The surgical sciatica

Representative Image

Benny walked into my room with an obvious limp and a grimace on his face. Taking one look at his visage, I knew he was in excruciating pain. As he sat down, his lips pursed into an O, but what he really wanted to say was ouch. "Would you rather lie down?" I asked, already having made my diagnosis. He agreed and warily made his way from the chair to the examining bed amidst a few more moans.

He was in his 50s. He wore a tight-fitting black polyester shirt whose microfibers were stretched to their limit by his underlying paunch. "Do your friends call you Pot Benny?" I joked, pointing to his belly. He was jovial enough to acknowledge it needed to go, gesturing it with a tap downwards. "I have severe back and right leg pain," he continued running his hand down the distribution of the pain along his cargo pants as he lay in bed. It had been two months now. He had tried the usual medication masala that we doctors prescribe for sciatica, a pain that radiates from the back along the path of the sciatic nerve in the leg. "I need to get back to duty, I can't take any more leave!" he finished, exhausted.

"What do you do?" I asked. "I work in the Army," he said matter-of-factly. "Really?" I asked, the question emanating from genuine surprise given his physique. "I have a desk job," he laughed, taking the suspense away. "Don't worry, I'm not on the battlefield!" he guffawed, putting me at ease.

"If you hadn't clarified, I would be worried for our country," I said in jest, but I also apologised for judging him so abruptly. "We are so programmed to make assumptions based on how we must look the part if we are in a certain profession," I thought aloud. "I wonder what people imagine doctors to look like…" I mused, throwing open the question. "Certainly not like you," pat was his reply. As he saw my crestfallen expression, he softened the blow by adding, "Because you are still so young." It seemed like we were already friends.

I was reminded of a "sports" theme party we once had in school. It was a classmate's birthday and everyone had to come dressed as playing some game. Some children wore cricketing gear, others wore shorts and carried badminton, tennis, or table tennis racquets. A few wore boxing gloves or got along a football or a basketball. One boy came dressed rather formally and all the other kids mocked him for being a party pooper and not taking the trouble to dress the part like everyone else did, until he said, "I'm playing chess." From then on, he was the hero of the party.

I examined Benny to notice that his right foot was slightly weak compared to his left, and that when I raised the right leg off the bed, he had a jagged pain down his leg from the disc in his spine that had prolapsed and was pinching his nerve. I showed that to him on his MRI film, holding it up against the twilight of Mumbai's skyline that came in from my window. "So many people in this grungy yet gorgeous city must be having what you have," I told Benny, "and so many just plod along in their suffering."

I pronounced that he needed surgery. In his heart, he too knew that there was no other recourse. "A large portion of patients get away without an operation," I explained, "but your disc is just too big, deeply indenting the nerve, which appears swollen on the MRI," I said, rationalising my decision. "The fate of the Indian Army's accounts is in your hands," he said in self-deprecating humour, poking fun at himself and at the desk job he needed to get back to. I explained to him that it was a minimally invasive surgery and assured him that he would be fine.

The next afternoon, we made a small incision in his back, and, using a set of tubular dilators, which only separate the muscle without cutting it, I got to the bone. I drilled a sliver of the lamina and bit off the ligament covering the dura. The disc had lifted up the nerve root, causing it to look angry and inflamed. I cut into it and with a forceps, grabbed the fleshy piece and wriggled it out. It was like unearthing a pale slug from the soil. The nerve root went instantly lax and retreated to its place, almost as if it were saying "thank you". We made sure there were no free fragments of the disc before we closed.

When he woke up, his pain had dissipated. He tested it by bending his knee and hip, and rehearsing the movements that had caused him pain earlier. "You must lose weight before you can try any stunts with your back," I warned him when he got discharged the next day, giving him permission to resume work in a week. He was eternally grateful.

Two weeks later, I got a call from the emergency saying Benny was back with the exact same pain. My heart sank; perhaps it was something ominous. When I saw him, he was in greater agony than the first time we met. "Did you do something silly?" I asked, knowing that his disc had probably popped out again. "I was feeling so good all these days that this morning I lifted a bucket full of water and poured it over my head while having a bath, and that's when the pain started," he said, shaking his head and tapping his forehead this time instead of his belly. "Courage is knowing it might hurt and doing it anyway.
Stupidity is exactly the same thing," I said, pulling out a quote from my armamentarium. "And that's why life is hard," he said, completing the saying for me.

In my earlier days, on the few occasions when someone whom I had operated upon for a slipped disc returned with pain within a short span of time, I would always blame myself for possibly a sub-optimal job done, until a surgeon, probably in witticism, once told me, "Always blame the patient first. Only if you can't find fault with them, blame yourself." I could never resonate with that until this day.

We did an MRI and saw that he had a large re-herniation of his disc. I told him it was best to bite the bullet and redo the operation. "Do I have a choice?" he asked. My usual philosophical response would have been, "We always have a choice," but this time I bluntly said "No!" I assured him that we would be done in 30 minutes. I went back in and removed that fleshy little monster of a disc that had exploded in his spine. The nerve once again said "thank you" for what I hoped would be the last time.

We discharged him the next day, completely pain free as if nothing had ever happened. "So, what should I do now?" he asked perplexed. My reply was to maintain "Status Quo"… and I then went on to paraphrase and sing a song by a band with the very same name.

Now you remember what the doctor said,
Nothing to do all day but stay in bed
You're in the army now
Oh-oo-oh you're in the army now!

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals