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A wretched back

These letters exemplify many that I have received, and duplicate the complaints of many of my patients over the years.

Professor Driver Jowitt, I have found your info by accident and what I have read has confirmed some suspicions I have had about my own care for some time.

About 30 years ago I had a Takata type disc extrusion which led to laminectomy discectomy including a dural tear and weeks on my back in hospital. It was not enjoyable.

I have just had a fusion to help with awful foot and leg pain due to instability and bilateral foraminal stenosis.

I still have pain in both legs and feet and my low back feels no more stable than before. I have suspected for a long time that I have not been fully informed on my true condition-based simply on how bad I often feel- and I know that my GP is taking his lead from the latest ‘expert’ and my outpourings are largely dismissed.

After all I have been ‘fixed’ now… so what is the problem???

My insurer is taking an increasingly hard line lately on folks like me. I am about to be sent for assessment by an independent contractor to determine if I can return to my trade as a carpenter. I fully expect this to be found to be true and my exit (from benefits) put into motion. I have not worked full time since 2002 – in great pain and discomfort – and lost my latest (light)job when I agreed to the fusion. I feel let down by my health services.

Dear Patient, I have the greatest sympathy for you. Medical investigatory techniques (including the most recently developed “scans”) are relatively crude. Therefore a meticulously accurate diagnosis is often lacking. At times the view is taken that “nothing shows, therefore nothing is wrong”. This is an inferior conclusion, which I often have to counter in Court. My argument is that “absence of evidence is not evidence of absence”.

By the same token, such an absence of an anatomical diagnosis defeats accurate treatment design.

However empirically and over a lifetime of involvement in vertebral management [both surgical and (mostly) non-surgical] the least dangerous and most effective form of management is in water, as described in my website.

I imagine you are seeking responses to those who might deem you “fit to work” and so cut your grants. If I can help further, please let me know.

Dear Doctor Driver-Jowitt, I have read some of your articles on spine surgery and tried, elsewhere, to contact you.

I am doing some research on my own situation post discectomy/laminectomy for Takata type extrusion (20mm) in 1989 and L5/S1 fusion recently. I have significant ongoing issues. I am a 52 year old ex tradesman.

Can you tell me how I can establish the current status of my ligamentum flavum? After reading what you have written I think I may have instability and weakness due to its removal in 1989. But how on earth would I know??

Dear Patient, As a beginning, it is not likely to be productive to return to the past in terms of unpicking previous events. What counts is to get going on a process of improving what you have at present.

However, having said that, it might also be important to provide your source of social benefits with some reasons why you may never have been truly “cured” following the original disc prolapse.

At the date of your original surgery it was widespread practice to excise the ligamentum flavum, and to strip away the inter-spinous/supra-spinous ligaments, as well as to elevate (and so inadvertently de-nervate) the mutifidus muscles. The last mentioned is an often unrecognised cause of “instability” as well as “transfer pathology” to segments above and below the segment of primary pathology.

Therefore those who might take the stance “you have been correctly treated, nothing can be found by experts now, and therefore you are fit to work as a carpenter” might well be wrong. Add the impairments at the disc level to other (unrelated and often subliminal) changes of age, and you could well have good reasons not to be able to return to work as a carpenter. Indeed if you are expected to build and mount trusses, or work on scaffolds and ladders, you should be prevented from those activities.

Have your hips been checked? An arthritis, at times not appreciated, can often exacerbate vertebral problems.

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Ageing and orthopaedics

 

 

Excess mass. Many of the degenerative changes of ageing are associated with excess body mass. It is a common perception that as one ages body-mass should increase. At times I am told by my affronted patients “I have always weighed this much, since I was a youth. How can you expect me to weigh less now?”

 

Get older, thinner. The reality is that an “ideal” body weight, which is probably acquired at the end of growth should, with ageing, decreased progressively. The reasons are that there is a loss of both the weight of bone and the mass of muscle. Therefore if the bodyweight remains the same it must be because there is more fat.

