Bump in the Road: There goes L4/L5

My blog entries to this point have mainly been race reports and a few minor write ups on my aerodynamic testing or other training points.  Today's entry is a bit less fun to have to make.  As I mention in my first blog post, I had two surgeries about two years apart on the same herniated L5/S1 disc about 15 years ago (reherniation of the same disc happens about 10% of the time), with the first surgery done when I was just 21 years old.  The MRI that I had done at the first surgery already showed that the adjacent disc between L4/L5 wasn't in perfect shape.  Since then, I have tried to be "careful" by avoiding activities that would put a lot of compression on my spine, which includes all running sports.  That strategy had been serving me fairly well, but it all fell apart this last week...

MRI Last Spring

Before discussing what happened recently, a little recent history is in order.  Last year, I got the stupid idea in my head that maybe I could safely run and was limiting myself unnecessarily.  Before making such a rash change, I thought I would go see an expert.  I exchanged some email with Dr. Witham, a highly recommended neurosurgeon at Johns Hopkins, who recommended I have an MRI and review it with him.  After looking at my MRI, he strongly advised against adding running since my L4/L5 disc already looked pretty questionable.  I agreed with that assessment and prepared myself to continue on the conservative activity route.

One Month Ago: Fly? Skating?

It was the beginning of December, and I was still feeling in perfect shape.  Then I woke up on a Saturday morning and my back was feeling a bit tight.  I went to help coach my kids' ice hockey clinic and by the end of skating I could tell things weren't quite right.  After practice, I had a hard time bending down to untie my skates and by that afternoon (my daughter's birthday party), I was having a hard time with the pain in my back.  I was feeling a bit low and remember telling my wife, "I think I blew my disc".  On the plus side, I didn't have any sciatica and the pain went away completely when I would lie down.  I started myself on some heavy ibuprofen, bed rest and some hot pad that a friend kindly gave me.  Since I am usually just coding from home, I can often manage to continue working from bed without any major hiccups, so I did that for a few days and started to feel much better.  At the time, I thought the trigger was that I had done a lot of butterfly (maybe 500 yards total) on Friday and then that I had exacerbated things by skating the next morning.  So I told myself I would avoid fly while swimming and try to take it especially easy when skating.  In the past, I sometimes let my enthusiasm take over while coaching and would skate hard while playing games with the kids (tag, etc).  I wasn't going to do that anymore.

The rest of the month of December was not terribly eventful as far as my back was concerned.  I was worried about being able to ski with my kids, so the week before our ski trip, I worked at least half time from bed and was feeling much better.  Over the course of our somewhat crazy ski trip (which started by missing our flight and driving to Colorado instead), my back didn't give a hint that there was a problem.  I skied every day with the kids and felt fine.

Skating. Again, Really?!

That brings us up to the first week of January, still feeling fine.  Again, the main event was ice skating.  I was again helping coach my kids' ice hockey practice when I felt a minor twinge while skating.  I don't remember any particularly traumatic event and certainly didn't skate hard the entire practice.  In fact, I finished the practice and thought I had just re-tweaked whatever had happened last month.  My wife happened to be at practice taking some photos, so here's what I looked like as coach demoing a simple drill for the kids.

After practice, we went shopping at Costco, and it was becoming clear that I had hurt myself, although at that point it still wasn't clear how bad it would get.  After shopping, I tried to rest for a while, hoping I would feel better.  I then took my son to his basketball game and during that time it became obvious to me that I was in bad shape.  I had a hard time finding any comfortable position to sit in and by the end of the game found that I could barely make the walk back to the car.  I believe people were staring a bit as I layed down next to my car to rest before driving home.  On the way home, I first noticed the numbness and tingling in my right leg. 

