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Surviving Surgery - When the Surgeon becomes the Patient

I’ll start this post by giving my normal activity level which is working out and or running at least 3 times a week. Disc golf, biking, running, and yoga on the weekends. If I wasn't training for a specific race, I might run 15-20 miles a week with a 30 mile bike ride with friends on the weekend. 

 

In 2019 my activity had slowed down and I was having consistent pain after my runs.

My most recent adventure was the Trans-Rockies in Colorado, which is a  3 day point to point adult running camp. It’s a 60+ mile run broken up into 3 days. Each night you sleep in tents, have catered dinners and are surrounded by the beautiful Rocky Mountains. My ankle was surprisingly pain free during the event. Towards the end of the summer the pain became consistent and isolated to one exact spot. Being a foot and ankle surgeon, I did what any Podiatrist would do. I applied some face paint like the

movie legend Rambo and did my own ankle surgery by candlelight. LOL, I wish. 

 

From a recent x-rays I could see the build up of bone inside the ankle joint that was likely limiting my motion. An ankle scope would be the perfect surgical procedure to clean up the ankle and get me up and running. I get asked this question all the time. “How does a foot doctor pick a foot doctor to do surgery on himself? ” That's a great question. I have access to people who have worked and seen other doctors in the operating room. I wanted to use someone who specializes in doing scopes or has a high volume of scopes. I started to ask the medical reps I use in the operating room. I had it narrowed down pretty quick. Just like any business, never use friends or family in case you need to get serious or lay down the law. 

 

I found my doctor and was scheduled for a right ankle scope on my 44 birthday in December.  The plan was a right ankle scope debridement/removal of the bone that was limiting my motion and inspection of the old talus fracture from 2006. I had my surgery, went home, and started some of the worst months of my life. After about 3-4 days, my foot started to burn and hurt in a spot away from where I had surgery. Thank goodness I’m a foot doctor. I decided to break down my cast and take off my ace wraps to investigate.  My right 4th toe was almost black due to the circulation being cut off. I rewrapped the ankle and adjusted the cast to a more comfortable position. 

 

The idea for this Blog came more from me researching post operative pain and postoperative neuropathy articles looking for answers. The ankle scope that was supposed to be easy and a simple clean up became complicated due to the old talus fracture that was repaired. When I pre operative plan with my patients the normal post operative experience goes like this. We go to the surgical center where they start an IV. Through the IV, they give you all the pain medications and preoperative antibiotics required from the hospital. During the surgery you receive a block to stop the pain. That block will last 24-48 hours then you will start taking oral pain medication given by the doctor the day of surgery. The BAD surgery pain should only last 2-3 day. Then it is common for the pain to slowly subside and the need for any medication will stop after about 3-5 weeks. 

 

The experience I was living was totally different. I had very little  bone or joint pain. I was having electric neuropathic pain like the foot was burning or numb. The pain would keep me up at night. It was impossible to go to sleep unless I took a pain pill. Like most, the idea of taking pain pills is unappealing. I tried everything in the book. For the first 2 month, I would need a pain pill just to distract my mind in order to go to sleep. Only the narcotic pain pill would work. I would get in bed about 10pm, toss and turn until about midnight, and then out of pure frustration take a pill. The pain was so consistent that after 1 pill I would wake back up at 4am, 4:05am, 4:04am almost comical. As time went on, the neurological pain slowly started to diminish toward the end of the 3rd month. By this time, I had started Lyrica 25mg twice a day. I'd like to mention one holistic trick that helped. That was a Castor Oil wrap. “Castor oil packs are used on the skin to increase circulation and to promote elimination and healing of the tissues and organs underneath the skin.  These can help stimulate the liver, relieve pain, increase lymphatic circulation, reduce inflammation and improve digestion” https://www.divinehealthnaturally.com/healthandwellness/2016/2/19/castor-oil-packs

 

Surgically induced neuropathic pain is what I'm living with now. I have never had any surgery patient experience this syndrome. The pain is like your foot is asleep or numb.  It's electric in nature and you cannot stand for anything to touch the skin. Pretty scary stuff. So, here we are today Easter Sunday April 12, 2020. Here is what I have re-educated myself on and found out. 

 

According to article written by Borsook, Kussman and Burke (Surgical-Induced Neuropathic pain (SNPP) Understanding preoperative the process: “Stated it is a significant problem in 10-50% of individuals, due to possible transection, contusion, stretching or inflammation of the nerve.”  I have read this article several times and it is very interesting, especially if it's happening to you. I knew the nerves were damaged, but I had little experience in managing this condition or knowing how long it will take to heal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546123/#S4title  

 

I have read several articles about the effectiveness of taking oral neuropathy medication and can say Yes it helps. I'm taking Lyrica 25 mgs twice a day. Lyrica is believed to work on damaged nerves or to calm overactive nerves down. According to the Lyrica website “it isn't exactly known how Lyrica works but studies suggest it reduces the ‘extra electric’ signals sent out by damaged nerves in the body”. https://www.lyrica.com/frequently-asked-questions#how-lyrica-believed-work

 

The most interesting component in this surgically induced neuropathy is the role of inflammation. If there is a limited amount of space between the bone to skin envelope then it's easy to understand that swelling will compress the already injured nerve causing it to react. 

Here is a summary: “It is important for physicians to recognize that not all neuropathies that occur in the post-surgical setting are due to compression, transection or stretch. If a neuropathy occurs after a delay or in a territory remote from the surgical site, an inflammatory-immune mechanism should be considered, and if possible, a nerve biopsy for confirmation should be performed to ensure that the best treatment is given. At this point, however, it is less clear how extensive a neurological evaluation (i.e. nerve biopsy) is appropriate in patients that develop neuropathies in the same limb that the surgery was performed on. Our data suggest that inflammation may be an important mechanism of nerve injury in these cases. But who should receive immunotherapy and how many patients need nerve biopsy are provocative ideas that warrant future study”

https://academic.oup.com/brain/article/133/10/2866/325481

 

I believe the human body is an amazing machine that has the ability to self heal given time. 

I put faith in God who always has the final say.  I still have a limp when walking and continue to use ice, castor oil packs, topical pain cream, and Lyrica to try to manage pain.  I’ve been doing physical therapy and biking a few times a week. My doctor has stated it could be 4-6 months before I'm healed. The symptoms are getting better slowly but  I'm ready to get back to my normal activity level.

 

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