, then it's time for the dreaded provocation discography to see if that can reproduce my pain syndrome. He said that I was an excellent candidate for discography (which was quite a statement coming from the man who is the #1 pessimist on discography.) He also wants a flexion/extension study to make sure things haven't gotten unstable. Like Dr. XX, he said he would be very hesitant to perform fusion on a patient without much lower back pain - like me (5% low back pain, 90% leg pains). I see the doctor again in about 1 month. I just hope I don't get severely flare-up from an accidental 'needle-stick' into my nerve root!
SIDE NOTE: I asked him about Dr. Yeung's SED procedure. He said, as did doctor ZZ, that he's seen some patients who have been hurt by this procedure and that it's just not reliable or "reproducible". I asked him about the use of infliximab (the anti-tumor necrosis factor alpha drug) for sciatica. He wasn't familiar with it but said that Stanford is conducting a double-blind investigation on another anti-tumor necrosis factor alpha drug right now. He said that he could be me the 'real-drug' to try as a last resort to fusion - if it comes to that. He couldn't remember the specific name of the drug that Stanford is testing.
MY THEORY: I still believe that my nerve roots - for what ever reason - have been permanently damaged by leaking nuclear material from the L4 and L5 disc. Some patients (certainly not all) seem to react violently against their own 'foreign' disc matter. I think I'm just one of the unlucky one's who are 'allergic' to their own disc material. The minor compression from my disc herniation had nothing to do with my pain syndrome (as I've learned the hard way).
Another thing: I seem to be developing a true centralization of my pain with 'spill-over' into the upper limbs. I've been studying the phenomenon of neuroplasticity (aka: neural plasticity) and believe that my wiring is screwed-up from the constant, daily, bombardment of pain signals coming from the damaged, spontaneously-firing, and hyper-sensitive nerve roots and maybe the disc.
Here's the story on this arm pain: If I really flare myself up, not only does my left foot and right inner knee burn/sting like hell, but both of my outer elbows also faintly burn! This is one of the weirdest feelings I've ever had! Once I lay down and the pains slow subside in this order: arm pains, right inner thigh pain, and finally the left foot pain.
Now that I've developed this non-injury-site-related secondary referred pain (which is probably coming as a result of 'Sensitization' in my sensory cortex (the brain)) in the arms, I feel terrible! I've had patients over the years tell me things like this but I just never believe it could really happen!
8-14-04: I'm just getting over a pretty big flare-up which almost put me back on the medication. I haven't been able to exercise at all for the last two weeks and have only today just started back on my core program - minus the 'squats' and minus the bike. I have been suffering through a full day of work, but can't seem to treat more than about a dozen patients. My up-time is pretty good (about 8 - 10 hours) as long as I'm careful. My stomach has recovered greatly since I've been off all medication - as the scale in our bathroom will attest to!
I think I can safely say that the surgery has failed although sometimes I try real hard to believe it wasn't all for nothing! After review my past Roland-Morris, Stanford Score, and Oswestry I'm exactly the same as I was before the surgery. The only difference is now I have a mild touch of RSD in my foot, my pain seems more non-dermatomal (probably secondary to centralization) and I've lost more power in my foot and quad.
I'm afraid this puts me back in the 'limbo-club' again, for I'm just not bad enough for another surgery (which may be ARD), or am I good enough to do anything remotely physical which includes ride a bike with resistance. This is NOT the six month report that I was hoping for! Damn this leg pain!!
I'm seeing the always skeptical 'Dr. Eugene Carragee' in two weeks. I've heard that he doesn't believe in 'discogenic sciatica' or 'discogenic back pain' for that manner. I'm almost positive that he's going to tell me to suck-it-up and live with it.
I had some e-mail conversation with our local ADR guru, Dr. Jim Zucherman MD of St. Mary's. After some history and looking at my old MRI at my site, he said this:
I greatly appreciated his offer but, again, I'm just not bad enough and the longer I wait, the better ADR technology will become.
The question is, what to do now? If I was giving myself advice I would say, 'just continue to do your core exercises, don't over do it, and give it another 6 months'. This is probably pretty good advice although when those flare-ups come its easy to through this sound advice right down the toilet! Give me ADR! I hate hearing those stories of how ADR patients are no out playing tennis and such! It's so tempting to run out and get one. But, I know that any type of fusion is a major ordeal and I'm smart enough to stay on the other side of the looking glass for now.
7-13-04: Things continue to go well for me. Sitting is still my biggest challenge but I can do it, although I still get the burning pain in my left foot and right inner knee after about 40 minutes. Interestingly, my lower back pain has been bothering me a little - this may be a good sign and indicate an 'unmasking phenomenon'. I still haven't needed any medication at all and continue to work 8 to 12 hour days, although I still take a half day on thursday and vegetated completely on Sunday. I'm still not up to treating 30 patients per day (which is where I need to be within the near future) but I can treat 10 to 15 patients every other day without too much pain developing (I still need the extra doc that we've hired). I'm thinking about canceling the Dr. Carragee appointment which is in late August, but I'll wait a bit longer. I took two weeks off all exercise and have now started back on my same program (My Exercises) including 15 - 25 minute on the stationary bike. I'm still taking things real easy and don't put any resistance on the bike. That's all there is to report at this time. I'm still not declaring the surgery a success...yet because I still can't do somethings that I could before the surgery but there are now things I can do that I couldn't do before the surgery - like work 12 hours and live to tell about it! 'Little by Little'.
6-27-04: I'm almost scared to type this, for it seems that every time I report improvement I "jinx" myself into another depressing flare-up. But, I've been doing much better again and have been off all drugs for over three weeks now. The last two weeks I've been working 8 to 10 hours per day, six days per week, with NO resting period at the half way point. I can finally say that this is something that I couldn't do before the operation. It seems that I've been taking 'two steps forward for every one step back'. Let's hope it stays that way. I'm still not calling this surgery a success yet, for there are other things that I could do before the surgery that I can't do yet.
I've been religiously doing this work-out and nothing more. I'm always a tiny be sore the day after the workout but overall, I'm getting stronger and stronger and able to have more and more 'up-time'. I'm even up to 10 minutes now on the stationary bike! I average three to sometime four 60 minute workouts per week.
There are still many things I can't do, yet, but I'm convinced that the stronger I get my 'core stabilizers' the more things I will be able to do in the future.
Famous Visitors at ChiroGeek.com: On 6-13-04 I received an e-mail from one of America's leading researchers in the field of disc/nerve-root related sciatic pain. Yes, the Volvo Award winning investigator, Dr. Robert R. Myers, contacted me asking permission to use some of my drawings in a paper he was preparing. He also had this to say:
Needless to say, I was tickled to death by this and offered to help him in anyway that I could.
Dr. Jinfu Lin MD, Neurosurgeon: As noted below, I've been in contact with a very gracious, hardworking, and now internationally known neurosurgeon from Taiwan China. Dr. Jinfu Lin, MD has asked me to co-write a research paper (for publication) on his experience with discogenic refereed pain, or as I like to call it, discogenic sciatica. Dr. Lin, who has just given a presentation on this subject to the "International Spine Society" in India, has collected a group of patients that had severe debilitating lower leg and/or foot pain (sciatica) but had no significant neural compression on CT, MRI, and/or Discogram. He believes that the L5 disc can refer a horrid radicular type pain into the leg and/or foot and that this discogenic pain response well to decompressive fusion (retroperitoneal approach). He fusion has given the lives back to many of these discogenic sciatica sufferers. This should be a lot of fun and I'll keep everyone posted on its progress.
5-30-04: Another Flare-up! Yesterday morning I tried to do a simple hamstring stretch, and for the first time ever felt a real pain in the butt and thigh. I wasn't sure if it was nerve or muscle so I continued the stretches and ignored the slight ache; three sets of 10 seconds was all I did. I suffered yesterday, all afternoon and again today. I'm back on percocet (which isn't helping that much today). My Memorial Day Weekend is ruined! I'm getting sick of this!
Input from afar: got a very candid e-mail from a Neurosurgeon from Taiwan. He did not want me to forget that the disc may still be the cause of this sciatica. He stated that he does get fooled from time to time into doing the wrong surgery (discectomy instead of fusion) and told me that sometimes its very hard to differentiate between root pain, and discogenic pain. This is the exact line of thinking of Dr. ZZ and makes think that its time to start exploring this possibility. This is the second weekend that I'm going to have to spend in bed! This discectomy didn't do squat for me other than move that 20% lower back pain down to 2%. I'm a little worried now that it may have worsened me. Maybe that disc needs to come out?
