Pain vs. Weakness: new information, and things in motion again
Marina will be having her second injection of Marcaine (like Novocaine) and Cortisone into the nerves next Monday, the 16th. Over the last few weeks, she reports that the sharp pains are entirely gone, but the non-sharp ("headache in the leg") ones continue. The improvement may be a result of the injections.

However. She saw a new physical therapist yesterday. Amy Sellenger deals primarily with people who have had spinal fusion surgery, and was recommended by Dr. Hu. Following an hour of testing, Amy confirms that the left leg is significantly weak, and the right leg is slightly weak.

Since this was certainly not the case pre-surgery, the question is whether the weakness comes from something that happened in surgery, or lack of activity, or some of each. Since the left leg weakness was noticed the first time Marina stood up, 3 or 4 days after the first surgery, the former seems likely.

Now what? Things will continued to be tried -- more injections, more physical therapy, perhaps more surgery -- and hoping for more improvement. Marina is generally of good cheer, but, needless to say, disappointed at the way things have gone (while also being very much aware that some people who have the same surgery end up far far worse, including paralyzed, blind, or even dead). She did spend the entire evening at our weekly circle dance session for the first time, dancing just the slower ones that don't require turning. But that's real progress too.

More, inevitably, after the next injections next week.

Life trudges on.
Very little to say. Marina has been hoping and hoping that the next cortisone-into-nerve injections would be scheduled, but to date, no word, which is disappointing.

As it happens, during my annual physical checkup yesterday,* there was more talk about Marina (who was Dr. Cohn's patient for many years) than about me. (She had to leave him, to join the medical plan that included Dr. Hu.) Dr. Cohn** points out that nerve tissue is the slowest-healing tissue in the body, and if damaged, can take 12 to 18 months to heal. He says that if Marina were still his patient, he would have prescribed Oxycontin instead of Norco, because its pain-killing effect rises quickly to a certain level, and stays there until the next dose, instead of rising and falling with time.
___________________
* utterly normal in all measurable ways
** under a pen name, he is the author of wonderfully funny books about the practice of medicine, including "Kill As Few Patients as Possible: essays on becoming the world's best doctor," and his scathing indictment of HMOs, "Dr. Generic Will See You Now." One of his many adages: "Choosing an internist who isn't Jewish is like buying barbecue from a place run by Caucasians: it might work out well, but why take a chance."

Neuroanatomy 101
Neuroanatomy 101
Here is an actual photograph (of a model, not of Marina's insides) showing where the three relevant nerves leave the spine en route to the left leg. The exit holes here are nice and large. Marina's are not, and therein lies the problem.

The pain is back. The next steps are clear.
Following the four totally pain-free days, each day a little more has crept back. Not quite as bad as before, and there are still occasional pain-free moments, but still . . .

The next step, says physiatrist Dr. Deviren, is to repeat the cortisone injections into the three branches of the sciatic nerve. This will be done as soon as her schedule permits. Cortisone can be cumulative, as we learn at the Barry Bonds/Mark McGuire Institute, so there is always hope that the next one will do better.

One doesn't want to overdo it, however, so if one (or possibly two) more don't do the job, then there is the prospect of more surgery, this time to enlarge the little holes at the base of the spine where L-3, 4 and 5 pass through.

Could this have been done during the original surgeries, if anyone had noticed then what the neuroradiologist (I get to type "Dr. Hogooghi" again) noticed after the fact, that the holes are too small? We probably shouldn't go there.

Meanwhile, Marina is generally of good spirit. She has been coming to our regular Friday circle dance evenings for a short visit, 2 or 3 dances. A lifetime of living with pain has few advantages, but this is one. And unlike the previous 40-something years, there is no back pain whatsoever since the operations.

Nuts. The pain is back.
After a glorious totally pain-free week, first there were a few twinges, then more, then longer-lasting pain in the left ankle. Things are still much better than 3 weeks ago, and there are periods of an hour or two pain-free, but clearly we're not there yet.

