#laminotomy

Ya girls out of surgery and back home with some food. Besides some soreness in my back and calf from the compression machine, I'm feeling great! I walked more today than I have in the past 4 months just making a loop around the recovery area, and just something as small as doing that or sitting g without fire going down my leg is so exciting. I'm so happy

I made it outside yesterday (recovery day 6). I'm so thankful that I have a balcony to sit on and feel the fresh air and warmth of the sun. Unfortunately, my apt is not accessible and has tons of stairs, so I've been trapped here since my surgery on Friday.

I had an L4/L5 and L5/S1 laminotomy. When the surgeon opened me up, he confirmed that I actually have a duplicate nerve root at L5/S1, not a cyst. He took a picture (those of you who know me should know that made me really happy) and he's going to show me how much bigger that nerve root is since it has two nerves wrapped in one sheath! He also confirmed his suspicion that my nerve roots exit the spinal canal much higher than the average person. This, he said, would explain why my pain did not match what he was seeing on my images - a validating statement that reminded me I wasn't making this all up in my head.

For years (8 to be exact), I have suffered from sciatica. It was really bad at first and then I don't know if I "got used to it" or perhaps it got slightly more tolerable, but it was only this past year that it became unbearable again. Every time I would see a doctor, they would look at my imaging and tell me that the minimal disc bulges I had on those two levels should not be causing me so much pain. In fact, one of my doctors suggested it could be psychosomatic and asked if I knew about CBT (I work in mental health, so this was a huge 🙄 for me).

Nevertheless, I refused to give up, even though my doctors were giving up on me. I finally found a pain management doctor who believed me and also wasn't afraid to prescribe pain medicine while I sought answers. After exhausting my options with him (i.e., steroid injections, exercises, medications, etc.), he referred me to a neurosurgeon. I'm too exhausted to go into detail about the horrific experience I had with this doctor, but I will one day. She eventually suggested I have a fusion and disc replacement (without ever seeing me in person except for 2 visits in 2016). I felt this was pretty aggressive for someone my age, so my pain management doctor referred me to see someone else.

For the first time, this new surgeon listened to what I was saying and actually believed that I could be in a ton of pain despite my images only showing "minimal disc bulging" at 2 levels. He showed me my scans and actually walked me through his thought process. He pointed out the "cyst" and said he thinks it could be a duplicate nerve root. He also drew pictures for me, explaining how nerve roots normally exit the spine and how mine seem to be exiting much higher up. He pointed to some bone erosion he noticed on the right side and suggested I get new imaging done since the last one wasn't very clear. Most importantly, he was straightforward with me and said this surgery might not fix my pain, but at the very least, we would eliminate one of the possible sources for my pain. The worst case scenario (barring any rare complications from surgery) would be going through surgery and not having my pain resolved. He also referred me to see his colleague for one more opinion, since his opinion conflicted with the first surgeon I "saw."

Fast forward to my surgery day - I'm pretty nervous, but once I meet my anesthesiologist, I'm much more at ease. He's a huge USC fan and alumni. The doctorate student (SRNA) working with him that day was also at USC, so we all bonded over that and I felt reassured that they would take good care of me. Both of them kept telling me what a great decision I made and that the extra year of PA school at USC's program is so worth it (woo!). Next, my surgeon came and marked "YES" on the right side of my back and they told me I was ready to go. I kissed Alex and my mom and the SRNA gave me a dose of propofol as I was being wheeled away.

Things happen at double speed once you enter the OR. EKG stickers get placed on me as an oxygen mask is strapped over my face. My gown is hooked up to a hot air pump (my favorite) and the anesthesiologist tells me he's going to start giving me the sleepy stuff. My left arm burns like my veins are on fire. I'm reassured this will pass quickly and it does. Someone stands over me and switches my oxygen mask and I drift off into anesthesia land.

My eyes peel open and they feel watery. Am I crying? I am. I hear myself gasping for air and saying, "I can't breathe!" Looking back on this, I think they probably had just pulled the intubation tube out, so I probably woke up during that and got scared that I wasn't breathing on my own. This has never happened to me before (or if it has, I don't remember). I then burst into tears again because the sciatica I had going into surgery was gone.