5-28-04: The flare-up is over, although I still have some residual left lateral thigh burning, and I'm back off the drugs again. I needed them for about 3 days. I had a very busy week! On Monday I had a 'weight-bearing-simulated' MRI with contrast. Talk about torture! They put you in a shoulder harness which resembles a straight jacket, attach the harness to the base of the MRI-bed, and crank you down (to simulate weight bearing) as much as you can stand; then they put you in the closed tube and tell you, "Don't move". Half-way through they bring you out (constantly reminding you NOT to move) and inject gadolinium (contract) into your vein. I've never had too much problems standing and honestly had more pain sitting in the weighting room than I did in the tube; although, it was quite uncomfortable and my chest is still a little sore today. I'll have the results up soon under "Doug's Story". Everything basically looked good; there was not too much scar tissue, no recurrrent herniation... anywhere, nor anything else of much interest. The disc herniation is definitely gone and you can see the swelling and scaring residual well into the disc. I got to spend about 20 minutes with Dr. Caulton (radiologist of Los Gatos MRI) as we scoured my scans for anything that could account for my continued root pains. There wasn't much too see, other than a "very deep looking" anular tear at L4. His theory is the same as mine: permanent nerve root damage (intraradicular fibrosis) from biochemical-leakage at both L4 and L5. Why some people are so sensitive to these biochemical is still unknown, but it is known that the size of the disc herniation often does NOT match the degree of the patients pain, nor neurological damage. Dr. XX still doesn't buy this theory.
Spine Surgeon Eval: On Tuesday I saw my spine surgeon (Dr. XX). When I told him that my sciatica was unchanged and maybe a touch worse he bowed his head and sulked! He seemed honestly saddened that the surgery hadn't worked, although he was happy that it had taken away all of my lower back pain (which is not what that type of surgery is designed for!). We went over my exercise program and he does not want me to rush into any other procedures...for now. I'll see him again in another 3 months. He wants me to not to push too hard but not be to 'lasa fair' either. He wants me to try and get back on that bike.
Yes, quite a week: To top it all off, my wife and I came down with a terrible case of food-poisoning on Wednesday. I was so sick I thought I was going to have to go to the ER and so did she, but we didn't. We are still are on a water, Gatorade, and cracker diet!
5-20-04: The downward trend continues. Now I've got that F*UKING burning pain down my left lateral thigh and I'm down. I haven't had thigh pain since way before my surgery. I have no idea what has happened but today I tried to do my regular exercise routine and I'm suffering the worst flare-up since my surgery. I've been having this new pain since my last walk (last friday). It's been 'on and off' since but not nearly as strong as it is tonight. I may even have to miss work tomorrow which will NOT be good since I've got three new patients on the books. How very frustrating these last few weeks have been, and just when I thought I was going to finally get some improvement. I really don't know how some of you people (MGH) have put up with this chronic sciatica for year after year after year! I've managed to stay off the drugs but that will change tonight for I really have to work tomorrow.
I had another very thorough EMG from Dr. Ali Soozani (who is the doc that does most of our clinics EMGs) last week. He 'stuck me' over 40 times (80 minutes) and everything was normal which I thought was good news; although, he reminded me that after 1 years time, the EMG is not very accurate.
I've got my weight-bearing gadolinium enhanced MRI this coming monday, so maybe we'll see something new. Why do I think that there will be nothing spectacular to see.
PLAN: Dr. ZZ (the Harvard Grad and Stanford trained doc we work with) still believes that IDD is causing all my troubles, even though I have only about 2% lower back pain which seems odd to me. Dr. XX believes that IDD will NOT result in pain past the knee and into the foot WITHOUT lower back pain. Ohnmeiss, has shown us that IDD can cause dermatomal pain that passes the knee; however, everyone in his study also had lower back pain. I really don't have any lower back pain (well maybe 1 or 2% lower back pain), just sciatica.
If my MRI is normal again, I believe its time for provocative discography to see if Dr. Derby can recreate my sciatica. If he can, I may be off to visit Dr. Yeung. Then again, maybe this flare-up will pass, and I will settle down, but I'm going to have to cut out my exercises - which will probably doom-me. I'm so sick of this sciatica! If I could cut off my leg and be pain free, I would do it! (unfortunately, the sciatica would still be there in the form of phantom pain.)
I'm probably suffering from 'intraneural fibrosis' of at least my S1 root, in combination with 'sensitization' of at least the S1 root, the cord, and possible the sensory cortex in the brain. This intraneural fibrosis seems to effect a certain percentage of people although we are not sure why some and not others. I've been reading a lot of the work by Freemont and Cooper who have shown that intraneural and periradicular fibrosis are very common in chronic sciatica patients. Since there is no real cure, there is no money for research into this area, so the research just stopped in the mid 1990's. Surprising they found NO INFLAMMATORY CELLS associated with disc herniation induced sciatica and even biopsied patients periradicular tissue during the surgical procedure to prove there were no signs of inflammation. So what's actually killing some of our neural tissue? We don't seem to know. I'll be addressing this more in my sciatica page - when I finish it. Probably this week-end for it looks like I won't be doing anything else.
Here's a quote from the above authors:
“It has long been recognized that pain, paresthesia, sensory deficits, and motor weakness are all clinical manifestations of neural ischemia with or without mechanical deformation, and that the natural response to such injury in time is neural fibrosis.” (62-66) 
5-12-04: (3 MONTH STATUS POST MICRO-DISCECTOMY): This has been a rather disappointing third month anniversary. My leg pains have been worsening somewhat with my increase in work load. Its almost to the point where I may need to go back on the percocet / neurontin again tonight. I've started treating patients again and the 15 full treatments today, lunch lecture, and PM new patients with x-rays was just too much today. (this work load is about where my 'road-block' was before the surgery). I think my walks may also be getting to aggressive, but the level two exercises seemed to be going well. I'm still not back to the level I was at before the surgery, although I'm close. I'm currently doing our 'level two exercise program' on day one, and a mile and 1/2 brisk walk on day two and rest on day three; then repeat. (two days on, one day off)
How frustrating it is to have apparently hit that the same f*cking 'road-block' I had prior to surgery. I just can't sit enough to get things done at work. I've sat a lot this week in attempts to catch-up on all my medical report dictation and transcription (which I do myself).
I would say at three months the surgery has greatly helped my lower back pain (which is not the intended effect of the surgery) which is virtually GONE but has really failed to help my leg pains. I've still got that same burning / stinging pain in my left lateral foot and the relatively new burning / stinging pain in my medial knee, distal anteromedial thigh, and proximal anteromedial leg; I've got secondary burning / stinging (which I can tolerate) in my L5, L4, and L3 dermatomes in my left lower limb. Strangely, I'm even getting some outer elbow stinging bilaterally that would mirror there stinging in my lower limbs. I'm afraid my brain has now become sensitized and is 'cross talking' with sensory cell bodies in the arms. I've become 'wired' for pain which is a 'bitch' to defeat!! Chronic pain is often a 'wacky' phenomenon although I prefer to hear my patients describe this 'wackiness' and NOT experience it myself!
I took the Oswestry Disability Test again and registered a 28% (moderate disability). This is not where I was hoping I would be but I think I've come a long way and hopefully I'll post a better score at 6 months.
I think its time to take get that pseudoweightbearing MRI and EMG just to see what I can see.
At this point, all I can do is pick myself back up, dust myself off, and try again.
05-04-04: Isn't this the part where I'm supposed to write something like "I'm terribly flared-up from lifting a sock off the floor"? NO, NOT THIS TIME! I continue to do well, despite my constantly pushing myself. Last Saturday I decided that I would do a health fair. I was up for 15 hours with no 'recovery reclining'. I avoided all the heavy lifting but did my fair share of making trips back and forth to the truck to load and unload all the 'health-fair stuff'. I even attended an emergency (a young traditional mexican dancing girl had a seizure, collapsed and broke a rib) in which I had to sit on the cement with the victim for 30 minutes - checking vitals and comforting - while we waited for the para-medics to arrive. I thought I was going to be sore for sure Sunday but NO. I had a little increase in right and left leg burning but nothing major. And boy am I breezing through my exercises! I'm on level two, including some gym ball work that I could have NEVER DONE before my surgery. (I'm working to get these posted soon) My back is getting stronger and stronger. I could probably get on my bike now but I promised myself I would wait until three month post. Today I worked on broken computers all afternoon, visited my injured god son (broke his femur in a motor cycle race), when for a 50 minute walk - including doing 1/2 ( 1/4 mile ) of the steep hill (10% grade). Last Monday and Tuesday I took the wife to Monterey for her B-day. I was able to sleep just fine in the 'not-so-comfortable' beg. No mid-day breaks were needed and I sat through "The Passion of Christ" (although I did get up and stand for about 10 minutes. (I hated the movie!!! There was no reason for Gibson to be that in-depth about the fate of Christ! I think we all got the message after that Horrible beating he was given in the city. I was a terrible death! I wish he would have went further into the 'tale' and covered 'his' arising etc..)
