nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Saturday, December 11, 2010

Doctors Get Sick Too - Part 2 - My Spinal Fusion Story

This is like those movie sequels, Return to the Valley of the Son of King Kong, or something.   I wrote a story about my appendicitis.  Here's another.

It’s disheartening, but inevitable, that our bodies wear out. One of the most vulnerable structures is the system of joints. Over the years the constant movements of one bone against another, with the intervening structures that lubricate and cushion that activity subject to pressure and injury, the parts break down, linings are worn through, and bone rubs on bone.


The process is called degenerative arthritis, due to the inflammation that comes from that rubbing of the raw surfaces against each other. We experience this is as pain…daily, unremitting, slowly progressive pain.

Live long enough and arthritis of this type will be a daily visitor, and one of the most common sites is the lower back. If you've ever looked at a picture of the bones of the spine and vertebral column you'll note there are lots of places where bones come in contact with each other at joints. Each one of these joints can wear down; several at once are a misery.

In my case the process became apparent a little over 10 years ago when I noticed that-- while stretching out to run--there was some pain on flexing and twisting my back. Sensing that this was the beginning of the aging process on the joints, I knew that my best bet was to stay active, stay flexible, stretch a lot and keep going.

That worked for a while; then it became necessary to take the occasional ibuprofen to counter the symptoms. At first it was one pill every few days or so; then it became a pill after almost every run. The next strategy: cut back on the distance. 6 mile runs became 4 mile runs, and so on.

Three years ago it became so bad I could run no more, and I underwent a series of injections of steroid to the back, followed by radiofrequency ablation of the sensory nerves that serve those areas that were subject to arthritis. This helped for a couple of years. Then the pain changed. I was now getting a sharp pain running down the back of my two legs to the bottom of my foot. It got worse as I walked. Over time the frequency and severity of it progressed to every time I walked.

This was the most depressing time of my life. Historically I loved strenuous activity. Pushing the envelope was the juice. Now, increasingly disabled, out of bed only to walk around the house, I had little left. As part of a routine checkup with my family doctor I mentioned that things had gotten to the point where the pain management techniques were not working and I could no longer exercise. He recommended referral to a spine surgeon.

At that consult I laid out all my history he took a few x-rays and in summary said "This is classic neurogenic claudication." It was like being struck in the forehead with a hammer. Of course! What was I thinking? Why had it not been apparent to me? I knew well the signs and symptoms of this syndrome.

Lesson One: The physician who diagnoses himself has a fool for a doctor. Old saying. There’s no way to be rational. There’s denial, target fixation, distraction, misplaced concentration…all the criteria for error. It’s not possible to be objective in the way you need to be with patients. There’s also emotional involvement. The same applies to a doctor’s family; I used to make sure that someone else took care of my family’s medical needs (an insistence that is sometimes hard to explain to one’s spouse, who has to take the time to get an appointment; “Why can’t you just prescribe what I need?”)

Back to the diagnosis. I felt doubly stupid because neurogenic claudication, caused by movement of one vertebra on top of another (spondylolisthesis), narrows the spinal canal, and leads to pinching of the spinal cord: these are anatomical changes that can be fixed, and the condition has a very successful surgical procedure.

And looking back over the last several years, I had been doing the little things to relieve the nerve pinching that caused the pain: like standing with your knees slightly bent, which reduces the stretch on the nerves that run from the spine down the leg. I had been doing this, and so gradually, that it never occurred to me it was an indicator.

Lesson Two: Don’t forget that when new symptoms occur, if may not be the same problem, even if the new symptoms seem related to the old.

Here’s a picture.



But still, I’m wary of back surgery. In some cases, it’s a 50-50 chance that surgery will improve the symptoms. And, cutting always leaves scarring…substituting a new pain for the old. Furthermore, we’re talking big stuff here: (1) cut away the muscles over the spine (2) remove the bone over the top of the spinal cord (3) avoid damaging the spinal nerves while pushing them out of the way to get to the vertebra behind them (4) take out the disc, (5) move the vertebra back in line, (6) put in a hollow implant (7) fill it with bone marrow taken from my hip (8) drill in four screws, left and right, on the vertebra above and below (9) put two vertical rods to connect the paired screws (10) back out and close everything up.

Don’t get me wrong. Surgery is frequently lifesaving. I wouldn’t try to avoid an appendectomy; that’s lethal. And surgery for spondylolisthesis, if severe like mine (unlike surgery for other types of back issues), has a high rate of success. But it’s just tough to cure pain with a knife. So, I waited, tried other types of steroid shots; intraspinal, this time. After two months, nothing was better.