I'm still off of my medication for my autoinflammatory disease due to the risk of infection if I'm immunocompromised in any way. My drenching night sweats are back and I'm not feeling that great, so hopefully I can go back on medication after my post-op appointment on 3/17. In the meantime, I'll just be here...resting...reminding myself I'm not a burden...allowing myself to ask for help when I need it. Special shout-out to my mom for flying out last weekend and taking care of me and my MVP, Alex, for being the actual best human in the world and loving me unconditionally.

Outcome of unilateral versus standard open midline approach for bilateral decompression in lumbar spinal stenosis: is “over the top” really better?

J Neurosurg Spine 31:236–245, 2019

In this retrospective analysis of a prospective multicenter cohort study, the authors assessed which surgical approach, 1) the unilateral laminotomy with bilateral spinal canal decompression (ULBD; also called “over the top”) or 2) the standard open bilateral decompression (SOBD), achieves better clinical outcomes in the long-term follow-up. The optimal…

Outcome of unilateral versus standard open midline approach for bilateral decompression in lumbar spinal stenosis: is “over the top” really better?

J Neurosurg Spine 31:236–245, 2019

In this retrospective analysis of a prospective multicenter cohort study, the authors assessed which surgical approach, 1) the unilateral laminotomy with bilateral spinal canal decompression (ULBD; also called “over the top”) or 2) the standard open bilateral decompression (SOBD), achieves better clinical outcomes in the long-term follow-up. The optimal…

I titled the blog discectomy to aid search engines, so that people who search on the word may have a better chance of finding my story, and that in some way my post may help you. I recall spending multiple days searching for answers online and I suspect others do the same. Throughout this post I may randomly insert words like discectomy and other search-related terms that are associated with back injuries which I'll put in brackets. You can ignore these, they're not meant for you but rather for search engines. I do this because I found it difficult to find relevant information relating to the personal experiences of others.

I told myself six months ago, should I ever get better, that I would write about my experience so it might help people who have injured their back and who are in the toils of a slow recovery. I write this to the people who are lying on their backs as they read this, to those who are missing work and agonizing over how long it may take to get better, to those who's lives have been so dramatically changed by a back injury that they're searching for any information that will allow them to take the next step.

I live in Seattle, Washington. I work for a technology startup. I'm 36 years old. I'm married with two kids. At the time of my injury I weighed 215 pounds, I am 6'2". This is my story about my back injury where I intend to share what I've learned over the past sixteen months related to my experience, and ultimately my recovery. 

In June of 2009 I had just parked the rental car at Charles de Gaulle Airport in Paris. My wife and 1 1/2 year old son had accompanied me on a nine day business trip where we had spent time in Paris, Lyon and Aix-en Provence.  My wife was two months pregnant with our second child. The trip had been enjoyable but international travel with a one year old had proven challenging at times, we were ready to be home. My wife was in the back seat of the rental car unloading the car seat as I opened the trunk of the car to unload the luggage. My feet were perpendicular to the bumper of the car as I twisted slightly to grab the largest suitcase. As I lifted it, using mostly my upper body, I felt a unique pain shoot up my spine from my lower back, I dropped the suitcase and fell to one knee. After a few minutes I stood up and carefully made my way to the gate and boarded a 9 hour flight back to the states. This was the beginning. 

By the time we landed in Seattle my back was really starting to hurt, the next day was even worse. Coincidently we had a week of vacation scheduled immediately upon our return from France. Two days after our return to Seattle we drove to Chelan, Washington for a lakeside vacation. My sixteen year old sister-in-law joined us and helped take care of our son. I spent a lot of that week in a lounge chair or in the hot tub. The pain severely limited my ability to enjoy myself but was a 6 on a 10 scale, so it was tolerable. I could lay down and it would subside. I did have sciatic pain but it was not severe or constant. Upon visiting my doctor when we returned from vacation I was prescribed Percocet, that got me by for a few weeks but did make me feel nauseous. During this first episode I did not get an MRI.  By September I was 90% recovered and able to return to normal life. The bulging disc had healed on its own after about six weeks.