Dr. XX should have had more confidence in himself and was an absolute idiot for telling me that my surgery had failed!!!!! Hasn't he ever heard of positive thinking! I can now say that I'm glad I did the surgery for I already can do things that I could before the surgery. Boy am I going to give him an ear-full when I see him at the three month mark (which is comings on 5-12-04). I'm still not 100%, (obviously) and still have pain in the two main spots; left lateral foot and right inner knee. But my lower back pain is gone, gone, gone! Its completely gone. Usually I've got about 20% lower back pain but I think over the last two months I've only had three days where I've had some lower back pain (all on Saturdays from pushing too hard at work.) Naturally I'm still off all drugs and my stomach is also finally getting back to normal.
04-22-04: I've had and excellent 11 days. I'm happy to report, that I'm off ALL DRUGS. This was a little tougher this time mainly because of sleeping problems (miss the neurontin and occasional sleeping pill.) but after about 5 days, I'm sleeping like a baby. I seem to be growing stronger and stronger. I'm tolerating all of the level one exercise and am moving to level 2 tomorrow. I'm also tolerating walks of 20 to 30 minutes on the flats. I exercise every-other-day, and walk on the non-exercising days. I'm working longer hours and have worked every day this weeks (still 3 to 5 hour half days). I must avoid heavy lifting for this did flare me up for a day last friday (three sets of x-ray thursday and friday). Taking x-rays and treating are the two things I'm still not doing or doing sparingly. I'm still getting the bilateral leg pains but they have somewhat reduced. Last weekend I was up all day. Saturday we went to a late breakfast, shopping, my first 2 1/4 hour movie - I was able to sit through the whole Alamo without getting up - the theater had new seats that partially reclined, and even dinner after the movie! The primary pain is as follows: #1 left S1; #2, left L5 (top of the foot), and #3 right inner knee. I'm still having some trouble going down the stairs and need the railing still - but this is also improving. My lower back pain is rarely present. All the cramping has stopped and I'm walking with a normal gate. I hope to get back on the bike this weekend, which mentally will help a lot!
04-11-04: It’s been a little over 2 weeks since I’ve reported to my diary. This last week has been the best week I’ve had since the surgery although I'm nowhere's near as good as I was before this surgery. This past week, I was able to work four of the five days and Friday I even worked a double-shift (AM & PM) for a weekly total of about 15 hours: I’m still not treating nor doing x-rays, only evaluations. Unfortunately, I paid for it yesterday by having a nasty ‘flare-up of sciatica’ that kept me in bed for all but three hours today. I also have not been able to stop the pain medication; I’m still on a low dose of percocet (1/2 to 1, 5/325 per day), and a low dose of neurontin (150 to 300 mg/day). My stomach is still killing me from that 10 day course of oral steroids (prednisone), so I’m on 60mg of Prevacid per day.
I’m still getting bilateral ‘burning’ pain in both legs that is relieved by resting in bed (non-weight bearing). I would say that the right leg is slowly worsening and has almost taken over as the number one pain. My biggest trouble is sitting. I have to stand throughout the day and avoid sitting like the plague. I still am cramping but all that ‘baseball bat’ pain is gone. My toe flexors on the left are still shot and cramp if I try and walk with a full stride.
Final Neurologist Visit: I saw Dr. VV last Monday. What a disappointment he has turned out to be. I’ve found he knows very little about disc pathology. He didn't’t even know to read my MRI; he had no idea about IDD nor the ‘chemical leak theory of radiculopathy; and had never even heard of TNF-alpha! He was so busy this day that he tried to escape the room without doing the EMG, which was the only reason I was there. He reluctantly did what I’ll call a ‘K-Mart’ EMG/NCV on me. He only tested five muscles below the knee (5 minutes tops) and said I was normal and there was nothing more he could do for me. He had no idea why I was having sciatica. I’m going back to the DO who specializes in EMG/ NCV's (and uses much smaller needles!) in two weeks for a proper 60 minute procedure.
I’ve had another talk with Dr. Murray Solomon, head radiologist of Los Gatos MRI. He wants me to come in and try a ‘simulated weight-bearing MRI’ in the next few weeks. They have a vice-like devise that ‘squeezes you’ to simulate weight bearing and beyond. He said I will be sore after the procedure but it might shed some light on what’s compressing my roots.
Exercise: I’ve also successfully begun my ‘level one’ core stabilization exercises and am just about ready to move to level two. I was sore for the first week with level ones but this week I’m tolerated them well. I still can’t walk much and have not started any such activity. I know the stronger I can get my ‘core’ the better off I’ll be. (Here's my current exercise program)
I’m finally running low on percocet and will see Dr. RR on Tuesday. She was very generous with her percocet prescription last winter and I’m hoping she will be up for just managing me with medication and not act like Dr. H.
3-29-04: Question to Dr. Whitworth MD:
Here's the first question I asked:
ChiroGeek: I’m now approaching 7 week post micro-d for a small contained herniation that we ‘thought’ was compressing / irritating my left S1 root. My pre-surgical suffering period was 13 months.
Unfortunately, not only has the surgery not helped me, it has greatly worsened my left S1 root pain, and neurological condition, i.e., virtually no toe flexion power which makes it difficult to walk without a severe limp. Strangely, it has also left me with a non-pain, RSD-like problem in the entire left foot and lower leg. I think you remember the picture I put up last time of my ‘lobster foot’ that only occur after a hot shower, or prolonged standing. ([url] http://neuro-mancer.mgh.harvard.edu/ubb/Forum259/HTML/016138.html[/url])
I’m now tapering off a 10 day course of prednisone which also has not helped. The plan is now to do some blood testing (looking for rheumatoid factors,) and proceed with a SNRB (that’s what Dr. H mistakenly called it) of S1, L5, L4 in hopes of calming that S1 root down.
I’ve made my rounds and seen all my doctor friends and (naturally) have gotten several different opinions on what is going on:
The physiatrist thinks that since it wasn’t the small disc herniation that was causing the problem, it must be the disc/discs. He believes that this is a combination of discogenic pain and chronic-disc-leak upon the obviously inflamed/damaged S1 root and feels the next step is discogram (after some time passes) and RF any anular tearing via fluoroscopy / contrast. If this fails, a fusion might be the way to go.
The spine surgeon feels this line of thinking is crazy and feels that discogenic pain can’t refer pain into the foot and can’t cause the motor loss that I’m suffering in the left foot. He feels there is really nothing more that can be done and stated that “no one in their right mind would do a fusion on someone (me) who has no lower back pain.” He is at a loss to explain my failed discectomy and stated that I’m only his fourth failed surgery in 15 years.
Has your “cogitating” and “cerebrating” been able to shed any light on what may be going on here?
The symptoms are still that same:
I would greatly appreciate any thoughts or recommendations you may have.
PS: Have your thought at all changed on infliximab?
Combination of events with some considerations:
1. Peroneal muscle loss suggests S1 motor dysfunction.
2. Since the DRG of S1 lies between the L5-S1 disc and the superior-medial S1 neuroforamina, it is unlikely this was injured directly as a consequence of surgery. However, the sympathetic system can be activated through nerve injury to the S1 causing the DRG to increase its outflow and develop a CRPS like syndrome in a non-dermatomal pattern
3. Would suggest an EMG soon....you may get some info regarding conduction delays with a surface EMG. If the EMG is normal, then try a lumbar sympathetic block.
All of these things could be directly due to surgical problems...if the HNP were long standing, it is possible fibrosis had developed between the nerve and the disc, thereby trapping the nerve adjacent to the disc and subsequently was injured through stretch injury. It is also possible that the annulus was disrupted, there was inadequate decompression of the S1 nerve root, or a fragment of disc migrated distally along the nerve root.
Let me know what happens with this...good luck Doug...
ChiroGeek: Thank you so much Dr. W. I'll keep you updated and see if I can get that EMG/NCV done tomorrow.Answer #2:
The scenario to left S1 root, as you have described, wouldn't be responsible for the right sided diffuse burning would it? (via cross talk in the cord?)
