5 Year Update

Yesterday marked the 5th anniversary of the ADR surgery on my lumbar spine at Hospital Quirón Barcelona by Dr. Clavel. Since I haven't been actively blogging over the past few years I wanted to give an update on how I'm doing and what I've been up to since then.

Physically, my body feels great. I haven't had any pain specifically in the lumbar region. Although I have minor sciatic pain that comes and goes on rare occasions, but not to the point it impedes with my physical activities or daily living. My back feels strong and the implants are holding up really well. I haven't had any complications nor have I had a reason to visit the doctor for back-related issues for many years now. I have no issues performing any activities of daily living and no longer have issues with standing or sitting for extended periods of time. 

On another note, my journey with the ADR surgery and time spent in Quirón led me on a different path career wise. The whole experience inspired me to want to pursue a career in the medical profession. Although I would have loved to become a medical doctor I couldn't fathom the idea of investing so much time and money to attend medical school. Thus, I opted for the next best option; I chose another respectable profession - nursing. This week marks the start of my second semester in nursing school. I'm hoping to bring back the bedside manner exhibited by the doctors and nurses I encountered in Hospital Quirón to the hospitals here in the states.

Me with my clinical group at the end of our first semester

Hello hello! I'm back...

After a year long hiatus I have lots of catching up to do. So much has gone on since my last post that I figured I should give you guys an update on everything that has taken place since then 'til now. Of course, I completely forgot what was last written and I had to take a look to refresh my memory. It also gave me an insight as to why I put this blog on the back burner in the first place... From the time that I made my last entry, it took Dr. Clavel or perhaps I should say his assistant Yolanda approximately 6 months to email his remarks after having reviewed the results of the CT myelogram. Here is his commentary:

“Posterior microsurgical revision of the lumbar nerves is not a complex surgery. Done under the microscope. Medial microsurgical facetectomy to unroof the nerves in the lateral recess.

The EMG states there is no acute radiculopathy and that they only detect chronic right S1 radiculopathy. Symptoms suggest right L5 distribution besides S1.

The CT myelogram does not show clear lateral recess stenosis.

Still the surgery may be done since we will cause no harm.

Still, we cannot guarantee improvement.”

Initially, I thought this procedure might help with the pain I'm still experiencing in my sciatic nerves. That is until I consulted Dr. Asdourian. Dr. Asdourian stated that that procedure is simple. It is a decompression of the nerves in the posterior area, but it will not address the issue. Since the nerve pain is caused by the bone spur impinging on them the only way to correct that is to remove said bone spur. That surgical procedure could possibly lead to more permanent nerve damage. Hence, the reason why Dr. Asdourian originally stated surgery being very risky.

I've come to the conclusion I am done with surgery. I will not be having anymore procedures trying to correct the issue. I'm also happy to announce I've been medication-free for several months. I no longer take Lyrica for the nerve pain nor do I take any anti-inflammatory meds. Obviously, I'm not pain-free nor will I ever be, but physically my life has been much easier since I had the ADR surgery almost two years ago.

On another note, I've managed to enjoy some activities without experiencing pain. Here are a couple of photos of me kayaking:

Kayaking in St. Thomas

Kayaking with Dolphins in Virginia Beach :)
 Sadly, there are no dolphins in this shot.

Over the course of the past few months, I've learned how long I can be sedentary without feeling pain. The time limit is approximately 2 1/2 hours. I figured this out while driving to and from Virginia Beach. The drive is about 5 hours or so depending on traffic. Unfortunately, I tend to be very stubborn whilst driving. What I mean by that is I do not make any unnecessary stops. Although I was writhing in agony for more than 3 hours I refused to pull over. Rather I endured the pain just so I could get to my destination quicker. I know it's not a logical way of thinking but like I said I'm stubborn. Anyway, the moment I got out of the vehicle I felt immediate relief. Will I be foolish enough to do that again?! Most likely, but at least now I know what to expect after 2 1/2 hours of sitting. 

Aside from kayaking I've taken up swimming. I presumed this would be a therapeutic activity for my back as well as a good way for me to be active. Perhaps this is the case for those who were already active swimmers prior to having back pain, but I must say for me being a beginner adult it is rather difficult, not to mention very painful. I've had five one-on-one sessions along with several hours of solo practice sessions for the past three weeks. Although I can swim, I cannot stay afloat. If my lungs are full of air I have no problem but the second I exhale I sink no matter what. And I digress...that is another story. Not only that but after 30 minutes of swimming my left leg cramps up every time; I cannot figure out why. After about an hour I start to have minor pain in the lumbar region. I've also noticed my left leg is much weaker than my right. (It would make sense if it was the other way around.) Consequently, I realize swimming is more arduous than I anticipated. The only thing that comes to mind is what my first orthopedist told me about 12 years ago... He asked if I swam to which I said, 'No, but I plan on taking swimming lessons this summer.' He replied, 'Don't bother. You won't be able to.' At the time I was only 21 years old and not very good at questioning doctors. I now wish I had taken the time to ask him why. Nevertheless it's a little too late. But I can't help wonder if there is truth to what he said. Clearly I'm struggling with swimming on so many levels. If any of you have some insight please feel free to share your thoughts. 