We have a rental house in Portland, Oregon. In late October of the same year I rented an industrial stand-up sander to refinish the deck.  I had rented it at Home Depot and when I arrived to return it I couldn't find anyone at the desk to assist me in unloading it, I waited for about ten minutes but ultimately became impatient when I couldn't find any help. I would estimate the sander weighed about 90 pounds and when I lifted it from the tailgate to the asphalt I felt and identical pain to that which I had felt in Paris - I immediately began mentally beating myself up, 'how could you be so stupid', I said aloud.  I made the three hour drive back to Seattle that evening and was in terrible shape for the next six weeks. I work for a software company, at a desk, so thankfully I did not have a job that required me to do physical labor and was able to gut out this second episode with the help of 1000mg/day of Advil and the occasional Percocet. Once again it took six week to heal and by the beginning of December I was again at 90%. I committed to not lifting anything heavy, stopped picking up my son at odd angles and lifted anything of necessity only while bending my legs and not using my upper body. I took it easy for the next few months and this second injury seemed to be healing.

In late January we had our second child, a daughter, and life at home became busier. Our son, now two years old, had started the 'I'm gonna push back' stage of his life and the new child added to my wife's challenges during the day. I could only afford a few weeks at home before I returned to the office as things at work were at a high water mark too. 

It was the first week of March 2010 when it all hit the fan. On Friday night we had just finished dinner and gone upstairs to start bath time with our son. He wasn't being the best listener and was delaying his bath by unplugging electrical cords, pulling socks out of drawers and being otherwise uncooperative. In some frustration I got up from the bed and bent at the waist to quickly grab him intending to carry him to the bathtub. It was this moment where life changed for me. 

Not only did I feel pain shoot up my spine like before, I also felt something, almost like the squishing of a grape, in my lower back. My son and I both fell to the floor, I couldn't move. I buried my head in my arms and my wife, knowing immediately that something was wrong, took my son in the other room to give me a few minutes alone. I've had twelve kidney stones in my life, which is another story, but I think it's safe to say that I do know pain, and this was real pain. Ultimately it would be determined that I had crushed the disc into seven pieces at location L5-S1, but at this moment I only knew that something bad had just happened. It took an hour, and all the strength my wife could gather to get me into bed. I did not sleep for the next three days. I got out of bed with my wife's assistance only to use the restroom, to which I had to crawl as my wife, despite valiant efforts, just wasn't strong enough to take me the fifteen feet to the bathroom. The process of getting out of bed, crawling to the bathroom, and using the toilet to urinate took 15 minutes, it took just as long to get back into bed as I often had to pause for a few minutes at a time along the way, by the time I had made it back into bed I was sweating and had tears in my eyes. The sciatic pain was extreme and going all the way down to the middle of my left calf, walking just wasn't an option as the pain was too great. As I spent day after day in bed I would sometimes put my face into the pillow so that I could scream. I tried endlessly to find a position that would cause the pain to subside. The leftover Percocet did not help. My wife began sleeping in the other room as I constantly rolled, twisted and moaned attempting to find a position of lesser pain, nothing helped. During the first five days I consumed only chocolate milk, a few slices of wheat toast, and analgesics that I had from the previous injuries, or still had from my last battle with a kidney stone. I could find no relief, the pain was either a 9 or a 10 depending on the hour of the day. Finally, on the sixth day my wife, seeing no improvement, made me an appointment with a neurosurgeon. Up until this point I was stubborn enough to believe it was going to heal just as it had before. Getting to the appointment was agonizing. I covered my face with a pillow as not to frighten my son with the pain during the twenty minute drive. I fell onto the pavement in the parking lot of the neurosurgeon's office and crawled part of the way to the door before standing. Ultimately the neurosurgeon came in to see us. He ask only a few questions before telling me that he'd heard enough and instructed me to go down the hall and have an MRI. He told me that this would be very painful given my condition but that it was absolutely necessary. The 35 minutes I spent in the MRI machine was awful, holding still for that long when you're in that type of pain is near impossible. I bit down on my shirt, clinched my hands together. I cried, I prayed, I closed my eyes as tightly as I could, and finally it was over. 

