The View from Sports Center

Chapter 7: The Plan (Part 2)

In the last chapter, which brings you up to March 13, 2008, I explained some of things I have done to help my lower back injury heal. I left out a few things though and would like to explain these before I move on to the next items.

To reduce the bending, twisting, and torquing of my spine, I wear a brace. By far, it's the best one I have used. It's called a System-Loc Brace. The company claims it unloads the spine by providing an upward lifting force. I haven't seen any proof of that but it does limit motion more than a neoprene brace. I wear this during most of the day except when I lie down (unless I'm in a recliner then I'll wear the brace to prevent my lower back from bending). I've found that when I wear it, especially while driving, I tend to have much less leg pain.

Speaking of leg pain, it's much worse after sitting (as much as I try not to) and sleeping. So, when I wake up, it's because my leg hurts and getting out of bed and walking is very difficult to do. A few times I did a sort of a hop-drag kind of movement with my right leg. I would place as little weight as possible on my right leg, quickly advance (this is the hop part) my left leg and then drag my right leg up to meet the left. After Elle saw that once or twice, she bought me a cane. I wouldn't use it though. I couldn't put enough weight on the cane to make any difference and a cane seemed so, permanent; so disabling (which is the main reason I wouldn't use it). And, as I leaned on it, the pressure seemed to unlock a memory, a flood of discussions I had had with clients. I remember helping them adjust to the idea of using a cane and although I understood their resistance, it wasn't until I had to use one that I really got it; really felt what they had felt. A crutch is better. It seems more temporary and I can place more weight on it. I have one in the bedroom within reach and one downstairs. I only need it for a few steps but I am quite thankful it's there. Thank you, Elle.

On March 18, 2008, I had a follow-up appointment with Dr. White. I felt a little better going into his office but not a lot. Apparently I looked better though. Dr. White said, "Well, you're moving a little bit better and you certainly look better. You looked really bad last week. I was concerned." Really? I looked bad? The great news out of that visit was that my reflexes are back. As he thumped his reflex hammer on my knee and then my heel cord, I could feel the leg jump. I said in a whisper, "Yes!" Dr. White checked them several times and every time, the leg jumped. Awesome news.

I told Dr. White that I dreaded going to bed; that the pain at night was awful. He prescribed two medications: Lyrica and Ultram. He also gave me Skelaxin and Vicodin. I guess one or more of those will take the edge off or just hit me like a hammer on my head dulling all sense of pain.

I resist taking pain medication. Not because I'm trying to be tough but because I'm concerned I may fall for the fragile armor it provides and do more, just a little more, than what my body can really withstand. You may be laughing at that thought - me - paying attention to what my body can tolerate - but I believe I have a better, not perfect, appreciation. But, there are some days when it's too much. I can't get comfortable, my leg is numb yet burning at the same time, and when I turn or just place weight on my leg in a unusual or unexpected way, a sharp, stinging pain rips through my hip and down my leg bouncing to the thigh, lower leg and foot and I wonder if it's laughing along the way. Pain feels so evil to me at times. There's nothing happy or pleasant or inspiring about it. It's nasty, ugly, and I imagine it has green bumps and hairy warts on its chin with long, snaggy fingernails to prick and claw it's way from spine to foot.

The drug that worked was Ultram. It knocked the pain level down enough that I could concentrate but didn't also knock me out. Currently, I take Ultram and Lyrica at night and during the day occasionally, Ultram. I came to the conclusion that sleep was more important than waking up at 2 or 3AM and then spending the remainder of the day in a foggy, slightly pissed off frame of mind. When I'm tired, I feel sick. Nauseated. Thick. Dull. It feels like my thoughts slosh through a muddy mind. Sleep fixes a lot of things. When I sleep, everything seems better even if I hurt, I have more tolerance. My mood is brighter. I feel more positive. Sleep is key.

Unfortunately, it's still a crap shoot.

On March 20, 2008, I added an inversion table to my home routine. I call it the teeter-totter. The idea was to reduce the pressure on my spine, introduce a little motion, and more importantly, give me something to do. Elle picked one up at Costco for about $200. It's great. The table tilts back, I have control over how far it goes, and I can easily rock it up and down creating the teeter-totter effect. It feels really good. I often climb in it at night when the evil green, hairy-chinned painster comes to visit. It soothes the fire in my leg after fifteen minutes or so. I spend about an hour a day in the teeter-totter in twenty minute segments. I listen to music, burn incense, meditate, travel in my mind. You know, I'll bet Austin would be just the place to start a spinal teeter-totter class. I can see a room full of teeter-totters all moving in rythym to the music.