CT Myelogram

I had the CT Myelogram done last month and already had the follow-up appointment with my orthopedic surgeon, Dr. Asdourian. The only thing I'm waiting on is Dr. Clavel's assessment of the test results; it's been three weeks since I've sent in my results. The CT myelogram was a fairly simple process. I was injected with novocaine to numb the area first before being injected with contrast. All of this is something I've grown accustomed to so it was a painless procedure. The table I was lying on was tilted upwards to allow the dye to move towards my lower extremity. I could feel the dye coursing through my legs. The lower half of my body immediately became numb and tingling. While I was on the table the radiologist took X-rays. Then I was wheeled into another room for the CT scans. All of this seemed simple enough till 72 hours had passed.

After 72 hours of having the procedure done, I was back at work and was experiencing the worst spinal headaches ever. Every time my body was in an upright position either from sitting or standing I had a massive headache and felt so nauseous that I was dry heaving...Gross! I know. It turns out I had a CSF leak that was causing the spinal headaches. After having spoken to Dr. Asdourian, I was en-route to the hospital. He suggested I go in for a blood patch. A few minutes later, the radiologist, Dr. Sexton calls and to tell me he would inform the anesthesiologist that I'll be coming in for the blood patch. Seconds later, Dr. Andrews, the anesthesiologist, calls to tell me to not come in. Even though I vehemently opposed the idea of waiting for the spinal headaches to pass, I finally took his advice and acquiesced to stick it out. For the next three days, I did nothing but wait. During those three days, I did a lot of lounging around either in bed or on the couch. Dr. Sexton was also kind enough to call me every day to see how I was managing the headaches. Sure enough the nausea and headaches subsided so that I did not need a blood patch.

Since the ADR surgery I have not been able to fully regain my flexibility. I now finally know why. The CT myelogram shows a large bone spur impinging on the nerves. Hence, I'm still experiencing pain in my sciatic nerves and in the anterior tibia muscle.

Dr. Asdourian told me surgery is an option. But he advised against it because of the size and location of the bone spur. He said it could possibly do more harm to the surrounding nerves. For now, I've decided to leave it alone in hopes that the bone spur doesn't get any bigger. I am also taking Lyrica for the nerve pain. Hopefully, the pain I'm experiencing now will be the worst it gets. If so, I can deal with that.

Test Results from MRI and EMG/NCV

After being down and out from being sick, I'm finally back to feeling like my old self. :) During my absence, I had a couple more tests done. I actually had two MRIs done as well as an EMG with a NCV. I ended up having to have two MRIs done simply because the first was done without contrast. The results of those test are as follows:

MRI # 1

FINDINGS: There is normal alignment of the lumbar spine. No marrow signal abnormalities are seen. The spinal cord is normal in signal and terminates appropriately at L1. The paraspinal soft tissues are   unremarkable. Lumbar fusion hardware is seen at L4-5 and L5-S1. Local susceptibility artifact limits revaluation of these disc levels. There apprears to be soft tissue in the ventral epidural space at L5-S1 which could be susceptibility artifact or soft tissue. If soft tissue, this may represent residual/recurrent disc herniation versus scar. There is effacement of the ventral space but no significant central stenosis is seen. There is mild bilateral facet osteoarthropathy.

    
IMPRESSION: Status post lumbar fusion L4-5 and L5-S1 with susceptibility artifact from the fusion material which somewhat limits evaluation of the L4-5 and L5-S1 as described above. Soft tissue of the ventral epidural space at L5-S1 could represent residual/recurrent disc herniation versus scar tissue but assessment limited by adjacent susceptibility artifact.

MRI # 2

FINDINGS: There is enhancing epidural tissue at the L4-5 and L5-S1 post discectomy interspaces that
is not exerting any mass effect and some of this is surrounding the right L5 and S1 nerve roots in their respective lateral recesses. The granulation tissue, slightly enhancing, at the site of the previous L5-S1 disc protrusion is unchanged from the recent study and smaller than it was on 6/2012. This is the only area where there is any mass effect. There is no evidence of disc space infection although that is somewhat compromised by the metallic artifact from the intervertebral spacers.  All of the higher lumbar intervals remain unremarkable. No new or different pathology compared to the recent exam. The intervertabral spacers are new compared to 6/2012.

IMPRESSION:

1. Stable or slightly decreasing regions of enhancing epidural soft tissue L4-5 and L5-S1.
2. No new or different pathology compared to the recent study on 02/2013.

