Updates

Hi all. Thought I'd post up a short update on how I am getting along these days with my training and my lumbar issues.

Overall, things continue to go well.  The leg pain, burning and numbness that I endured for a year and a half has not returned, fortunately, and though I do have occasional nerve twinges in the hip (that don't extend past my left glute), I'm not 100% sure that those are actually from my L5 nerve root vs. the L4 nerve root (where I have a small disc bulge as well).  Overall, those are fairly minor and do not impact walking, running, dancing, training, etc.

I am still being careful with CrossFit loading and volume, and I am not Rx'ing every WOD, to be sure.  I have continued to focus on really good technique and form, and only go heavy in low-volume strength work.  I rarely deadlift right now, and I don't think I'm suffering for it.  Since it tends to induce higher lumbar shear stresses, I'm OK avoiding it for the most part since I am retaining posterior chain strength via squatting, kettlebell swings, weighted glute bridges and also via some olympic lifts - cleans, snatches.  My clean and jerk is about 25# below my all-time PR, and I don't see any big reason to push it, and recently I snatched 155#, about 10# below my all-time PR.  I'm good with those numbers for the moment, and most importantly, they haven't caused me new pain.

I still hammer my core with planks, weighted planks, suitcase (kettlebell) carries, Chinese bridges, glute bridges, bird-dogs, etc. and I think it really helps to maintain the lumbar stability, especially post laminectomy.  I continue to avoid sit-ups and most flexion-based movements except for on rare occasions when I feel like doing a few toes-to-bar, and I am being especially careful w/WOD combos that combine burpees and flexion with high rep lifts per this recent interview with Dr. Stu McGill.

I continue to do decompression (hanging from the pull up rig, arm supports from tabletops, etc.) a few times a day, and that does help especially after sitting at work a lot or driving.  When I work from home I use a standing desk and alternate between sitting and standing.  I also continue with mobility work on glutes, hams, hip flexors, etc. though not as much as before.

Interestingly, I've had a few PT's and docs tell me over the last few months that I was wise not to go for a fusion at this stage.  No sense in starting the clock on further disc degeneration and with leg pain as the primary symptom, fusion didn't make sense at this point.  Hopefully it stays that way.

Anyway, I hope this blog is proving useful to those going through a similar journey.  I'll post an update over the summer.

Be well, fellow aging lumbar athletes!

#crossfit #weightlifting #spondylolisthesis

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

Initial Discoveries & Treatment

So, there I was, in the summer of 2013, having just been diagnosed with an isthmic spondylolisthesis at L5-S1, wondering what that meant for me - how would I treat it, what would I would be able to do going forward, what were the risks for me, etc.?

My sports med doc said that though this was obviously a serious diagnosis, that it was a "stable" spondy (I had flexion/extension x-rays done to confirm it was "stable" and not experiencing excessive segmental motion) and that much of the research shows that spondy's don't tend to increase in slippage without a major trauma, so I didn't necessarily need to worry too much at this point. Now, every case is unique, and obviously the nerve was pretty compressed, but he didn't think that the nerve pain and numbness would necessarily progress unless there was a major trauma.  He thought that ultimately I should be able to return to doing the kinds of activities that I like to do assuming I could get the nerve pain calmed down.  He suggested some initial rest and some PT to see if we could calm down the nerve pain.  This seemed like a reasonable approach to take, so I stopped CrossFitting at the end of July, and went ahead and scheduled PT to begin in August.

Of course, being a research nerd and a CrossFitter, after my diagnosis and during my rest, I started scouring the net for information on the condition and what the best course of action would be beyond PT.  I wanted to know about the risks of doing CrossFit, lifting, playing sports, etc. with a spondy and degenerative disc, and whether I would make things worse.  It was (and is) hard to find great info on spondy and weightlifting, Crossfit, etc. but I did find a few posts here and there, some conflicting and some in agreement.  Mark Rippetoe, of Starting Strength fame, seems to suggest that lifting can be very helpful for those with spondy in terms of maintaining core and overall strength (obviously while maintaining strict form), and Kelly Starrett also suggests that those with spondy can continue to lift, assuming they stay primarily to "stable" category 1 movements (squats, deadlifts, push ups, pullups, etc.) as well.  So, there was some encouraging news there, but obviously disappointing in the fact that going hard with Oly movements might not be the best idea going forward.

