Eclipsed by a spinal disk
During a cold in February 2010 I had to sneeze so hard for two consecutive days that I largely lost my voice. The sneezing also started a bad pain in the lower back that lasted for about three months. In that same period, a pain in the outside of the back of the right knee and part of the back of the lower leg began, that got worse when stretching the leg. Actually, there was pain all the way from the lower leg to the buttock and lower back when trying to stretch the leg, the pain mainly being along the back and outside of the leg. I also felt the pain when coughing, sneezing, and so on. And, there was a problem with the tracking of the right knee cap, and pain behind it, especially when coming down stairs.
I went to a doctor for the back pain, and later for the pain in the knee. I did not know those were related. I got pills (diclofenac) for the back, and later physiotherapy for the knee. The back pain got better, the therapy seemed to improve the pain behind the knee cap, but not the pain in the back of the knee. A Röntgen photo of the knee had shown no arthrosis or other knee problems.
In November and December the pain in the back of the knee got worse and spread out to the buttock and lower back, so that much of the back of the whole leg was hurting. This worsening probably resulted from stretching exercises for the back of the upper leg, which I had restarted after leaving them out since early 2010 because of the pain in the back of the knee. Late December I realized the pain had to be nerve pain of the sciatic nerve.
Early February 2011 it had got so bad that I went back to the doctor, who now suspected a herniated disk. A magnetic resonance imaging scan confirmed this; it was at the level L5-S1, right-sided. I was prescribed Cesar therapy, but during the first weeks of therapy the pain worsened such that I had to abandon this and go back to the neurologist, who suggested surgery. I now had pain, tingling, and numbness in the outside of the right foot and ankle, achilles tendon, back and outside of the lower leg, back of the knee, back of the upper leg, buttock (including inside the buttock next to the anus), and hip, including an area in the lower back just on top of the hip. I learnt this was the entire range controlled by the S1 nerve root, which exits the spinal canal at this level. Also, there sometimes was pain at the tail bone, anus, testicles, penis, and apparently in or around the prostate. These latter three were not dissimilar to what one may get after riding on a hard bicycle saddle. The sensations in the groin and anal area probably suggest the herniation was also pushing on the cauda equina a bit; the "horse tail" of nerves that runs downward down the middle of the spinal canal there. The pain got so bad I could only stand or walk for a few minutes at a stretch, and mostly disappeared when lying down. I decided to have an operation.
It is good to point out that the greatest deterioration took place in February through March 2011, while I was following the current advice for herniated disk treatment: stay in motion as much as possible and take pain killers as needed. Apparently this was not the right approach in my case, perhaps because the herniation had existed for about a year already, and the material gone hard, or something like that. I used ibuprofen at first, and later tramadol. Both had side effects: From ibuprofen I seemed to lose blood in the stomach, and from tramadol I got trouble with urinating, which was especially problematic since it could also have been caused by the herniated disk itself, in which case an emergency operation may be needed ("cauda equina syndrome"). I had to visit the emergency room three times in two days while using tramadol.
Also worthwhile noticing is that in at least two periods of several days - to wit, early 2010 when the back pain had just started, and March 2011 when the problems were getting much worse - I had sharp pain in the middle of the back of the pelvis, toward the tail bone. This was very bad while walking, so that I had to take small steps. Standing on one foot was painful, it felt as if the pelvis halves came apart. It struck me that this could be what some call "pelvis instability"; in my case, it seemed to be caused by pressure on nerves by the developing or changing herniated disk.
After stopping with tramadol I adopted the method of avoiding anything that hurts - standing, walking, and sitting on hard chairs - and doing the remaining daily activities lying down if possible. Thus, it did not get worse, but neither did it get better. A video showing how I walked in this period is on my YouTube channel.
I was pushed in a wheelchair to the hospital department where I was taken in. They gave me paracetamol, and I had to change into an operation jacket which was entirely open on the back. I then lay on bed waiting for a short while. Not long before the surgery I was given a tranquillizer pill called dormicum, and could visit the toilet one last time. The evening before I had already applied a laxative.
Then I was pushed to the operating room while lying in bed; this was like a dream coming true, since my dream car has always been a bed on wheels. It went fast and the wind blew through my luxuriant hair. While waiting until the operating room became available, a plastic hat was placed on my head, and one came to look into my file to see what had to be done. Then I was rolled into a kind of antichambre - or limbo if one prefers - of the operating theatre, where two girls readily attacked me from both sides. One stuck patches with wires attached to them on my chest, and the other put a tight band around my left arm and began to pat my wrist as if to comfort me. "We have a vein", she said, and pushed a drip into it, which would be used to keep me more or less asleep during the operation.
