I'll start by saying that this story does not yet have an end; I'm at the beginning of what I am beginning to suspect will be a long journey. But I have several reasons for getting this page out there. First off, writing about things is one way that I cope with them, and I'm having to do a fair bit of coping at the moment. Second, I choose not to be defined by the issues with my neck; I was dumping stuff in my regular journal, but I refuse to have that become overwhelmed by this story. But third, hunting around the net reveals a lot of hysteria and scares about this stuff, and I figure some day it may help someone else to see a calm, rational recounting of a herniated cervical disk and its aftermath. Hopefully this can be one.
The story actually starts back on June 27, 2009. As I mentioned, I keep a journal, and that was the day that I recorded a sharp pain in the middle of my right shoulder blade after weightlifting. (I don't - or rather, didn't - lift for sheer amount; I'd bench-press 60 pounds or curl 25, just to keep muscle tone). I had about a week of difficulty sleeping, the pain was so sharp, and it was July 4 before it was really cleared up. In retrospect, this was not the muscle pull or sprain I had assumed at the time; I simply did not recognize the symptoms of cervical spine difficulty. I could speculate on what would have happened had I known, but that seems rather pointless.
Fast forward to Tuesday, September 27, 2009. That was the day that I recorded "Pulled a muscle in my back doing a clean & press, and had to take a naproxen to get any fitful sleep." There were 50 pounds on the bar.
The pain woke me up early the next morning, and I spent an uncomfortable day, assuming that this was just a pulled muscle healing. By Friday the 30th I had pain in my right arm as well, and the pain continued to worsen over the next few days. Being stubborn - or stupid - I even worked out a bit with the free weights on Halloween Saturday, since I know from past experience that too long a break makes it tough to get back to a routine.
By Sunday night, I was on the couch trying to sleep in fits and starts, and not having much luck. Fortunately, there's a decent orthopedic practice not far from us, with a Monday morning walk-in clinic.
Bright and early Monday I was in the clinic, where I got a near-instant diagnosis (after a round of x-rays) of what I'd finally figured out myself: a herniated disk at the C6/C7 level, pressing on the nerve, causing pain down into the trapezius and triceps on the right side. The physician started me on dexamethasone (a steroid medication) to combat the inflammation, and metaxalone to relax the muscles, and sent me off to make a physical therapy appointment.
So, what's going on here? In simplest terms, the spine is made up of separate vertebrae, which are numbered; C6 and C7 are the sixth and seventh cervical (neck) vertebrae counting down from your skull. Each pair of vertebrae is held apart by a disk, which is sort of a goop-filled shock absorber. The spinal cord comes down the center of the spine, and nerves peel off of it to sneak between the vertebrae and head out to other parts of the body. The nerve that exits between C6 and C7 deals with the shoulder blade, triceps, and outer surface of the hand.
Now, enter the herniated disk. One of those little shock absorbers busts a hole, and goop squirts out. The goop presses on the nerve. The nerve does what nerves do when they get excited, and starts sending electrical signals. And the signals down tell the muscles "get to work" and the signals back up tell the brain "something is up here." The brain looks at this continuous flow of electricity from the nerve, and says "whoa, looks serious! Feels like, hm, sharp pain HERE and sharp pain THERE and cold hands and oh yeah, pins and needles in your arm. Wow, what'd he do, stick his arm in a tree chipper?"
Or, in layman's terms: it hurts like hell, continuously. (Side note: if I ever get the job of refactoring the human nervous system, we're putting in switches to turn parts of it off.) As of November 24, the constant level of pain is somewhere between 4 and 7 on the traditional 1 to 10 scale.
Coping and Therapy
So, there's this leaky goop in between those vertebrae, and though I haven't had a medical professional confirm this to me, it seems likely that it's still leaking. I draw that conclusion because the pain spent most of the week of November 2-6 getting worse, though it may (knock wood) have stabilized. The meds are giving me some relief, but not more than a few hours at a time, and not enough for sound sleep.