Marina will be in touch with the physiatrist on Monday, and predicts there will be another cortisone shot. The effect may be cumulative.

Well, at least the cause is now known, and the ultimate solution (more surgery) is also known.

Four days. So far so good (with only a tiny 'oops')
Four days since the magic injections, and still no real pain other than two very short one-second 'twinges' over the last two days, perhaps a reminder that it's not completely all over yet.

The left leg is still weak, and, curiously, Marina has been having muscle cramps in her back. But these seem to pale in comparison with being essentially pain free -- not just for the first time in four months, but actually, since there was considerable back pain before the surgeries, for the first time in decades.

The other happy news (for me) is that Marina's 'just in case' pain medication (Norco) is reduced to every six hours, instead of every four. This now means only one middle-of-the-night light meal to prepare to go with pill-taking, instead of two. And, we hope, a strong prospect of being weaned off of Norco entirely in the weeks to come.

11 a.m. the next morning. Zero pain. Best sleep in 4 months.

[Lest enthusiasm run unfettered . . . there is still weakness in the left leg, apparent since the first operation. Next matter to take up with Dr. Deviren, I suspect.]

But, as I may have mentioned, no pain!

3 pm. Zero pain. (Hard to type with fingers crossed.)
5:30 pm. Zero pain.
10:30 pm. Zero pain. (Easy to type with big smile on face.)

Results of the nerve-blocking procedure (early report)
12:30 pm, Friday

The nerve-block procedure was performed by Dr. Deviren between 8:30 and 10 this morning at the UCSF Surgery Center. The original plan had been to block just the L-5 nerve, and if that didn't produce results, then try the L-4 and L-3 later. But she sensibly decided to do all three at once. The procedure consisted of injecting a sedative (Marcaine) and a steroid (cortisone), the first to see if the pain would be lessened, the second to facilitate growth or strengthening in the nerve (while disqualifying Marina from playing major league baseball this season).

At 11 am, Marina reported being pain-free in the left leg for the first time since December 14th.

At 12:30, she reported a "tiny twinge" in the left heel: perhaps "1" on a scale of 0 to 20.

This is encouraging news.

Even if the pain returns to its previous level (it could be that, or it could be less), the pain-free period shows that it is clearly the nerve problem, and that the problem is almost certainly the size of the opening where the nerves leave the spinal column and enter the leg. (This was the pre-existing condition noted by neuroradiologist Dr. Hoghoughi earlier.)

The cortisone takes about two weeks for full effect -- and can be repeated if it seems to be working.

I'll post pain scores later today. If they stay low, that is wonderful. Even if they rise to last week's level (typically between 5 and 10 on the 0 to 20 scale), there is hope that the cortisone will have good effect. And even if it doesn't, now that the cause is clear, the prospects for successful corrective surgery are good.

Our car was stolen 2 days ago and I have a cold, but somehow things feel brighter.

More surgery now a possibility.
Because Marina's left leg pain and weakness continues pretty much without interruption--sometimes sharp pain, sometimes major aching--there are now three possibilities, depending on the outcome of the nerve sedation test on April 8th.

In this test, the nerve is chemically blocked with an injection (lidocaine?).

1. If the pain is reduced, and does not come back when the sedative wears off, that is the best possible news.

2. If the pain is reduced, but does come back when the sedative wears off, this is an indicator that further surgery may be required on the nerve itself.

3. If the pain is not reduced by the injection, then it may be something else entirely, and it is back to the drawing board (and possibly to the Pain Clinic, not for a cure but simply to try to reduce the pain).

Marina is doing more and more, through the pain, and I find it both heroic and very sad to see. We walk nearly a mile every day, a little more each day. Last week, she went with our visiting daughter, Tanya, and Tanya's children to the weekly circle dance event, and actually danced four dances, including one that moves briskly (Alpha's Dance) before going home.

So we wait, and see, and hope for the best from the nerve test on April 8th, which I'll report here as soon as something is known.

Thanks for checking in.