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My L5-S1 Disc Explosion Pt II

Continued from Part I So after bucket-loads of pills, rest, e-stim, physical therapy, decompression treatment, chiropractic adjustments, and acupuncture I was still a mess. My pain had only gotten worse over the course of 6-7 months. What was the next step?

Steroids

I was referred to another doctor, this time a pain management specialist. I gave him the story that I’ve been repeating over and over to the other health care professionals. He took notes, reviewed my MRI and my treatment history, and decided the next step was to try an oral steroid treatment. Before you shake your head in disappointment and disdain, understand that we aren’t talking about anabolic steroids (I doubt those would have helped me much). The treatment consisted of 10 days of a corticosteroid drug, specifically Prednisone, in a hardcore attempt to kill the inflammation in my spine. The doc was straight up with me and told me that there’s a chance it will help but it’s a far cry from a guarantee. He wrote me the prescription and warned me of the side effects:

-High blood glucose

-Fluid retention

-Insomnia

-Anxiety

-Weight gain

-Severe facial swelling

-Fatigue and weakness

-Mental confusion

-Steroid dementia syndrome

-Infection

-Joint pain

-Blurred vision

-Acne

-Depression, mania, or psychosis (wait… what?!?!)

I followed the directions closely and took the pills everyday for ten days. The dosage started high and tapered down throughout the duration. I can’t say I felt much of a difference throughout that time. The pills didn’t make me feel better at all, but I didn’t get any noticeable side effects either.

So soon after that I’m back in the doctor’s office to see what the next step is. We agree that something more invasive needs to be done, but not surgery… yet. He suggests an epidural steroid injection. An epidural injection does not “fix” the issue of the blown up intervertebral disc, but can provide lasting relief for anywhere from a few weeks to a year or more. In combination with a solid rehabilitation program, many patients have had great success with these injections.

A few weeks after the oral steroid treatment, I’m in the doctor’s office ready for my first injection. It was definitely a scary thought, the idea of an enormous needle driven right into your lower back, but I was a desperate man ready to take desperate measures.

They provided some local anesthetic to my lumbar region, and proceeded to stab me in the spine with a Super Soaker of a syringe. They warned me that it would hurt, and it did. I felt an extreme sense of pressure in my lower back, as if an elephant stepped on it, followed by intense pressure down my left leg. When I got off the table to stand up I almost collapsed, because my left leg was still numb. They told me this was normal and that I should regain the feeling in my leg in a couple hours.

The pain in my back and down the leg at this time wasn’t completely gone, but it was significantly dulled. I remember feeling a sense of hope, that I was FINALLY on the path to recovery. The dulled pain continued for a few days, but then slowly started creeping back. I called the doctor with concern, but he let me know that sometimes it actually takes a couple weeks for the drugs to kick in 100%, so I should give it time.

Over the next two weeks I remember trying to ignore the fact that the pain was coming back, but after a few days of waking up to the full blast pain that I felt before, I went back to the doctor. He recommended a second injection. The second injection was just as pleasant as the first one, and left me numb for a day. This time the doctor also wrote me a prescription for Cymbalta.

“An anti-depressant?!” I asked. I mean this injury is depressing for sure but c’mon doc.

He explained to me that the drug is a seratonin-norepinephrine reuptake inhibitor (SNRI) and that yes, it is used to treat clinical depression but also to treat peripheral nerve pain. Reluctantly I took the prescription and took about a weeks worth. I quit after that first week because I felt like it wasn’t helping and I was becoming paranoid about the dictionary-sized list of associated mental side effects.

The dulled pain lasted about three days this time and immediately returned. After another couple weeks I came back for injection round three. The limit for these injections is three per year, and I reached this limit within a couple months. These injections definitely aren’t child’s play and you can’t haphazardly just shoot them up into your spine whenever you want to. With each injection you run the risk of infection, dural puncture, nerve damage, and even joint degeneration in the long run!