I limped into the surgeon’s office and said, “When’s your next opening on the surgery schedule?”

Two weeks later, I reported to the hospital at 6AM, sans coffee (a cataclysm). They take me in at 8:00, I get sleepy and the next thing I know, it’s Recovery Room and the clock is on the wall across from me. 3:00 PM. Let’s see, counting pre-op, moving me, induction, ET tube, and positioning on the front end. Then moving me to Recovery, and about an hour there before I return to this world. We’re still talking 5.5 hours! What the…

Here’s why so long. After doing the research on the different surgical techniques for this procedure, and getting a second opinion, I decided that rather than do the operation directly from the low back, I wanted a different—and new—approach. The technique, in use for only a few years, is called Extreme Lateral Interbody Fusion (XLIF). The old technique was PLIF (posterior lumbar etc). There is even a TLIF (transforaminal etc). This last tries to come in at an angle, but still in the back.

XLIF is done through an incision in the flank (yeah, from the side of the body) and slides in between the muscles of the back—without cutting them—to approach the backbone (I’m all for not cutting muscles in two). An electronic probe is used to test as you go in for nerves that supply the muscles, making sure you don’t get close to them. The implant work is done, this incision is closed, and the patient is then turned from the side to prone, and using two small incisions just to each side of the midline over the lower back, you use probes to remove the bone over the top of the spinal canal, one side at a time, No cutting muscles, and the spinous process in the middle is left behind. Screws and rods then get put in.

If you’re still with me after all this minutiae, you can see the thing that decided it for me. There’s no monkeying around with the spinal cord nerves that would risk damaging them. Yes, damage the spinal cord and you won’t have pain any more; you won’t walk either. Although that risk was low, it was the Big Kahuna of bad outcomes (other than just not making it).


Someone else would have decided on a different procedure. I did the math, made my decision, and fortunately, live in the US…where patients still get to decide what’s most “effective” for them. I’m concerned that comparative effectiveness under Health Care Reform will eliminate some of these options. The risk I was avoiding was theoretical; we don’t have 20 years of data to see whether XLIF has better outcomes than PLIF. And it’s expensive. In any case, it ought to be my decision, not a government panel’s.

But that’s another story.

These new procedures are called “minimally disruptive” because there are smaller incisions, less tissue trauma, less scarring, less post-op pain, shorter hospital stay, and quicker recovery.

Thirty-six hours after surgery, having walked the halls on two occasions, with assistance and without incident, the surgeon said, “Wanna go home? Just gradually work back into full activity.”

Recovery was uneventful; symptoms of claudication were gone from day one. Except…I got too rambunctious: I started walking a half-mile a day on the fifth post-op day and injured a leg muscle. My guess is that, since anesthesia is eliminated from the body over a period of weeks, I was still feeling the effects and shouldn’t have pushed it.

Lesson Three: Follow instructions and don’t think you know better than everyone else.

A minor annoyance was lack of appetite. For four weeks I couldn’t stand the sight of food; it made me nauseated (anesthesia again, probably). I got by on 3 cans of Ensure a day. And lost 15 pounds.

But I don’t recommend it as a weight loss regimen.

Now, I can jog--a little--again. Not the 10-mile runs of two decades ago, but it’s enough. I can lift heavy boxes; dig in the garden; etc. New bone has grown into the implant and fused the two vertebrae.

But the arthritis is still there, and will continue. You take the victory you can get.

Overall, I think being an active, inquiring patient led me to the right treatment choice, something any patient can do. Being a Dr. Know-It-All caused the problems.


Doc D



PS: Disclaimer: There are companies who specialize in making and selling the tools for the procedures above. I’ve avoided using any proprietary terms or company names. None of this is an endorsement of any particular company’s product.

2 comments:

Mike and Denise said...

If only the patient had read"Free your Back" by Moshe Feldenkrais years before he started to suffer the arthritic pain and learned and practised the principles of movement outlined in the book he may not have needed the back operation. My mother said "yes doctor" too often and agreed to spinal fusion after a first operation provided no relief. She "lived" till she was 90 but for the last 30 years of her life after the operations, walking was so painful that she just sat on a chair in her kitchen and answered the phone.

Doc D said...

I was active duty military for almost 30 years--special ops, airborne parachutist,runner. A lot of chronic trauma over the years. Also, spondylolisthesis is a different process from degenerative arthritis. It has a different etiology. While I'm not familiar with "Free Your Back," I agree that preventive physical therapy can delay the onset of arthritic pain.

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