This (right lower limb stuff) started in early February (before the surgery) after a long weekend of sitting at relicensing seminars. The MRI, which was done the day before surgery, didn't show a thing that could explain this (other than the same HNP at L5 and an apparent anular tear (with HIZ) at L4.
MLW: While RSD does cross over at the cord level approximately 5-15% of the time, it would be a bit early for that since it is a very slow process. The right leg burning pain may be postural/gait related, or perhaps piriformis related due to leaning away from the affected side....
3-26-04: It has been a few days over 6 weeks and I'm feeling like shit again. I've seen another medical specialist since my last entry, and have also gotten an completely unexpected phone call from my spine surgeon today (he's obviously worried). I'm about half way through a 10 course of oral steroids as ordered by the neurologist. At first I thought it was going to work, for Wednesday I had one of the best days I've had since the surgery. Unfortunately, I probably over did it by working four hours and skipping my afternoon 'rest period'. I got in bed early, but it was too late. To make things worse I had to work Thursday and Friday (two hours each day) in moderate to near severe pain. Yes, the dreaded sciatica reared its ugly head again with even a little back pain to boot. I'm still suffering today and have spent the whole day (and probably weekend) in bed. This seems to be my 'typical' pattern; work about 10 to 15 hours per week and then try and recover all weekend in bed. I'm back on Percocet & trying some Neurontin, which has ended my 10day drug free run! I hate being on drugs but its nice to get rid of the pain too. I fear I'm developing neuropathic pain from the aggravation to the already inflamed root. The discectomy has really set me back by greatly worsening all of my lower limb pains and worsening my muscle weakness in my left foot, which make it impossible for me to even do walking exercise. My left leg and foot symptoms also have worsened, but I'm not sure I blame the surgery for this, for my right leg pains started after all my prolonged sitting in Jan and Feb, secondary to the mandatory Chiropractic, and QME relicensing practices.
Physiatrist: I saw Dr. ZZ on Tuesday of last week. Dr. ZZ is a young PM doc who I use, along with Dr. YY, for evaluating and performing ESIs on my patients and me. After his quick exam he announced that I've got a definite S1 root problem. He also believes that I've got discogenic pain on top of this and recommends a discogram after three more months to confirm IDD as a cause and to see how much pain is reproduced in my lower limb. The whole reason I went to see him was to confirm that he has seen discogenic pain reproduce my kind of clinical situation, i.e., 5% lower back pain, 95% lower limb pains. He immediately announced "oh yes, I see this presentation all the time....severe lower limb pains that are reproduced on discography." This would confirm the work of Kuslich et al. but Dr. XX (spine surgeon) doesn't buy it nor am I sure that I do. How can discogenic pain, pain caused by an irritation to the posterior 1/3 of the disc by escaped nuclear material, cause my moderate neurological loss in my left foot? Can chemical disc leak ALONE (since I only had mild compression) cause this much trouble? These are the answers that no one really knows for sure. Dr. ZZ believes that if the discogram is positive, then the application of RF to the disc tears is in order. This is not a IDET nor Nucleoplasty, but is 'radio frequency' current that can be applied (under fluoroscopy) directly to any anuluar tears that are lit up by contract injection. (I'm now wondering if Dr. Yeung's SED may be helpful, for I believe he uses RF current and injected dye in his 'debridement' procedure to help 'neutralize' symptomatic disc tears.)
Spine Surgeon: I was very surprised to get a call from Dr. XX. He's turning out to be quite a caring doctor, of possible 'worried' doctor. He finally fessed-up and admitted that he has had three other failures in his 15 year career; four now counting me. He's wants me to see a rheumatologist next and is concerned that this, in part, is being complicated by some bizarre rheumatoid factor. He concurs with Dr. ZZ that the S1 root is severely inflamed - but has no idea why. I guess this is the million dollar question; why is my S1 root so 'upset'? He does NOT believe that discogenic pain can cause pain below the knee, especially not into the foot. He wants me to finish the course of steroids (prednisone) and see him after I get my blood work (for rheumatoid factors plus) done. I thinks he's out of answers. He wants me back on neurontin, although I didn't tell him I'm mixing it with a half to full Percocet for I don't want to hear that lecture again.
I've been ordering research papers again on the topic of nerve injury and I'm learning a lot. As Dr. ZZ joking said, "you probably know more than all of us (doctors) on this subject". He's probably right, although its nice to tap into their personal experience with real patients and not just research. I've learned that when a nerve root becomes severely aggravated it can indeed cause a 'spill-over' effect on the neighboring roots (probably at the cord level) and 'widen' the dermatomal symptomatology of the patient, even setting off dermatome disturbances in the other limb. I don't think that this explains my distinct L4 root pain in the right leg. If it were a right S1 pain then maybe I'd buy this spill-over theory. Based on the fact that I initially had L4, L5 radiculopathy, its not surprising that these levels are now involved but I'm stumped by the negative MRI and the increasing right L4 root pain????
Current symptoms: 95% lower limb pain (cold-buring type pain) and 5% lower back pain (same old spot - left paravertebral L5). The left S1 is still the number 1 pain, although left L5 is almost as bad. L4 (medial leg and knee foot) is worse on the right but now present in the left. Summing it up you could say I've got L4, L5, and S1 (basically entire leg / foot - except the back of the calfs) symptomatology in both legs. Where in the hell is this all coming from???????? Neuropathic pain (sensitization, centralization)???? IDD?????? Left S1 'spill-over' phenomenon?????? MS, ALS, my mind is racing. I also still have occasional global muscle fasciculation (twitches) as well as heart palpitations (but these are old problems) and really don't bother me, but yet I can't help but wonder if these symptoms (which are nerve related as well) are somehow involved, but probably not... just my imagination run amuck.
Current Treatment Plan & Theory:(3-26-04/6-27-04) My gut feeling is that my left S1 root (for reasons unknown) is scared on the inside (intraneural fibrosis, aka: intraradicular fibrosis) from chronic irritation from 'something'? (Maybe I'm one of the unlucky ones who are 'sensitive / allergic' to leaking disc material and just 'inflame' easier than others or possible my immune system is attacking the nuclear material bathed S1 root because it thinks the root is now foreign.) That 'something' is the question that still needs to be answered. We know that the surgery changed nothing, only aggravated everything, although now the nerve root is so aggravated that I've developed mild signs of RSD. This tells me that Dr. XX. was in the right spot, for his surgery would naturally 'stimulate' both the S1 root (through the retraction and manipulation) AND 'stimulate' the posterior of the nerve-infested posterior anulus and PLL (through his cutting through the PLL and digging out that small stringy piece of nuclear material that he said was "behind the PLL"). So, here are the possibilities in my book: 1) chronic disc leakage upon the nerve roots (TNF-a, and company) from two grade 5 discs (L4, and L5) [we know the L4 disc is involved here since I had mainly L4 and L5 radiculopathy back in the beginning], 2) referred pain from the posterior of the L4 and L5 Discs. This may be termed 'Discogenic Sciatica' and was studied extensively by Ohnmeiss et al. In fact, i will be co-writing a published research paper with a prominent spinal surgeon from Taiwan China in the near future. 3) Maybe, since my discs have been exposed to years and years of abuse via 11 years of olympic level hammer throwing and heavy weight lifting, they have lost the ability to carry axial load. Maybe, when weight bearing, they bulge outward tremendously and are compressing that "swollen" S1 root? This would explain why I always get relief from lying in bed and only have pain when the disc is pressurized via sitting, standing, and walking, although my recent pseudo-weight bearing MRI didn't show anything that would confirm this.
5-28-04: The only thing I would add here is that I believe that the L4 disc has to be involved: how else could I have developed a L4, L5, and S1 radiculopathy? There is no way the L5 disc can affect the L4 root. Based on my new MRI, and the fact that the "deep" anular tear remains, I'm wondering if these flare-ups are from micro-expulsions of nuclear material from this disc? unfortunately (or maybe fortunately) they don't do fusion for sciatica only. Fusion is more for lower back pain complaints. My only 'last-shot' is to possible try SED or something similar to address that L4 disc. For now, I'll stick with Dr. XX's advice and give it three more months.
Plan: 1) at least six more weeks of recovery time, who know's, maybe things will clam down? 2) EMG to access whether to try a massive TFESI (L4, L5, S1) or a sympathetic block. 3) complete one of these new 'standing', bending, sitting, MRIs which may give us further clues (Fonar weight-bearing MRI) 4) If suffering continues, Discogram and maybe visit Dr. Yeung and the SED procedure. I've learned from three different sources that IDET may be not the greatest nor safest prodedure, (so Dr. Schiffer, who uses IDET in his LED procedure, is out) but 'radio frequency' (aka: RF) is the only safe and effective way to attempt to heal an anular tear. Dr. ZZ and Dr. YY (who don't know each other) both have told me this. 5) Finish blood work for rheumatoid factors.
