Tag Archives: Anterior Lumbar Interbody Fusion surgery

Having an infiltration anesthesia test and probable Rhyzotomy

***** 1-30-14: Update #2, I had the test last week and it worked, I was pain free for the first time in 17 years, it was injected lidocaine so it only last 24 hours but it means I can have the Rhyzotomy that has not been scheduled for February 5th.  The doctor I work for is off the 6th and 7th so if I need those days to recover I can take them easier than if she is here.  The website said it may take a week to recover and it is considered a surgical procedure.  I will have more pain for the first week at least and it will provide about 6 months relief.  I have new insurance so that if I have it done at the hospital I work for there is no copay so nothing out of pocket, so much better than last year.  I will keep you posted but the test injections were nothing to be worried about, no pain after at all.Click below for a link for the description given by the practice I go to and who will do the procedure.

http://www.southeasternspine.com/procedures-treatments/rhizotomy/

*****Update 6-27-2013 These 2 procedures have been put on hold for financial reasons.  I had no idea how expensive they were and the practice wants me to pay me entire balance even though I have been making regular payments to them and really my insurance is excellent, they have collected tens of thousands from my insurance in the last 18 months I have been there.  So I have an appt with a PA (the same one I have been seeing who really doesn’t understand pain) on July 3rd at 230pm.  I will update more on what my other options are after that appt.  I was very disappointed by having to postpone this potential for relief.

Well I am so disappointed to report that the news at my spine doctor’s appt yesterday was not at all what I was hoping to hear.  I was really hoping they would say that I still have pain because I was originally told it would take a full year to recover completely and to expect it to taper off and in the meantime we can just treat it with medication albeit lower strength medication than before which is fine with me and actually preferable. I want to avoid all of the oxy-codones at all costs.

Instead, the PA took out my MRI report and told me something I didn’t know before I had the surgery back in October.  What I knew then was that I had 3 herniated discs L3, 4 and 5 as well as some facet joint damage from these discs being herniated and that L4 also had a tear in it.  I could only have 2 discs repaired in a surgery so they replaced the worst ones, L4 to S1 with titanium implants and told me that L3 was damaged but not as severely but I could expect it to cause pain in years to come and actually it is now with pain in my left thigh.  With all this being said, apparently I also have problems from L1 all the way down.  The vertebral joints all have arthritis (most likely from the years of having the injury putting more stress on them than would be normal for my age) and she used the term Spondylolysis: “A weakness or fracture between the upper and lower facets of a vertebra. If the vertebra slips forward (spondylolisthesis), it can compress the nerve roots causing pain.”   So, this is the reason I am still having pain all these months after surgery.  I have tried so hard to will it away, stay active (those of you that know me know that sitting still is not something I am good at) and was beginning to feel that this was a weakness in my character that I couldn’t rise above the pain and was still resorting to medicating it.

rhizotomy-chart

So here is the game plan, next Wed the 19th, I am having a procedure is called infiltration anesthesia  where local anesthesia is produced by injection of the anesthetic solution in the area of terminal nerve endings.  In my case L1-3 since they can’t do anything with the ones that have had surgical intervention.  If this produces pain relief, I am supposed to call the next day and tell them, if it does relieve my pain, then I am a candidate for a Rhizotomy.  This is the scary part; if it doesn’t relieve my pain at all then I don’t know what the Plan B is.  But the following is a description and indications for Rhizotomy as found on this website: 

http://www.espalda.org/english/divulgativa/dolor/como_tratar/informacion_paciente/rizolisis.asp

“Basis, indications and risk

 

Rhizotomy

It is the destruction of the nerves in the facet joints, normally by burning them with radiofrequency current.

Objective

To improve pain in instances of facet joint degeneration.

Theoretical base

There are no nerves in the cartilage of the facet joint. These are located in the bone placed underneath. This is why joint degeneration may not cause problems until the bone is affected. When this occurs, pain nerves are activated, with the subsequent onset of pain.

Conceptually, rhizotomy aims at destroying the nerves in the facet joint to eliminate pain sensation. It is usually performed by burning the joint nerves. Obviously, this procedure is only considered in those cases in which pain is due to activation of these nerves by facet joint disorders.

However, each facet joint enfolds nerves from two, and in some individuals three, different vertebral levels. Thus, for example, the facet joint between the fourth and fifth lumbar vertebrae may receive nerves that originate from, for example, the third, fourth and fifth lumbar level. Therefore, nerve destruction of only one of these levels may have no effect, or have a temporary effect until the remaining nerves take on its nerve field.