This time the doctor wrote me a prescription for Gabapentin as well. Gabapentin, also known as neurontin, is a drug used to treat epilepsy but has been successful in treating neuropathy as well. Apparently it’s also a popular recreational drug because of its potential psychoactive effects. What is this doctor feeding me?!

Anyways, after three injections and a bunch of sketchy drugs, I was back to square one. No relief. When I came back to the doctor I already knew what they were going to tell me: “We’ve exhausted all of our options and it may be time to consider surgery.”

The Surgeon

My girlfriend, who works at INOVA, did some digging on several reputable orthopaedic surgeons in the area. After consultations with three different surgeons, I decided to go with Dr. Thomas Schuler of Virginia Spine Institute.

As one of the top 100 spinal surgeons and specialists in the country, recognized among the top 1% of physicians in his specialty, and top 10 spinal surgeons for the NFL, his reputation preceded him. Being the spine specialists for the Washington Redskins had nothing to do with my decision… I think…

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During the consultation at his office, he and his assistants spent almost two hours of dedicated time with me, running me through a myriad of tests, looking through my records, performing another x-ray on my spine, and analyzing my MRIs.

When it was all said and done, he was confident that a microdiscectomy would be the way to go.

A micro-what now?

The plan was to perform a “micro-surgery” that was relatively minimally invasive: The doc would slice into my lower back, push the erectors out of the way, cut some bone away from the lamina of the vertebrae, find that insidious piece of disc that was pushing on my sciatic nerve and ruining my life, decapitate the herniation, and stitch me back together.

Terrifying… I thought. “Let’s do it,” I said. My consultation was on a Thursday, and the operation was scheduling for the following Monday.

The Surgery

Like almost everything in life, the operation came with a bunch of paperwork. I filled out all my papers, signed a will (yeah, really), and they sent me home with my pre-op packet filled with instructions.

There wasn’t much to do from my end pre-op. I couldn’t eat or drink anything the night before and had to shower with a special soap.

The next day I showed up at the hospital, checked in, and waited in the waiting room with a number of other poor souls like myself that were about to get cut open. When I was called up they prepped me up in a gown and surgical socks and rolled me away on a bed to the anesthesiologists.

The anesthesiologist prepared the IV and stuck it into my arm. She explained that she would soon inject the drug and I would fall into a deep sleep. I remember her asking me where I went to school, to which I replied “George Masgfughabluhhhhhhh…” BAM! I was out like a light!

After what seemed like a minute or two, I slowly woke up, very hazy. One eye half-open, I looked up at a nurse and asked “when are they taking me to surgery?” She chuckled and replied “Oh honey, you’ve been out of surgery for hours.  It went perfectly!” I didn’t want to argue so I went back to sleep.

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The second time I woke up I was in the recovery room with my girlfriend and family. After the blur started to wear off I realized that the intense pain in my back and left leg were gone. I was so happy I could’ve cried. Pain had become such a huge part of my life that I forgot what it was like to not be in agony. I was definitely sore from the flesh wound I now had in my back but it was merely a slight discomfort compared to how I’d been living that past year.

I spent the night there, still in a daze from the morphine and eating French toast while watching The Simpsons. It was definitely one of the most joyous days of my life.

Stay tuned for Part III!

Colorado Dreamin’

Last week I had an awesome opportunity to spend a few days snowboarding, relaxing, and getting beat up by trees in Winter Park, Colorado.  Having spent most of my time here on the East Coast it was amazing to witness the breathtaking scenery and culture out in Winter Park.  If you like snow and want to get away, I definitely recommend visiting! The Mountains are Huge… Like Really Huge

Growing up I’ve frequently visited the local mountains within a few hours of Northern Virginia, and they now seem like mole hills in comparison to the mountains out west.  In the handful of days that I was there I did my best to explore as much of the mountain as I could, but despite my efforts the last day of my trip came and I realized I only hit a tiny fraction of the skiable terrain (which turned out to be over 3,000 acres).

Altitude is No Joke

I’m by no means an elite level athlete, but I feel like I’m in decent shape.  So when I began walking up a flight of stairs and started breathing heavy I couldn’t help but think… “HUH!?”

