2019 Brian's Neck Surgery

(6/20/2019)


 

Timeline:
 - 5/20/2019 Monday - Brian has sudden pain in left shoulder blade and neck - hurts to cough
 - 5/26/2019 Sunday - Brian goes to Urgent Care - Dr Wang says it is pinched nerve in shoulder, prescribes anti-inflammatory Prednisone
 - 5/29/2019 Wednesday - Brian sees Primary Care - Dr Roey disagrees and thinks neck injury, orders MRI to confirm, prescribes Gabapentin (nerve pain killer)
 - 6/4/2019 Tuesday - Brian gets MRI (earliest possible appointment)
 - 6/6/2019 Thursday - Doctors first look at MRI, Dr Roey calls Brian and says it is bad, Brian sees new Physical Medicine specialist Dr Perkash in person who says "needs surgery"
 - 6/7/2019 Friday - Brian sees surgeon Dr Wachhorst who says "not ER critical/dangerous, but requires surgery soon" so schedules for 6/20/2019 which is first opening
 - 6/20/2019 Thursday - NOW CANCELLED - Brian was to undergo "Anterior cervical discectomy and fusion (ACDF)" - remove pressure on spinal cord, insert titanium blocks, fuse 3 vertebrae.
 - 6/21/2019 - 8/2/2019 - NOW CANCELLED - Brian will wear a neck brace 24/7 (including while sleeping) while neck bones knit together.  The NIH says this is useless and based on obsolete and incomplete information.
 

Most Recent Status:
 - BrianW is looking into a newer, better procedure called Total Disk Replacement (TDR) where a FLEXIBLE device is implanted instead of fusing the spine solid (no flex).  The M6 is an example of the device. Also the ativL.
 

Imaging includeing MRI, CTscan, and 2 X-rays:
 - Click This Link to Download an MRI ZIP file of BrianW's spine/Neck (about 100 MBytes, so super tiny by modern standards!)
 - Click This Link to Download a ZIP of a CTscan, and 2 X-Rays of Brian's Spine. (about 100 MBytes, so super tiny by modern standards!)
             INSTRUCTIONS ON A WINDOWS PC (Note: this is not my fault, it is Sutter Health Medical who wrote this!!!!):
            1) Download the file
            2) Unzip file the file somewhere (I am VERY SERIOUS about this, it will not run directly from the ZIP contents!!!!)
            3) Double Click the file called "start.hta" and it will lauch a program that allows you to view the MRI and other images
 

Hopeful Outcome?
 - Hopefully Brian will be cured forever, and only have about 10% - 15% reduction in neck mobility (which is fine for a software engineer).
 


 

Research Notes
 
- Neck Braces don't help.  The National Institutes of Health (NIH) says: "Conclusion: We recommend against the routine use of ECO after ACDF due to a lack of improved fusion rates associated with external bracing after surgery."

- My surgeon is doing ACDF and implanting: The interbody implant is Titan Endoskeleton (TC or TL?). The plate and screws are Synthes CSLP Cervical Spine Locking Plate.

 - An alternative surgery is called Total Disk Replacement (TDR) or Artificial disc replacement (ADR) where an artificial disk is inserted which allows motion after the surgery (instead of disk fusion). The FDA products approved for neck are:
       1) Synthes Spine ProDisc-C , PDF Handout,
       2) Prestige LP by Medronics, Medronics Website about it,
       3) Mobi-C Cervical Disc made by LDR who is now Biomet. "In the two-level study Mobi-C demonstrated SUPERIORITY to ACDF..."
       4) M6-C or M6-L?, Spinal Kinetics Dynamically Stable Cervical Disk Replacement.  Look into surgeon Sigurd Berven
       5) The activL by company "Aesculap" may not be FDA approved yet, but Dr Richard Guyer likes it.

 
 - Dr Richard Guyer (worked on Tiger Woods) in Texas.  Google Reviews Article about 15 years of Total Disk Replacement by him.
 - Dr Todd Lanman (Los Angeles). Press Release
 - Dr. med. Karsten Ritter-Lang - Germany?
 - Nick Koske, VP Engineering and Operations at Orthofix


 “Though the short term results may be similar to fusion, the real difference comes with long term follow up of greater than 5 years. The fusion patients are up to 3 times more likely to have surgery at the next level compared to the disc replacement patients.”

"I see my patients who have been lucky enough to be covered (by their insurance) for artificial discs and those who were denied by their insurance carrier and had to have fusion surgeries."