3-18-04: (5 weeks status post): Wow, finally some good news to report. The week-end of 'confinement' paid off, for by monday I was feeling somewhat better and today I feel much better; almost as good as 'pre-surgery'! And, let me tell you how good it feels to be off the drugs! I had weaned myself down to 1/2 per day for about three days and monday was my last 1/2 percocet/nortriptyline! No real withdrawal symptoms - other than a headache. I got more business stuff done today than I have in the last two months put together!!!! I have been able to work again this week but I'm limiting myself to 1/2 days (no more than 2 - 3 hours max) and nothing heavy. I've started some 'straight leg raising and stretchs and will start some ball exercise and BIKE next week. Its been hot here in California and we are 'de-winterizing the pool in anticipation of water-exercise time.
I guess you really don't know doctors until your under their care! Dr. H. has turned out to be the 'jerk' and Dr. S. is off my shit-list and acting very human like again. I won't get into all the details regarding the last week with H. but lets just say that there were 'strings' attached to H. drugs. Once I cancelled the 'selective nerve root blocks' he refused to give me any medication and insulted Dr. S. for interfering in his treatment plan for scar tissue (which both S. and I feel is nonexistent since my problems happened immediately after surgery - no time for scar tissue to be involved)! That was fine by me since I no longer needed the drug (although I still might need it for future flare-ups on a PRN basis) but what an jerk he was! He finally called me back the next day and, after lecturing me on the dangers of this narcotics, offered to give me 60 tabs. (I think he realized that I do supply him with quite a bit of business and though that maybe he over-reacted a bit?). Too late for him for I saw his true colors. He wrote it but I'm not picking it up.
Spine Surgeon Evaluation #2) On 3-16-4, I had another eval with Dr. XX. (spine surgeon). He was much more human this time and very caring. He say something like ' Doug, I'm afraid we have been duped', (meaning that the small herniation was NOT the cause of this radicular pain) but I'm not giving up on you. We will figure this thing out." It felt good to hear him say that! He admitted that my loss of foot power had worsened and referred me to a top neurologist today, who squeezed me right in.
Dr. VV : What a very cool guy this Dr. was. Surprisingly, he too had went through this same thing: A EMG confirmed radiculopathy (which he did on himself! ouch) with a normal / near normal MRI. He too had tried two epidural injections from non other than Dr. H.! (Its a small world!) He stated that Dr. H. was a jerk and had no compassion what so ever! did I say What a small world..... After the most thorough neurological exam I've ever had (including vibration testing) he announced how he beat his radiculopathy. A ten day course of oral steroids (prednisone)! That's what did the trick for him. He laughingly admitted that he didn't think of it but referred himself to another neurologist who suggested it. He thinks my compression/irritation is past the axilla and actually within the cauda equina. Just out of reach of ESI's. (I'm not so sure about this theory because the nerve roots in the cauda equina have NO epineurium or perineurium, hence its virtually impossible for them to get inflamed since they are constantly being bathed in CSF.) But at this point, I'm up for anything! So I'm gearing up to try a 10 day run of prednisone - after five days of Prevacid (I forgot to mention, like a fool I tried to add Bextra into my pill regimen last week. Now my stomach has been hurting after only four days of the NSAID) to calm down my tummy. He's also doing blood work (complete rheumatoid panel plus) to look for any other possible causative factor (which is the reason why Dr. S. sent me here in the first place). My neurological exam showed weakness not only in my foot, but my left quadriceps as well. Dr. VV is a strong man and really tested my muscle power which showed quit a disparity between my thighs. He concluded as many have: something getting irritated somewhere but it's certain not from scar tissue. Let's try to shrink the swollen nerve roots (where ever the compression/irritation) and hope for the best.
3-12-04: Another missed day of work. I'm a little more comfortable today but still grounded to my bed. The lower back has been doing great but the left leg and foot still feel like I've been hit with a baseball bat! It's a cramping, throbbing, muscle type pain in my calf, soleus and shin that are new and the number one problem. None of my medication seem very good at touching this pain when it goes off. I've had a couple of really rough night because of this pain. It's also preventing me from walking and in fact I believe it to be the walking that has caused it. Besides this new pain I've still got the original complains - times 4 (no longer times 10): Strong burning pain in the left lateral, and dorsal aspect of the foot; burning pain in the right medial knee; and lesser burning in the left lateral thigh, & leg, and burning in the right lateral leg and dorsum of the foot. The red blotching on my feet is improving and not bothering me much.
Dr. H. MD Pain management: I saw my long time college yesterday over his lunch break. We talked for an hour and he examined me. He feels that I do have a very slight case of RSD but its not worth targeting, especially since its improving on its own. My neurological examination was basically the same as usual although the loss of toe flexor power has slightly worsened. He feels that scar tissue is 'entangling' my already swollen S1 nerve root, hence giving my the extra pain. Treatment Plan: Dr. H. wants me to try some fentanel lollipops on a PRN basis to control the pain. [BTW: He said XX's attitude on opiods is "typical" of spine surgeons and naive. He's not at all worried about me becoming addicted and said I'm going to need some 'serious' medication to get me though this.] I have agreed that a 'selective S1 root block' is in-order and it has been scheduled to be done next week - under fluoroscopy. He also wants to proceed with an epidural neurolysis, from the cauda approach, to 'free' the root from any perineural scar tissue, which is his main concern and diagnosis at this time. If this fails, he wants to go back into the space with a scope and physically look in there to see what he can see.
I'm not so sure about this diagnosis of 'scare tissue' and am not going to jump into that procedure quite yet since only 2% develop this syndrome following discectomy. It would be more likely (6 to 10% chance) that the disc has reherniated and got the nerve, so I would think a new MRI is in order before we start recklessly playing around in the epidural space. He's forgetting that the reason I had the surgery in the first place was because of leg pains and that had nothing to do with scar tissue (virgin epidural space) SO, where is this pain coming from? This is the question.
I'm still planning on seeing Dr. XX this coming Tuesday. It would be easier and cheaper to 'let him go' but I think he needs to know that his surgery has not only failed, but has greatly worsened my condition. Maybe he will think twice about operating on a small contained disc herniation, 16 month post injury? OR, maybe not? Or maybe-hopefully it's still too early to tell yet. I'm still awaiting for Dr. Whitworth to comment on my condition but I've got a feeling he's not going to get involved, which is disappointing.
I have a feeling that if I rest up this 'long' week-end, I'll be doing a little better on Monday. Lets hope so! I'm no longer feeling guilty about taking the percocet (my insurance is refusing to fill script for the fentanel lollipops which I didn't like anyway) but I'm getting low and am again waiting to see if H. will let my wife go pick up a script for more before the weekend. (I'm still using the very generous Dr. RR had given me last october!) Maybe I should just go back to her for care and don't let anyone touch my epidural space ever again! I guess I'm still rather confused!
3-10-04: I've had a set back and I'm not even sure how it happen. I seemed to have a pretty good day on Monday (3-8-04). I worked 3 hours (nothing heavy), picked my daughter up from school, iced in bed for 1 1/2 hours, took the beagle for 30 minute walk and ZZscribed some reports (I'm way behind). Tuesday AM I awoke with that same 7-8 lower back pain (usual spot), right and left leg and foot pain! I've been miserable for two days now and feel almost as bad as my worst ever. I'm so frustrated and depressed I can't begin to explain. I also was down to 1/2 percocet per day but that is gone now. Yesterday I tried the Topamax (50mg) at bed time. I would say it did OK with the foot pain but didn't help much with this throbbing acute LBP (which is still secondary to the left foot pain). I finally put a call into Dr. H. I've known and have referred patients to doctor H. for years and am hoping that he will get me on a 'stable' regimen of medication that WORKS! I feel terribly guilty taking the percocet - after the scolding by Dr. XX - but it is the only drug that really helps with the pain and allows me to use my brain 'enough' to work. Maybe there is an even better medication than the percocet? (BTW: My desperate phone call seems to have gone unanswered! His secretary couldn't get me in even on an emergency basis but said he would call me.)
