Neurosurgery & Beyond

In June of 2014, I happened to be having my annual physical, and as I was discussing my spondy trials and tribulations with my internist, he suggested I go see one of the top neurosurgeons in the area.  I told him that I had already seen two top spine surgeons, but he suggested I go anyway since a) I had nothing to lose, and b) he might have a different perspective on my condition.

I sought out the neurosurgeon, and after redoing my x-rays and MRI (it had been about a year since my prior images), I went to see him in September.  Within 10 minutes of reviewing my images and examining me, he suggested a different strategy.  He said that, for my case, since my spondy was low grade and stable, and since I was very fit, that he would recommend a simple decompression procedure that would involve a hemi-laminectomy, foraminotomy, and removal of the broken facet joint fragment that was pressing on the nerve (Gill procedure).  Recovery would be quick and much less involved than fusion surgery, and he said that I was not in need of a fusion at this point given my overall health and level of slip.  And while he couldn't guarantee that I wouldn't need a fusion at some point in the future, he agreed that it didn't make sense to "start the clock" on the adjacent disk degeneration at this stage either.

This revelation was like jumping into a cold, refreshing swimming pool on a 100 degree day.  Wait a sec...I wouldn't need to fuse my spine and lose mobility, face a long recovery with no bending, lifting or twisting for 6-8 weeks, and I would be able to go back to my activities (within reason - more on that later)?  Seriously?  My wife (who is also a doc and accompanied me on the visit) and I looked at each other in disbelief.  Was it even a question?

Within a few days I went ahead and scheduled myself for the decompression procedure at the end of October.  My surgeon said I would be in the hospital overnight and could go home the next day, and would be OK to go back to work after a 10 days - 2 weeks.  This sounded good to me.

On the morning of my surgery, I was scheduled as first case (yay), and arrived at the hospital before 5am, was prepped and ready to go by 6am.  At 7:45am I was wheeled into the OR, given a spinal block and some sedative, and was back in recovery before 9am.  After regaining feeling in my legs (yikes that sensation was weird) by the middle of the day, I was feeling pretty good and recovering in my room.  The pain in my incision was fairly significant, and the muscles were tight and in spasm, but I didn't end up taking much of the pain pump since I hate pain meds and they drop my blood pressure (that's a whole other story that I won't go into).

I was able to get up and walk around the room a bit that afternoon, and I noticed that the reduction in my leg pain was significant.  It wasn't completely gone, but it was already greatly reduced.  My surgeon told me that my nerve was very severely compressed, and that I should expect gradual improvement over months as the nerve takes time to heal completely after being under such compression.  After a fitful night's sleep, and some lousy hospital food, I was home by lunchtime the next day.  Though I took a prescription for pain meds, I ended up only taking Advil after leaving the hospital.

Per the discharge instructions, I began walking around the house over the first couple of days, and iced my back several times a day.  By the end of the first week, I was walking up to a 1/2 mile around the neighborhood, and within a couple of weeks, I was walking up to a mile.  The reduction in my pain and numbness, even in those first couple of weeks, was remarkable.  It was like getting a new leash on life.

During that first month, the nerve continued to improve, with occasional twinges or soreness, as the back gradually loosened up.  But what a difference from pre-surgery!

During my post-op checkup, my doc declared that he was impressed by my recovery and told me that I could gradually begin more movement and exercise, but to still be careful as I wouldn't be considered "healed" until at least 3 months out.  He also told me, at this point, that I should avoid weight lifting going forward.  Well, if you're reading this blog, chances are you know what my response was.  Right.  So, while I didn't get into a lengthy discussion on the merits of lifting and CrossFit, the nuances of proper lifting technique, and Mark Rippetoe's opinions on the matter, I did ask him to give me some guidance on what would be considered "lower risk" lifting.  Of course, he said deadlifts should be avoided and that I should keep weights under 50 lbs.  OK, well, sure.  With that, I said I would modify and be careful and keep the weights down, but press forward.

Feeling good, by the beginning of the 2nd month following the procedure, I began to work on my core strength again, doing abdominal bracing, planks, side planks, glute bridges, birddogs, etc. and rebuilt my core (which fortunately hadn't really declined much even through the surgery), and I kept walking (which is great, by the way, regardless of your fitness level or other chosen fitness activities).  My incision began to feel less painful each day and the leg pain continued to disappear.

By the third month, I returned to my CrossFit box and began some basic modified WOD's with movements that would keep my spine stiff and not involve repetitive bending movements (air squats, pushups, pullups, step ups, lunges, etc.).  I also avoided jarring movements like box jumps, double unders, running so as not to irritate the healing nerve and spine.  My fitness began to return as my leg felt good.

Over the last two months, I have gradually reintroduced many CrossFit movements into my repertoire, at gradually increasing weights, such as squats, cleans, jerks, deadlifts, etc.  Though I am not going near as heavy as I did before the injury and surgery, I am definitely working hard on strength, at least in low-rep sets, and continuing to push the metcons.  During metcons, I go lighter and I substitute for certain movements that are likely to irritate the nerve or put me in significant extension.  For example:
- for high rep snatches or clean and jerks, I might sub KB swings
- for high rep deadlifts I might sub rowing on damper of 10
- for GHD's, situps or Toes-to-bar, I'll sub knee raises or weighted plank holds

So far so good.  Through the increased activity, I do have some sore days where my lower back gets tight and the muscles spaz a bit, but fortunately I have not had any leg pain or numbness return.  I was wavering on participating in the 2015 CrossFit Games Open, but in the end decided to give it a go, and it has mostly gone pretty well for me, without any major setbacks in terms of pain or dysfunction.