MRI Screenshot:

Diagnosis: "Cervical Stenosis"
Herniated Cervical Disk c6/c7, Cervical Radiculopathy

I added the red text on the MRI screenshot below to help describe that my main issue is a bulged disk between vertebrae C6 and C7 causing pressure on my spine.  In the picture below, the doctors said the white spinal fluid sack SHOULD be the thickness it is between C2 and C3, and that the reduction in spinal fluid sack thickness from C3 - C6 "is not good, but not the cause of my immediate pain and possible danger".  The biggest problem is the meniscus (disk between vertebrae) between C6 and C7 is pushing on my spinal cord, causing pain.  The reason I feel it in my left shoulder also is because that is exactly where the nerve travelling to my shoulder connects.

 

Longer Version of Story for those interested::

On Monday, 5/20/2019 I woke up and my left shoulder and neck was in severe pain for no reason.

Sunday, 5/26/2019 - After a week of not getting better at all, I went to Urgent care on Sunday, 5/26/2019 and Dr Victoria Wang mis-diagnosed me as "Suprascapular nerve entrapment" (pinched nerve in shoulder) and she prescribed 5 days of Prednisone (as a strong anti-inflamatory). Dr Wang gave no other guesses or a percentage chance she was correct, she just handed me the final diagnosis, and a couple printed sheets describing this condition (which I do not have) and how it might require as much as a cortisone injection and some physical therapy.

Wednesday 5/29/2019 - I followed up with an appointment with my primary care doctor as soon as someone could see me, and my main doc was on vacation so I got in to see Dr Steven Roey (stand in replacement) on Wednesday 5/29/2019. Dr Roey immediately disagreed with the previous diagnosis and said "I think it is in your neck, not your shoulder at all" and even said he thought it was a pinched nerve in my neck in a particular location. He thought the Prednisone was useless but I was only a dose away from completion so he said "finish it just so we can say you tried that" and Dr Roey said "but we are all just guessing so let's find out who is right with an MRI".

Tuesday, 6/4/2019 - The first time I could get an MRI was on Tuesday, 6/4/2019, in the afternoon. This 7 day wait is because the hospital (Sutter Health in Mountain View) own this $3 million piece of hardware that can diagnose things deep in the human body without harming one cell, but they only run it a very limited number of hours M - F, and NEVER on the weekend, and there is a long line of people in pain who would like to pay them money to use it. They COULD allow people in extra pain to bonus them more money (in addition to insurance) and run it after hours, all night long, but they are REALLY BAD AT BUSINESS (and arguably health care) so they just allow long wait times for people in pain and who are dangerously mis-diagnosed (like me).

I found it particularly interesting that the waiting room for the MRI was filled with people like me - twisted people hunched over wincing in pain some with visible injuries. So I got the MRI. It took 15 minutes of lying on a flat slab motionless wearing ear plugs. A shaved monkey could operate this completely automated MRI machine - the machine did all the work automatically and spoke to me in a clear woman's voice about what was going to occur next. Mostly the machine made loud noises for either 30 second intervals or 4 minute intervals, and rested for a minute or two between scans. Sometimes it moved my flat slab I was lying on a few inches.

The whole thing took 15 minutes, as I left another person in pain was getting loaded onto the flat slab of the MRI machine as fast as possible to keep this pipeline going. Honestly, it could be done as a self serve thing with no technician and a kiosk to sign into. Safeway self checkout is more complicated than this.

Thursday, 6/6/2019 - Dr Roey had referred me to a Physical Medicine and Rehabilitation doctor to interpret the MRI, and the first one that could see me in network after the MRI was Dr Rajan Perkash on Thursday, 6/6/2019 so another 2 day delay.

Thursday, 6/6/2019 - 8am while driving - So on Thursday, 6/6/2019 as I was driving to my 8:30 am appointment with Dr Perkash, Dr Roey called
my cell phone, and Dr Roey scared the crap out of me the way he was saying he just saw my MRI for the first time and that I definitely needed surgery and it was "very bad and needs immediate spinal surgery".

Thursday, 6/6/2019 - 8:30am Dr Appointment - So I was a little freaked out and getting used to this idea as I went to my appointment with Dr Perkash.  Now, I want to point out I knew the diagnosis already, but to "check into a doctor" they did the standard incompetent "1920s medicine act" measured my weight and took my temperature and blood pressure to check me into this appointment.  Like always, I had to fill out a piece of physical paper saying what my problem was.  I had to write my own name at the top, because the technology to print out paper with my name hasn't been adopted by hospitals yet.  You check into flights at the airport on a kiosk, you order meals at TGI Fridays with a wireless pad, but doctors can't seem to move out of 1953.  So after these artificial delays, I met with Dr Perkash for the first time 30 minutes later, and Dr Perkash ALSO was extremely agitated and mentioned the "very bad MRI" and gave me a bunch of physical tests like "pull against my arm" and "do you feel this pinch equally on both arms of your body". Dr Perkash was VERY SURPRISED that I wasn't in worse condition and that very little permanent nerve damage had been done yet, given the horrible MRI results I had not seen yet.  (Remember, this was the first time I ever met Dr Perkash.) 