I'm not one to beg or whine but I finally asked Dr. Whitworth (who is a PM doctor [who actually teaches other PM doctors] that graciously fields questions over at the MGH web site (see contact info)) for help. The doctor has read my plea for help and is currently "cogitating and cerebrating" my lengthy case history. Here's what I posted:
Hi Dr. W,
I’m sorry this is so long but I wanted you to have all the facts.
It's been almost four weeks since my micro-d and I'm still miserable. Dr. XX (my orthopedic surgeon) stated that the surgery went well and that he removed a small stringy nuclear fragment (L5 disc) that was to the left and somewhat behind the PLL (still contained). He had to make a small slit in the PLL and "fish it out". He stated that the mild compression that had been on the left S1 root was gone and that the nerve was moving freely. He also noted that the protrusion was not initially adhered to the root but that the root did appear swollen. He ended the surgery by bathing the root with a steroid (I’m not sure what he used) and xylocaine.
At two week post he evaluated me and announced that the surgery was a failure for the sciatica should have been gone. I now believe him to be correct.
He seems to refuse to believe that my original lower limb symptoms are now worse and told me that this (increase in sciatica) has never occurred with any of his patients before?
He also refused to refill my percocet for he feels it’s too dangerous and addictive. He stated “Doug, I would be doing you a great disservice by getting you hooked on that drug. I’ve seen it take down so many good doctors that I just can’t do it to you.” He's had me trying amitriptyline, nortriptyline, neurontin, topamax, and Vicodin – all of which I’ve tried before the surgery to no avail. The percocet, which I have used very sparingly over the last year (never more than one pill a day and never more two days in a row) has worked the best since the surgery but I now need it daily (down to one tab per day) now (unlike before). I've been able to work 2 to 3 hours without ‘making too many mental mistakes’as long as I avoid anything heavy.
I’m so confused on just what is generating this pain: My EMG was initially positive for L4, L5, and S1 left radiculopathy (psw & fibs lower limbs) and then clear up at one year except for a ‘soft-finding’ (paravertebral) for left S1 radiculopathy. I have mild weakness of the left peroneals and toe flexors but my Achilles’ reflex came back. I’ve noticeable non-progressive atrophy in my left calf (2cm). The MRI showed a small 3-4mm contained HNP contacting but not compressing the left S1 root – confirmed during surgery. CT myelogram w/ flexion/extension showed only slight deviation of the left S1 root secondary to the small to moderate protrusion.
Here’s the confusing part: My symptoms [b]were[/b] always in the left S1 root distribution, UNTIL I had to do all my relicensing seminars (24 hours worth over a month) in January 04. Since this marathon of sitting and driving I’ve got the following (which has been magnified by the surgery) on the LEFT: ‘burning and numbing’ pain in the S1 (side of foot heal), L5 (top of foot) and L4 (instep) and a touch of burning over the medial knee. The RIGHT foot burning mirrors the left symptoms only not quite as strong. Plus, I’ve got a stronger burning over the medial right knee (3-4 inches proximal and 3-4 inches distal). I have some focal throbbing pain over the Left multifidus in the lumbosacral region but this is secondary to the leg problems.
Finally, my foot seems to be having some trouble regulating temperature. If I take a hot shower my foot turns lobster red, much more so than the right foot which also dose this to some degree. Both of my feet seem either freezing cold or have the rock lobster look. If I eat a bunch of sweets, I get the rock lobster foot. This is new since the surgery but does seem to lessening.
Here's a picture of my feet after my usual hot shower:
Note the left foot is Redder and more swollen, with blotching as compared to the right? I also noted that my toe nails have been changing, almost clubbing. It this a sign of RSD? How could this be happening?
If you were in my shoes, what would you do next? Dr. XX is completely stumped and just wants me to take nortriptyline and use ice. He feels it is NOT discogenic pain and that a fusion is not indicated for this lower limb pain. I have studied the discordant work of Kuslich and Ohnmeiss and believe that discogenic pain can cause lower limb symptomatology but XX says no. I also believe that he irritated the already swollen root by simply handling (ah al Kuslich).
I guess I probably have somehow damaged my left S1 root but how? There was very little compression and the ‘evil chemical gang’ would need significant compression to cause this much misery, wouldn’t it? An then how would one explain the development of the right limb symptoms. I do have a tiny central disc protrusion at L4/5 that is 1 or 2 mm tops. Honestly, my MRI of today doesn’t look much worse than my MRIs of the 1990s?
Do you think that Dr. Yeung’s SED procedure may be an option for this leg pain with minimal back pain?
Do you feel it reasonable for me to continue with the percocet or something with even less side effects? XX has got me feeling guilty for touching the stuff but I think I’m suffering today because it’s not in my system.
I greatly appreciate any recommendation or ideas you might have and greatly respect your opinion. I would even consider fling over to see you, if you think that would be of use.
3-6-04: I can say that I've had a steady, but very slow, decrease in leg and foot pain over the week, especially over the last two days. Yesterday I over-did-it by staying at work for three hours, then trying to shop for food and ice(6 hour up time) afterwards: I treated 4 patients (cox, massage, and myofascial release ONLY), did two full exams/reports, and then did a new patient including x-rays. (The x-rays is probably where I over did things - kind of heavy moving the tube and bucky around although I had one of my girls do all the lifting of cassettes and initial set-up of the bucky). Today, for the first time since the operation, I've got some lower back pain but diminished sciatica. I took it very easy today, lot of ICE and laying around working on my web site. (I finished my 'masterpiece' today, finally, after over four months of work and research (here). I started some very basic stretching today for the first time as well. I also walked for 10 minutes on the tread mill.
Dr. XX Call: I decided to give the Vicodin a try (I really want to give Dr. XX 'way' every chance possible) for the last three days. I shouldn't have, for now my stomachs a little up-set for the first time in months. So, yesterday I went back on 1 percocet per day. I called his nurse and again told them (again) that I've gave everything the "old college try" but still find that the percocet is better for me than anything else (kills the pain but leaves me with more of a brain for work) and that my stomach was now upset from the vicodin. Dr. XX called me yesterday and told me that he would be doing me a "huge disservice" by prescribing percocet because it was too easy to get addicted to them. He told me he has "seen too many good doctors ruined by the stuff." I told him I was down to needing only need one pill, sometimes only 1/2 pill per day, but he still insisted that I use something else. "We have to fine some other way to treat your pain". He wants me back on the Nortriptyline. I'm a little disappointed in his apparent believe that I will turn into some sort of a drug addict and don't have the will power to resist the drug. I've never like drugs (that's why I'm a Chiropractor) of any kind and don't enjoy taking anything. I don't like being stupid! Its just that I hurt without them and think that my natural weaning off trend (of percocet) is a good sign (I needed them four - five times per day for the first week and now I'm down to 1 pill to 1/2 (today) pill per day.) This drug has helped my tremendously and I bet that by six weeks I'll be free of them- despite what he things. I also told him of another sZZge problem I'm having with both of my feet. I seem to be having, or my feet seem to be having trouble regulating temperature. If I take a hot shower, or eat sweets (like a big bowl of icecream) my left foot turns beat red, like the color of a cooked lobster! It would seem that there is a slight problem with my 'sympathetics' but how could that be? Dr. XX said this was another first in his career and had no clue as to why I've got a 'rock lobster foot'. This problem has also been decreasing.
3-1-04: I'm happy to say that I'm feeling a little better and have that leg and foot pain under control, i.e., down to 3-4 from a 7-9. I still need medication (percocet seems to work the best) but at least I can control this pain. It sure was a rough weekend though! As of today, my wife reports that I have went through 240lbs of ice, in using my "Iceman" icing device, which is a very very cool (no pun intended!) device for icing down your back.
I can be out of bed for two to three hours at a time now, as long as I keep moving; I can't sit very long at all. I did go into work on Monday for about 1 ½ hours. I just did four evaluations / dictations and that was all I could take. I'm still much much worse since the surgery with respect to my left leg and foot pain. Now, my right leg and foot are mirroring the exact same symptoms as my left leg and foot only to a less extent?! These right sided symptoms started after that QME seminar I had to attend where I had to sit 12 hour (not including 4 hours of driving) and I told XX about them before the surgery. The MRI two day before the surgery showed nothing that would explain this right sided pain and XX is stumped. I still think its discogenic pain, although is might be a stretch since I have NO lower back pain (or very little over the last few months). It sure would be scary to have a fusion, even the ADR, without having any lower back pain! I doubt that anyone would even try it on me. XX said he wouldn't. Maybe SED with Dr. Yeung? Maybe I've had enough of surgery and will wait until I can't function?