I would like to tell you about about my exploration into unknown, belief-stretching, and challenging territory  and  whole bunch of other things, but I have to hop into (not the drag-hop :) the teeter-totter and do some traveling.

Do Women with Chronic Knee Pain Get Left Out?

If you have knee pain that did not respond to conservative care (physical therapy, cortisone injections, medication) and happen to be a woman, you might not be getting the same treatment options as a man.

In a recent Canadian study, men were offered knee replacement surgery twice as often as women even though women tend to have more arthritis, worse symptoms, and more severe disability.

And, this isn't the only problem that women seem to have trouble getting the same treatment as men. Other studies have found women who have a heart attack are less likely than men to receive cholesterol-lowering drugs or to be admitted to an intensive-care unit. And, you can add cardiac catheterization (to remove blockage in arteries), kidney dialysis, and kidney transplants to the list as well.

But, in the Canadian study, few of the doctors were women. So, you might consider a second opinion from a female surgeon. In any case, ladies, speak up. Don't get left out.

Chapter Six: The Plan (Part 1)

After my second consult with Christine, I had at least a sketch of a plan going forward. Physically, I had to do five things: reduce (and ideally eliminate) the loads on my spine (sitting primarily) in my life, wake up the muscles located deep in my spine, use a crutch when I needed to, be open to taking pain medication, and keep moving. Mentally, I had to be aware of negative thoughts masquerading as worry and wonder and give them no energy; no life. Emotionally, I needed to remain open to feeling whatever stirs around inside of me; not run from it or squash it or explain it or defend it. Just feel it and let go.

Honestly, it was a lot.

I fought the issue of eliminating sitting at home for a day or two. I had convinced myself that sitting for a short period of time, like sitting at the dining room table for dinner, would be ok. And, this is not a conscious sort of discussion. It's not like I'm standing in the kitchen having a conversation with myself. No, I just decided that I wanted to eat dinner with my wife at this awesome dinner table and visit with her. So, I did. I think what I need though is a Dick Tracy watch with my own channel directly to Christine so I can tap the watch and say,"Hey, C - I'm going to sit down and eat dinner. Just to let you know," which then gives her the opportunity to yell through the watch, "Are you crazy? " Oh, yeah. I am. Right. I'll stand. But, that's not what happened. I sat through dinner shifting my weight, moaning and grunting and groaning, which, by the way,  creates a lovely dinner ambiance, and then when I went to stand up, I couldn't. I had to slide out of the chair onto the floor like as if I had been magically turned into a snake and lie face down on the floor for nearly fifteen minutes. And, there is nothing notable about the smell of carpet except that it just doesn't smell very good.  I then was able to get up and walk away leaving all dignity behind embedded in the carpet fibers.

I stopped sitting after that dinner.

I take my meals at a bar, glad we have one now, in my favorite room, the Man Cave (the Man Cave is a dark, cold, room with a big screen tv, great sound, and cool furniture). At first, it didn't seem so bad to stand up for meals. But, after a few, it lost its appeal. In order to work on my Powerbook, I created a set up so I could lie down. I should tell you though first, that I normally work in a Zero Gravity Chair but the term is not actually true. It's not zero gravity as my spine quickly let me know. So, I had to abandon the chair for a position that has an even lower pressure.  I have a few props though to make this work. I have a wedge under my knees and an adjustable Aerobed. By flipping a switch on the bed, I can prop the head of the bed up and change the angle as needed (one of the keys to keeping the pressure in my spine low is to keep from staying in exactly the same position for too long). I use a LapGenie (seriously, NOT the branding image I would choose if I owned the company, but they didn't ask me) which is a very cool device. It's an adjustable aluminum frame that holds my Powerbook and rests over me. I place a partially inflated beach ball (about 12" in diameter) under my lower back. If I don't my right leg gradually goes numb and feels as if there's a small campfire buried in it somewhere. I place two smaller pillows under each arm to prevent my shoulders from working too much and thereby overloading my neck. And, finally, I have a pillow under my head. Whew. In this position, I can work for about an hour or so then I need to get up which is when I wish I had a crane in the room.

