Wednesday, March 30, 2011

The path to the exit...

What wasn't so great was that my right hand side, which had been largely pain free before surgery was now painful. It was as if I had swapped the pain from the left to the right hand sides! The explanation was pretty simple: I'm a big bloke and in order to get access to the various bits of my spine and to place the screws and the fusion cage it was necessary to use a fair amount of force, including retractors and a "scissor jack" style distractor to re-establish the old disc space. This led to some substantial bruising and perhaps some bleeding. I suspect that the "handedness" of the surgeon who inserted the cage from the right hand side also had something to do with it.
The upshot of all of that was that it was hard to get and maintain pain control. I kept getting muscle spasm in the right buttock and that is a vicious circle - more spasm = more pain = more spasm. At about the same time the line in the back of my left hand got knocked out by a clumsy movement and an attempt to re-establish a line in my right hand was unsuccessful. That left me without access to morphine. The whole situation culminated in me sitting on the edge of my bed in tears at midnight one night unable to cope with the pain. A phone call or two and a sharp increase in pain control medication got the situation back under control. In retrospect that was the nadir, life improved quickly from there.
Days three and four saw the return of the torturers (the lovely physios)! They had me out walking again, firstly with the frame then without, then climbing three "mock stairs" then out to the fire stairs for a scary unaided climb up and down one flight of them. At the end of that process they declared that they were finished with me and I was fine to go home!
Friday also saw me off to the X-Ray department for a quick picture to ensure that everything was where it should be. Only two things were holding me back now: pain control and the delicate matter of "opening my bowels". To put it bluntly you can't go home until you can control your pain successfully and until you've demonstrated your ability to have a crap! Opiate pain medication is not helpful in achieving the second of those goals!
As far as pain control was concerned I was getting about 2 hours between bouts of medication. My nights consisted of two hours sleep, some medication, half an hour's walking the circuit of the ward and another couple of hours sleep before the cycle started all over again. I could shower myself, dry myself, dress myself. The drain and catheter had been removed. I just wasn't really on top of the pain and it was now 7 days since I'd had a crap. Finally on Sunday night it all came together and on Monday morning - 7 days exactly after I'd entered the place I was kicked shakily out onto the street.

Tuesday, March 29, 2011

Working Back Through the Intervening Days

So what happened after coming out of surgery and leaving hospital on day 7? Well quite a lot really.
I vaguely remember this insistent voice in recovery saying "what's your pain now dear?". The scale is 1 (no pain) to 10 (unbearable pain, worst you've ever felt). I remember answering "7" every time. It sounded like a good number in my semi-conscious state. The unexpected result was that I arrived on the ward from recovery with 40mg of morphine on board and quite quickly accumulated another 4mg. Life was pretty painless at that stage!!
I also had various tubes and lines in place. A venous line into the back of my left hand, put there by Charles when he anaesthetised me and now being used for the Patient Controlled Analgesia (PCA). This is a marvellous device that delivers 2mg of morphine every time you press the button, limited to 1 press every 5 minutes and 95mg total over some time period which I never worked out.
I also had an arterial line in my left wrist, which soon came out leaving a big bruise; a drain from the wound on my back and an in-dwelling catheter in my bladder to remove the need to get up to go to the loo; and finally a further "spare" venous line in the crook of my left elbow.
The wound was dressed with a waterproof dressing which was in turn covered with a heavy "cushioned" dressing of something like rubber or neoprene. I never suffered the slightest pain from the suture line, however all tapes and adhesives give me some degree of inflammatory reaction so that was an issue from time to time.
Bruising after removal of the arterial line from my wrist

The first 24 hours focused on keeping pain relief up and helping me learn to turn with assistance from the nurses. I was allowed no water or food whatsoever until bowel sounds returned just the occasional wipe around my mouth and gums with a dampened swab. Once small bowel sounds returned I was allowed crushed ice to suck. What we were all waiting for was a full-blown fart! A sign that my gut was again working. Apparently surgery on the spine can cause your gut to go into a sulk. Taking food or drink in that situation leads to nausea, vomiting and other dire consequences so crushed ice it was. Finally about 50 hours after my last food I finally produced the requisite fart and was allowed to begin a light diet.
About 30 hours after I returned from surgery I was encouraged to hoik myself out of bed and into a vertical position. This involved edging towards the edge of the bed in lateral recumbency and then pushing up with my arms as I swung my feet to the ground. That happened all in one motion and got me to a sitting position with the minimum of twisting and very little pain. From there it was simply a case of using a small walking frame and what remained of my wasted thigh muscles to rise like Lazarus to my feet. The first thing I noticed was that my left side, that had been so painful pre-op, was now completely pain free.
That ws a huge milestone getting to my feet again and taking a few small steps.