Throughout my searches, I kept coming across info by Stuart McGill, a PhD from Waterloo, Canada, who is regarded as an expert in the field of spinal research.  He has conducted dozens of experiments to determine the effects of various types of loading on the structure of the spine and his conclusions and recommendations for improving core/spinal stiffness have been used and shared widely.  In short, McGill is a big proponent of maintaining spinal stiffness (i.e. no relative lumbar motion) in athletic endeavors (which CrossFit also prescribes in pretty much all movements) and doesn't like movements that emphasize spinal power, especially loaded flexion (think rounded back deadlifts) or repetitive flexion/extension movements like sit-ups, back extensions, toes-to-bar, knees-to-elbows, etc. due to risk of disc damage.  Now, how much of that repetitive motion disc damage applies to those with spondy is a question I don't have an answer to, but I've taken McGill's notion of spinal stiffness to heart with a vengeance, since it seems to minimize risk of further damage, and I try to apply it to all of my movements.  Indeed, I had found that many of the sit-up and back extension movements were irritating to the nerve in my case so I've stopped doing those.

As far as sports go, I did come across a few folks who have reported continuing to play their sports with spondy (most notably, Steve Nash of NBA fame) so that seemed reasonable as long as I could get the pain under control and maintain core stiffness.

With all this in mind, I moved into August of 2013 determined to decrease the pain and build up the necessary strength and skills needed to ensure that I could go back to doing what I wanted.  I began August by resting completely for a couple of weeks, and then began a formal PT program.  PT at first involved some massage and mobilization of the lower back muscles, pelvis, quadriceps and hamstrings, as well as some attempts at mobilization of the nerve itself using "flossing" technique (as described by McGill), and then we progressed into core strengthening work including bird-dogs, glute bridges, clamshells, etc.  I discovered some core weaknesses that I had despite CrossFitting 4-5 days/week (especially in the gluteus medius), and got an opportunity to really work on those.  Unfortunately, though I initially saw a bit of decrease in pain levels, it wasn't a major improvement, and I was beginning to get a bit discouraged by the lack of progress.  I continued on the path for another 5-6 weeks hoping that things would get better.

Up next: After PT

#crossfit #weightlifting #spondylolisthesis

Background & Initial Diagnosis

Hello, world.  This is my first post to this blog, and my hope in starting it is to provide some useful info to others who are in a similar situation - (aging) athletes still trying to hang on to glory despite some significant back issues.  Over the last year and a half, since I discovered I have a lumbar spondylolisthesis, I have been searching for info online about how to navigate CrossFit, weightlifting, sports and other strenuous activities with this condition, and the info has been pretty limited.  So, my hope is that those who are looking for this kind of info in the future will find this a helpful resource.

First, a little background.  I am a 40-something professional with a wonderful  family and a full-time job, and I have been active all my life.  Growing up I always played and participated in various sports - soccer, baseball, basketball, lacrosse, tennis, skiing, etc., and started lifting weights in high school.  After college, as my career interests took off, my athletic endeavors were put by the wayside a bit, but I always tried to continue training and lifting weights to maintain a base of strength and conditioning that would allow me to continue to participate in whatever physical pursuits I wanted, and also just to not suck at life in general (and, probably, so I could eat more too...but that's a separate discussion).  This waxed and waned over the years a bit, depending on what was going on in my life at the time (work, grad school, new puppy, new baby, etc.) but I have never strayed too far from some sort of athletic pursuit.

About 9 years ago, my yearning to return to competitive sports grew big enough that I could no longer ignore it, and I started playing lacrosse again in a very competitive post-collegiate club league, mostly with guys 10 years younger than me.  In order to keep up, I began training hard - lifting, running, sprinting, agility work, etc. - and it began to pay off for me.  My play improved and I got in some of the best shape of my life.  Around 2007, while searching for training info online, I accidentally discovered CrossFit, and started experimenting with it on my own.  I soon became hooked and began building my own basement and garage gym - barbell, bumper plates, rower, jump rope, squat rack, etc.  - so I could do the WOD's from the main page, and from various CrossFit affiliates who posted their WOD's online.  I mostly trained on my own, learning from countless videos and Journal articles, and supplemented my knowledge and experience with drop-ins to various boxes on my work travels.  In 2012, a new box opened up right near me, and since that time, my wife and I have become regulars in the box as we have jointly come to know the great sense of community and friendly competition that a box brings (in addition to greater levels of fitness, PR's, etc.)  I became an L1 in January of 2013 and began coaching at our box shortly thereafter.