The reason that I am so vigilant about decreasing the pressure on my spine is that too much pressure interferes with the natural healing process of a herniated disc and it can worsen the degree of the injury (in medical terms that is often called, "extending the lesion"). The disc is a blend of a tough, fibrous outer ring (called the annulus) and a softer, gelatinous inner core (the nucleus) and sits in between two vertebral bodies or bones . Its job is to absorb force of everyday life (like sitting, walking, etc.) and guide the complex, three-dimensional motions of the spine (as in bending and twisting). Along the outer edges of the annulus, on each side, are nerves that come together to supply sensation and movement to your lower body (from the lumbar spine). A herniation happens with you tear the outer layers giving the nucleus an unrestricted pathway to the nerve (in the image below, the pink is the nucleus while the red is the nerve). So, as you add pressure to the injured disc, the nucleus can ooze its way out. And, the more pressure you place on it, the more it oozes.  Fortunately, it moves slowly because it's thick but your nerve is haphephobic (fear of being touched) when it comes to the nucleus. It treats the nuclear material like our body reacts to a sliver in your finger: inflammation. You then develop pain in your leg or back or both. Sitting isn't the position with the highest pressure on your spine but it's close. And, since it is something that permeates our lives, trying to eliminate it really impossible and reducing it is tough to do.

The research on disc healing suggests that the herniated disc will reduce in size by 50% within 6-9 months (assuming you do not make the injury worse) and nearly 90% of people will have a good to excellent outcome. So, why do people end up in surgery then if in 9 months, the problem has resolved? There are two main reasons: neurologic compromise and severe disability. If your nerve isn't functioning properly (so, your muscles are weak and you're leg feels numb or you have lost bowel and bladder control), allowing the disc to continue to press on the nerve may lead to permanent nerve damage. Surgery is required.

I have a high level of disability according to the Oswestry questionnaire. This is a widely accepted instrument to identify the degree of disability following a back injury. The higher your score, the worse the disability. My score fell in the "severe" category. Most people cannot tolerate the severe disability because it just wrecks their life. They can't tolerate standing to eat dinner, not sitting, not going out to dinner, to see a movie, to visit with friends, etc., for 6 to 9 months so they opt for surgery.

There are days when I'm sure I can ride this out for 6 or 9 months and then there are days following nights of burning leg pain and 3 hours of sleep that I'm not so sure. I know it can be done. A friend of mine and former student had a similar problem (his MRIs are below). It took him a year but he recovered and returned to cycling and a very active lifestyle.

(If you look near the bottom of the image on the left, you can clearly see a dark glob protruding into the region of white. That's the nucleus - the herniation.)

 

(In the image on the right, notice how much smaller the "glob" is a year later.)

 

 

It's been a physical and emotional roller coaster and there are some days, hours, that I wonder if my reaction is unusual and then I remember all of the people I've interviewed and examined and realize that, no, what I'm going through is not unusual. I'm just sharing it and that might be unusual.

Some people have asked me, "So, what do you do in therapy? Is there anything that can really help this?" The short answer is, "Yes." The long answer is next.

 

 

 

 

A Line to Avoid

Chapter Five: Crying with Christine

”What scares you about surgery?“ asked Christine.

The question seemed out of context. The clarity of it rescued me from the emotional fog of the last question. I snapped into Spock mode. ”Well, I’m not really scared of surgery. I mean I’ve been through surgery before. Knee surgery. Shoulder surgery. I did fine. I don’t think it’s surgery that’s a problem really,“ I said.

”So, what is so scary then?“ asked Christine.

Christine had skillfully lead me where she knew I did not want to go but needed to. She knew there was something I needed to face; something I needed to admit and that unless I did, whether I had surgery or not, my healing would be incomplete. There was no way out.

"Well...a lot stuff. A lot of bad things can happen in surgery like stroke, infection, death, paralysis. It's a big deal," I said. "And, I guess...I don't know...I had surgery on my shoulder and my knee and I felt ok about it. Even though I was told when I had the knee surgery, I would never run again. I knew that was probably not true. I had confidence in the rehab that I stood a good chance of running," I said.

"Yeah, and why is that?" asked Christine.

"Well, I knew that the surgeon was just coming from his perspective, experiences and most of the rehab wasn't designed to make your joint healthier and I knew we could do that so I wasn't too concerned about it. It bothered me when he said it but not like this with my back," I replied.

"So, it sounds like you had confidence in the rehab after the surgeries? Are you not so confident about rehab after back surgery?" asked Christine.

Right about here, I think, things started feeling shaky like I was standing on one of those rope bridges and it started to sway. "I think it's just...I guess losing some bone, losing the muscle, the stabilizers, I just don't think you can take impact, like jogging, after something like that and I don't know if people lose their abilities because that's just what happens after surgery, because of the surgery, or if they lose function at a higher level because they never rehab in a way to get to that level again," I explained. And, as I heard myself say this, at the same time, I had this sense that somehow this wasn't true. I had helped a lot of people return to high levels of function after they had been told they never would. The truth was still hiding.