EMG/NCV Study

     Summary/Interpretation:

1. The only abnormalities of this study were the absent right and prolonged left H-reflex consistent with chronic S1 radiculopathies.
2. On clinical grounds a mild residual right L5 radiculopathy is suspected.
3. Importantly there was no electrodiagnostic evidence for an acute/ongoing right lumbosacral radiculopathy at this time.

Basically, the neurologist believes the radiculopathy I am experiencing is a result of scar tissue. I inquired about getting a CT myelogram and he advised against it because it is invasive. He believes the pain I have now will subside with time. On the other hand, my orthopedic surgeon wants me to go ahead and get the CT myelogram because the MRI results are inconclusive. Personally, I'd like to know why I'm still experiencing pain in my right leg. So I have decided to get further testing done. I'm scheduled to have the CT myelogram in a couple of weeks. Hopefully, that test will provide some much needed answers.

 

Residual Nerve Pain

It's been 5 months post surgery and I have some lingering residual nerve pain.  I have pain in my sciatic nerves and the anterior tibia muscle that is isolated in my right lower extremity. The pain level is manageable with the NSAID I'm currently taking. It does get aggravated the longer I sit. After about two hours of sitting, the pain becomes more intense and it's coupled with numbness. Since the pain has not completely subsided Dr. Clavel has ordered more testing. On Friday, I'll be going in for another lumbar spine MRI to rule out any nerve compression. At the end of the month, I will be going in for a Nerve Conduction test along with an EMG. 

On another note, my lower back feels great. I have absolutely no pain in that region; it feels much stronger than it has ever been. As far as the scar on my abdominal goes, I think it looks slightly better than before. I went from using Mederma to coconut oil and now Vitamin E oil. The scar itself (in texture) has completely flattened out. It is hard to the touch, and there is absolutely no sensation to the bottom half of the scar. I think the appearance of it is the best it's going to get.

On My Own

A couple of weeks ago I had another reevaluation at Active Physical Therapy. Here's the latest assessment:

Active Range of Motion (AROM):

• Flexion - 64°
• Extension - 17° 
• RSB - 30°
• LSB - 35°

Manual Muscle Testing (MMT):

• Core - 4+/5
• Hip - 5/5
• Knee - 5/5

Other Tests/Measures

• Straight Leg Raise (SLR) - both at 88° 
• Sit and Reach to Anterior Ankle
• Numbness and Tingling to right lateral shank intermittently

According to the physical therapist, I had reached my maximum potential and was finally discharged. I had been going to PT since late February to late December. After several months of going to PT, it feels strangely odd to not have to go for my weekly workouts. Since I've been discharged I haven't kept up with my exercises. I know, it's terrible! Once the weather clears up a bit around here I will get back in to my old routine of going for a walk at least three times a week. As for now, the residual pain I have is minimal and definitely manageable. I am in the process of weaning myself from the two medications I'm currently taking: Neurontin and Meloxicam. After about two weeks, I should be completely medication-free.

On another note, I finally received a response from Yolanda. It turns out they were in the process of moving office locations. Hence, the delay in her response to my emails. Unfortunately, Dr. Clavel has not been able to give me any feedback on my last x-ray results. I'm hoping within the next week or so he'll have time to review everything and provide some answers to questions I had brought to Yolanda's attention.

X-Rays taken at the Three-Month Mark

Sorry, I've been slacking with this blog.... It's been exactly 4 months since I had the 2-level ADR surgery. I had x-rays taken last month on 11/28/12 and had sent them in for review, but I have yet to hear from Dr. Clavel. I had hoped to hear from him by now considering it's never taken this long to get a response. I'm assuming it's because of the holiday season.... Anyways, I had the x-rays taken at my orthopedic surgeon's office. Dr. Asdourian said the images looked great; the implants are settling in nicely with the vertebrae. Of course that was great news. The only thing I'm slightly concerned about is the fact that I've been having constant pain in the anterior tibia muscle. This has been going on for the past 2 months now. Dr. Asdourian is not quite sure why I'm experiencing pain in that part of the leg. He gave me a plethora of reasons from scar tissue to possibly a pinched nerve, etc. He wants me to get either a MRI or a CAT scan (it depends on Dr. Clavel's recommendation) just to make sure a nerve isn't pinched. In the meantime, he prescribed Neurontin and Meloxicam in hopes it will help alleviate the pain.

Frontal View

Lateral View

Once I hear back from Dr. Clavel, I'll post an update. Thus far, I've been doing relatively well aside from the pain. I have already gone back to work full-time and have been driving around without any issues (yes, I still wear my back brace for safety precautions). I've regained most of my strength and flexibility...thanks to my awesome little family at Active Physical Therapy. (Tomorrow I'll be going in for another reevaluation so there is a good possibility my PT sessions will be coming to an end). I'm not as ecstatic as I thought I would be for hitting this milestone...perhaps my celebration will happen once I hear back from Dr. Clavel and get the reassurance I need that everything is going as well as expected.