Also, it was traditionally believed that all pain nerves reached the medulla through the posterior root, which permitted the localization of the site where nerves had to be destroyed to eliminate the pain originated in the facet joint. However, recent studies show that, although there are individual variations, in some individuals up to 20% of pain nerves reach the medulla through the anterior root. Muscle nerves also pass through this root so it cannot be destroyed since, in doing so, it would cause paralysis of the innervated muscles.

It may only be indicated in cases that comply with the following criteria:

Indications

The existing evidence based recommendations do not recommend rhizotomy, essentially because they are focused on the treatment of acute cases and rhizotomy can only be considered in chronic cases.  It may only be indicated in cases that comply with the following criteria:

 Characteristics of pain:

    1. local pain with no radiated pain nor signs of nervous compression (such as loss of strength or reflex or sensibility alterations)
    2. Pain resistant to non-surgical treatments for more than 12 months.
  1. Pain origin:
    1. Rhizotomy should not be performed on patients whose other organic alterations of the spine may explain the pain.
    2. – It must be assured that pain results from alterations of the facet joint. This is the most important criterion to recommend rhizotomy and also the most difficult one to prove. The detection of signs of joint degeneration through radiological test is not enough, since many healthy persons have it. To verify it, a test with anesthetics is needed (see below).
  2. Test with anesthetics:
    1. – Before a rhizotomy treatment, an anesthetic infiltration test at the joint should be done. If pain is due to the activation of nerves at the joint, pain should disappear completely. Some authors recommend doing three infiltrations spaced out in time; two with anesthetics and one with a placebo (substance of similar appearance but with no effect), without letting the patient know which is which).
    2.  ***** this is what I described above and will be having the 19th (next week)
    3. – Rhizotomy should only be performed on those patients in whom pain disappears completely with the anesthetic injections and remains unchanged with the placebo shot.
  1. Patients:
    1. – An adequate selection of patients is the key criterion to assure that Rhizotomy has acceptable chances of success.
    2. – It should only be considered on patients whose pain complies with the above described characteristics, after discarding that it may be due to any alteration different from that of the facet joint and where pain disappeared with the anesthetic infiltrations.
    3. Technique:
    4. – The destruction of the root should be performed under radiologic control, to assure it is done in the right place.
    5. – The roots of, at least, two segments should be destroyed and two or three lesions should be made at each location, to accommodate personal variations in the course of the nerve.”

So knowing all of this, I am worried, I really had hoped I would have much less pain than I do at this point being 8 months post surgery and have done all I can do myself to try and alleviate and relieve it so apparently this is the next logical step and I will definitely let you all know how these tests really feel.  Of course, I was told that they were “easy” and “not any worse” than the epidural injections and the discography test that I had before surgery.  I will keep you posted 🙂  Thanks as always for reading and I hope that the information I share is helping someone out there going through similar situations with chronic back pain and injury.

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Physical Therapy is even more important than I thought!

I am amazed at how much physical therapy is helping me.  I have to admit I was skeptical about it.  I was feeling pretty good and having people tell me that they couldn’t even tell I had any surgery because my mobility is so good.  However, when the therapist evaluated me she found some problems with my gait (the way I walk) that are easily solved with stretches and exercises.  My hip flexors have shortened because I have been over-compensating when I walk from when I was in pain and now it’s a habit I have to break. 

I have progressed to the point that I now have about 6 different exercises to do every day.  There is the hamstring stretch, the hip flexor stretch and pelvic tilt to strengthen my lower abs.  Two new ones are designed to strengthen my thigh muscles;  using a medium sized ball between my knees with a belt around my ankles I pull my ankles apart and squeeze my knees together at the same time and hold for a count of 10, then put the ball between my ankles and the belt around my knees and this time pull my knees apart and squeeze my ankles together.  It’s important for both of these that your ankles, knees and hips be in perfect alignment.  My thigh muscles are probably going to end up better than they were before so it’s dual purpose exercise just in time for swimsuit weather! J  The other new one is called “the clam” you lie on your side with your knees bent, do a slight pelvic tilt and while pushing the leg that is on the bottom down, you lift the other leg so you look like a clam shell opening.  This one I am supposed to work up to doing 3 sets of 10.  She also taught me a great hip stretch but you need a buddy.  You lie on your side as if you are going to do “the clam” you have someone strong stand sideways in front of you, put the upper leg around their waist so the back of your thigh is against their side, they provide resistance for you to push against, when you push against them it stretches your outer thigh, hip and glutes. 

