There are about 52 images in here, so I apologize for the load time.  But they’re worth it.  :)  I also apologize for the layout problems on this page.  They’re due to the width of the CT images, and I will work on getting it resolved at some point, but I make no promises.

Overview Images

This is just a basic image from the front.  In addition to my dental fillings, you can see the the small square-ish plate in the front of my spine.  It has bulbous, round corners and the top row appears in alignment with the bottom two screws.  If it seems a bit unclear now, I think the later images will clarify it for you.

Here is a similar view from the left side.

C6 Top-down Images

This series of images shows you the C6 vertebra from the top down, i.e. the first image is the most superior (highest) image of C6 in the series and the last image is the most inferior (lowest) image of C6.

For reference, the top of each image in this series represents the anterior (front) of my body, and the bottom represents the posterior (back) of my body.

This image clearly shows the two screws in the anterior (front) that hold the small plate in place, and the screws in the posterior (back) of the spine.

C7 Top-down Images

Just like the previous series, this sequence displays the C7 vertebra.  All positional and referential information is the same.

Front-back Images

This series is pretty cool.  It starts at the anterior (front) of my body, looking straight at me.  It then progresses more posteriorly, showing the entire cervical region.  It gives a very clear view of the plate and the screws.

Left-inward View

This series starts from my left shoulder and shows cross-sectional images moving towards the right side.  You can see the screws on the left of both vertebrae, then the plate in front, and finally the other (right-side) screws on both vertebrae.

Pretty interesting, I think. I’m hoping to get ahold of the pre-op images showing the extent of damage to the cord, but that is going to take some time. Once I do get them, I’ll be sure to post them here.

In my last post, I shared my understated excitement at having movement in my big toe.  The post was intentionally succinct, as I wanted to share with you just how speechless I felt when I first saw movement.

Every morning since arriving three months ago, I would try to move my legs and my toes while sitting in the shower.  And every morning, nothing would happen.  Once in a while I would think I saw small movement, but it always turned out to be my mind playing tricks on me.  This time, there was no mistaking the more gross movement.  In a state of shock, I tried again.  It moved again.  Right when I told it to.  I tried about twenty times before I let myself even consider the possibility that it was real.  Then I prayed that this was the beginning of the next stage of my recovery.

I felt exhilarated and scared at the same time.  Scared that my exhilaration would be consumed by the realization that the toe movement was just a spasm I was somehow able to influence.  Several times before, I’d had my hopes dashed by reality.  I would see something change and think it was a sign: spasticity disappeared when I had a fever, feeling became more acute during injections below the injury level, even positive changes to my mood with no direct cause.  But time and time again, nothing big happened.  I kept telling people, “I’m seeing positive changes, staying positive, but nothing major yet.”

This was major.

Unfortunately, it was Monday at the start of a week when Dr. Stein was on vacation.  The attending covering for him was a more than capable physician, but I had wanted to allow some time to ensure the changes were repeatable before discussing them with a doctor.  But I did share my observation with my physical therapist.  Her face attested to her shock and disbelief, but she did promise later that day during our session to check things out.

Her confirmation that the tendon pulling on the big toe was actually moving was the first thing that allowed me to believe that it might be real.  The following Monday when Dr. Stein returned, he also confirmed what I suspected: I was able to control the toe.

That changed everything.  My therapy now focused on the legs and getting additional movement that was just starting to appear.   It also changed the classification of my injury from ASIA B to ASIA C.  This was also major.  The image on the right describes the different levels used to classify SCI, and although my reclassification as ASIA C by Dr. Stein did nothing to change the movement that I’d regained, it further made the changes to my body real.  They were now on paper, not just a supposition of my own, but a medical fact.  I was now making major progress, one toe at a time.

The days after that brought further return.  First I noticed I could swing my leg out just a bit.  Then I could contract the leg medially.  At the start of this past week, my therapists did an eval of what functionality had returned so far.  My left leg was bending at the knee (allowing me to kick), and was even able to resist some basic resistance provided to it.  This garnered a score of 2+ on the ASIA muscle grades (again, see the chart just on the right of this block of text).  I could also bend the toes upward and flex the leg up at the hip.  But only in the left leg, nothing in the right.