I am keeping my fingers crossed that I can sustain this current state and that the slip does not progress nor compromise the nerve root again.  I continue to focus relentlessly on:

- technique ("chase technique and the weights will come!")
- scaling appropriately and checking my ego
- core strength and stability
- mobility work
- spinal deloading and decompression

I have been using what I have learned on my journey to help others in my CrossFit box and I am happy to answer questions as well.

That's it for now.  Hope this has been useful.  I will post periodic updates as time goes by.  Good luck to those of you going through a similar journey.  Just remember - there are always ways to move forward and improve.  Never stop looking for answers!!!

#crossfit #weightlifting #spondylolisthesis

Conservative Treatments

So, there I was after a couple of months of PT, and I wasn't seeing any real improvement.  While I was developing some better glute strength and coordination, there really wasn't any change to the pain levels down my leg, and the numbness wasn't changed by the PT.

At this point, I began to return to my CrossFit routine with modifications for weight and certain irritating movements like situps, T2B, etc.  I worked with a top-notch CrossFit instructor who helped me continue to develop my core strength and groove excellent lifting technique so as to minimize chances of injury and ensure a rock solid midline through all my WOD movements.  I was still in pain after WOD's, and when walking/standing for extended periods, but dealing with it.  In the later fall, I also spent about 10-12 sessions with a chiropractor doing decompression/traction on a special decompression table, as well as some basic lumbar adjustments, but that yielded little benefit in terms of pain reduction as well.  Towards the end of the year, when the pain really started to eat away me, I decided to return to my doc to see what he recommended as a next step.

My doc suggested that I could try an epidural spinal injection over the L5 nerve root to see if that would help, and after researching it online and weighing the risk/benefit, I decided to give it a try.  Since my ESI was going to be placed outside the spinal canal under x-ray fluoroscopy, and not near the spinal cord/dura, I figured it would be relatively low risk.  I went ahead and scheduled an ESI for late December.

On the day of my injection, I was taken into the treatment room and placed prone on a table, where the doc proceeded to position the x-ray scope over the lumbar area.  He then numbed up the injection spot and inserted the needle carefully and incrementally until he was directly over the nerve root. Of course, it hurt like hell when the needle made contact with the nerve, but within a few seconds of the anesthetic and medication going in, the nerve calmed down and I felt a delicious numbness wash down my leg as the pain went away.  After the procedure was over I went to stand up off of the table, and I discovered that my left glute was a bit numb from the anesthetic, which made my first couple of steps rather interesting.  But I left the clinic feeling pretty good and mostly pain-free.  I was told to take it easy for a few days to let the nerve heal and not irritate it, and then go from there.

For the first couple of days, I was feeling quite good and had much lower levels of pain, though the pain was certainly not gone, and I still had a bit of numbness.  I followed the instructions and took it easy for a few days before starting up again with some basic PT type work.  Overall, I was feeling pretty good for the first couple of weeks.  I wasn't doing any heavy duty workouts or CrossFit - just core work and some pullups and pushups, with an occasional Turkish Getup thrown in for good measure.

By the third week, the pain and cramping sensation began to return and by the end of a month I was more or less back to where I started.  At this point, I began to look for surgeons to discuss my situation with, and in the meantime started a few Pilates classes as well to see if they would help (they didn't).

During February and March of 2014, I met with two well-respected orthopedic spine surgeons in the area to get their opinions of my case.  The first surgeon reviewed my images and symptoms and told me that he would want to perform a spinal fusion of L5 on S1, and would cut me open from the side or from the front (ALIF procedure) and that I should never lift weights again (LOL).  The 2nd surgeon, who I really liked, also said that a spinal fusion was my best bet and that I'd be back to my activities in a few months after recovery, though I should seriously think about giving up weight lifting and take up running, etc. (also, LOL, considering how many injuries running can lead to as well).  He said he would go in from the back (TLIF procedure) and that I should recover fine.

Through my own research on the topic of spondylolisthesis, I have come to understand that fusion is considered the "gold standard" surgical treatment of the condition, but I have also come to understand (and the 2nd surgeon was quite honest about this) that fusion introduces new risks to other segments of the spine above the fusion location.  With the kind of active lifestyle I prefer to lead, this concerned me greatly.  Clearly, there is a tradeoff to consider here, and at this point I was not quite ready to "start the clock" on that adjacent disk degeneration.

Given the various factors and risks, and also including the significant recovery time and activity restrictions after a fusion, not to mention the downtime from work, I decided to put off considering a surgical option and continue to find ways to reduce the pain through conservative means.  I got back on my mobility and core work, continued doing decompression using my decompression device, and went back to working out and playing sports, trying to manage the pain as best I could.

In the spring of last year, I also went through a 7 week course of acupuncture, in the hope that it could trick the nerve into not feeling the pain.  Although I found acupuncture quite relaxing, ultimately it failed to have any effect on the nerve pain and numbness.

Through early summer of 2014, I continued to suffer from significant pain and numbness and it definitely began to affect my workouts and sports more and more, adding to my frustration and despair.  I decided to go through an additional injection in mid summer but it offered little lasting benefit.  Ultimately, since my nerve compression was anatomical in nature, injections and other conservative measures were unlikely to relieve pressure on the nerve due to the simple fact that the opening was simply too small and bone fragments were pressing on it.  Thus, there could be no real healing of the nerve.

Next: A new option

#crossfit #weightlifting #spondylolisthesis