 

The lungs and stomach. The vertebral column shortens was ageing, and therefore the volumes in both the abdomen and thorax decrease . If the same amount of fat (or progressively more fat) is compressed into the abdomen then the diaphragm will be lifted and the space in the thorax compressed. This may be one of the reasons why reflux oesophagitis increases with ageing, as does the hiatus hernia. Add to that decreases in respiratory capacity, often in lungs which are functioning sub-optimally, and one has extremely good reasons for reducing mass. Oesophageal reflux can cause further deterioration in the lungs, coughing at night and so the cycle continues.

 

Weaker body more load. Therefore we have the unsatisfactory situation with weaker muscles and more frail bones being expected to carry a far larger body-mass, comprising a primarily of fat.

 

Metabolic effects. Excessive fat is not innocuous, as it has a huge influence on the hormonal balance of the individual, including the factors that go to create a diabetes, and creating excess female hormone.

 

Weaker structural tissues. Structural tissues, such as ligaments and tendons  lose their mechanical strength with ageing. This is partly because the blood supply to those structures diminishes and partly because the reparative processes following minor injury are slower.

 

Exercise plays many roles in musculoskeletal health (as it does in the health of the entire biology).

 

Hormonal benefits of exercise. There are general effects of exercise, which stimulate the production of natural anti-inflammatory medication substances, natural antidepressants and natural analgesics. For those with aches and pains, as well as the sense of depression that inevitably accompanies the degenerative processes of ageing, these are exceedingly important.

 

Strengthening benefits of exercise. In more specific terms exercise will retain, or perhaps increase muscular bulk and strength, which is so vital in protecting the joints. The calorie burn will be the most effective way of reversing the ratio of fat to muscle.There is nothing better than low impact exercise (such as cycling and swimming) to stave off arthritic degeneration in the knee

Osteoporosis. Exercise is the most specific counter to osteoporosis.

 

What type of exercise? In the ageing body by far the most effective form of exercise is swimming. However, if an exercise program is to succeed, and for that matter if any exercise patterns are to succeed, it must be firmly scheduled, so that the exercise is consistent. Three times a week is probably ideal, with a necessary day of “recuperation” between each session.

 

Particular care with swimming. Those who have problems with the joints, particularly with the vertebral column, but also the large joints of the body, need to exercise particular care in swimming. A painful back or a dowager’s hump, and many forms of scoliosis can make it exceedingly hazardous to enter the water unassisted. It is recommended that swimmers with these problems should always be accompanied whilst in the water, at least in the beginning.

 

Swimming and Gym coaching. It is also recommended that a swimming coach be employed initially. Many elderly people will regard this advice with scorn, saying “that is for children and toddlers. I know how to swim”.
However this is not an appropriate answer. Anyone who wants to brush up their foreign language or musical instrument playing needs help as an adult. Perhaps even more important is the fine tuning of swimming skills, which will allow the swimmer a more effortless period of exercise, and  consequently a longer period of exercise. Ideally the aim is to churn through the water without significant tension or stress for forty or more minutes during the session.

 

Cycling is a realistic form of exercise, with great benefits, particularly, to the knee. This is because it develops the quadriceps and other muscles which control (and so protect) the knee joint. The loads on the lower limb during cycling are less than walking and running, whilst the range of movement is often more than walking. If there are disabilities in the knees which prevent adequate movement then the use of shorter pedals shanks can overcome the problem. Ideally, adjustable shanks could be used and as the range of movement in the knee increases, so the length of the shank can be increased.

 

Cycling has the advantage that one can listen to music, dialogue or watch television. Reading a book is not realistic because of the jolting and sweating.

 

Making exercise fun. This is an important aspect of exercise as a therapy. Exercise must be attractive, appealing and fun. If exercise is a drudge then enthusiasm will be lost rapidly and ultimately the endeavour will fail, leaving only a large burden of guilt.

It is therefore suggested that careful attention be given to the “fun” aspects of exercise. The iPod has created a new dimension of music and literary content, and it might be that the iPod should be bought before the exercise bicycle.