Some time had passed since my left toe started moving, but the right still wasn’t waking.  I often watching other patients walking in the gym and it always seemed that one of their legs was dragging.  This, I reasoned, was due to one leg returning sooner and stronger than the other.  Dr. Stein confirmed this to be the case, which temporarily assuaged my concerns that the right leg might not wake.  And while he had previously seen instances where one side would wake up and the other not at all, this was much less often the case.

But still, the right wouldn’t wake.

As recently as the past few days, muscles in the right leg are starting to move.  I can move the big toe just like a could the left at first, the hip adductors are also under my controlled contraction, and I have some ankle plantarflexion as well.  It seems as though the right is waking up in a similar manner as the left, but it’s just a couple weeks behind.

So what does this all mean?  Yes, the legs appear to be slowly waking up.  But make no mistake, they are nowhere near as strong as they were pre-injury.  Many movements I can only do when not fighting gravity or friction, and it can take significant effort to evoke even the slightest movement.  But it is definitely big progress in the right direction.

There is no guarantee as to what functionality my legs will be able to regain.  They may plateau at a certain point, leaving me functionally in a wheelchair.  They may reach a point where I can walk, but not without assistance or for too lengthy a distance.  They may continue to wake up until I am walking as I was pre-injury.  There is no way to know.

But the one thing I do know for sure is that I am going to fight for every muscle that I can get back.  I am going to fight harder than I’ve fought for anything in my life.  I  couldn’t imagine doing anything less.

I was put on Etidronate to attempt to slow or halt the HO, and then several weeks later I would be X-rayed to see if the formation had continued to the point where it was visible on a regular X-ray.  The hope would be that nothing would show up on the X-ray – this would suggest that progression of the HO had been retarded.  But the expectation was that something would be visible on the X-ray.

Well fortunately for me, nothing showed up.  At all.  Dr. Stein seemed encouraged, and indicated another set of X-rays would be taken in another several weeks.  Those X-rays were taken last week, and again nothing appeared.  I was taken off the Etidronate last week (which is good, since it was irritating my esophagus), and Dr. Stein has indicated he believes the initial bone scan was a false positive.  Yes!!  He wants to do another set of X-rays just before I leave, for precautionary measures, but he again seems confident that things are in the clear.  Which is good, since I really didn’t want my hips to form a ton of bone were they shouldn’t.  It would make walking quite hard in the future.

Today while sitting in the Guggenheim Atrium (the Times seems to like it) chatting with a few other SCI patients, I saw the derm resident from Friday’s incident walk by.  I think she saw me, as she looked over several times.  Now, I doubt she realized they never came back to explain their suspicions.  But I was SO tempted to chase her down and ask why they never returned, why they never explained what they suspected, why they were putting me on the specific meds they did, or why they did not show proper respect to a patient.

But I decided to wait until I find the attending.  Yelling at a resident is nothing special, but getting to point out a mistake made by an attending is something that I won’t be able to do for a decade come the start of medical school.  So why not enjoy the fun while I can? 

I was watching a repeat of House, M.D. tonight and I noticed one of the hospital beds.  It was the same type of bed as they have at Mount Sinai, by Hill-Rom.  The odd part was, I saw it and my thoughts were, “that’s the same kind of bed I’ve lived in for two months.”  It made me realize how much all the parts of hospital life have crept into what is accepted as “daily life” for me at this point.  Leaving is going to be very weird.

I hope that once I’m out, I don’t constantly notice random things and have them remind me of my time in rehab.  But I am fairly certain it will happen for a while.

My injury is a subluxation of C7 over C6.  The American Journal of Neuroradiology has an interesting article that explains how subluxation presents, which helps provide an idea of how my injury may have looked.

Effectively what happened was (and if I get my child-like drawing skills ready, perhaps I can provide a visual of this – I stopped after image googling through a number of pages), my C7 vertebra broke from the posterior point of attachment on the spinal column, slipped anterior to the column and then slid back in superior to C6 (we’re unsure if C6 also broke from the posterior part of the column as well – it seems like it might have).

This is obviously not a good situation.