Monday, March 28, 2011

7 Days On

Pedicle screws, rods, cross link and the radio-opaque markers in the fusion cage (from the back)

Pedicle screws from the side showing the hardware at the back and the radio-opaque markers in the fusion cage.

Last Monday morning, bright and early at the hospital for all the clerkly things to happen, then to be weighed, have blood taken, an ECG done and finally to meet Charles, the anaesthetist - and coincidentally the guy who was going to be keeping me alive for the next few hours. After those formalities and me grilling Charles, it was off to the holding bay. This is a little area just outside theatre and was the last walk I was to make for a few days. I was placed on a trolley with a big sign "Pre Warm". I was placed under a large bubble cell blanket that was in turn connected to a hot air blower. The idea being that I was going to be in a cold environment for the next few hours so I might as well get as warm as possible.
Next on the list of visitors was Tim, the surgical assistant. Tim was a friend of a friend so a nice chat helped to bust my mounting anxiety.
Finally Peter the surgeon came along for a chat and I was wheeled in for Charles to weave his magic. The next thing I recall was Peter telling me that he'd just rung my wife and that all had gone well.
Operative time was a very quick 140 minutes - we'd all been expecting 180 to 220 minutes, so that boded well.
During the operation Peter had removed the laminae from between the L5 and S1 vertebrae, together with the facet joints; cleaned out the intervertebral space; and inserted a fusion cage and finally placed 4 pedicle screws, two rods and a cross link. As well he had opened up what remained of the neural foramina on both sides to give a clear path for the nerves to exit.
So far, so good and I was off to the ward.

Monday, March 21, 2011

D-Day the early morning

Alarm went at 5:00am, I have to be at the hospital at 6:30. Currently making coffee for others! I'm hungry, thirsty and dying for a cup of coffee...and I can't have anything.
That saying "ignorance is bliss" has got a lot going for it. I think if I didn't know what was at stake here I might have had a decent night's sleep. Instead I tossed and turned and worried.
Soon it will be off to the hospital and I'll talk to you on the other side. Wish me luck.

Sunday, March 20, 2011

D-Day minus 1

Tomorrow's the day. I'm having a single level spinal fusion - L5-S1 - with inter-body fusion cage, pedicle screws and rods. Doesn't sound too bad when you say it quickly.
For years I've had back problems firstly with a ruptured disc at this level and then as time has passed the facet joints have collapsed and I've developed stenosis of the neural foramen, particularly on the left side. In plain language that means that the nerves that run down my leg are being trapped and squashed.
Over the past 3 years or so it's become increasingly difficult to stand - 5 minutes is generally too long now, and increasingly difficult to walk. A couple of weeks ago it got to the stage that I had to sit and re-gather myself 3 times whilst walking a single city block. It makes life pretty limited. Going to the art gallery is out of the question, travelling is a problem if you have to queue at the airport or walk to your departure gate. About 2 weeks ago I went to listen to the MSO. It was all I could do to cope with the queue and get to my seat - a real feat of endurance that left me pale and shaking.
So to surgery. The problem with something like this is that no matter how intolerable the chronic pain and reduced function is, the prospect of surgery is not nice, not nice at all. You know that there are risks, anaesthetic risks, surgical risks... and you know that you are going to face a period of acute pain, rather than the chronic pain you have been facing. You are going to be in the hands of others, dependent on their care and skill. Not to mention minor indignities and inconveniences.
I'm supposed to be first on the list tomorrow morning - around 7:00am - and I'm told that it will take 3-4 hours for the procedure, followed by a week or so in hospital and 6 weeks off work. I'll try to keep this blog up-to-date, no doubt for the first couple of days it will be entirely unattended, but as soon as I can I'll give you some details.