Real cycling is an option which can give much additional interest to exercise, as well as a social and even the travel aspects. Many people combine an exercise bicycle with the “real” bicycle, and so are able to enjoy summer but continue to exercise during winter.

 

The importance of the logbook. Another ploy which is useful in maintaining stimulus and interest is to keep a detailed exercise logbook. This logbook should include details of the period of the exercise, and if it’s possible to measure  (as  is possible on many types of exercise bicycles) the total calorie burn. The logbook should also include a daily resting pulse (before getting out of bed) and the pulse rates before and after exercise as well as weight daily.
There is a tendency to forget how one improves was exercise and therefore the recording of this will not only stimulate the aim to keep improving, but demonstrate the efficacy of past exercise.

 

What can you expect if you  lose weight by reducing calories?

 

A number of chronic illnesses can be reversed, sometimes completely, simply by calorie reduced loss of weight. These include:

Diabetes of maturity

High blood pressure

Gout

Lower limb arthritis

Reflux oesophagitis

Respiratory incapacity and breathlessness

Prevention of hernias, or recurrence of hernias

 

Possible improvements include:

 A longer life. People (and animals) live longer on restricted calorie diets.

Reduced sleep disturbance from oesophagitis, reflux pharyngitis or apnoea

Urinary incontinence

Cardiac failure

Chronic bronchitis

Chronic sinusitis

Shoulder pain (when this is caused by lifting the body weight out of chairs).

Low back pain and sciatica.

Painful feet

 

All these illnesses are frequently treated by long-term medication. It seems so simple to be able to effect an improvement with less or no medication, at less cost, more energy, and a better quality of life by weight loss and exercise. Surely you owe it to yourself to try?

Swimming in post-spinal surgery rehabilitation

Management of vertebral problems neither begins nor ends with any surgical procedure. The likelihood of it success is determined in the pre-operative design. Post-surgical management also requires careful design and execution. At times apparently unimportant or inconsequential actions have a major bearing on outcome, and it is the responsibility of the surgeon to correctly emphasise and arrange these.

One of the objects of this web-site is to disseminate information which I have found helpful in the past, to a wider audience. The following is an extract from a letter written to someone who felt that she was recovering “too slowly” after a decompression for a narrowing of the vertebral canal which was threatening her with paraplegia.   

One recommendation is that you spend time in a swimming pool. This does not mean swimming initially. To begin it means simply getting into a pool, to the level of mid chest and walking about the pool, perhaps using your hands as in breast stroke. What this does is to make you “weightless” on your low back, and gently allows a rhythm and harmony of movement to return. Ideally this should be twice a day.

Developing the anterior abdominal wall (tummy muscles) is an important aspect of spinal rehabilitation. Traditionally “crunches” and “sit-ups” have been used. These are not recommended as they produce a significant compressive effect on the vertebrae. Instead backstroke is excellent. This can be varied to kicking the legs alone whilst floating on the back, or (where the edge of the pool coincides with the water level) resting the head on the side of the pool and kicking the legs, as in back-stroke.

After three or five days begin gentle hoola-hoop movements with the pelvis. This should be slow with as large a circle described by the pelvis as possible. Very slowly! After another week begin treading water. To begin with you will have difficult in doing this for more than a few minutes, but with persistence over three or four weeks you should manage up to twenty minutes. This will be excellent general cardiovascular exercise, but in particular will strengthen the anterior abdominal wall and the para-vertebral muscles markedly. Ultimately aim for swimming as an on going, life-long “maintenance”. The best strokes to begin are side-stroke, then a gentle crawl plus or minus backstroke. At that stage, if possible, you should get a swimming coach, Sounds dramatic? Not really, swimming should become a big part of your life, a regular recreation. Like learning a language or musical instrument one needs professional help to get optimum expertise. The aim is to be able to slide through the water effortlessly (really!) for forty or sixty minutes twice a week (at least), as an ongoing therapy.