The base of Winter Park is about 9,000ft above sea level, with the highest peak being 12,060ft.  Compare this to Northern VA’s ~500ish ft above sea level.

I could almost FEEL the decreased oxygen levels in the air, which is a big reason for some endurance athletes using altitude training to improve performance when competing at lower elevations.  The idea is that the body will start to acclimatize to the thin air and adaptations will occur, such as naturally increased erythropoietin (leading to increased red blood cells), increased number of blood vessels, and increased buffering capacity.  In other words, improving the body’s oxygen delivery system.  It is still a controversial training method and I cannot say from dedicated experience that it “works” (I was there for five days and I doubt my mile time improved).

If you’re planning a trip to a location of high altitude I’ll pass along the advice that the locals told me: “Drink a ton of water and don’t overexert yourself.”

Elbow Dislocations are a Rare but Awful Injury

Like other sports and activities, injuries are just an unfortunate slice of the snowboarding pie.  A friend of mine took a hard fall while bombing down a hill at probably 45 mph, and didn’t get up as quickly as I’d hoped.  During the tumble his shoulder ended up locked into internal rotation with his forearm trapped between his back and the ground, all while skidding across the snow.

This resulted in the bones in his elbow (humerus, radius, and ulna) separating from eachother.  Despite the severe pain and gross looking elbow he handled it like a champ and we were able to get him to ski patrol.

According to a veteran in the ski patrol department, an elbow dislocation is one of the highest ranked injuries purely from a pain scale perspective.  Apparently it is a very rare injury as well, at least on the slopes.  With close to 40 years of ski patrolling under his belt, he has only seen two elbow dislocations during his career.

Pizza and Honey is a Match Made in Heaven

After a hard day of riding we went to get some food and ended up at the resort’s pizza parlor.  When I walked inside I noticed something strange: there was a bottle of honey at the tables.

Confused and afraid, I demanded answers.  The response was simply “Um… to put on your pizza? Duh.”  I drizzled some honey on my pizza and was very pleasantly surprised at how delicious it was.  It was even better with honey+sriracha.

My friend’s injury was a bummer, but otherwise I had a great time in Winter Park.  The community is extremely friendly (no one locks their doors!), the food is great, the mountain is amazing, and the scenery is really out of this world.  I definitely cannot wait to visit again!

Lessons of the Jaw: A Few Thoughts on the Body's Intradependence

As you read this, I'm either in surgery or in the recovery room. For those who don't know, I am having lower jaw surgery to correct a severe over (also called "open bite") and cross bite. That being said, blogging might be a bit spotty (more so than usual) over the next couple weeks, but I'm going to do my best. Seeing as this surgery has been on the forefront of my mind for quite a while, I thought I'd share a bit of the physiology connections I've learned over the past year or so. It's actually pretty interesting how dependent the body is on it's collective parts. So dependent that something up in my face affects the rest of my body rather dramatically.  We'll do bullet points because I really like them.

Lesson 1: Pain is sneaky. Sometimes the origin and/or cause is not where you think.

I've known I would need this corrective surgery at some point for quite a while now. About 3 years ago, I experienced severe and prolonged pain in my tempromandibular joint (TMJ), the hinge joint of your jaw that connects the lower to the upper. I didn't have the means to have surgery at the time and the pain receded a bit, so I put it on the back burner. Just over a year ago, I started having migraine/severe headaches in the front of my head that would last for days, even weeks. Medications didn't help. Then I started to have shoulder pain on my right side. This made me think something else was going on since I knew I wasn't doing anything that would aggravate my shoulder.

I popped over to this site and discovered that a tight sternocledomastoid can cause both pain in the head and shoulder. Sure enough, I had knots the size of marbles all along these muscles. Guess what? The SCM connects right up behind the ear, near the TMJ, thus a misaligned jaw (being used for thousands of reps per day) will definitely cause some tension in the poor ol' SCM.

Lesson 2: The suboccipital muscles are really, really important.