We are also still working on thinning out my scar through massage, now I am massaging it side to side now, this is kind of graphic and I’m sorry but what I am doing is to “pick it up” and slowly move it back and forth to break up the scar tissue underneath that has been causing all the pain, I do this twice a day morning and night.  I really wish I had known about massaging the scar earlier than this, for anyone reading this who has yet to have surgery, scar massage is safe to do as soon as you are healed so about 6 weeks.  The earlier you start it the less likely it is that you will have adhesions like I did, this is a good preventative treatment for that.

All in all I am continuing to improve although am still on pain medication daily at least for now but it’s not as strong as the one I used to be on and I will continue to try and reduce that at each visit with my pain doctor, Dr. Netherton.  Thanks for reading and if anyone has any questions or comments feel free to post them I am happy to help if I can!

Road to recovery, this time for real!

Thanksgiving was just lovely and I am amazed that I managed to pull it all off.  I think everyone in attendance had fun.  My niece Sarah spent the night and we always have fun when we get together.  We went shopping at Michael’s yesterday and it was the first time I drove since the surgery a month ago.  Gosh, was that only a month ago????  Even that fact amazes me.

Healthwise I am still battling my Coumadin level.  I am going every week on Wednesdays to have my level checked.  A week ago I was over 3 which is too high so my dose was changed.  This week it was 1 (obviously too low)  they want me in the 2 range.  I am taking 5mg every day except the weekends when I take 2.5.  At least I don’t have to do the shots anymore.  I also had a blood test to see what type of genetic trait I have that caused me to have the emboli.  I was shocked that this test took about 15 vials of blood, thankfully I am not squeamish!!  Even the phlebotomist was surprised by that number.  I am awaiting those results now.

My energy level is coming back, slowly.  Actually I feel pretty energetic most mornings since Wednesday of this week and am finding that it makes it easier for me to overdo it.  Brian has been pushing me to take daily walks.  Today I really didn’t want to go but I made myself do it.  I said I was only going to walk 20 minutes but ended up walking for 45.  I am pretty sore now but I know every day gets better and better….  I took some great pics out in the SC woods today and will put those up as a gallery.  When we got back, He and I worked together to clean out my little zen garden next to the back patio and plant a little fern we transplanted from the woods into it.  I also pruned my little rose bushes and fed them and noticed that my camellia tree has it’s first bloom of the season as of today.  All of these things combined make me feel grateful to be alive and make me realize how very very lucky I am to be here.  I think all my senses have been amplified by this realization of my own mortality and I am looking at it as a positive thing.  I wish everyone would look around and appreciate the beautiful small details around us every day.  There is beauty everywhere if you notice it and now I am!  I said it before but feel its true, there must be a reason that I didn’t follow Debbie on November 4th and I plan to keep looking to find out what that reason is.

Thank you so much for reading and if you have any questions or comments please feel free to post!

Day 15 Since Surgery improvement in baby steps

Day 15 since surgery; the most frustrating thing about this whole thing is not being able to do the things that I want to do.  Went out this morning to take Savannah to the vet and thought I could also go grocery shopping.  Of course Brian did the driving but even still, I barely made it through the vet appointment before the pain slammed me to the ground.  The ride home was excruciating, every bump in the road sending a shockwave of pain across the small of my back and down my left thigh. Actually the roads around my house have way more bumps and potholes than I ever noticed before!  After all this, the idea of grocery shopping is out of the question.  So, here I am back in bed propped up with an intricate pattern of pillows for support after only being out for about an hour and a half.  Everyone says to me, “enjoy this time that you don’t have to do anything” and of course I know what they are saying but it is easier said than done.  I have never been good at sitting still. The first few days out of the hospital were kind of like a vacation but the novelty has worn off at this point. Recently I have an increase of pain at my incision site.  The swelling in belly is finally going down.  I was shocked at how swollen I was right after surgery, I looked about 4 months pregnant!  Glad that is going away! Another strange thing is that the skin around it is completely numb so when I change the dressing I can’t feel it.

Brian and the kids have amazed me with their ability to pull together as a team to keep everything going.  The laundry and dishes are always done, eventually, the meals get made, the cleaning gets done.  While it may not be exactly the way I would do it, I am grateful that they are doing their best.  I am very proud that the kids have stepped up and worked as a team to get everything done without complaining.  I will need to practice patience with myself, and I promise I will try to enjoy my time “off”.  Today is a gorgeous sunny day in the low 70’s, really perfect weather as far as I am concerned.  Days like this are exactly why we love living in SC.  As much as I wish I could be outside taking a nice long walk with Lily, I will have to be contented with  carefully and slowly walking around my yard with her instead.   We have all the windows open today because it is so beautiful, it’s nice to have nice fresh air coming into the house after an entire summer of air-conditioned “canned” air.