Physiotherapists who use water in their therapy are excellent, but at times difficult to find.

Swimming in the ocean is not recommended. Walking through (even small) waves produces considerable buffeting, which recruits rapid (and undesirable) vertebral movements to balance. The slope of the beach, both inside and outside the water can load the vertebrae excessively. Walking on sand will load the back more, and aggravate most back pains. [The same applies to foot pain, which some find paradoxical as they feel the “softness” of the sand should be beneficial. It is not]
Many accidents are waiting to happen in the ocean, from stepping on unpleasant objects to dropping into holes in the sand, all of which will jerk the back.
Stick to the controlled environment of the swimming pool, and always be accompanied in the pool if you are post surgical.

Piriformis Story

The Piriformis Syndrome seems still considered “controversial” with a small group of followers and, it seems, a far larger group of non-believers.  My own experience began in this way:

As the young doctor in the west of Wales I often encountered coalminers with back pain and sciatica.  One had a clear history – he had fallen back onto the the sharp corner of a metal scuttle used to carry coal which struck him in the buttock.  He was clear that his persisting symptoms began at that moment. It seemed that he had a focal injury in the buttock affecting the sciatic nerve trunk and the nerve was trapped in the buttock, not by a disc in the back.

The consultant surgeon was adamant that this was a nerve root entrapment by pressure from a disc.   In the early 60’s the dynasty of the disc was accelerating its momentum, but precision in diagnosis was notably poor.  All that was available was the myelogram, which like many medical endeavours could only assist by negativities.  The ” exploratory” surgery on the disc was not beneficial and I continued to think about the outcome with regret. 

In 1980 a man in his early 30’s walked into my office. “I don’t know why I am here,” he said “but I was passing, saw your name and took a chance”. 

He had had three laminectomies by a professor of neurosurgery at a teaching hospital and now was being told to “live with the pain”.  That morning he had resigned his job. “I didn’t have the energy to get up and walk across to the filing cabinet”.  He had sold his house at a  desirable beach location, because  pain prevented him climbing the stairs to the car park. 

His pain was located precisely over the piriformis in his buttock and he had a notably sensitive sciatic nerve when felt rectallyPalpating the nerve in the buttock duplicated his symptoms. His replicated the Welsh miner.

“A new machine has been installed in the city” I said “it is called a computerized tomogram”. 

He looked blank.  I welcomed the chance of testing this machine.

This was the scan, which showed an enlarged piriformis muscle in all cuts.

mcculloch-painted-compressed

The piriformis is red, the sciatic nerve blue

“I have had so many opinions”, he said “which have all been wrong.  I am sure you will understand if I take the scan and ask for a further opinion.”

He had a  contact with another professor of neurosurgery who, as it happened, was hosting an international neurosurgical conference that week.  The scan was presented at the conference.  The opinion of the meeting was universal: “This is not the cause of your problems.  We advise you to stay away from further surgery.”

He returned despondently.

“You can’t continue through life as matters are.” I said

“I suggest that I release the piriformis muscle. There is minimal downside, and the potential to make your life worth living again”.  He nodded in dumb acceptance. 

The procedure was photographed, and later that day the photographer boasted  that he had seen a man who “was going to have a big pain in his behind!”  The woman to whom he was talking responded “No he is not. He is my boyfriend and he has no pain”.

A week or so later Mac did a charity walk of some kilometers without pain for the first time in years and, as far as I am aware, he never again had pain.

As I had mainly spinal practice persons with piriformis entrapment appeared from time to time.  However precession in diagnostic accuracy was a concern, since it soon became clear that CT alone, and ultimately MRI alone, could not provide an unequivocal diagnoses.  What was helpful was to paralyze the piriformis with a local anaesthetic. Initially this was done blindly by advancing a needle a centimeter or so from the lateral edge of the sacrum.  This usually gave persuasive diagnostic information by abolishing the pain for the duration of anaesthetic effect.  But it did not give the certain anatomical precision which I would have liked.  Later  I began injecting the piriformis under CT guidance and this technique became widely adopted, and spread widely internationally.

