On April 12, 2017

Opening up a nerve gap

So now I have some thinking to do. As I mentioned before, the day after the cortisone shot I was pain free. In the week after I have been in more pain than I was before the shot. They say to give it a couple of weeks, that the cortisone crystallizes in the tissues where it was injected, and it takes a while to fully dissolve.

I will say that the hip pain related to spinal stenosis (restriction or narrowing of the nerve escape gap between two vertebrae, often referred to as sciatica) has been greatly reduced, which was the point of the shot, so in that, the shot was a success. That said, I am having more soreness in my actual back (which was rarely more than stiff before), and some tenderness and itching.

I assume that the tenderness and itching are from tissue damage that will heal. We will see.

My second surgery appointment was with a neurosurgeon in Lebanon, whom, it turns out, my ex-wife used to work for when we were first moving in together (they didn’t like her, either). In any case, she was capable, communicative, and all sorts of other alliterative complimentary words.

Her assessment of my spine was very interesting. She is the only one who noticed (and she noticed immediately) that my L3 vertebrae was not only offset 9mm from its intended place (spondilolisthesis), but that when I bend backwards, my spine slides nearly back into alignment, and when I bend forward, it slides forward to its fully displaced position. Also of interest is that on the MRI you can see that the L3-4 gap nerve on the right is thick, bright, and healthy, and that the same nerve on the left is half the size, and not nearly as bright on the MRI.

One would expect, therefore, that the greatest restriction of nerve would come when it was fully displaced, bending forward (when the injury was first acute in 1988, this was in fact the case). But at this point, bending forward creates relief, and arching backward (unless carefully approached in a yoga type position or hanging upside down) causes an immediate flare of pain in my hip, which is relieved when I straighten my spine.

This is counterintuitive, and has to do with the fact that there is no space between my vertebrae.  As the spine has settled onto the collapsed disc, the L3-4 vertebrae have stopped rocking as much (as vertebrae do when there are discs involved). Because the L 3-4 vertebrae have settled together into an unseparated stack, the supraspinous, interspinous, intratransverse, and facet capsulary ligaments have become loose. The way to imagine this is to take a short piece of rubber band, and hold it stretched at a length that maintains tension, pluck it, and then move the tension points for the rubber band proximal to each other. The rubber band will be slack, and incapable of maintaining a position.  This state of ligamenture allows the vertbrae to slide back and forth within the tensile range of motion of the ligaments.  To better follow this discussion, Google “spinal ligament anatomy” and look at the first few images that come up.

Furthermore, it is likely that the superior and inferior facets (which make up the zygapophyseal joint behind your spinal nerve), which are the other part of the spinal structure upon which you stand, are worn down due to excessive friction created by the weight shift coming from a collapsed disc.

The assessment of all three surgeons to whom I have spoken (one of whom I skied with on Saturday’s delicious powder day, a total surprise storm!) is that my spine is too far gone for a disc replacement, that there is likely very little range of motion left in the joint as is, and that fusion has likely begun. The further assessment is that I am too far gone, and my vertebral environment too unstable (too much intervertebral motion to do a disc replacement.)

This of course is a contradiction, because if my spine was in danger of fusing any time soon, it would have done so during the last 28 years that I have had bone to bone contact, or during the last 16 years that I have had significant spondilolisthesis. The true state of the matter is that I have done such a good job of keeping my vertebrae moving that these doctors, and spinal medicine in general, have no fully coherent solution for me.

I will not accept a fusion solution at this point. I have only had one fusion patient tell me “do it, it was amazing for me.” The rest of them said “avoid it as long as you can” and one surgeon told me that basically once you fuse one set of vertebrae, you have about five years before you need to deal with another.

The solution offered by the surgeon I met with this week is one that I like. It is not what I was hoping for, but it is a two part solution that can be executed in an either/or/both scenario. The first part of the solution is intuitive, mechanical, and solution-oriented, and that is to simply do a minimally invasive procedure, and basically grind away some bone in the nerve gap, unrestricting the nerve in a permanent way.

This is very attractive to me, and my only concern is, what if it is those bits of bone that are keeping my spine from slipping further?  I will of course ask this of my surgeon during a follow-up appointment.

The second part of the solution will require some research, and it is called a “coflex” device.  It is a “C” shaped piece of metal that sits in the dorsal gap where the interspinous ligament would be, grabbing the bone on both sides, opening the zygapophyseal joint, providing room for the nerve to thrive, and providing some stability from a sliding vertebral gap.

While this would support the separation of vertebrae and will allow for some rotation and rocking back and forth (it would in fact provide a pivot for back arching, which would be really nice), it could cause a restriction of motion significant enough to allow those vertebrae to actually fuse together, which is something that I do not want. It could also cause the spinous processes (that bone bit that makes the bumps on our backs) to fuse to it and each other (not my ideal).

The question I have for the surgeon is: has the coflex ever been used in conjunction with a disc replacement? The coflex could provide the stability necessary to avoid slippage, while the disc replacement would separate the vertebrae, relieve pressure on the nerve, and allow for full motion.

I have a lot of thinking and a lot of research to do, but at least now I know that if chiropractic care will not provide a solution, at the very lease I can get surgery to open up the nerve gap, and provide myself some relief from the hip pain and nerve inflammation.

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