Following the completion of the 2013 CrossFit Open and my first taste of CrossFit competition, I began to participate in the competitor training program at my box and began to increase the workload (and wear and tear on my body).  My weights increased, I hit some new PR's, and my metcons improved further.  I was enjoying the heck out of it, aside from the increased soreness.  Within a few weeks of starting the program, however, I began to experience some occasional pain and tingling down my left glute, hamstring and lower leg following my training sessions, and with extended periods of standing and walking.  Initially I thought it had to be something relatively routine - muscle strain, ligament strain, piriformis syndrome, etc. and tried various stretching and massage to alleviate the pain.  Nothing really made much difference, but since it was intermittent and I could still work out without any weakness, I plowed ahead in my training.  As the next few months wore on, the pain got increasingly worse and I began to experience numbness and tingling, and walking for any distance and standing still for more than a few minutes became painful.

After a visit with a local chiro (mainly for another orthopedic issue) and his mention that I might have a bulging disc, I began to do some research online and came across some sites like Fix Your Own Back and others, and began to try McKenzie press-ups and other exercises to see if perhaps a disc was indeed my issue.  After a couple of weeks of trying the press-ups with no change in my pain,  I figured it was probably time to get it checked out by a doc.

Following an exam, my sports medicine doc ordered up some imaging to see what was going on in my spine, and in addition to severe disc degeneration at my L5-S1 level, what the X-ray and MRI also showed was a bit unexpected:

"Bilateral spondylolysis at L5-S1 with grade 1/2 anterolisthesis of

L5 on S1 causing severe left and moderate right neural foraminal
narrowing."

In layman's terms, at some point in my life, the back half of my L5 vertebra cracked at the connection to the front half (spondylolysis) and separated from the front half, causing the front half to slip forward some 25-30% (spondylolisthesis) .  Since the disc between L5 and S1 is the only thing holding the segments together, it takes a lot of abuse and has been pretty worn down over the years.  The decrease in disc height and slip of the vertebra had resulted in a lot less space for the nerve roots that run down the legs to exit the spine.  In other words, a severely pinched L5 nerve root.  Ouch.

I was pretty surprised to see these findings on my MRI, especially since, aside from a couple of back tweaks/spasms over the years, I had never had any other back or leg symptoms and couldn't recall any big traumatic events that would have created such a break.  According to the doc, I've probably had the spondylolisthesis since I was a kid and just didn't know it.  But all kinds of questions began to flood my mind - was I only now suffering symptoms due to years of sports, CrossFit, weight lifting, etc.?  Could I have prevented it?  Would I be able to continue with CrossFit and my other activities?  What kind of treatment will I need?  Will I need surgery?

The reality is that I'll never know what caused the spondy specifically, but it's not likely I could have prevented it in any meaningful way at least in my youth.  Has weight lifting and increased levels of training made it worse?  That's hard to say.  I do believe that I probably have accelerated the wear and tear on my discs from weight training, but on the flip side, the training has made me much stronger overall and thus better able to function even with degenerative changes in my back.  Not to mention that imaging results don't always correspond exactly to symptoms, so the degeneration may not have meant much absent the spondy finding.

I have come to believe that there are mechanical aspects of movement, especially in weight lifting, that can be focused on and improved to minimize chances of causing a spondy, especially the overemphasis on lumbar (hyper)extension when setting up for lifts, and perhaps if I had known some of this earlier, I might have minimized the damage, though it's really hard to say for sure.  I don't think I hyperextended when I lifted prior to this, but since I don't have much video evidence to review it's all speculation at this point.  Anyway, it may have been invevitable in my case.  (By the way, cues such as Posterior-Pelvic Tilt, as suggested by Tony Gentlicore, and Kelly Starrett, can help address the hyperextension issue and could potentially reduce the risk of injury over the long haul.  No guarantees, but it likely couldn't hurt.)

In my next post I'll go into my initial discoveries and experiences after being diagnosed.

#crossfit #weightlifting #spondylolisthesis