Not only is it bad because of the subluxation itself, but the extreme movement causes the spinal cord to be stretched fairly significantly out of its normal pathway.  A good way to demonstrate just how mangled the cord gets is to borrow a person (you will need their fingers) and a piece of string (thin cords, such as headphone cords, shoelaces, etc also work just fine).  Here is how you can see:

1. On one of their hands, have the individual make a ring with the thumb and index finger.
2. Have the other individual suspend the string through the ring formed by his or her fingers.  The ring represents C5 in my injury (one vertebra higher than injury level).
3. Now make a ring with each of your hands around the string below theirs.  Your top fingers represent C6, and the bottom represent C7.  Although it may not look it, pretend all three vertebrae are in the same orientation.
4. Decide which directions represent anterior and posterior.
5. Now the injury: slip C7 out of the column anteriorly, and back into the column above C6

Note the distortion of the cord, the stretching, and the scissoring action between the vertebrae.  Frightening, isn’t it?  This is the demonstration my neurosurgeon, Dr. Ashok Anant provided to my girlfriend (yes, that is him in the #1 spot of the neurosurgery list in New York Magazine’s Top Doctors 2007 – I was truly blessed to find him at Lutheran at 4am early on a Monday).

The first thing Dr. Anant tried upon bringing me into the OR was to apply traction to my head.  The hope was that the traction would cause C7 to come out of the column and slip back into its proper place without surgical intervention.  I was under a local anaesthetic at the time, and they attempted a surgical halo with fifteen pounds of traction.  Part of applying the halo is making sure it is firmly attached to the head, so screws were hand-driven into both sides of my skull.

I’d always wondered what it felt like to have halo screws driven into my skull.  Not that this was a good way to find out, but it was interesting nonetheless.  I didn’t feel any pain at all, but you do feel the pressure of the screws boring into your head.  And the sound.  I thought the sound was actually pretty interesting and, dare I say, cool.  It’s somewhat of a grinding sound, as you would imagine, but feeling the pressure and knowing screws are going into your skull just inches from your brain is quite an experience.

Unfortunately, the traction didn’t work.  C7 would slip out of the column once traction was applied, but instead of slipping back into its proper spot, it would just slide back in between C5 and C6.  Surgery was a necessity.  Needless to say, I don’t remember the rest.  I now have scars both on the front and back of my neck – the one on the back is much more complicated.  Thirteen staples closed it, and at this point it is a zipper of sorts.  A long line on the middle with thirteen descending dots on each side.

I was told they had to flip me over from stomach to back several times (four?) during the procedure in order to actually get the vertebrae all in the right place.  The procedure took seven hours, and I now have several titanium rods and a cage anterior to my spinal cord.  They will remain for the rest of my life, as structures will form and grow around them.  And no, they won’t set off airport metal detectors.  Granted, the wheelchair just might.  Maybe.  Possibly.

My column and cord are now properly aligned and bolted into place.  I was finally allowed to take the cervical collar off after four weeks, on February 26th.  The collar is secondary to the titanium in my neck, and was primarily to keep me from any extreme motion in the weeks following surgery.

With the surgery behind comes the real work: rehab and recovery.

Then I felt nauseous.  Because of the suspected spinal cord injury they were not about to  roll me, either.  The nurse grabbed a suction catheter: “Go ahead and throw up, I’ll suction it.”  When one realizes somebody has just said to throw up all over your own face and head, the feeling is indescribable.  A mixture of disgust, anxiety and shock.  It’s enough to make you throw up, really.  And I did – all over my face.  I was squeezing my eyes together as much as possible, but I could still feel the acidity creeping through.  Try as she could, the nurse and her suction catheter were no match for the contents of my stomach and small intestine.  I was covered in it.

From the imaging, it was determined that in my fall, I had subluxed C7 over C6 (here’s some more detailed medical information about anterior subluxations in general).  We had arrived at the hospital shortly after midnight (I believe), and at approximately 7am, I was taken into the OR.  The procedure was to last seven hours and my closest friends and family waited together for news.  I hear rumors that somebody was social engineering the hospital staff via in-house phones to obtain more information on my surgical progress than was being provided, but I can neither confirm nor deny the validity of those rumors.

I won’t get too far into details here regarding the injury or surgery.   If you’d like to read more, please read the post entitled Details on My Injury and Surgery.