"Those are all really good points. But, what would it be like for you if you had to give up some things? You might not need to, of course. You're assuming you would but like what happened with your knee, it may not turn out that way. But, what if it did? What would it mean to you to not be able to jog or do some of those kinds of things?" asked Christine.

The truth started stirring, whirring inside me. I pushed it down. What is this? What is this feeling? Why is this....No. I am not going to cry. Not here. Not now. It chugged and churned swelling up until I could no longer hold it. It rolled up out of me; out of my eyes in tears; out of my chest in sobs. I held it as long as I could trying to talk in a voice I no longer recognized. "It's just....it's the start of the end. It's the end," is all I remember being able to say.

I turned my back to Christine and held my head in my hands and cried. I cried for all I had lost. I cried for the pain; the loss of control; the fear; for reasons I didn't understand. I cried and Christine listened quietly with her heart.

She handed me a tissue. As I took it to wipe my eyes, I said, "I'm sorry...I'm sorry."

"I am so glad to see that right now. It's a good thing to cry. It's ok, " said Christine in a soft voice.

I took a few deep breaths. A calmness settled on me. I felt better. I felt oddly better. Lighter. My voice returned. "Well, that's never happened to me before. What was that?" I asked.

"Pain. It's normal to grieve for things you lose and things you loved. It's part of the healing process. It's a really good thing," said Christine.

She stood and hugged me and told me I was going to be ok.

And, I believe I will.

The words, "start of the end" troubled me for a while after this visit with Christine. I had adopted the belief that my active life was over even though, logically, emotion removed, it was likely not over at all. I was otherwise quite healthy. I have a great group of people to help me. I have access to excellent care. I was borrowing trouble from the future and I wondered why. Why with this injury, of all the ones I've had, why is this one so different?

As I thought about this, wrote about it, an image appeared in my mind. It was a vivid, vibrant one of my dad when he was near the end of his life in a nursing home. In a hospital bed, a sterile, cold room, alone, by himself at the end of his life. And, how did he get there? How did my dad end up in this spot? Spinal surgery. He had an operation on his neck and never recovered.

Whether I end up in surgery or not, whether I ever jog again with my buddy Spencer, I'm ok with with the future now. I'm not so scared of it. I realize that some of my fear and troubles with this injury have emotional ties to what happened with my father. Recognizing the connection helps me but the emotional winds will come and go, I know that. I realize that I will have some good days and some days that aren't so good. I'll hurt, and lose some sleep. I'll miss some dinners out, the movies for a while.  I'll have waves of sadness, anger but I will also have days of great joy and happiness.

I found something that day crying with Christine: a beginning.

I believe I'll be ok.

Does Exercise Just Make You Healthier or Does it Save You?

If you're a frequent reader of The View, you know how strongly I feel about exercise as a foundation of your lifestyle. Well, here's a study just out that not only supports the idea that exercise can make you healthier but also is the key to preventing certain diseases.

Onward....

Chapter Four: The Assessment

I called Christine the night before my appointment with her which was schedule for March 12, 2008. I didn’t reach but left her a message that I wanted to talk with her about a new strategy; that I thought my symptoms were not all from the herniated disc and that I wanted her to conduct a few more tests to help sort out the nature of the problem. I was very excited. I suddenly felt a lot better about this whole thing and I was certain that between the two of us, we could overcome this injury and avoid surgery.

I was back; back in my element doing what I do: figuring out the problem, designing a solution. In control.  I finally had some clarity and knew, once I had explained everything to Christine, she would feel the same way.

I have had a few students over the last twenty years that I would consider outstanding and Christine Springer was one of those students. Before she started studying with me, she would make an appointment to visit me in my office. Most of our conversations revolved around the general theme of learning. She asked me, “So, is there a book or something that you would suggest I read? Something that covers the things you know? Is there some resource so I can figure out what to do with my patients like you have figured out? I mean, where did you learn this stuff”

We were sitting in my office which at the time was in Sports Center and also functioned as the library. Behind me was a large bookcase filled with books on a variety of topics: tissue physiology, spinal biomechanics, osteoarthritis, medical diagnostics, psychology of pain, and bunch of other stuff. I said something like, “Well, they’re pretty much all right there on those shelves.”  There was a long pause. Then she said, "How do I get a job here?“ I have always admired that about Christine. The proof of desire is pursuit and Christine is the definition of pursuit. She eventually found her way to a staff physical therapist position and got her wish. She’s now a great physical therapist, not because of me, but because of her desire to learn, her willingness to accept and learn from her mistakes, and her passion to be the best.