I know the study by Ohnmeiss clear finds grade 2 IDD causing lower limb symptomatology, but XX gave me another study by Kuslich that found NO relation between the outer anulus and leg pain. This is a fascinating study that I should have up shortly but here's the bottom line of the study: Kuslich performed 193 back surgeries for decompression of compressed nerve roots, secondary to disc herniation or stenosis. He ONLY used local anesthesia and kept the patient awake to answer questions. He then electrically and manually 'stimulated' every spinal tissue imaginable. There was only one tissue that reproduced the patients 'same sciatica' almost every time (99%). It was a swollen, compressed, or stretch nerve root [remember XX said my root looked swollen]. Any 'fooling' with this 'pissed-off root' resulted in the patient suffering thigh, leg, and foot pain. A bath of Xylocaine immediately stopped the sciatica. When they 'stimulated' the posterior anulus of the disc, it caused 'lower back pain' in over 70% of the patients but NO LEG PAINS AT ALL? So, we have a conflict between the work of Ohnmeiss and Kuslich which I happen to be in the middle of! If it is true that XX barely touched my S1 root, then what tissue did he 'assault' that has now magnified my symptoms? The PLL, which was slit, and my posterior anulus, in which he had to "fish-out" a "thin and stringy piece of nuclear material that was behind the PLL. That spells an irritation of the anulus to me but that goes against Kuslich's Study?????
The meds war with XX has been lost. He knows I have a stomach problem and can't tolerate NSAIDS. He even knows and respects my gastroenterologist. He still will not refill my percocet and called in Vicodin and Nortriptyline. There is no way I'm chancing upsetting my stomach again (it took months for it calm down last fall) so I'll be seeing my PM doc next week. VERY DISAPPOINTING although at least my lower back is doing GREAT! I'm thankful for that.
Today was like that old move 'The Wizard of Oz'; remember that part near the end where Dorothy finely pulls back the curtain and discovers that the 'Great and Powerful Oz' is just a normal average human who really doesn't seem to know as much as everyone thought....
The Dr. XX was still 'literally shocked' that my leg pain has not improved, and even more unbelievable was that he told me (in front of my wife) that he has never had a case like mine before, i.e., he has never had someone's leg pain get worse on him? (That seemed strange, seeing that he's been doing this for 20 years.) He could offer no explanation for why the nerve pain was still there. He admitted that there was only minimal compression on my S1 root and that the nuclear fragment he removed was "long think and stringy" and behind the PLL. He said he handled my nerve very little. He was happy that I have no back pain (other than a twinge here and there) and that everything has healed up fine, other than some swelling under the incision.
Brutal honesty? To my horror, he next announced that the surgery had failed and that there was only a "very slim change" that my foot and leg pain would get better. Needles to say those words were quite depressing and I wish he could have waited a little longer than 2 weeks post to say them.
I knew that I was NOT the idea surgical candidate (I'm not nearly as surprised as he seemed) but I would certainly think that more than two weeks is needed to judge whether the surgery worked on not? I also know from the work legendary work of Kuslich et al.(1991) that inflamed and swollen nerve roots (which he again noted was true of my left S1) of disc patients are quite sensitive to compression and stretching, and are the only structure that can reproduce sciatica when 'stimulated' during surgery: so I could understand my symptoms being worse. Why can't he???
He went on to say that a fusion would not help me since I have no or very little lower back pain. He thinks it unlikely to be IDD.
He would not refill my percocet and wanted me to take neurontin. I told him that the neurontin is what pushed my stomach over the edge last year so he said, "let me make a phone call to a physiatrist, for I always prescribe the same stable of medication for my patients" (my stomach problems through him for a loop I guess). After 45 MORE minutes of waiting (90 minutes total torture time) he comes back in and give me a script for TOPAMAX and said if that doesn't help the leg pain, we will try a tricyclic anti-depressants next week. (I guess after this appointment I could use them NOW! LOL) I could tell that he felt bad and ended the appointment by quoting the famous Weber study of 1983 by saying, "hang in there Doug, you know what the natural history of this problem is." [yes doctor I do know, probably better than you, and am now wondering why you wanted to defy this 'natural history' by operating on a small contained disc herniation, that was 16 month post, a negative SLR, normal reflexes, and changing symptomatology? I guess I got what I asked for?]
Now, I know spine surgeons aren't the best at pain management but I truly expected a little more pharmaceutical knowledge, compassion, hope and promise from the good doc. He could have at least told me that it's too early to tell?
So, basically it's back to square one or currently negative 5. I'm definitely going to give this a little healing time before I run off and do another crazy thing and get back to my pain management doc in the mean time! I still stand by my decision, for if I'm going to be stuck with a permanent disability, which is extremely difficult for an X-jock like me to fathom, I'm NOT going down without a fight!
2-26-04: I was doing pretty good over the last few days, until today. My 44th birthday required me to spend about 8 hours out of bed - (3 hours AM, 2 hours noonish, 3 hours evening). Nothing heavy but sitting, and standing and out of my bed. My f*cking foot is killing me again - all S1this time. My lower back is even a little sore. I'll give the foot burning/numbing pain a 7-8, which includes some cramping pain in my calf and butt [all left sided]. I've also got some level 1 - 2 numb/burning in my right inner knee and leg. Over the last few days I was down to one percocet every 20 hours until this evening. I've had two since 3:00pm and may need one more before I fall asleep. I see XX (my NS) tomorrow AM. I'm sure he's not going to pleased, especially since his 'Darvocet' didn't do squat for me except upset my stomach. Why do I have a feeling he won't give me anything stronger? I'm also 'miles' away from being able to work; Dr. XX said I'd be able to do 1/2 day after 7 days! NOT! I predict that my L5 and L4 disc need to come out - ah la fusion or ADR (which I'm not even sure we can afford (the Germany trip) [four kids in and out of college, one in high school!]), but then again maybe my S1 root is fibrosed and permanently damaged so the fusion wouldn't even help? Maybe the inevitable discogram will shed some light on where thing pain is coming from. Nerve root damage just does not seem possible since I had such little compression but maybe I'm just 'sensitive' to the evil chemical gang? Or maybe I'm one of the unlucky ones whose immune system has mounted an attack again the chemically bathed root? Or maybe I shouldn't write in my diary when I'm in pain, and pissed off! Happy birthday.
2-23-04: My lower back is improving, but my left foot, left foot, and right inner knee and leg pain continues to a stronger degree than before I had the surgery. I had a very rough Friday and almost had to go into the hospital for I could not get my left leg (it felt like someone hit me in the shin with a baseball bat) pain to stop. After 3 percocet over 8 hours the pain finally abated. I think I've got my medication dialed in. I need one 5/325 percocet every 6 to 10 hours. I tried the Darvocet that Dr. XX prescribed but it didn't do squat, other than make me sleep. I'm still pretty much bed ridden and only get up to eat and go to the bathroom, although today I'm trying to keep my up time to about 90 minutes. I see Dr. XX. later this week. I'm sure disappointed with the outcome of this surgery. I bet its going to take a good three months before I will know where I'm at. I've got to try and get back in the office soon! I'm not going to push till Thursday (my two week mark.)
2-19-04: This has been one rough week! This Discectomy was certainly no walk in the park! For the first time in my entire life I'm dependent on Percocet! 5mg of percocet keeps my pain at about a 2 or 3, but like clock work, after about 20 hours my back and leg pain intensity rises to about a 7 or 8. I'm also no where nears being able to return to work and am fighting to stay out of bed for 2 hours in the AM and 2 hours in the after noon and 2 hours in the evening. The rest of the time I'm forced into bed (can't even sit in my old trusty recliner yet!) with my 'ice pump' on. I've never iced myself so much in my life! My foot pain continues to be my 'limiter' with my lower back pain not far behind. My sitting tolerance is 30 minutes tops. I've been able to start 20 minutes of walking per day and have learned NEVER walk barefoot on a treadmill; I did this today and soon felt my foot burning with the pain rating up to about a 9! I never would have imagined that this operation would have thrown me backwards so severely! I have a feeling that 'compression' was not my problem, which leaves either IDD or nerve root fibrosis as my problem. I hope its not the latter for there is no treatment for permanently scared nerve roots. I'm going to need to get researching this topic.