They always want you to rate pain on a 1-10 scale, where 1 is very mild and 10 is the worst you can imagine - I got used to doing that back when I was fighting through migraines (which is a whole different story). This stuff...it can be a 2 if I'm just sitting, but it's been up into the 8-9 range more than once. It depends a whole lot on the particular angle my neck is held at, as well as whether I've been moving around or needed to do something challenging like put on my shoes.
Tuesday morning (we're up to November 4 by now) I had my first physical therapy appointment. As I wrote at the time "I saw a nice young lady who experimented with various ways of manipulating my neck, sometimes with the help of one of her colleagues, most of which hurt. The visit culminated with instructions for some light exercises and about 20 minutes on a nerve stimulation machine. Now I know what Galvani's frogs felt like." She sent me home with some very mild exercises (shoulder squeezes, chin tucks) that are apparently designed to at least try to increase the range of motion a bit.
The second PT appointment - Friday morning - was almost not worth going to: "The therapist today essentially gave up on things; all she did was put me on TENS for a 15-minute chunk (it cut perhaps 80% of the pain while it was on, but did not provide any lasting relief) and then sent me home."
Monday November 9 was my third PT appointment. Looking back over the week, the pain has increased in intensity, duration, and distribution. I talked things over with the therapist and had another session with the e-stimulation machine (which did provide some relief). We agreed that there was no point in more PT just at the moment, and I put in a call to the physician: I want to discuss more aggressive pain management immediately, and possibly a referral to a neck specialist. Ended up with a referral to the local hospital's pain clinic, which hopefully will schedule me in soon. In the meantime, I'm coping as best as I can.
Tuesday November 17 was my first follow-up with the physician. We discussed where things stood, and the conclusion is that further investigation is needed - which I pretty much already knew. So, the main outcome of this visit was to schedule an MRI.
Friday November 20 I was scheduled for an MRI. Unfortunately, this proved to be impossible. They're very picky about the angle that you go into the MRI machine to get good imaging, and for a cervical spine MRI, this is "flat on your back with a pillow under your neck." Unfortunately, that position, with my neck flexed back, is about the worst possible one for me as far as pain. I loaded up on the maximum allowable dose of both ibuprofen and acetaminophen before going to the MRI, and even so, I was only able to be in that position for 30 seconds or so before my eyes were filled with tears and I was starting to suppress screams. Given that it takes 20-25 minutes of laying still to do the MRI, I cancelled instead.
Tuesday November 24 was another follow-up with the physician. The plan was to discuss the MRI, but that didn't happen. The only useful guidance from this visit was to talk to the pain management people about next steps. I'm not utterly satisfied with this, and if I don't get some answers about prognosis from the pain clinic I'll be pursuing a referral to a neck specialist.
Wednesday November 25 I had and initial consult with the local hospital's pain clinic. This turned out to be a much more satisfactory experience than yesterday's appointment: the physician I saw was willing to discuss treatment options and prognosis, listen to me, and give me his thoughts on what could be done. He prescribed tramadol and amitryptiline for pain management, and will be doing a direct steroid injection to the affected area after getting approval from my insurance company. By delivering an anti-inflammatory directly to the injury site, the hope is to bring the nerve and disk swelling down enough to allow me to lie down and get an MRI, so that further treatment can be more informed.
So far, I'm not seeing any loss of reflexes or muscle tone in the affected arm. The overall prognosis is guardedly good - it's too soon to be thinking about surgery until we get some decent imaging of the inside of my neck. He also says that the main limit on using the right arm is how much pain I can tolerate; I don't need to worry that lifting things will make the situation any worse. That's good, as it means I can keep some muscle tone at least.
Tuesday December 8 I was scheduled for a CESI (Cervical Epidural Steroid Injection) procedure at the pain clinic. However, for the day or two before this, my pain level had actually been quite low (mostly 4-5 on a 1-10 scale). After consulting with the physician, we agreed that there had been enough improvement that it made sense to continue on a "wait and see" approach, with the current medications, rather than take the risk of the CESI.