Weekend Wait

At this point, I was still vaguely hoping that this was a minor event even though there was a fair bit of evidence that it was not.  Unlike previous "minor" flair ups, I could not find any pain free position.  Lying down was sure better than standing, but it was still painful.  More disconcerting was that I had pain, numbness, tingling and muscle twitching down my right leg.  I could tell that one of the nerve roots for my right leg was getting some serious action.  I knew enough about the human anatomy to figure out that it was likely the L4/L5 nerve root, which made sense based on my spring MRI.  Over the course of the weekend, the pain got a bit better.  I could generally lie down mostly pain free with sufficient ibuprofen.  On the other hand, the numbness if anything got worse and I couldn't stand for much more than a minute without the pain coming back at an unbearable level.  I found myself crawling around the house in preference to walking if I needed to get somewhere.  My wife and I considered going to the ER a few times on Saturday and Sunday night, but decided against it, holding out to see someone on Monday.  I also had to watch the Redskins devastating loss on Sunday night, which was almost as painful as my back :(

Monday: Paging Dr. Clark, Drop Foot

There are a few heroes (at least to me) in this story.  My wife is clearly hero number one for putting up with this crap and helping get me through it, in fact she did almost all the leg work to setup our stories other heroes.  Hero number two in my story was Dr. Clark.  On Monday morning, I tried first thing to call my regular doctor's office.  Unfortunately, my doctor's schedule was all booked and they scheduled me to see a nurse practitioner mid afternoon.  This made me a bit nervous; I wasn't sure how much experience an NP would have and wasn't excited about waiting till the afternoon.  The thought occurs to my wife that we should try our friend Dr. Clark.  It turns out that one of my daughter's best friend's mother is an internist who actually makes house calls.  A few calls from my wife and Dr. Clark shows up in my bedroom by 10:30.  She does the exam and quickly relates to my wife and I that things look quite serious.  In particular, she noted during physical exam that I have "foot drop", which means that I have no ability to raise my right foot or toes.  I hadn't noticed that myself to that point, but once she pointed it out it was obvious and really disconcerting.  Dr. Clark set me up with a steroid prescription that would help with the swelling (my neurosurgeon later said this was exactly the right move) and later that day was critical to helping me setup an MRI as soon as possible.  Dr Clark also made it clear that I needed to consult a neurosurgeon.  Fortunately, I had one in mind...

Dr. Witham is a busy neurosurgeon (and hero number three in my story).  When I saw him in the spring, for what amounted to a well visit consultation, it took about two months to get an appointment on his calendar.  I wrote Dr. Witham an email after seeing Dr. Clark asking if he might be able to see me, describing in brief my symptoms.  Dr. Witham quickly responded that he would, asking his scheduling assistant to setup an MRI "ASAP" and setup an appointment.  I was getting a bit nervous as the day proceeded and I hadn't heard from the assistant.  Eventually I heard back from her that I had an MRI and an appointment setup for the first week in February!  I wrote back to Dr. Witham, asking that if he didn't have room, maybe he could suggest a colleague.  He quickly wrote back to his assistant saying "He has foot drop!" and that he would find a way to squeeze me into his schedule one way or another.  I was eventually scheduled to see him Friday at noon.  In the meantime, with the help of Dr. Clark, I had scheduled an MRI for first thing Tuesday morning so that would be ready in plenty of time.

Tuesday: MRI, Dr. Witham

Overnight, my wife had a brilliant idea.  By  coincidence, my mother in law had recently had surgery with Dr. Witham and was scheduled for a routine follow up Tuesday at noon.  My wife wrote to ask if Dr. Witham would allow us to switch our appointments, with my mother in law seeing him on Friday.  So long as I got the MRI done in time, this could work out nicely. Fortunately, the MRI went about as smoothly as you could expect (thanks ProScan) and I had both films and an electronic copy in hand by 10 that morning.  I couldn't help myself and took a peek at my own films.  Reading an MRI is no easy task, there is a reason radiologists require lots of training and get paid well.  I'm sure a real radiologist sees all kinds of subtleties.  I don't think it required that much expertise to look at my scan and see that something was very wrong.  I even had my old spring MRI to compare to, which made the compare and contrast easier.  The first shot shows a particularly gruesome part of my current MRI.  The next two show a comparison of my spring MRI (on the right) with my recent MRI.

When we saw Dr. Witham a bit after noon, I had looked over these pictures myself already and anticipated that the news was not good.  After a short consultation, Dr. Witham was already talking about scheduling me for surgery.  He couldn't do it that day, or Wednesday due to his clinic schedule, but was going to schedule me for first thing Thursday, bumping another surgical case of his to the next week.  He said it was good that we caught things early, but then gave what I'm assuming is the standard "you never know what you'll get" talk about what to expect from surgery.  By the end of the talk, you figure your lucky if you aren't dead or paralyzed after surgery.  I guess if you are still willing to get surgery after that talk, you are clearly in a lot of pain.  He said I should check into the hospital on Wednesday afternoon to get prepared for the surgery.