2-15-04: Like yesterday, I spent the whole day in bed, with only 20 to 30 minute up-times to eat and go to the bathroom. I'm pretty depressed for my left foot pain/burning is significantly worse than its been in a very long time; about 5, 6 and even 7 (12 hours after a percocet) on the 1 - 10 scale where 10 is severe. Specifically the problem is my left foot: (lateral side, bottom, in between my toes, and especially my big toe) This would be even worse if it weren't for the percocet which I'm taking every 12 hours. The lower back feels just about as Dr. XX said it would; as if someone hit me in the back with a baseball bat. (well maybe not that bad since I have no lower back pain with rest, unlike the constant burning I'm getting in my foot.) I'm being super careful not to damage any of the sutured muscles or ligaments and really babying my back per Dr. XX's instructions. I'm also using the 'ice-water pump' that I was able to take home from the hospital. What a cool (no pun intended) little contraption. It literally pumps ice water into a rubber bladder that is secured to my back with an elastic belt. I've been using this a lot (so much for the 'Hunting response'). I know I need to give this some time, but have been become quite depressed and worried that I've made a big mistake. The look disappointment on Dr. XX's face has me very anxious, but I still stand behind my decision. I've been this bad before (in fact I've been much worse than this before) and bet I will take me a good three months to improve - which is going to kill my practice! (No disability insurance). My biggest fear is that my problem was NOT from the mild compression I had but from scaring which occurred within the nerve root its self and a result of chemical irritation. One thing that is promising; I know that Dr. XX was messing with the correct tissue (pain generators) for he has aggravated the exact same symptomatology that I've had in the past. Nothing new, maybe that's a good sign? Only time will tell.
2-13-04: I had very little pain over night and only needed four 1cc hits of morphine since the surgery. The hi-lite of the morning was my first urination! I was told that if I couldn't go, not only would I have to stay in the hospital another night, but I would also have to have that catheter put back in! Needless to say I was very happy to go pea. I also went for a walk around the ward under my own power, which was the signal that I was ready to go home. So at 2:00PM, 29 hours after the surgery, I was on my way home. Unfortunately, I went home with worse leg and foot pains than what I came in with. I was also a little unhappy with Dr. XX's attitude. #1) I would have liked to see him sometime after the surgery but didn't see him until the next day (the anesthesiologist check on me before he did!). #2) It would have been nice if he asked me if I felt that I was ready to go home, rather than telling me I was going home. I would have chosen to stay one more night for my pains were increasing as the epidural effects were wearing off. #3) I didn't like it that he wouldn't prescribe me any percocet - other than the left over percocet I had from another doctor. I've only got 14 pills left and he felt that this was enough? I'm sure I can get more if I need them but he just didn't seem very compassionate. He did call me my first night home to make sure I was Okay, which was great. We shall see how this all pans out with time.
2-12-04: At 7:30 am I under went a microdiscectomy of that small contained disc herniation. It was over so fast I didn't know what happened. The anesthesiologist gave me a shot of Valium and something which knocked my out just as they wheeled my into the OR. I never got a chance to see the 'bright lights'.
The Surgery: Dr. XX talked to me around noon today and asked how I was feeling. He seemed very surprised that my foot and leg pain was not gone. I didn't like the look on his face, for it made me feel like he thought that maybe it was a failure already! He said that it may take a few days or even three months for things to settle down. He stated that I have a rare lumbosacral anatomy (10% of population) that allowed him to not only re-attach the multifidi muscles that were removed to gain access to the HNP but also to re-attach the ligamentum flavum (which is almost always completely removed with discectomy) which will act as a barrier against the formation of scar tissue and prevent my spine from losing stability. He stated that he was able to remove a small fragment of nuclear material that was under the PLL (inside of the 4 mm contained herniation). It did not 'pop-out' like a zit when he put a single slice in the PLL, but he was able to fish it out through the incision he made through the PLL. He stated that it was NOT associated with a huge anular fissure (which is great news). He stated that the S1 nerve root was being compressed by the protrusion and that after he removed the fragment, the S1 root was very happy and not being interfered with at all. (He must have tested it by sliding it around.) He did mention that the S1 root did seem somewhat swollen and inflamed. He wants me on 7 days worth of percocet, and then he prescribed me Darvacet. I can shower on Monday but go easy over the butterfly bandages (no stitches). He will see me in a week. I can try and go to work Tuesday 2-17-04 or Wednesday but no twisting, bending, or treating patients. ( I doubt this will happen cause I'm hurting pretty bad.
I have very little pain this whole day, due to the epidural bath he gave everything before he closed me up. I didn't even need much Morphine - which surprised the nurses. I did have one little problem. I was so full of fluids, that I couldn't pea. My bladder felt like it was going to explode so Nurse Ratchet had to 'catheter me'. OUCH! That was no fun at all. They left this in over night and pulled it out at 7:00 AM. That was by far the most un pleasurable part of the day!
2-11-04: Discectomy surgery is on for tomorrow AM: my Pre-Surgery Oswestry score is 22%, which is just unacceptable! At 16 month post incident, there is just not much more room for improvement the 'natural way' and its time to get aggressive. I would say that I've come along way from the 42% disability I had in November 2003 but I'm out of time and patients. If I'm ever going to get more of my life back, I'm going to have to try something more invasive. (here's my latest Oswestry Test.) I'm pretty darn scared for I know that the odds are often not the best for some of my circumstances: 1) small contained herniations, (MRI pictures & report here) 2) long pre-surgical sciatica duration, 3) weak neurological examination (neg. SLR, reflexes now OK, ROM OK, and slight weakness of peroneals.) and 4) the involvement of 'root irritation' other than the surgical target. My neurosurgeon, Dr. XX, feels confident that the surgery will succeed, especially since I have virtually NO lower back pain; just sciatica - especially in my left foot. He does not believe that a patient MUST have severe neurological deficit and in severe pain to qualify for discectomy. He is convinced that a good size 'fragment' is hiding beneath that 3-4mm HNP, which is super-imposed on top of a moderate bulge. There's a lot of hiding room in there! Specifically, he is going to make a small incision in the PLL and then "squeeze" around the margins of the HNP in an attempt to "pop-out" that fragments - like popping a zit is the analogy he used. He will only superficially debris the anular tear and NOT go fishing and cutting deeper inside the disc. It is his experience that this exploration will lead to an increased risk of reherniation. So, I guess my 16 months of suffering and current 22% disability is enough reason to give it a try, and as a fellow spiny & friend of mine has just so elegantly put it, "sometimes you just got to say, what the fuck" - Risky Business. WISH ME LUCK!!!!!!!
02-10-04: Yes, now I do believe I've gone insane! After a 12 hour seminar (which was 1 hour away) I've decided that the disc herniation must come out NOW. It was ridiculous: I made it through two hours ok but that was about it. Now, not only is my left foot (lateral and medial side) hurting/burning but i'm getting L5 root burning/tingling on my RIGHT foot, and a new bilateral medial need faint burning (not as bad as the left foot- which is the worse - but enough to put me back in the MRI tube for the 5th or 6th time in a year (i've lost count!) I'm scheduled for surgery again on Thursday AM. I'm seeing Dr. XX tomorrow morning for one last exam. This is going to be the hardest decision of my life for I'm certainly doing better than three months ago, but I just can't sit! In the seminar (which was mostly comprised of MD's) I had to stand up because of leg pains about every 30 minutes, and then stand in the back (with a few other MD spinys - none of whom were as bad off as me.) for 10 to 15 minutes then sit down for 20 to 30. At the breaks (which occurred every two hours) I would go walk around in the parking lot which helped. Seems like a no-brainer, surgery right? All it took was about 60 minutes in my home recliner and I was feeling good again, without taking any medication? I haven't needed any medication in quite some time. I'm back on my gym ball program and riding a bike 10minutes per day.
So here's the question: Do I take a chance with the surgery; given that fact that I've only got a 4 mm HNP, its been 16 months, my SLR is negative, my ortho exam is normal, I have no lower back pain or very little, I can work a full day (although I need a 30 to 60 minute recliner break to make it without suffering), and my symptoms are changing to indicate that the L4 disc may now becoming active (although the MRI of yesterday show only a very small 2mm central protrusion)?????????? OR do I go for it in hopes of ridding my self of this left foot pain, and what ever other (referred pain) pains goes with it???????? There is no question the left S1 root is contacted (although its not smashed), I've got 2cm of left calf atrophy, and I've got mild weakness of the left evertors and toe flexors [all S1- the perfect match] and my EMG shows S1 root signs for chronic radiculopathy. I'll know the answer tomorrow. Have I waited too long? What if I get worse and can't work at all? I've got no disability coverage! How will I support my family? Small herniations are known not to have the best track record with micro-d (although small herniations usually don't cause the radicular symptoms that I objectively have.) I think its time to let go and trust and believe in the doctor I've selected! (future: big mistake! 2012).
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