This was one of those weeks I expected to happen and fortunately I have plenty of time to rectify. First, I over scheduled the day job. Secondly, our group had to take care of the in hospital Neurology consults after office hours. The hospital schedule is available but that type of detail consistently evades me.Then there were a few baffling hospital cases which are always unsettling (to put it mildly) and lastly, I got sick for the second time in 3 months which has never before happened.
Consequently I rode very little, slept less and the riding I did do was not hard enough to be helpful. Every time I got the least short of breath I started coughing. At the end of the week I was exhausted with little to show for it. Fortunately I started to feel better this weekend, and rode out to the new hay fields west of town (see photo below). The weather was perfect. The hay looked blue, almost psychedelic and there was no traffic.
In Neurology we are consistently presented with complicated cases that always have the potential of randomly developing into something devastating. Occasionally the threats dissipate, the patients magically recover and the worries I have carried over many days fade. On other occasions, however, the complexity of a patient's symptoms mystify and bewilder me. There is an entirely rational obsession that something has been misinterpreted or overlooked. The resultant anxiety can be disabling.
This week I saw a guy with several months history of bilateral leg pain and progressive leg numbness and weakness. Initially he was found by other physicians to have severe spinal stenosis in his lower back. This means he had significant pressure on the nerves going to the legs which is a reasonable explanation for the problem. The patient had the standard surgery and though he may have improved for a short period of time, his condition deteriorated. He lost his ability to walk and a short time later began to lose any leg movement. He was then re-admitted to the hospital.
It was at this point I was asked to evaluate him and make recommendations. On my examination the man had an interesting micro neurological finding, a very subtle reflex jerk in both legs at the hip when I stimulated the bottoms of his feet. This usually indicates a spinal cord problem higher up than the lower back. The admitting physician arranged for a second MRI of the lower spine that showed an accumulation of some fluid. This fluid appeared to be the problem supported by several findings on his examination. He did not have an increase in his reflexes (you know, that rubber hammer on the knees thing) which should occur with the higher spinal cord problem I suspected. Also he did not have a 'Babinski reflex' which is usually a very reliable indicator of spinal cord or brain problem (Scratching the bottom of the foot in pathological conditions causes the the big toe to go up instead of down).
All the studies I ordered were normal with the exception of the upper spine MRI. He did have tightness of the cervical (neck) spinal canal with an abnormal subtle spinal cord brightness. Radiology attributed this brightness to old bruising/scaring which could cause some difficulty, but not to the extent of this guy's problem.
He needed something done and it was my call. I was baffled and somewhat unhinged, the latter being the consequence of the former, especially occurring in anyone of Irish descent who practices Neurology. It was important to know if the original surgery was helpful. Because I was not initially involved, I had to rely on the man and his wife's sequencing account of what happened after his initial surgery. Getting that history answered was a like an Abbot and Costello skit as the family members and I went back and forth with a re-creation of the story. According to various family members, the patient was walking with a cane before surgery, then had the surgery, "got better," but was then walking with a walker. Yikes! Was he better or not better after the surgery? On the second look at the MRI, with a different set of radiologists, we determined the cervical (neck) spinal cord was not bruised and scarred but actually swollen, likely from a recent fall with minimal whiplash. This more accurately explained the situation. I ordered steroids. The patient quickly improved, regaining sensation and movement with some strength. He will have surgery on his neck in a day or two which will likely also help.
It's been a hectic and stressful few days, but hopefully I will get back on the training schedule this week...63 days to go!
The "unsettling" hospital cases took a lot of my time this week, however, and one case in particular, deserves some mention. The stress of being correct is the entire stimulus for my riding. Some bikers may ride for glory, and others ride for health, which is a bit ironic, considering the danger. Many bikers ride to burn calories so they can eat all they want and not get fat, which is nice bonus for me given the glory I acquired from racing was scarce and now a distant memory.
In Neurology we are consistently presented with complicated cases that always have the potential of randomly developing into something devastating. Occasionally the threats dissipate, the patients magically recover and the worries I have carried over many days fade. On other occasions, however, the complexity of a patient's symptoms mystify and bewilder me. There is an entirely rational obsession that something has been misinterpreted or overlooked. The resultant anxiety can be disabling.
This week I saw a guy with several months history of bilateral leg pain and progressive leg numbness and weakness. Initially he was found by other physicians to have severe spinal stenosis in his lower back. This means he had significant pressure on the nerves going to the legs which is a reasonable explanation for the problem. The patient had the standard surgery and though he may have improved for a short period of time, his condition deteriorated. He lost his ability to walk and a short time later began to lose any leg movement. He was then re-admitted to the hospital.
It was at this point I was asked to evaluate him and make recommendations. On my examination the man had an interesting micro neurological finding, a very subtle reflex jerk in both legs at the hip when I stimulated the bottoms of his feet. This usually indicates a spinal cord problem higher up than the lower back. The admitting physician arranged for a second MRI of the lower spine that showed an accumulation of some fluid. This fluid appeared to be the problem supported by several findings on his examination. He did not have an increase in his reflexes (you know, that rubber hammer on the knees thing) which should occur with the higher spinal cord problem I suspected. Also he did not have a 'Babinski reflex' which is usually a very reliable indicator of spinal cord or brain problem (Scratching the bottom of the foot in pathological conditions causes the the big toe to go up instead of down).
All the studies I ordered were normal with the exception of the upper spine MRI. He did have tightness of the cervical (neck) spinal canal with an abnormal subtle spinal cord brightness. Radiology attributed this brightness to old bruising/scaring which could cause some difficulty, but not to the extent of this guy's problem.
He needed something done and it was my call. I was baffled and somewhat unhinged, the latter being the consequence of the former, especially occurring in anyone of Irish descent who practices Neurology. It was important to know if the original surgery was helpful. Because I was not initially involved, I had to rely on the man and his wife's sequencing account of what happened after his initial surgery. Getting that history answered was a like an Abbot and Costello skit as the family members and I went back and forth with a re-creation of the story. According to various family members, the patient was walking with a cane before surgery, then had the surgery, "got better," but was then walking with a walker. Yikes! Was he better or not better after the surgery? On the second look at the MRI, with a different set of radiologists, we determined the cervical (neck) spinal cord was not bruised and scarred but actually swollen, likely from a recent fall with minimal whiplash. This more accurately explained the situation. I ordered steroids. The patient quickly improved, regaining sensation and movement with some strength. He will have surgery on his neck in a day or two which will likely also help.
It's been a hectic and stressful few days, but hopefully I will get back on the training schedule this week...63 days to go!
Get ready go, T.dom.fast! You have my attention. All the stress,baffling mysteries, expectations and training anxieties are bringing out the fascinating writer in you. Sounds like the food and all the accoutrements of ABB will give you the fuel. I have no doubts that you could start the tour now. I can't wait to tune in.
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