Things got generally better over the course of December, and after this visit I started ramping down the drugs. As we roll from Christmas into the new year, I'm taking 50mg of tramadol each evening to get me through the night, and occasional ibuprofen. We're in "wait and see" mode; things may get better (from the current constant ache and parasthesia) over the next 4-6 months, or they may not.
Wednesday December 30 I had another follow-up with the pain specialist. We agreed that the CESI is off the table for now, and he's out of the picture unless I have a sudden spike in pain levels.
Where Things Stand
Right now (late December), I'm surviving on a combination of tramadol, occasional TENS, and toughing it out. While I can live and work this way, quality of life is still decreased for me, and I hope the long-range improvement continues. After two months, I can drive short distances, carry a 4-year-old upstairs, or sometimes sleep in my own bed, but I pay for it in increased pain later. But at least it looks like surgery is off the table for now, unless I do something to make things worse again.
The big challenge is still sleep. I get 2 hours of fitful sleep at a time, and end up propped up with pillows on the couch most nights. Some of this is my natural insomnia; when the pain wakes me, I'm often ready to be awake for a while anyhow. But plenty of other things are tough too: washing hair, carrying groceries, driving...I can put up with the pain, but it makes me cranky at times.
Here are some earlier observations from right after the pain started to ramp up in early November:
- The biggest challenge at the moment is sleep. I've got one position, propped up by pillows, which I can get to sleep in if I'm tired enough. The problem is that even with pillows I eventually shift position in my sleep, which puts me into a bad position, and wakes me up in pain. So things are worst right when I'm getting out of bed, and it takes a while before it settles down enough for another try. I'm getting 2-3 hours of sleep per night, which wouldn't be enough except that the drugs are a bit speedy.
- Looking or reaching up is bad. Putting things away on high shelves is not on my agenda right now. Hair-washing is also on the "not so much worth it" list.
- My desk chair is very comfortable for me, and makes me happy I spent $700+ on it. It's probably the best spot in the house for me at the moment. Combine that with lack of sleep, and my billable hours are up.
- Contrariwise, a hard wooden chair is deadly. I made the mistake of trying to join the family for dinner, and was in a lot of extra pain for hours.
- I've developed some sniffles the last two days, perhaps because the steroids tamped down my immune system. This especially sucks because coughing or blowing my nose hurts.
- Either the dexamethasone or the metaxalone, or both, are making me nauseous. So my appetite is down. Secondary effect: I'm a bit constipated, maybe from the drugs and maybe from not eating much roughage. This is bad, because straining also stresses the part that's hurt. So, time to force myself to eat more fiber.
- I may be getting a tiny bit of pain relief from my one cup of coffee these days. I'm not positive about that, but I'm keeping an eye on my pain monitoring and looking for correlations.
Six Month Followup
It's been six months or so since the initial injury, so it's time for an update. I'm going to leave the earlier content intact, because a number of other cervical spine patients have told me that they found it useful. But I'm happy to report that things are much better for me. The pain level continued to drop into the new year, and I quit the Tramadol entirely (by the way, you will get nasty withdrawal symptoms when you stop using that particular drug). Now I'm at the point where the pain comes and goes, instead of being constant, and it's distracting rather than disabling.
I still have bouts of pain on a daily basis, mainly in my triceps on both sides. And there's still some residual parasthesia. But though these are evidence that something is still not quite right in my neck, they don't do more than remind me that over the long term I need to be careful. Will they go away entirely? Darned if I know; ask me again in a year or two, I guess. Meanwhile, things are so much better than they were late last year that I'm happy. Occasionally things will flare up to the 2 or 3 out of 10 level for a day or two, but nothing I can't get through with ibuprofen and patience.
I've largely resumed my regular activities, with one glaring exception: no more free weight work for me. I'm just too scared. My exercise regime these days consists of time on the stationery bicycle and a few curls without much weight. It's better than nothing, but I do miss the muscle mass that I lost over the course of this experience. My sleep has improved to the point where I can get 5 or 6 hours broken up into small chunks over the course of a night, and I wake up aching rather than screaming.
So overall - I feel reasonably healed. Any sort of pain into my arms makes me worry that the time bomb is going to go off again, but I can live with that.Pain Management