I used to answer emails sent to me from this blog. I don't anymore (see LEGAL STUFF on the side bar). But, I used to.
Someone would send me their story, struggles, how do I fix this problem, what exercise should I be doing, is my therapist an idiot, should I get another opinion, etc. and hope that I can somehow solve the issue in a completely virtual way. I can't. I tried because somewhere inside of me is this "I need to help people" engine that runs on emotional fuel and helping people fills up my tank. But, I learned that to solve issues and struggles, I need a dialog.
Books, blogs, videos, and other media all help. Information about injuries, surgeries, exercise, mental or emotional adjustments, nutritional facts, can go along ways to helping you move forward; get better. That's the point of this blog - to get information to people who need it and help them as much as possible.
So, from time to time, if I think your email will help others, I'll post the email and respond to it here. You won't find a name or any other personal info in the post unless you tell me otherwise.
Below is an email I received recently about my hesitancy regarding spine surgery. There are a couple of questions in this email so I'll separate them out and respond.
FROM A READER:
I want to know your thoughts about what scares you about surgery. You have seen patients that have been through the suffering and denial and those that have been through the surgery and that are ready for recovery in your hands. There has to be a point that you say the time has passed, the work has been done and you are or are not improved enough to KNOW that you will or will not improve enough to have a quality life. If you do not have an extrusion then the fragment will not shrink like a raisin., at least in theory. What is next beyond surgery? Steroid injections? I had a patient that had a 8 mm. HNP with considerable compression into the cord and nerve root and a steroid injection "cured her after a month of therapy that failed to relieve the pain. She is a MD!
I want to know your thoughts about what scares you about surgery
Well, honestly, a lot of things scare me about surgery: death, stroke, infection, paralysis, nerve root adhesions to mention a few plus there's no guarantee that after surgery I will be substantially better than before surgery. I think we, as a society, take surgery very lightly as if we're going in for a massage. Surgery is very serious business. Yes, a lot of people seem to do just fine. But, the risks are very real. Maybe I know too much or maybe because I have worked with people for whom surgery failed, I have a negative bias. It doesn't matter to me. If I can avoid surgery, I will.
There has to be a point that you say the time has passed, the work has been done and you are or are not improved enough to KNOW that you will or will not improve enough to have a quality life.
This statement captures the real issue for not only me but a lot of people with a moderate to large disc herniation: when is enough enough? When do you say, "Ok, I give up. Sign me up for surgery." ? For me, here's my list:
- Severe, unrelenting leg pain with nerve root symptoms (numbness, tingling) that has not responded to conservative interventions over a three month period.
- Loss of reflexes or severe suppression of reflexes.
- Muscular weakness in the nerve root distribution that has not improved and interferes with daily life activities.
- An Oswestry score in the moderate to severe category that has not improved over three months.
The tough part is adjusting your life to match your real physical capability. If you can't do this or won't do it, then you'll probably end up in surgery sooner than later. The thing to remember about surgery is that the long term studies show that both surgical and non-surgical patients end up in the same place, have the same outcome, but surgery gets you there faster. Both of the surgeons I saw said the same thing: "If you can handle the pain and disability, and your nerve function improves, you won't need surgery."
When I say "adjusting your life", what I mean is bringing the physical loads of everyday life down to a level that my spine could handle. The problem I have is that the nuclear material has ruptured through the annulus (the ligament of the disc) and is rubbing on the nerve. It's a bit like having a big, nasty pimple. As long as you don't push on the pimple, you don't hurt too much. Put a little pressure even on a small pimple and you can hurt a lot. Pressure on the disc is what makes the nerve react kind of like a pimple. And, when your nerve hurts (which by the way, nerves have nerves so you know when you're hurting it. Great design.), you feel pain in your hip, buttock, leg depending on how much of the nerve hurts. So, the first steps are to keep the pressure off the nerve and do whatever possible to help the injured tissue heal. When I saw patients, I would give them a detailed list of the things they should and should not do. Here's the list that Christine and I created:
- Don't sit unless absolutely necessary and even then as little as possible.
- So, no meals sitting down.
- No eating out.
- No movies.
- Drive only when necessary.
- If you must sit, use a substantial lumbar support to reduce the chance of your spine bending.
- Stand or lie down.
- Don't clean house.
- Don't cook.
- Don't make the bed.
- Don't bend, stoop, twist, lift, push, or pull.
- Walk as much as you can.
Think about what your life would be like if you had to follow all of these rules. Could you do it? Imagine not sitting down at work or not playing with or lifting your children. What if you live alone? And, think of the impact that these changes have on your relationships. If you're married or in a committed relationship, this list can strain the relationship a lot and create all sorts of issues. So, I think the decision to pursue surgery is a very personal one with a matrix of factors and you have to be honest with your self. Don't try to just tough it out. Persistent inflammation around the nerve root can lead to scarring of the nerve. This leads to a lot of problems later because just about every time you move, you tug on the scar which tugs on the nerve (remember the pimple idea?) and you hurt. So, if you can't follow the rules, whatever they might be for you, fess up.
If you do not have an extrusion then the fragment will not shrink like a raisin., at least in theory. What is next beyond surgery? Steroid injections?
This may be confusing because terms describing disc injuries get tossed around like a child playing with toys. A protrusion is an injury to the disc but the inner nuclear material has not leaked outside the walls of the disc. An extrusion is what I have, on MRI. The outer wall of the annulus has ruptured allowing the inner, gelatinous nucleus to seep out. A sequestration is a rupture of the annulus and the nuclear material has seeped out and part of it has broken off. Sequestrations typically shrink. Extrusions often do not shrink which is why people sometimes end up in surgery (although look at the MRI of a friend of mine whose extrusion shrank nicely). It takes a long time for disc material to "shrink". Basically, the body digests it. I plan on having another MRI in the future, assuming I skip the surgery step, to find out what happened to my extrusion.
My surgeons, Christine and I talked about steroid injections as a possible intervention short of surgery. But, in the interest of good story writing, I can't tell you about that just yet. It is on the list though of options.
I had a patient that had a 8 mm. HNP with considerable compression into the cord and nerve root and a steroid injection "cured her after a month of therapy that failed to relieve the pain. She is a MD!
Well, a month of anything is not very long. So, I wouldn't beat your self up over it. As I said before, lifestyle plays a huge role in recovery and some people don't have time, hurt too much, have too many demands to help and wait for their body to heal. The thing to remember about steroid injections is that the steroid acts as a massive anti-inflammatory (there's the pimple thing again) and can reduce pain a lot. But, you still have a disc that's banged up and can't do the job it's supposed to. You still have spine muscles that have atrophied and need reconditioning. The pain is the least of your problems for the long term.
So, I don't think I'm stubborn - if I end up in surgery, I end up in surgery - but I am still scared of what could happen. I pursue recovery without surgery recognizing that it may not work and if that time comes, I'll deal with it, face the fears, do the best I can, and hold on to my faith.