Ninety minutes later I was back with the neurosurgeon and I had found a position on the floor of his office where the pain was a nine instead of a ten. I talked to the doctor with my head buried in my hands. He told me it was one of the worst he'd seen, that the fragments of the disc were bunched together and pressing firmly on the nerves and on my spinal cord. He suggested I have surgery the very next morning and I didn't argue.

The next morning I was given morphine while in pre-op. This gave me some comfort. Two hours later I awoke in post-op. The neurosurgeon had performed both a laminotomy and discectomy at L5-S1 to remove the disc fragments that had been pressing on my spinal cord and the surrounding nerves. A laminotomy is the process of removing a section of bone to provide an entrance to the disc, mine was done on the left side.  After surgery the sciatic pain was gone and I was thankful. I spent the night at the hospital and felt enough relief to catch up with email on my iPhone. I must have typed for two hours trying to make up for my lost week at the office - I fell asleep around 4am after the battery died. Little did I know at the time but I had a very long road ahead of me before I would recover. Sadly, the worst was yet to come. [discectomy] [laminotomy] [sciatic pain]

The first two weeks were as-advertised and I took it easy. I did have some pain at the surgery site but it was minimal. I didn't lift anything heavier than my laptop and I spent an additional ten days away from the office while recovering. Somewhere around two weeks after surgery the pain began to increase, mostly at or around the surgery site. I became very unstable, to the point that if my son were to walk up and hug my leg that I would collapse. If I even slightly bumped my hip on the counter or the side of the bed I would collapse. The motion of sitting down or standing up became difficult and painful. I went back to work but by the end of the day I would be in a lot of pain and would need help from my wife to get up the stairs.  I began waking up at 4am to take 1000mg of Advil just so that I would be able to shower and drive to the office at 6:30. Throughout the day I'd take another 1400mg of Advil and I did this for the next four weeks before going back to the neurosurgeon. At the appointment I was told that it may take time, that there are 8-10% of people who have this surgery that don't recover well, that I would need to wait it out and that he estimated it could take another 30 days to fully recover. I was prescribed more pain killers (Oxycontin). This would be my first of ten appointments with the neurosurgeon over the next three months.  

The next week things got even worse.  I would go to the office about three days per week, otherwise I would be in bed. I was no help to my wife with the kids, I simply couldn't do anything as the discomfort was too great. My wife helped me get dressed in the morning and helped me to get undressed in the evening, I couldn't have put my socks on if someone had offered me $1000 to do it.  The pain was at the surgery site and also wrapped around to the sides of my hips as if it were a muscle that was on fire just under the surface, I couldn't lay on either side and could hardly roll over due to the hip pain, if I did I had to hold onto the nightstand and pull myself over and I screamed in pain when I had to do this.  I knew that quite a few nerves had been cut during surgery and assumed this was the cause of the hip pain but wasn't sure. I continued taking the pain killers and 2000mg of Advil each day but got little relief.

I went back to the neurosurgeon and tried to explain the extent of my pain and limitations. He prescribed a week of Prednisone for inflammation, refilled my Oxycontin and also gave me some Demorol. The Prednisone did help so there was obviously some inflammation, but it's a very powerful drug and has some dangerous side effects if taken for too long. When I rolled off the Prednisone a week later the pain came back even worse than before. When I was able to make it to the office I sat in a big oversized bean bag in my office. I had network cables strewn across the floor and I shut my office door much of the time. When I had to use the restroom it took me five minutes to get from sitting to standing, I would then gingerly walk down the hall.  By the time I got back to my office I was near collapse due to the pain. Oxycontin, Demorol or Advil were no longer helping, though I continued to take them at maximum prescribed doses. 

I went back to the neurosurgeon and pleaded with him to educate me on what was happening. Why was I not recovering, more pointedly why was I getting worse? He gave me the advice that I grew very tired of hearing "it just takes time, not everyone recovers at the same rate." I was frustrated with this advice, how could I have fallen into the 10% which is sometimes referred to as FBS or Failed Back Surgery? I did not distrust the information I was given, after all this guy had been doing an average of four of these surgeries a week for the past 23 years, he was listed in a local publication as one of the top doctors in his field in Seattle, as voted by his peers. Other than being somewhat short and concise during my appointments I did dislike his approach and did not lose my trust in his abilities or experiences, but I was frustrated. He told me that there could be an infection and that an infection in your spinal column is not good. He ordered an aspiration, a procedure involving a very long needle and a CT machine where the CT-guided placement of the needle would draw fluid from the surgery site to check for infection, it was scheduled and nine days later I was laying face down with some level of general anesthesia, I wasn't fully conscious but enough to feel a great deal of pain over the 40 minute procedure. If you have to have an aspiration to look for an infection in your spine be prepared for an uncomfortable experience.

