- March 2013
Back On His Feet
Avid Walker Gets Moving AgainBy: Roxanne Jones
The pain in his back and leg had gotten so severe that 74-year-old Jay Kepner could barely walk.
“Even with a walker, I couldn’t go any distance,” recalls the Bermuda Dunes resident, a former long-distance runner who, after a hip replacement in 2008, began to walk for exercise, customarily clocking five kilometers. “I was in excruciating pain. It hurt to sit or to stand for any length of time. I couldn’t trim my roses or pull weeds.”
Nor could he fulfill his service as a lay minister to give communion to Catholic patients hospitalized at Eisenhower Medical Center.
“It entails quite a bit of walking, and I just couldn’t do it,” he says. “I couldn’t do anything.”
Kepner had tried conservative measures including pain and anti-inflammatory medications and some physical therapy. He also had seen a chiropractor with whom he discussed atreatment called decompression therapy, a non-surgical approach to relieving back pain and other problems associated with spinal disc injuries. “But he was honest and said I wasn’t a candidate for that treatment,” Kepner says. “He recommended that I see Dr. Shen.”
Alfred Shen, MD is a Board Certified Neurosurgeon with Eisenhower Neuroscience Institute who specializes in complex and minimally invasive spinal surgery, surgical treatment of brain tumors and stereotactic radiosurgery.
“I first saw Mr. Kepner in August of 2012,” Dr. Shen says. “His symptoms of leg and back pain had been progressively worsening over the past year and, in the four months before his visit he could only walk 50 yards. He’d have to stop and rest after 50 yards before resuming, only to have the pain hit again.
“For his age, he was in otherwise excellent health, and this [not being able to walk] was a major handicap for him,” Dr. Shen adds. “He also is a great communicator and was able to pinpoint where the pain was, explain what aggravated it or what made it better, and that it was his leg, not so much his back, that bothered him.”
“We examined Mr. Kepner and observed that he did have some weakness in his legs,” he continues. “He had trouble getting out of a chair and had to use his arms to push off. For someone who up until recently had been walking 5,000 meters, that was a drastic change.”
“His MRI revealed stenosis (narrowing of the spinal canal and compression of the spinal cord and nerves) at two of his spinal levels,” Dr. Shen notes. “He also had a tremendous amount of arthritis in his back, as well as degenerative disc changes.”
The diagnosis was a condition called neurogenic claudication. “It’s a constellation of symptoms affecting the leg and back,” Dr. Shen explains. “The hallmark of the condition is that symptoms get worse when you walk long distances. After a period of rest, one can resume walking.”
“Another thing is that people with this condition tend to walk with a stooped posture,” he notes. “When they go to the grocery store they’ll grab a cart and lean on it as they shop, since it’s the only way for them to get through the store.”
“Many of these patients can, however, ride a stationary bike seemingly forever even though they can’t walk a block,” he adds. “The forward-flexed posture helps open the stenosis.”
What Dr. Shen found particularly disturbing in Kepner’s case was the evolving leg weakness. “It suggested possible damage to the nerves that innervate [stimulate] the thighs.”
While corticosteroid injections were another conservative measure that might have provided Kepner with some pain relief, Dr. Shen told him that they were not a long-lasting solution, and that he felt surgery was the best option.
“I really appreciated that he took the time to explain everything,” Kepner says. “He has a nice demeanor and good bedside manner.”
The procedure that Dr. Shen performed is called a laminotomy and decompression. It involves partial removal of a small portion of the lamina (the thin, bony layer that covers and protects the spinal canal and nerves) to alleviate pressure on the spinal nerves. In Mr. Kepner’s case, this involved both sides of the spinal cord at the two levels.
“We make small windows in the bone to free up the underlying ligaments and nerves passing through that segment,” Dr. Shen explains. “We do it under a surgical microscope; it’s a very meticulous type of surgery, like working through a keyhole to free up the nerves.” Kepner’s procedure took between three and four hours.
“It’s a traditional, open surgery — you might even say an old-fashioned procedure,” he notes. “But ‘oldfashioned’ still works very well in the right hands.” It worked extremely well for Kepner.
“From the minute I woke up, I haven’t had a moment of pain,” he says. “Dr. Shen had given me some pain medication before my operation which I used a little, but after the operation, nothing.”
Kepner’s surgery was on a Thursday in mid- September, and he was home on Saturday. He was prescribed a back brace to wear for additional support, and Dr. Shen told him to gradually increase his physical activity.
“I saw him two weeks after surgery and he was already walking a half mile at a time,” Dr. Shen says.
Today, Kepner is back to walking his 5K distance, often while pushing his grandchildren in a double stroller. “I also got all my trees pruned, and I’ve increased my barbell weight from five to 25 pounds,” he says. “And I’m back to serving at the hospital.
“I thank God and I thank the doctor for what he was able to do,” he adds. “What a blessing it is to walk; you just don’t realize.”
Considering Surgery for Back Pain? Help Your Surgeon Help You
“When you see a doctor about back or leg pain, be as specific as possible about what the problem is,” advises Neurosurgeon Alfred Shen, MD. “If you say that everything hurts, it’s hard to hone in on what the problem is. But if you can articulate exactly where the pain is, where it radiates and what makes it worse or better, it’s extremely helpful.”
“In this day and age, everyone gets imaging studies and expects them to reveal precisely what the problem is,” he continues, “but it takes some back and forth communication between doctor and patient to figure it out.”
“In Mr. Kepner’s case, his MRI looked awful; he had such severe multilevel disease and diffuse arthritis that the changes in any level of his spine could have been causing his pain,” Dr. Shen says. “But because he was so good about communicating the details of his pain, we could accurately determine its source and apply a specific treatment to ensure a good outcome.”