Open Spinal Surgery
E. Noel Preston, MD

   It started with feeling as if my shoes were tied too tight, even when I was barefoot. Then it started feeling as if someone was poking the bottoms of my feet with a dinner fork. Later on I started having a backache that radiated down the back of one leg. And then one day it felt as if someone had suddenly kicked me as hard as he could on the outer side of my leg, just above the ankle. And the key to whether this was cardiac pain as opposed to spinal pain was this: the pains did not diminish or go away with rest -- they persisted nearly an hour and might get a little more bearable if I laid down on the floor and put my feet up on a chair or a sofa.

   The doctors asked if I could date the back troubles to a specific event or if they just came on gradually with no apparent cause, and I could date the symptoms back about 30 years to when Caroline came home from eighth grade at school. She was trying to do cartwheels in the back yard and wasn't quite able to get the hang of it. "No, Caroline, that's not how you do it," I said. "Watch Daddy -- this is how you do a cartwheel!" And Criminy! It felt as if a lightning bolt had hit me in the small of the back and shot fire balls down the back of my leg all the way down to my toes. Ever since, I would get a backache now and then, but it would go away with rest and some acetaminophen or ibuprofen. (Backache that comes on gradually with no apparent cause is often due to senior citizen arthritis, and pain dating back specifically to a remembered injury is usually due to a slipped or ruptured intervertebral disc.)

   The neurologist ordered a spinal MRI, and it showed a collapsed disc space and no disc at all between L5, the last and lowest lumbar vertebra, and S1, the first and top sacral vertebra. It showed a disc that had slipped to the right and a cyst bulging on the left between L4 and L5, and a severe narrowing, or stenosis, of the spinal canal, through which the spinal cord passes on its way from the skull down to the base of the spine. The neurologist wanted me to take prescription anti inflammatory medicines and to consider having steroid epidural blocks of one or more of the spinal nerves. I asked him if these would actually reverse structural damage or just make me feel better, and he said they would improve function but have little if any likelihood to reverse structural damage.

   One of the first things I learned in medical school was "at all costs, keep your patient out of the hands of the surgeons," and if anyone was willing to avoid surgery, I was the one. But this was different. If medical treatment could not reverse structural damage and could only delay the inevitability of surgery, it seemed to me it would be better to have surgery on my terms instead of on an emergency basis. If I had the surgery now, I would be in reasonably good health, I could choose the day of the week to have the surgery (Wednesday is best, to avoid weekend mishaps among the staff), the surgeon, the hospital, the anesthesiologist, and the rehabilitation center. If I put it off, I might have to have emergency surgery when I was out of town on vacation and not able to choose anything.

   And so I went to see Dr. Max Steuer, one of the finest neurosurgeons in the United States, and he's right here in Atlanta! Max said I would be a perfect candidate for surgery: I'm thin instead of heavy; I don't smoke, I wasn't on steroids or anti inflammatory medicines that would delay and interfere with healing, and I had MRI demonstrably serious structural bone disease. All of these would be factors favoring an excellent result.

   I asked the spinal surgery case manager, one of the surgical nurses at Northside Hospital, what would be the best rehabilitation center for me to use after surgery, and she said that by law, she couldn't recommend any one center over another -- but she did suggest I look at the Medicare web site for rehabilitation centers and skilled nursing facilities, and look especially at the number of Certified Medical Assistance hours per patient per day. The national average is 2 hours and 16 minutes, and the highest one I could find on the Internet for the Greater Atlanta area was (dreadful name alert) Golden Living (fka Beverly) Rehabilitation Center on Meridian Mark Road, just down the street from the hospital. Golden Living's average CMA per patient per day was 1 hour and 58 minutes, and the thing to remember is that "average" means some people get more and some people get less.

   Patients in the rehabilitation centers are recovering from all sorts of things: severe dog bite wounds, gunshot wounds, domestic abuse, home invasions, robberies, lawn mower accidents, falls from ladders, auto accidents, strokes, house fires, industrial accidents, and various surgical procedures. Some of the patients are quite elderly and some aren't. Some are going to be there a very long time, and others are anxious to make a quick recovery and get out as soon as they can. And so, some of the patients are going to tell the therapists that they are fatigued and want to go back to their rooms, and the therapists are obligated to respect the patients' stated wishes. If a patient responds affirmatively however, to the therapist's offer to go on to the next treatment or to repeat a particular exercise, the therapist will be delighted, and the patient will get much more CMA activity than the average. I never told a therapist I was tired. I never said I wanted to back to my room. I always accepted their offers to go on to another level of difficulty. I averaged almost 3 hours of CMA per day, and I was out of the rehabilitation center in 10 days.

   One month after surgery I was walking with a cane and able to drive my car. Two weeks later I put the cane in the closet and haven't used it since. I'm a little unsteady on my feet, but I'm out of the house every day and I work as a part time pediatrician for other doctors about twice a month. I've taken a plane to Maine and have driven to Asheville and St. Simon's Island, and I've used a gas powered leaf blower to clean Susan's outdoor deck. And nobody's poking me with a dinner fork anymore.

   And so for me, spinal surgery was great. The key to getting a good result is to learn as much about it as possible, to follow instructions, to have a great surgeon, and to participate in as much rehabilitation as possible. The other important thing is to have a positive attitude. Set yourself a goal for being independent again, and don't let anything interfere with it. A week before surgery I bought non refundable, non changeable airplane tickets for Maine for travel 10 weeks after the operation. I was determined not to let them go to waste, and they didn't. Knowing I had those tickets made me get well faster. If you are anticipating a serious operation, schedule something pleasant a realistic time afterwards. It will give you something to look forward to, and you will enjoy it all the more.

E. Noel Preston, M.D. is a pediatrician in solo practice in Peachtree Corners. 6063 Peachtree Parkway, Suite 202-A, Norcross. (770) 448-1553. More information can be found at www.PeachtreeCornersPediatrics.com

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