Location of the drip
The anaesthetist came in and discussed possible allergies and sensitivities. As I had indicated on a form I was allergic to Mexican ketchup by Heinz, he assured me they rarely used that in surgery. I was then asked to sit on the edge of the bed, and an anaesthetic was injected into my back. I asked if it was spinal or epidural; he said spinal. After having made certain the needles had been removed, I lay down on my back again and was taken to the actual operating room. Since my lower extremities had ceased to function, they lifted me from the bed and put me on my belly on the operating table. The operation began.
I remember noticing that someone was doing something in my lower back. Then a girl appeared in front of me and said, "It is finished". The surgeon, unmasked, came to tell me the operation had gone well. He was from Afghanistan, which inadvertently makes one wonder whether the Taliban are now operating in neurosurgery as well as in Islamism. I was lifted from the table onto my bed again, and pushed to the recovery room where I arrived around 10:30 (the operation had begun about 9:10). I saw a lady to my right who was rather quiet, and a man with wild hair in front of me who was looking strangely out of his eyes. A girl measured things like my blood pressure and the contents of the bladder, and a bit after 10:45 I was driven back to the nursing department.
A nurse removed the operation jacket and dressed me in the top part of my pyjamas. My bottom half, which was still unable to move, was left undressed, and I was given a bottle to urinate in, which, as I had suspected beforehand, would be the hardest part of the process. Not long thereafter lunch was served, and I ate and drank as I pleased even though the body parts needed for excreting waste were still paralyzed. After lunch I kept trying to urinate. I did feel that the bladder was full, and the muscles around it worked, but the part just thereunder, with the prostate and penis, was numb and did not let anything through. I was getting visions of kind and helpful nurses waiting to come to my rescue just outside the room, urinary catheter at the ready.
Finally, just after 14:00 hours when the visiting hour had started and my neighbour patient was entertaining her husband and two teenage daughters, a little bit seeped out, although I did not feel it going. I kept the bottle under the blankets all through the visiting hour, and managed to get ever more out over the next three quarters. "Did you succeed in peeing?", a nurse then asked loudly, and I had to hand the bottle to her as proof. She emptied it and brought a new one, just before the visitors said goodbye. After the visiting hour I made her put my underpants on (although she was reluctant at first, fearing it would be too tight, and indeed it looked strange on her).
Meanwhile the effect of the anaesthetic had fully worn off, and I felt hardly any pain in my back. They gave me paracetamol for it anyway. Late at night the drip was removed from my arm, since all body functions worked well and there was no need to give morphine intravenously. I had been in bed ever since the operation, as was required.
The next morning a nurse washed me in bed, put a new and larger bandaid on the wound, and put the bottom part of my pyjamas on as I would have to get out of bed. Then a physiotherapist came, and I was allowed to stand up and walk, which went well. The pain in the leg had gone, and there was only little pain in the back from the operation. I got out and walked two times more later on the day. In the evening there was a thunderstorm, and lighting struck close to the hospital and put two houses on fire, as reported by nurses looking out of the window.
The next day I had to wash myself. The physiotherapist came again and gave some instructions, and in the afternoon I was allowed to go home, with an appointment to see the surgeon in seven weeks. Once home I discovered the earth leakage circuit breakers had broken the circuits, probably during the thunderstorm, and I had to throw away the food in the freezing compartment of the refrigerator.
Right after the operation, the pain in the leg was completely gone and I could walk normally again. Unfortunately, three days later it came back, though much less severe than before. The pain was mainly in the buttock, but also in the back of the upper leg, back of the knee, and outside and back of the lower leg. It is said to be normal for this radiating pain to return three days after a herniated disk operation, and supposedly it is caused by a swelling of the wound which pushes on the nerve root, causing the same pain as the herniation did before. But it may also be a new herniation at the same site, or nerve damage from the original hernia or from the operation.
I still had to lie down a lot, walk now and then, sit as little as possible and not more than twenty minutes at once, do no household work or sport, lift nothing heavier than one and a half kilogram, not travel by public transport, and not drive a car or ride a bicycle. A stationary bicycle was allowed though. In general, I had to keep the back straight, not make it convex, and not turn or twist it. Several times a day I had to do an exercise to prevent adhesions of the nerve to the wound or scar tissue. The recovery phase was four to six weeks. After about a week I removed the bandaid:
In the first week after the operation I walked up to half an hour on end; in the second week up to eighty minutes. The pain persisted but was bearable and did not keep me from walking normally. During the third week, the pain in the leg slowly became less. In the fourth, fifth and sixth weeks, the pain stayed about the same, and mainly occurred after sitting for a while. By then I had walked up to 15 kilometres, and in the fifth week I had also started cycling outdoors again, and driven a car once.