The student had now become the teacher. She said, ”So, you said you had some ideas or a strategy that you wanted to talk about?“

”Yeah - right. So, I’m just not convinced that all of my symptoms are from my disc. I had a really hard fall, a lot of energy transfer. I’m sure I injured joints, ligaments and those structures could also refer pain in the same areas that I have pain now. And, surgery won’t fix them. So, I would like you to do a Gap test, Spring test, Iliolumbar ligament test, SI Compression test. And, I think we need a sit-stand test too - a load tolerance test. We need some benchmarks. I just need to know some things here. Like how many other things are going on and how bad it is.  Also, there’s some research on disc resorption that’s promising. It takes a while, several months, but even a herniation like mine can gradually disappear as your body basically digests the nuclear material. Treats it like a foreign body. But, perfusion is key. We have to get my blood pressure up to increase the perfusion rate. Without adequate perfusion, macrophages won’t make it there...the effect will be much less. See what I mean?  So, we can use the Newton. I can get my heart rate up but control the load into my spine and we can also unload me on a bike. A 10-20 minutes on each, several times, get a sweat going. So, the combination, you know, of the disc resorption and likely ligament injuries made me think that between you and I, if you’re okay with me being apart of the strategy, kind of, well not directing things but just being a part of the thought process, I just think that you and I, we can beat this. I know we can.  I’ve done this before. This will work,“ came crashing out my mouth like thoroughbreds out of the gate at the Kentucky Derby.

Christine said, ”Ok, let’s do some of the tests. We may not be able to get through all of them though. I want to leave enough time for us to talk.“

She did a physical exam. She checked my balance standing one leg which was wobbly at best. I walked on my heels then toes. I squatted down and up five times which hurt some in my right hip. She asked me to lie down on the table. The transition from sitting to lying down hurt as it has for the last month. But, once I was fully supine, I was ok. She lifted my right leg up and as it rose a few inches off the table, i felt a jolt of pain fly down my leg. She could tell. She measured the angle and gently set my leg down.

”Could you test my posterior ligaments now since I’m in the position?“ I asked.

”You’ll have to tell me more about that. I’m not sure I know the tests,“ she replied.

I talked her through the test. As she got ready to perform it, she stopped and said, ”You know, this is probably going to hurt. If you look at the angle of your leg and the force I have to use, I just think...“

”It’s okay. Just do it. I need to know. It’ll be all right,“ I said.

She was right. It hurt.

”Are you ok?“ asked Christine.

”Yeah, yeah. I’m fine. I’m ok. So, that hurt some in the region of the ligaments and produced some pain that felt familiar. Ok, so that was helpful. Now, we need to do the Spring test then the Gap test,“ I said.

Christine did the tests. The Spring test is done lying face down. She placed her hands on my lower back starting near the junction of the thoracic and lumbar spine. She pushed down quickly. Then, she moved her hands down a little to the next segment of the spine. Again, a quick pressure only this time, I jumped. It hurt. She then asked me to lie on my right side. She stood behind me and placed her hands over the left part of my pelvis and pushed with a down and forward pressure. No pain. She then asked me to roll onto my left side.

As I rolled onto my back, I felt a sharp twinge in my right hip. Then, as I rolled onto my left side, the jagged spear was back. I had a sharp, intense pain radiate through my hip. I couldn’t move. My breath quickened. I just waited for it to go away.

”I think that’s enough right now. How about if we stop?“ asked Christine.

”Yeah. Sure,“ I said with a muffled voice. I tried to sit up. I couldn’t. I could not get my legs to drop off the edge of table and when I finally did, it felt like someone was tearing my hip off my body by twisting it back and forth, back and forth.  I slowly sat up, breathing hard, trying not to cry and inside thinking, ”This is not good. Not good. This is not good. Keep it together. Breathe. Just breathe.“

I had to get up and move around. It’s the only thing I knew that would bring me back to a semi-normal state. I walked around in the room a little, shifting my weight side to side praying for the ache to quit. Just give me that. Just give me that - let the ache go. And the pain subsided -  a river of relief flowing through my leg. I could move.

”I’m ok. I’m ok. So what’s next?“ I asked.