The results of the aspiration were given to an Infectious Disease doctor. At the time I walked into his office to discuss the results I was almost hoping that I did have an infection, at least then my pain would be treatable with antibiotics, I had also had the full suite of blood work done that would be used to correlate with the results of the aspiration. The blood test results suggested that I may have some type of infection in my body, but the cultures from the aspiration suggested that what did grow in the cultures -which usually proves the existence of an infection- was likely taken from my skin when the needle exited my body, how they know this I have no idea. The conflicting information just increased my level of frustration as the aspiration results seemed to override the blood work despite the presence of 'something' and I was never given any antibiotics. The pain got worse over the next week and was almost as bad as the week leading up to my surgery, it averaged an 8 on a 10 scale throughout the day, though I could, at times, find a position that allowed me to sleep a few hours per night. Sleeping for only 2-3 hours per night week after week takes its toll. I was not only in pain all day but also exhausted. 

My wife didn't have a husband, my kids didn't have a father and I was very fortunate that I had an empathetic employer and a wonderful spouse. By June I was in really bad shape. The neurosurgeon ordered another MRI. The forty minutes in the MRI machine was horrible. I clinched my teeth, was drenched in sweat and it was all I could do to stay still, what motivated me was getting accurate results. The MRI results didn't show anything other than a cyst that developed as a result of the surgery that he decided was not contributing to the level of pain I was experiencing. All else was as-expected after the surgery. This was highly frustrating, how could I be in so much pain and an MRI suggest that my body was 'fine' ? 

By this time I was ingesting so many drugs that I would often vomit in the afternoon. My system was beginning to reject all of the narcotics that I was taking to control my pain. The neurosurgeon gave me a 30 day prescription of Prednisone. Although hesitant, I began taking this and dialed down the pain killers slightly. A prescription of this length is rare, I think. I got the impression that this was the last bullet in the gun. I also was given a bone scan that week, this is evidently different than an MRI but was equally as painful to experience given that I had to lay flat on my back for forty minutes. 

The Prednisone helped, but it's a very powerful drug and taking it for extended periods has great risk, including causing very serious hip problems. Prednisone, as I understand it, prevents that body from allowing inflammation to occur, so it make sense that my pain would diminish while I was taking it.  However, it can also cause avascular necrosis, particularly in the hips. If this occurs you often have to have a full hip replacement, so long-term exposure to Prednisone or other similar acting steroids does have risk. Thirty days later I was done with Prednisone and the pain return to the previous levels (8/10). 

At this point I was beginning to become convinced that I would require spinal fusion. After having the first surgery go so poorly I was highly concerned that fusion could go even worse.  Recently there was an interesting article written ( I've included it here ) that councils those considering spinal fusion and it seems it certainly does not always fix the problem. I would suggest reading this and other information, as well as getting multiple opinions before making such a decision. It is said that orthopedists are more likely to suggest spinal fusion than a neurosurgeon, I would suggest the conservative approach first....waiting. If you do pursue fusion know that there are two ways to perform this surgery, one where the incision and hardware placement is done in your back; the other is an incision and placement that goes through your stomach and it seems there are strong opinions on both sides as to which is better. I would ask your surgeon to explain both options, but know that most surgeons either perform the procedure one way or the other, not both, so you may need to seek multiple opinions.

For another sixty days I experienced a lot of pain. I went through all narcotic options and ultimately I was prescribed morphine in pill form, and this was helpful.  Outside of this morphine I found - through endless trial and error - that 600-800mg of Advil 3 times per day worked best. At this point I was taking a fair amount of morphine and a lesser amount of Advil and that seemed to work well enough.