After exactly seven weeks I saw the surgeon, who found I had been healing very quickly. He said the little pain in the leg I still had would get better slowly, and was a result of the nerve having been compressed for a long time by the herniated disk. In the eighth week, a notable further improvement of the pain occurred, and two months after the operation I took part in a 20 km walking event; this went well, although I did notice a tendency of the right heel to run into the ground too soon now and then. The improvement of the eighth week did not set through during the following weeks, it rather went up and down a bit, and three months after the operation the situation was really the same as at seven and eight weeks. Four months after the operation it was significantly better than at three months though, but still not entirely gone.
Six months and about a week after the operation I restarted running. I had stopped running three months before the operation because of the pain. I began running twice a week, 5 to 7 km with walking breaks, and it went without problems and did not cause any deterioration of nerve pain (which was still not entirely gone). Running appeared to be good for my walking too; the tendency of the right heel to run into the ground too early, which I still had when walking far, mostly disappeared.
Two years after the operation the little pain I still had in the leg was again much less than after six months; it had diminished extremely slowly over time, with now and then a few days when it was a bit worse again. Some movements and changes of position could still evoke a very mild pain in the buttock and near the back of the knee, but it felt such that it seemed realistic that this would one day be completely gone.
A few adaptations made while suffering from the herniated disk and during the recovery phase are worth mentioning:
I put a sticker on my letterbox indicating that no advertisement brochures or local free newspapers should be thrown in. That way I did not need to pick so much up from the ground, and did not need to put so much out in the street when the old paper was being collected. I removed the sticker again about five or six weeks after the operation.
On both the stationary bicycle and street bicycle I put the saddle in a much lower position than normally. Before the operation, this prevented the pain in the leg that occurred when stretching it; with the saddle low, the leg is not stretched so far with every revolution. After the operation, this allowed for a straighter back while riding, especially since on the street bicycle it was not possible to put the handlebar higher, so that a lower saddle position was the only way to sit straighter.
On the stationary bicycle I put the saddle back to its normal position only a few weeks after surgery (the handlebar was such that sitting straight was still possible), but on the street bicycle I kept it low for much longer.
To reduce shocks and vibration on the back after the operation, I reduced the tyre pressure on the street bicycle by about one atmosphere.
I bought a mop to clean the floor, to avoid having to bend or squat. For the same reason I got a dustpan and brush with long sticks attached to them, and a bicycle maintenance stand (wherein a bicycle can be hung at working height). I also obtained knee protectors for those occasions when working low can really not be avoided, because sitting on your knees is better for the back than is squatting.
In hindsight it is interesting to note the greatest deterioration took place after the doctors had established a herniated disk, and I was following the recommended advice and treatment: Cesar therapy, staying in motion as possible, using pain killers as needed. Before that, the condition had remained more or less stable at a low level for almost a year. It might be hypothesized that this combination of advice and treatment constitutes the cause of the worsening. If I desired to be cynical, I could say they did it on purpose to keep the surgeons busy.
Also, once I had decided on an operation, I quit all of that: I stopped the therapy, lay down much of the time and avoided all painful activity that was not strictly necessary, and took no pills at all any more. From then on I felt much better, the condition stabilized, the worsening stopped, and in the last week before the operation it appeared to be getting very slightly better. About the reasons or causes of the deterioration, I would like to say the following:
While improving one's posture with Cesar or Mensendieck therapy might help to prevent back problems, it is doubtful whether it can also be good for an already existing herniated disk. I clearly noted that some of the exercises actually caused or worsened the pain in the nerve, so I could not do those. And when assuming the correct posture according to Cesar/Mensendieck (which I do not deny is a good posture otherwise), the pain immediately got worse, because, as I clearly felt, the nerve root was being pushed against the herniated disk harder then. With this therapy I was constantly thinking: This may be good, but I should be doing it after I get better, not now! After three sessions, I was not able to travel to the therapy any more, and had to let someone drive me back to the neurologist.
Remaining active with a herniated disk constantly annoys the nerve, causing the various kinds of nerve pain which are basically irritation, inflammation, or downright damage of the nerve. Some activities, especially those involving bending the back or making the lower back convex, mechanically push the herniation further out and thus make it worse. This also goes for any activities that cause shocks on the back, such as running or jumping or stamping one's feet on the floor (but in this stage one is probably not doing the latter things anyway because of the pain).
With pain killers one does not feel well exactly which movements make the pain worse, so one can also not avoid those movements. Pain killers therefore seem less than helpful, especially in combination with the advice to remain physically active. A counter-argument would be that the painful movements and activities help to push the herniation back into the disk through mechanical pressure on it by the nerve root, and that one needs pain killers to bear that. I do not know how it is for others, but a possible next time I think I will avoid pain killers and painful movements or activities.