Skepticism remained.  At that time access to literature was difficult and I could find no previous experience with the entity.  Some years later I discovered that a description from Durban, South Africa, from about 1947  by, as I remember it, a Dr Adams. A neurosurgeon once asked me where he could find the literature on Piriformis Syndrome.  I said that I did not know of any literature but I could explain to him my experiences.  He said that he was not interested in my opinion and put the phone down.

I have had three failures following piriformis release, each of which, in retrospect, could be explained as failures in selection.  Nevertheless, the procedures were relatively innocuous, and had, as far as I am aware, no downside.  Balanced against that were a great number of successes.

 [A discussion on the etiology of this syndrome will be addressed in another paper.]

Rethinking orthopaedic and forefoot surgery.

This post continues the page Stop! Wrong way! in relation to orthopaedic management

Deformities of the forefoot. These include “bunions”, Morton’s “neuroma”, clawed toes and “flat foot” (whatever that is intended to mean). It is unlikely that any group of elective procedures has been performed, in total ignorance of the causative factors, more often, by more people, in more ways, than various forms of surgery to the forefoot.

Fractures being “set” as soon as possible after the injury. This damaging policy produces significant, irreversible, complications. It will be addressed in a separate post on this site at a later date.

Finger-tip injuries. These common injuries produced a plethora of surgical treatments, from skin grafts and”rotational flaps” to “cross-finger flaps”. These required not-inconsequential surgery, sometimes under general anaesthetic, were expensive and incapacitating for various periods, and unnecessary. Harvest was taken from uninjured areas of the palm and other fingers, scarring those. The best results however have been shown to be obtained by doing nothing beyond usual wound care! The body’s capacity to heal itself at that site is not unexpected, being as easily and frequently injured as the fingers are.

“Traction” for so called “slipped discs” (mostly that diagnosis was incorrect, in the event). Tens of thousands of patient-days were lost by placing these unfortunates in hospital and attaching weights by cords to their legs, literally tethering them to their bed for days or weeks. This was entirely ineffective since the friction of the legs prevented transmission of any “traction” to the discs. The management was adversely effective, since most low back pain improves more rapidly with movement (ideally in water). Deep vein thrombosis would be expected to be increased by this form of immobility. I wonder how many died of resulting pulmonary embolisms.

 Osteomyelitis. Antibiotic usage and aggressive resection of bone is often counter productive and dangerous. The loss of the limb might result from some current management policies. This is addressed in a separate post on this site.

The spine is not so simple

Back pain, often associated with leg pain, is common. Rapid conclusions as to the cause are often made, and the unfortunate victim is told with authority by friends that “this is obviously a ‘disc'”. Even the profession was beguiled at one stage into believing in the “dynasty of the disc” for nearly half a centuary. However back pain originating is the disc is relatively rare.

The compendium of potential caused of back pain is large, and often originates from causes external to the vertebral column such as inequality of leg length and restricted (but unrecognised) limitations of hip movement. Even changes in the feet, by disturbing the fine and specific axis of balance of the vertebral colum can produce back pain. [This will be the subject of a dedicated page in the future].

Events near the vertebral column can produce back pain, such as gynaecological or bowel disease. Others include disease of the min arteries or ulceration of stomach or duodenum.

The ligaments, particularly the ilio lumbar ligament and fascia can produce intractable back pain. [Entrapment of the sciatic nerve by the piriformis muscle will be considered in a later post].

The problem is that the vertebral colum is an exceedingly complex anatomy of fine dimension, and is hidden deeply within the body. It is frequently assumed that one or other type of “scan” will be all-revelatory. Unfortunately even the most sophisticated investigatory equipment is too crude to give precise answers. Instead this equipment might show an abnormality which is no more than a “red herring”, with the regrettable outcome that  patient and therapist  alike begin to pursue this misleading cue even to the extent of attacking it surgically. Another problem is the cavalier surgeon who is determined to “explore”. Pain, however, is never found with a knife.