[mmglobal]

In July, I was with a client in Munich for his ADR surgery. He's a young man of 32 with 2 discograms that were BOTH positive at 3 levels. His imaging looked as you'd expect for a man of 32... not too bad... still good disc height. However, he was SEVERELY disabled, on high doses of medications, and was completely at the end of his rope. Both discography reports were well written. (You must understand that some of the reports we see clearly tell us that the test results must be taken with a boulder of salt. A well written report about a well-done test yields much more confidence in the result.)

The case was confounding. The severity of the disability didn't seem to match the imaging. Doing a 3-level is reasonable in the presence of a very clear diagnosis, but this case had us scratching our heads. We went to see Dr. Baumbach, the neurologist for his evaluation. Unfortunately, this patient was so pain sensitive and was having anxiety attacks, so a meaningful neuro exam was impossible. A full-spine MRI was ordered to rule out cervical and thoracic issues that may be responsible for the patient's extreme symptoms. Interestingly enough, he had a substantial thoracic disc herniation, so it was back to Dr. Baumbach to evaluate whether or not that issue could be responsible for his symptoms. Dr. Baumbach did not believe that the thoracic issue was responsible for the symptoms.

What to do? There was some discussion of going straight to a 3-level because the discography seemed to be so well done. I was VERY uncomfortable with that. The most recent discography had been performed by a doctor I know, so we called him on his cell phone and fortunately we caught him at a time when he could talk. We discussed the test for about 20 minutes... he remembered the patient and the testing very well... clear positive at 3 levels. Zeegers was not comfortable going to a 3-level procedure on such a young man with tall discs without doing the discography himself. I was very concerned that we would not be able to get reliable discography. If the patient's pain sensitivity was such that we could not get through a basic neuro exam, how could we get reliable discography?

For years I have discussed discography techniques with the surgeons and every one I know who performs his own discography (which I believe is superior) - does so without sedation. Zeegers had always been adamant about the need for clear pain responses, not clouded by sedation. I suggested that in this case, the patient was too pain sensitive and he should consider using sedation. Dr. Zeegers said that he'd consider it, but wasn't sure. I was very worried about a potential 3-level in a 32 year-old man with confounding symptoms.

I insisted that we have a plan-B. What if we could not perform reliable discography. This was discussed at length with the patient and his wife, me and Dr. Zeegers. The patient decided that he trusted the 2 doctors who performed the prior discograms and had nothing to lose in trying the 3-level... he had no life and was unable to get help any way he turned. He'd do the 3-level. I was so, so uncomfortable with this decision, but after the discussion I kept quiet about it. He understood the issues. It was his decision to make.

The next morning when I got to the OR, Dr. Zeegers told me that he'd studied techniques the night before and had already discussed it with the anesthesiologist. The test would be performed with sedation. I'm not sure about the compounds used, but it was much like the tests we see in the US with Versed. The anesthesiologist could bring the patient in and out as needed. Under more for needle placement... almost fully awake for testing. Here is how the test went:

L2-3 - zero pain at high pressure and volume
L3-4 - zero pain at high pressure and volume
L5-S1 - low level of non-concordant pain at high pressure and volume
L4-5 - extreme concordant pain at low pressure and volume
L2-3 - did not retest because this level was NEVER suspect
L3-4 - zero pain at high pressure and volume
L5-S1 - zero pain at high pressure and volume
L4-5 - extreme concordant pain at low pressure and volume

I was so happy for my client! Immediately following the discogram, he was prepped for surgery and Zeegers performed a 1-level Activ-L. After the surgery, I went to Dr. Zeegers and asked him what he would have done if we could not have gotten through the test.

"I can always get it done", he replied.

"I want to know... what would you have done if we could not get through the test?", I insisted.

"I would not have done the surgery. There are more tests we could have performed. I would not do a 3-level unless we have done everything we could have!"

I have to tell you... I feel so proud and honored know Dr. Zeegers and to be able to participate in this process. This is the way medicine should be practiced. He cares deeply about his patients and does for them what he would do for his brother.

In the days that followed, I was expecting to have a very difficult time. Usually, the clients I go with for surgery who are on high doses of pain meds have a difficult time post-op. This guy absolutely kicked ass. His post-op days were a pleasure... just watching him come back to life. I had to leave Germany while he was still tender and moving slowly, but in the week that followed, his wife kept saying, "I can't keep up with him... he's walking everywhere... I can't believe how well he's doing."

The following week, another client was at the AlphaKlinik and benefited from Dr. Zeegers changed views on discography and sedation. In previous a previous discography, she had a vasovagal reaction to the pain which halted the test without meaningful results. She feared not being able to complete discography with Dr. Zeegers for the same reason. Armed with his experience from the prior week, Dr. Zeegers again did discography with sedation.

I think that the jury is still out on this. I believe that well performed test will be successful and reliable in most (but not all) cases with or without sedation. Poorly performed tests will be unreliable no matter which technique is used. I still believe that less sedation is preferable to more sedation. However, in some cases, particularly when the patient is pain sensitive, having anxiety attacks or has a history of bad reactions as Fiddle had... for these cases, sedation will allow the doctor to get good results more reliably than if the tests are performed without sedation.

Mark

PS.... On my recent trip to NY, I had a layover in the first client's city. He and his wife met me for breakfast. He's over 2 months out and is still coming down on the meds. He has nothing but positive things to say as he continues to do extremely well. In so many cases, I never get to meet my clients. Although I did go to Germany with him, it was still a great treat to see him post-op... especially doing so well.