 I am also happy to report that Brian and I are still non-smokers for over 2 weeks. We last smoked the day before surgery, cold turkey!   This has not been an easy thing to do especially through all this stress but we are doing it.  I am only willing to say that I won’t smoke today, it seems like too much for me to say never again even though I can’t imagine why I would ever start again.  I feel like I can breathe better already and I really don’t miss how smelly they are and the expense!  Our budget is going be helped dramatically by not spending $250 a month for smokes.  Now that I am only taking in short term disability we need to make every penny count.  I am not saying that I don’t crave them, I do but I will NOT give in and smoke!  We have done it without the use of the gum or the patch because the nicotine in those products would prevent the bone growth between my vertebrae.  Brian could use those products but I think he did it the same way as me as a sign of solidarity……….. so sweet 🙂

So all in all I am getting better every day, little by little.  Monday I start in-home physical therapy and am looking forward to that.  As always, thanks for stopping by and feel free to leave a comment and let me know your thoughts or experiences with what I have written about today. Ttyl

 

ALIF device Anteror Lumbar Interbody Fusion

This the device installed during the ALIF (anterior Lumbar Interbody Fusion) surgery that I had yesterday. It ia installed into the disc space after  the disc is removed.  It is held in with 2 titanium screws going up and 1 going down.  These devices are what holds the disc space while my own bone grows to fill the space.  That can take 1-3 years..

Pre-Surgical Appointment with my Vascular Surgeon

I met with my vascular surgeon yesterday (look in my nifty links to see his background) and I must say he was extremely thorough in telling me exactly what his role in my surgery is, what he is going to do and all of the myriad of complications that I could have (also how incredibly rare they are).  I learned something new about the differences between arteries and veins. I didn’t know that veins were so much more delicate than arteries.  He said that during surgery if he damaged an artery it could be sutured very easily because of the tough muscular-like structure of them.  He said by contrast, if a vein needs repair “it’s like stitching 2 pieces of wet toilet paper together”.  However he said that he is so careful he hasn’t had to stitch a vein because of his techniques to prevent it.

In 1500 procedures they have only had 1 fatality and that was from a pulmonary embolism or blood clot in the lung.  This caused them to send every patient home with an injection kit of an anticoagulant called Desirudin that I will inject myself with once a day for 2 weeks after the surgery.  The major complication that happens after these surgeries is DVT and Pulmonary Embolism.  Both are blood clots,  DVT is in the legs and PE is in the lungs.  This  injectable medication will prevent these for me.  I probably won’t see him again, he will be doing about 5 surgeries that Friday so he will be going from one OR to the next without stopping.  I felt very comfortable and confident in him. 

There was one thing he told me that bothered me. Apparently I will have 2 incisions.  One vertical incision about 4-5inches long to the left of my belly button and the other on my side horizontally.  I wasn’t aware of this until yesterday and it hit me pretty hard. I don’t know why I thought they could get to both discs from 1 incision and for some reason I pictured it being horizontal so it would be invisible in a skin fold.  I have been very lucky so far in my life and really don’t have any major scars so the idea of not just 1 but 2 fairly large scars is bothering me…… A LOT.  I am crying on the inside thinking about it but am trying to maintain a strong exterior.  I know that I have to have this surgery so I won’t have the pain anymore but I feel that these scars are disfiguring.  He said “your bikini-wearing days will be over” and I wanted to cry, tears did well up.  I told my boss about it this morning and she said “well who cares? You’re not 20 anyway”  Wow that was a kick in the teeth, She also said “you should just get a tankini instead” I may be 46 but I have tried to stay in fairly good shape and quite honestly I do have a bikini and maybe I will just wear it anyway scars and all. I still have to look in the mirror at them everyday and believe me that thought scares me.

Here is an illustration of where my incisions will be according to the vascular surgeon.  Tomorrow I meet with my orthopedic surgeon to finalize my surgery plan and he may tell me that they will be in different sites.  I will let you know what he says.

***In the interest of full disclosure, I have had a very hard time quitting smoking, so today I am not going to buy another pack.  Normally at lunch I would run to the store but today I will not.  I hope……….although I admit that right now after writing all this, i really want one!