Thursday, 6/6/2019 - 9:00am - Dr Perkash then finally showed me the MRI for the first time with the pinched spinal cord between C6 and C7 vertebrae. Dr Perkash kept saying "there is only one solution and that is surgery". No cortisone, no Chiropractor, no Chinese medicine, don't wait, get surgery NOW.  I should mention Dr Perkash is not a surgeon, more of a physical medicine specialist for things like rehabilitation and physical therapy.

Friday, 6/7/2019 - 8am next day Surgeon consult - From this point onward there were no more long waits for me for medical help or tests. I saw the surgeon the VERY NEXT DAY because he simply cancelled on another patient to clear his schedule to see me. This scared me even more, because it was so strange to see doctors actually doing things quickly like seeing patients with less than a 6 week wait.  The surgeon I saw is Dr Scott Wachhorst.

Dr Wachhorst gave me a ton more physical tests and was glad to see that I did not have much nerve damage (or any nerve damage) because he had already seen my MRI. Dr Wachhorst also went through my MRI and spent quite a bit of time showing me different views and parts and explaining things much better.  To determine exactly which type of surgical procedure to do (mainly whether to relieve the pressure
on one side of the spinal cord or the other), Dr Wachhorst wanted two more X-Rays and a CT scan to figure out if a shadow on the MRI was "calcified".  If it was "calcified" the surgery would be to make space on the OTHER side of the spinal cord by removing some bone over there and that surgery would NOT be done by Dr Wachhorst.  The X-Rays and CT scan showed no calcification so the surgery would be done by Dr Wachhorst.  To prepare for surgery Dr Wachhorst also wanted an uptodate EKG, Urinalysis, and blood work to make sure there is a good chance I could survive the 6 hour surgery under general anethsesia.

Dr Wachhorst had a more calm diagnosis than the previous two doctors. He said this took years to get this bad, and my head isn't about to fall off, and that if it was that serious he would be sending me to the ER to do the surgery immediately, but it isn't that much of a panic. His first available surgery slot is 6/20/2019, and after that he is on vacation for a few weeks so why don't we take care of it. However, he did NOT like the idea of putting it off for two or three months, that made him uncomfortable.

Friday, 6/7/2019 - 9:30am - 11:30am - The X-Rays, CT Scan, EKG, Urinalysis, and blood work were all done IMMEDIATELY after I walked out of Dr Wachhorst's office in the same hospital.   All of these things happened instantly with no wait, I just walked out of Dr Wachhorst's office and into each test department one after another and they did each test - no more multi-day waits. It was kind of what I might like medicine to be like normally, except it was kind of scary how each test technician said hello, pulled up my record on their computer, frowned, looked back at me for a second, then looked back down and started moving faster than normal and looking worried. That part was unsettling.  I left the hospital after the last test and drove towards work.

Friday, 6/7/2019 - noon - as I arrived at work, I got a phone call from Dr Wachhorst's assistant saying I needed to come pick up instructions for the day of the surgery, plus a neck brace for the day of the surgery (I will wake up in the neck brace), plus she wanted to give me some surgical sponges filled with antibiotics that I use the night before surgery to clean my neck before I sleep, then the morning of surgery to clean my neck, then they will still scrub my neck when I get to the hospital.  So I turned around and drove the 30 minutes BACK to the hospital to pick all this stuff up and get all the explanations about not eating or drinking after midnight.


Thursday, 6/20/2019 - The Surgery They Will Perform
The procedure they are going to do I think is called: "Anterior cervical discectomy and fusion (ACDF)" which is to enter through the front of my throat, stretch my  vocal cords out of the way (not cut them), stretch some other tendon stuff out of the way (not cut them), then drill right down the center of the meniscus (the cushion between the vertebrae) to reach the bulges and remove them. Thus removing the pressure on my spinal cord.

This leaves a gap in the meniscus, so to repair that this particular doctor uses a titanium box with holes or something to allow bone to grow through it, and fills the box and area around with chips of cadaver bone and then I spend 6 weeks in a neck brace while my spine bone fuses together and heals. I think they also put in a plate or "strap" on the back of the spine to stabilize it. Titanium is not affected by magnets, so I can still get MRIs in the future after having this done.

The procedure takes about 1 hour per vertebrae. Plus an hour to open and hour to close. So it's a big 5-6 hours and the longest time I've ever been under general anesthesia which worries me. Dr Wachhorst has done thousands (?) of this particular surgery which I like - studies show repetition lowers error rates.

So that's about it for now.

 

 

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