I also had pain in the base of my skull on a regular basis, thanks to irritated suboccipital muscles. I trolled around to find some information and perhaps home treatment to help manage the pain symptoms. I came across fellow strength coach, Patrick Ward's post hereReadit, seriously, it applies to everyone. It'll blow your mind how important those little muscles are to your overall health.  Patrick Ward goes into the implications of tight suboccipitals and their effect down the stream, such as posture in general and neural control over postural muscles. I found it interesting that "voluntary trunk control" was one of the muscle functions affected. Guess what? I struggle with bracing my right side. I know that sounds weird, but I can not get as "tight" on the right side without really thinking about it. Might be why I have a collapsed disc to the right side?...

Lesson 3: It's seriously all connected.

Then I came across this paper (you don't have to read the whole thing unless you're super-into-science and research papers) that linked symptoms of TMJ dysfunction and jaw pain with the suboccipital muscles. Check out pages 13 (yup, I have all those symptoms, including impaired vision) I should also note that I've suffered from vertigo since I was 13, so perhaps, once my jaw/bite is corrected and those muscles are no longer strained, I might see a decrease in symptoms.  Page 15 which connects hypertonic (too tight) neck muscles with TMJ muscles dysfunction and pain, and 17 describing short cervical muscles and posture and how they research has found correlations... craziness. Upper cross syndrome, a posture <--- description used by those in the health field, is either a creator of tight neck muscles or the result of tight suboccipitals. It's a bit of chicken-egg questions, but either way, they tend to coexist. So, if you have a hunched posture, try massaging the base of your skull, that might help loosen some things up!

Lesson 4: Pain eventually conquers proprioception

We recently had an in-service where we learned about the neuromuscular implications of injuries in regards to training athletes. The main point I retained was, if muscle tissue is acutely damaged, such as a sprain, or chronically irritated, such as repeated spraining of said ankle, the muscle spindles, which reside in the tendons, will no longer respond accordingly, much like Ariel responding to her father's command to stay away from land... Poorly.

Muscle spindles are proprioceptive organs that control the stretch-reflex, for example when the doctor taps your knee and your leg kicks forward a bit, the muscle spindles are rapidly stretched (when the mallet hits your patella tendon) and they respond by sending a signal to your brain to flex the quads (thus, pulling your knee into a bit of extension).

So, damaged muscle tissue, specifically the muscle spindles and especially chronically damaged tissue ("damaged" doesn't necessarily mean an acute injury, but a chronic posture, like your shoulders slumping and your neck protruding forward as you peer at the computer screen) tend to lose their ability to provide valuable feedback to the body in the form of proprioception (where your body is in space i.e. balance). Instead, pain signals are sent. This is bad on two fronts: 1) it hurts 2) lack of proprioception means loss of muscular control, be it voluntary or involuntary.

I don't know too much on how to restore muscle spindles and transfer them back to being proprioceptive and not pain oriented, but I do know that a) removing the irritaing stimulus (in my case, setting my jaw in the correct alignment) b) improving tissue quality through manual therapy (professional or at home) and c) retraining the muscles to move how they should (i.e. standing up straight instead of slouching, or going back to the ankle example, walking without a limp or favoring the ankle).

Lesson 5: Implications for training.

Another random fact, there's a correlation with a cross bite and scapular winging (the shoulder blade sticking up instead of laying flat on the rib cage). Winging impairs overhead movement, messes up the rhythm of the humerus and shoulder girdle and makes picking and lifting heavy things a bit problematic. I've done just about every exercise under the sun to fix my wing, to no avail... maybe surgery?

Anyway, as a coach, just by looking at my own situation helps me work with our athletes here at SAPT. If at first the basic, usual cues don't fix a problem, like "pulling yourself to the floor" during a push up to fix a winging scapula or "crack a walnut" to prevent knee pain during the squat, then, maybe there's an underlying issue that demands a different approach. Maybe some dedicated soft tissue work is in order to correct a nagging pain or it might be severe enough to refer out to a physical therapist or doctor. Whatever the case, if after working with an athlete diligently doesn't solve the problem, probably time to delve a bit deeper. (and check their bite! Kidding.)