Thoracic disc herniation
When you've served in 130-degree heat in Kuwait and jumped out of an airplane a dozen times, it takes more than a little discomfort to grab your attention.
The discomfort definitely had Rusty's attention when, sitting in a chair, he could no longer lift his foot off the ground.
"Life had been going along normally," says Rusty, a U.S. Army veteran and former paratrooper who designs railroad tracks and operating plans for a living. "Then one day I just started getting a little numbness in my thighs and feet. It wasn't too bad, but it kept progressing, and in January of 2017 I started having a lot more problems. My left leg wouldn't do what I wanted it to do."
But Rusty's doctors couldn't pinpoint the problem. An MRI of his lower back revealed what proved to be a red herring, a bulging disk at L5-S1. Rusty was advised to continue with physical therapy and come back for a follow-up appointment in three months.
Meanwhile, Rusty had no idea what had caused his difficulties. Perhaps the disc had simply degenerated. Maybe he had set the stage years ago while playing football or landing hard after a half-mile plummet from a plane. Confusing matters even more, he had no pain anywhere in his back. All he knew was that "things just weren't working."
Rusty got an unofficial – but valuable – second opinion in May 2017 when he went home to North Dakota for a wedding. His mother, a registered nurse, couldn't believe what she saw. Her strong, athletic son was leading with his right leg when he walked and dragging his left leg behind him. To get into a car, he had to grab his pant leg and pull his knee up. "My left leg was at best a peg," Rusty says. "I could put weight on it, but I couldn't use it." His mother begged him to see another doctor.
Finally, a diagnosis
Rusty saw another doctor. And then another, neurologist Ty Brown, MD, at St. Elizabeth Healthcare in Crestview Hills, Kentucky. Dr. Brown was concerned enough about Rusty that he stayed late to see him and immediately ordered an MRI of Rusty's thoracic spine – his middle back.
An MRI of Rusty's thoracic spine revealed a herniated disc
"That was the ticket," Rusty says. "It turned out that I had a very pinched nerve at T-6-7. The disc was herniated, or squished out if you will, and pinching off the spinal cord very severely to the point where my motor senses were not getting through. My spine was pretty sick at that point."
The neurologist referred Rusty to Mayfield Brain & Spine, which gave Rusty a priority appointment with Zachary Tempel, MD, a new Mayfield physician and an expert in complex spinal disorders.
Dr. Tempel understood why Rusty's diagnosis had proven elusive. "Identifying it as a lumbar (lower back) problem is a fairly standard thought for someone not trained in spine surgery," he explains. "Thoracic disc herniations represent only about 5 percent of all the disc herniations that we see. The vast majority are lumbar or cervical."
A correct diagnosis did not mean that Rusty was home free, however.
"Treating a thoracic disc herniation is challenging," Dr. Tempel says. "The problems are several. One, these discs are often calcified; they are hard instead of being soft and fairly easy to extract. Second, to operate on them you have to literally operate in a space directly underneath the spinal cord. So the risk of neurological injury is higher from that fact alone. Third, it's hard to get there. You can't go through the chest cavity, through the heart and lungs, to reach the disc. And once you get there, you find the spinal cord stretched and draped over a large disc herniation. And any manipulation of the spinal cord results in injury.
"Finally, you're literally operating blind. You're operating by feel, dissecting the spinal cord off the disc and trying to remove that disc material from an area where you don't have direct visualization."
Preparing for treatment
The former paratrooper and the surgeon bonded at once. Both were husbands and fathers, both were in their 30s, and both were comfortable with risk.
"He asked good questions; he listened," Rusty says. "I could tell he knew what he was talking about. I was comfortable and I felt I could tell him what was going on. I felt I could ask him questions and he'd answer. Sometimes people hesitate to tell a doctor that they're having bathroom issues."
Mayfield surgeons agree that having difficulty emptying the bladder is a sign of a serious spine problem that should be promptly addressed. But before Dr. Tempel would schedule Rusty's surgery, he scheduled a second appointment that included Rusty's wife. "That impressed me," Rusty says. "He needed to bring her in, too. Even me, I needed to hear it again."
Rusty with a few of the old tractor grilles that he will convert into lamps
"I always quote these patients that they have a 50 percent chance of waking up much weaker than they were when they went to sleep, but that it usually gets better over time," Dr. Tempel says. "And I tell them they will probably have to go to rehab, because if they are already weak in the leg, their spinal cord is sicker and has less capacity to absorb some manipulation. There has already been some impact."
Indeed, on the day of surgery, Rusty's spinal cord had been compressed to such a degree that Dr. Tempel was unable to measure Rusty's neurologic function from his legs to the spinal cord.
"When we checked his signals before we started the operation, we didn't have anything to follow," Dr. Tempel recalls. "So we had no way of knowing during the operation whether we were harming his spinal cord. That is not how you want to start a case."
But Dr. Tempel had no choice. Failure to intervene would have left Rusty to a lifetime of disability. Working carefully over a period of 2 ½ hours, Dr. Tempel performed a 2-level fusion. He created a small cavity in which to work, manipulated the protruding disc material into the cavity, and then extracted it. Confident that he had removed all of the disc, Dr. Tempel sat with his patient in the recovery room, waiting for him to wake up.
"I remember waking up and Dr. Tempel asking me to move my left leg," Rusty says. "I did and he said, 'Thank God.'"
By the next day, Rusty was up and getting around with a walker better than he had before his surgery. He was able to use the bathroom. He went home the second day, completely bypassing rehab. Within a week he was navigating his home with a cane.
"Everything below the ribs is working," Rusty says. "Absolutely, my leg strength is coming is back."
Rusty is grateful for the care he received at Mayfield. His praise extending beyond Dr. Tempel, he is also thankful for Dr. Tempel's assistant, Crissy, who ironed out an insurance glitch shortly before his surgery.
Rusty advises anyone with an unresolved spine problem to get a second opinion. "When a heavy construction project like a steel mill gets built, owners always get multiple bids," Rusty says. "The same should go for your back. Always get another look. If I had stayed with the first bid, it would have gone very poorly for me."
~ Cindy Starr
Hope Story Disclaimer -"Rusty's Story" is about one patient's health-care experience. Please bear in mind that because every patient is unique, individual patients may respond to treatment in different ways. Results are influenced by many factors and may vary from patient to patient.
Learn more about the anatomy of the spine.
"Dr. Tempel said, 'I'm not going to progress with surgery until I sit down with you and your wife.' That impressed me. He needed to bring her in, too. I needed to hear it again as well."
Rusty, a U.S. Army veteran, serving in Kuwait