Wednesday/Thursday Morning: Checkin+Surgery

By Wednesday, I was already counting the hours till surgery, looking forward to whatever would take away the pain and numbness and hopeful that I might return to some form of normal.  While things didn't exactly go smoothly checking in (I waited for four hours in the admission lobby while they tried to get me a room) it all seemed quite minor in the grand scheme.  I settled into my very nice private room and tried to get as comfortable as I could while waiting.  It was a bit hard to sleep as I was poked and prodded virtually from the moment I got into the room, including an EKG, a chest X-ray, an IV, blood draws, blood sugar checks, periodic blood pressure checks, etc.  I mainly passed the time reading and was generally as comfortable as my physical condition would allow.  I experimented a bit during the night and determined that I didn't generally have pain for the first 15 to 30 seconds after standing, but remaining in an upright position, even without moving, would get progressively more painful.  My wife came to the hospital early Thursday morning as they moved me down to prep for the OR.  There we saw Dr. Witham, who we learned was a hunt and peck typist, something I found ironic for a guy who we presume (or at least hope) is dexterous with his hands.  He seemed serious and confident.  We waited a while for the OR and then not surprisingly I don't remember much (they knock you out pretty good!).  

Thursday: Post Surgery

When I describe my first surgery to people, I say it was like someone removing a big splinter.  I felt really sore, but immediately could tell the original pain was gone.  This time had some similarities, but was not exactly the same since I was immediately trying to figure out not just if the pain was gone, but whether I could use my right foot properly.  My previous surgery I had lost most of the ankle jerk response in my left ankle, but that wasn't a real functional deficit, so I had no point of comparison.  Immediately on waking, I found that I could at least very slightly move my right foot and that most of the numbness was gone, but it was by no means "right" yet.  For example, I could not independently move my big toe up, just slightly pull up my whole foot. I got up and walked within about an hour of waking and was pleased to not feel any pain down my leg.  My post surgical pain was very minor; for the next twelve hours or so I didn't end up taking any additional pain medications until finally taking some Tylenol after midnight.   I experimented with walking more through the afternoon and evening and while I felt a little wobbly I was pleased to confirm that I didn't have pain walking for minutes at a time around my room.  

My food situation was also slightly entertaining.  I had last eaten at about 10 pm on Wednesday and ordered a lunch after surgery.  They managed to screw up my order somehow, so I ended up getting both my lunch and dinner back to back at around 4:30 pm.  The guy delivering the food commented on how quickly my "lunch" disappeared.  I did manage to hold off on eating the "dinner" part till I let the vanquished lunch settle a bit.

Friday: Home Again

By Friday morning, I was ready to go home.  At that point, most of the pain I had was from the soreness of the operation site and the stupid IV in my hand.  I gather that for safety they put the largest gauge IV they can fit in you and had multiple nurses and other hospital staff comment on the unusually large gauge of the IV on the back of my left hand.  My back itself was quite tender, making lying on it a bit uncomfortable.  In some ways, getting up and walking felt better since I wasn't in any acute pain.  For anyone who has read Lance Armstrong's book, he relates this point where he is asked to blow on some device to show he has enough lung capacity and blows the shit out of that thing and says he never wants to see it again.  I felt a little that way when the PT department took me to a set of stairs to make sure I could go home.  They needed to check if I could safely do stairs and started describing how I could hold on to the rails and walk sideways if I needed to.  I restrained myself from running up and down the stairs (it would have hurt like hell), but I sure didn't need any rails!  Even with some slight foot drop, I can get around just fine and compensate.  My wife came to pick me up after taking my mother in law to see Dr. Witham and we drove home.  I was a bit more sore in my back than immediately after surgery; it felt difficult to try to engage any core muscles to try to sit up in bed, etc.

Saturday: Hockey?

I helped take my kids to hockey this morning.  I didn't skate.  Instead I took lots of pictures and video.  It was my first trip out of the house post surgery and felt good to start to return to normal.

I'm not sure yet how much function I will recover, but I'm optimistic that I am back on the right track.  I'm hopeful that I'll be able to resume swimming and biking again, although I have to admit that being competitive there suddenly seems a bit less important.  I guess we'll see what the coming days bring...