Christine sat down in her chair and looked at me. She took a marker pen and began writing numbers on a white board. My tests. She explained to me what they meant. I knew the numbers; their meaning. She then drew a triangle. I knew this too. I created it. One side is pathology or tissue injury. One side is mechanics or how your body moves and the other is attitude or the way you deal with the mental and emotional aspects of an injury or surgery. And then a circle around the triangle to represent the spiritual element. All these things come together to form your condition following injury or surgery.

Christine said, ”I think your diagnosis is fairly clear and your mechanics are clear as well. But, what really concerns me is how you’re dealing with this. I’m concerned that you’re denying to your self how bad this injury really is and all the work-arounds you have in your life to get through your day, well, I’m concerned that it’s going to really take a toll on your spinal joints. You worked so hard to to improve your spine health over the past few years and I think your denial is going to just wipe all that away.“

I thought, ”Why is she talking so much about denial? I am not in denial. I know I ruptured a disc. I hurt like hell. I feel like crap. I sleep 3 hours a night. I am not in denial,“ and what came out of my mouth was a very Spockian, ”Could you give me some examples? I’m not sure what you mean.“ I'm sure the temperature in the room dropped a few degrees from the icy delivery and I may have even raised one eye-brow.

”Sure. For example, I think that you say you’re not hurting too much or that you’re ok when your movements and facial expressions don’t match,“ said Christine.

”Like what?“ I asked.

”Like when you went from sitting on the edge of the table to lying down. Remember? I asked you how much that hurt and you said is was about a 2/10. Your face and body motion did not look like a 2/10 to me,“ replied Christine.

Busted. She was right but I all I said was, ”Okay.“

”You have this history of, well, hurting your self. Like the time you jogged in the neighborhood after you knew you had a spine fracture. And, well, you know there have been other times too. I’m not so concerned with those things as much as why you choose to do them? Why is that?“ she asked.

”I don’t know,“ I said rapid fire.

”Well, okay. So, help me understand something else. Why is jogging or skiing so important to you? What do those things mean to you? What would life be like if you could not do those things?“ she asked.

I just stood there. I had asked this kind of question in consults hundreds of times and now it was my turn.

”I...I..don’t ...I’m not...“ and my voice just trailed off.

”What scares you about surgery?“ asked Christine.

The question seemed out of context. The clarity of it rescued me from the emotional fog of the last question. I snapped into Spock mode. ”Well, I’m not really scared of surgery. I mean I’ve been through surgery before. Knee surgery. Shoulder surgery. I did fine. I don’t think it’s surgery that’s a problem really,“ I said.

”So, what is so scary then?“ asked Christine.

Christine had skillfully lead me where she knew I did not want to go but needed to. She knew there was something I needed to face; something I needed to admit and that unless I did, whether I had surgery or not, my healing would be incomplete. There was no way out.

What happened next has never happened to me before and I will never for get it.

Stone Cold Kelsey thawed.

Blinded by Your Focus?

I remember when I would return from a physical therapy seminar, didn't matter really what it covered, all of sudden, it seemed as if all of my patients had the condition that was the subject of the seminar. If we had discussed fat pad impingement, sure enough, that week, I suddenly had this run on patients with fat pad impingement. Or, a labral tear of the shoulder - you bet. Tons of labral tears. It took me a while to figure out that I found whatever I was looking for.

This is both a blessing and a curse. Pattern recognition is what helps clinicians identify certain conditions but if you walk into the room with a pre-conceived notion or frame of mind, you no longer are searching for a pattern. You're blinded by your bias.

To prove my point, watch this video.

Miles to Empty Tank

I climbed into Elle's Volvo XC90 to make the trip down to Sports Center. Flipped the key in the ignition and noticed that the fuel gauge was very low - down around the orange indicator - right above "E" for empty. I thought, "I didn't plan on getting gas. I'll be late. Great," and backed the Volvo out of the garage. As I turned onto the street though, I noticed another indicator" an LCD panel that displayed "105 miles to empty tank." Instantly, I felt better. I only had to travel 30 miles or so, so I could skip the pit stop for fuel and head on down to Sports Center.

That made me think. You know what we need? A human "miles to empty tank" tool. Something you could stick your finger in and get instant feed back like, "Presently, system analysis suggests you have 48 hours until emotional and physical reserves are depleted. Please take appropriate measures to replenish reserves."

The way things are set up now, you have to do an "under the hood" check about every day and if you don't, well, I don't know about you but it seems like I get stuck on the highway with an "empty tank" a little too often.

I guess until the "empty tank" tool shows up, I'll have to do the check the old fashioned way: pay attention.