After seven hours in the OR, I was finally done and moved to the SICU (Surgical ICU).  Seeing as I was still under anaesthesia, I don’t remember any of this.  After being put down for surgery, the next thing I recall was waking up in the SICU in tremendous pain.  Morphine, it turns out, does not work very well for me – save for making me very loopy and disoriented while in searing pain.  My girlfriend indicated that I was yelling and cursing at lots of people around me: her, the staff.. basically anybody who got near me.  That much I don’t remember.  All I do remember is becoming aware post-op and realizing that I was in tremendous pain.  When I asked about pain killers, I was told morphine can only be given every six hours.

Next dosage?  “You had it half-an-hour ago, so five-and-a-half more hours.”

I remember pulling at my gown and the lines that were coming out of me all the while screaming and cursing about how much pain I was in.  The drug-induced logic being, “this is all I can do to demonstrate to them just how badly this hurts.  Maybe they’ll understand.” Then I think I passed out from it all, because I don’t remember anything after that.

When I woke up next, I wasn’t in such agonizing pain.  “We switched you to Dilaudid.”   For those unaware, Dilaudid is about eight to ten times as strong as morphine (which it is derived from) and is only indicated in cases of extreme pain.  Thankfully, it worked for me while simultaneously not leaving me in the loopy state that morphine had.

For those who have not experienced surgical pain with insufficient pain meds, it entirely changes your basis for a one-to-ten pain scale.  My former definition of ten is now more like a four.  I don’t remember what the pain actually felt like, thankfully, but I do remember it was by far the most agonizing pain I had ever felt.

The next several days are all somewhat of a blur.  The first day (perhaps two) I wasn’t allowed to have any liquids or food.  So despite how dry my mouth and lips were, I couldn’t have any ice or water to help.  Then gradually, they allowed people to dip a large cotton swab into some medicated ice chips and moisten my lips.  After a day or two of that, I could drink real fluids.  The first guzzle of ice water I had after those few days felt like I’d been in the Sahara for weeks and had just found a canteen with ice cold water.

I spent time in the SICU joking around with a few medical students who were there, and chatting with people around me.  I don’t recall having a TV there (I’m sure I did, but I never watched it), and usually there were people around.  After several days there, I was moved out of intensive care, and on to a separate wing of the hospital.

On Sunday night, January 27th, my lovely and amazing better half had just headed home to prepare for a long week, as is our usual routine.  We had eaten dinner in from a nice restaurant in the neighborhood, from which I chose the gorgonzola-encrusted filet mignon with two glasses of red wine.  I had been working from home on some issues for the better part of the evening, and all of that finally wrapped up around 10:30pm.  Shortly thereafter, I stood up from my desk.  I do not remember standing up, and I do not have a clear recollection of what transpired.  What I do remember is, from sitting at my desk the next thing I knew I was lying on my stomach on the floor in pain.

It took no more than a couple of seconds to realize that I couldn’t move my legs.  Somehow, I managed to roll myself over from my stomach to my back and kept my neck level and aligned.  Doing such without the ability to use one’s legs or hips is quite a challenge.  I’m sure adrenaline was the key.  Rolling myself over using just arm strength and momentum is getting easier now, but it is still a challenge and not something I can readily do in one fell swoop.  Realizing that I quite possibly had a spinal cord injury, I thought back to my EMS days and knew I had to stabilize my spine immediately.  I grabbed a book that was handy, fortunately of just the appropriate size, placing it gingerly under my head to keep my cervical spine aligned.

Little did I know at the time, my spine was anything but aligned.

I cannot possibly explain the thoughts and feelings one has upon realizing that paralysis is a very real possibility.  I begged, pleaded with God.  I cried.  I thought things I won’t repeat here.  I felt scared.  I felt hopeless.  I felt alone.  I felt petrified.  All of those thoughts and feelings alone are life-altering.

I saw that my phone was sitting on top of my desk, with the charger cord dangling off the desk.  Using a loose cable that was close by, I lassoed the end of the charger cord and managed to pull my phone off the desk.  It landed close enough to me, and I called my girlfriend to rush over with keys (since EMS and FDNY’s only alternative would have been to destroy a heavy wrought-iron gate or carry me up and down some VERY narrow, steep steps).  And I called 911.

Within 10-15 minutes, she had arrived and then let EMS in when they arrived.  After they called for some help carrying me out the narrow halls in a cervical collar and immobilized on a board, we were on our way to the hospital.  The shock of the situation still hadn’t faded, but the journey was just beginning.