Chapter Three: The MRI Results

I had an appointment with Dr. Gordon White, neurosurgeon, in his office on March 11, 2008. I knew Dr. White from the early days of our practice in the 80's. He operated on my father. I trusted his judgment and I had seen him four years prior when I first started the process of rebuilding the active, physical part of my life.

Based on the neurosurgeons I had met and worked with over my career, I found Dr. White to be unusual. He takes his time; he's considerate; thoughtful. I knew he would sit in front of the lightbox, the large white, backlit rectangle that hangs on the wall on which he places x-rays, MRIs, CAT Scans to inspect them for abnormalities, at some point and explain whatever it was he saw.

As I walked into his office, I saw Dr. White behind the front counter writing something down on a piece of paper. He was dressed very neatly in a blue button down oxford shirt, a tie, and tan paints. Dr. White is African-American which has no bearing on his skill or anything else for that matter other than the odd pairing of his heritage with his name.

"Well, Doug Kelsey!" said Dr. White. I extended my hand, we shook hands as he asked, "How are you?"

I didn't get to answer because his office manager, Peggy, whom I have known for a long time as well, appeared, and asked the same question to which I replied, "Well, I feel a little beat up today actually."

"I am so sorry you're not feeling good," said Peggy.

I stood at the counter, had something to sign, I don't remember what it was, but do remember being thankful that I didn't have to sit down in his waiting room and fill out a long health history form. I didn't want to do the zombie dance again.

I reached for my wallet to get my insurance card out and then realized I had left it in the car. "Peggy, I left my wallet in my car. Should I go get it now? You'll need the insurance card right?"

"Oh, don't worry about it. We'll take care of that later," said Peggy.

"Yeah, we know where you live," a smiling Dr. White added. "I'll be with you right away."

Peggy showed me to an examination room where I waited for Dr. White.

On the left wall was a wooden examination table covered with white paper. A white pillow rested on one end. A reflex hammer was perched on the pillow like a special chocolate you might get at a Four Seasons Hotel. On the right wall was the light box. The back wall displayed a large, black & white, out-of-focus image of the human brain. There were a couple of chairs. I ignored them.

After about ten minutes, Dr. White appeared at the door.

"Hi, Doug. Nice to see you," said Gordon.

"Thanks, hi, Gordon. I appreciate you seeing me today," I replied.

Gordon sat down on a rolling stool and leaned up against the wall just to the side of the lightbox.

"So, what's going on? What happened?" asked Gordon.

I told Gordon my story; how I fell, when the symptoms started; what they felt like. I told him the things I couldn't do and what seemed to make me feel worse. He interjected a few times for clarification.

"Do you have any numbness or weakness anywhere?" asked Gordon.

"No," I said.

"What about the left leg? Any symptoms in your left leg?" he asked.

"No, that leg feels fine," I said.

"Ok. So, your pain is in your anterior and lateral hip, and posterior buttock, sometimes into your thigh and the front of your lower leg and the dorsum of your foot. Yes?" asked Gordon.

"Right. It's the worst in the hip by far. Front and back," I said.

"What does it feel like?" asked Gordon.

"Really sharp, tight. Piercing. Takes my breath away. And, when it's like that, I can't move much at all," I replied.

"Ok. Let me check a few things. You'll need to sit on the table but it won't take too long," said Gordon.

I sat on the edge of the table as if it had a sharp edge to it. Gordon began checking my reflexes. I noticed the Achilles reflex was sluggish and the patella tendon reflex was not even there.

"Hold out your hands, clasp them in front of your chest, for me like your going to pull them apart and when I ask you to pull, pull with each hand really hard," said Gordon.

I knew this was a procedure used to increase the sensitivity for tendon reflexes. If the reflex was absent after this trick, then it was really absent.

I saw my right knee jerk some. My right foot barely moved.

"I think your reflexes are little slow; sluggish," said Gordon.

"Ok, last test. I'll test your quadriceps strength. Just push out against my hand," said Gordon as he placed his hand on the lower part of my leg.

I pushed and felt a sharp, razor-like pain surge in my right hip. I thought if I looked down I might find a long, jagged spear sticking out of my hip. I yelled, "Oh, shit! Oh..sorry!"

Gordon said, "Ok, I'm sorry. That's all we need to do for now."

"Your hip pain...that's an odd presentation really. I think...well, let me go over a few things with you first," said Gordon.

He then snapped two MRI films onto the lightbox.

I looked at the images and said, "Hello. Ok, I got it. Man, that's obvious enough, huh?"

Gordon said, "You mean the herniation at L4-5?"

"Right. Looks pretty big to me," I said.

"Well, it's a moderate sized herniation. If you look here, it extends down the back of the L5 vertebrae almost to the bottom of it. Can you see that?" asked Gordon.

"Yeah, looks like a pony tail. That can't be good," I said. I thought, "I wonder what a large herniation looks like? That looks really big to me." And, I also had a sort of queasy feeling looking at something in my body that was oozing out of a place where it naturally belonged; like it was hemorrhaging and I was just letting it happen.

"I think it's nuclear material and it's a continuous mass; not fragmented," he explained.

"Ok. So, fragmented is better, I guess?" I asked.

"Well, somewhat, yes. A fragmented piece of the disc is more likely to resorb than a continuous piece. The body will sometimes treat the material like it's a foreign body and digest it. So, the question is, will this injury heal on its own or will you need some type of surgical procedure," said Gordon.

"Yeah, ok. So, if it doesn't heal, then what kind of surgery?" I asked.

"You don't have any indications of significant instability so you wouldn't need a fusion but because the herniation is lateral, posterior, and central, I'll need to come in from both sides of the vertebrae and do a decompression procedure," explained Gordon.

"Such as what?" I asked.

"Laminotomy. I would remove a small piece of the lamina on each side and remove the debris and free up more space around the nerve," said Gordon.

"So, you'll cut a hole in my bone. Right?" I asked.

"Correct," said Gordon.

And, I would lose the multifidus too, right?" I asked. The multifidius is a muscle the connects to the lamina in the lumbar spine and provides for a substantial amount of stability.

"Yes, you would. But, you would still have some of the lamina in place. By using a double approach, I won't have to retract the nerve and soft tissue so much to get to the central herniation. Look here on the film. Can you see this? This is where the disc has leaked straight back and I think even a little to the left side. To get that out with a single approach, I'm concerned i would have to really stretch these tissues and that increases the risk of nerve damage," said Gordon.

Nerve damage. I knew that was a possibility with surgery but hearing Gordon say it, gave it more weight.

"So, you said something about an unusual presentation. Could we talk about that?" I asked, shifting the conversation away from surgery and possible nerve damage to something less scary.

"Sure. You see the herniation? Well, that nerve distribution, at L4-5, the pain is more typically on the side and front of your thigh and sometimes over the buttock as opposed to up near the front of your hip," said Gordon.

"So, have you seen this before? I mean, this combination of MRI findings and symptoms?" I asked.

"Well, yes, sometimes, well...look at your imaging for a minute. If you look closely, you can see that there is some evidence even at L3-4, not a lot, but it's possible that those nerve fibers could be involved. And, sometimes the anatomy is different in people too.You have a mixture of symptoms. Certainly, the pain in your lower leg, buttock, and foot matches with the MRI results. The pain in your hip, that's not as clear," answered Gordon.

"So, maybe surgery? Maybe not? Sounds like it's not for sure?" I asked.

"I think we should repeat the Medrol for a week, stay in therapy, modify your activities, and I would like to see you again in a week. If, after you come off the Medrol your symptoms are much worse, then, surgery might be what we need to do. But, for now, let's just see how things go and we can talk more about it next week," explained Gordon. "I'll also write you a prescription for some pain medication to help you with the symptoms."

As I left Dr. White's office, I wondered how this whole thing was going to turn out. It had a more serious tone. I didn't feel very confident; not like I did when I proclaimed to Ross, shortly after the skiing injury, that I would be just fine a couple of weeks and i would be back skiing next year. Maybe it was seeing the MRI or maybe how little force I had to exert to feel like a spear was stuck in my hip. Or, maybe it was the zombie walk that would come and go after sitting for a while. I don't know. But, I felt different on my way back to my car. Surgery seemed drastic; too soon. I had had the symptoms only a month. Surgeons generally wait a few months unless you have loss of nerve function, which I didn't or pain that was severely reducing your function. Ok, so, sure, I had lost some function but, I wasn't that bad, was I? I could walk, sort ofm if you don't include the zombie walk. I could get dressed, as long as I didn't have to tie my shoes. I had to eat standing up. Well, yeah, ok, so I had lost a lot of function but it was still only a month. I could get better and, besides, a lot of things can happen in surgery: infection. stroke, paralysis, death. Of course, if I had to have surgery, it could also turn out well. I just couldn't seem to fix my mind on that possibility. It was if I was Magneto from "X-Men" and the worst possible outcomes were metallic thoughts stuck in place by my super charged brain.

There had to be some new info on disc resorption. I need some data; I need some time to figure this out, ran through my mind.

I'm not ready for the operating table. Not yet.