Intervertebral disc herniation is no longer a troublesome problem in modern times. If detected and treated early, most cases can be relieved conservatively. Surgical removal of the nucleus pulposus can only relieve symptoms but cannot change skeletal changes. Maintaining correct sitting and standing postures, reducing the frequency of bending and preventing strenuous exercise are the focus of conservative treatment.
But for patients like Lao Marshal who have severe lumbar and leg nerve pain, the protruding nucleus pulposus has severely compressed the spinal nerves, and only surgery can relieve the pain.
Ludwig is over 60 years old, anesthesia is risky, and surgery will definitely be difficult. Although Carvey has been involved in spinal surgery, at least he is much more familiar with it than maxillofacial surgery, lumbar disc herniation is not a common operation performed by emergency surgery. In order to complete this operation, Kawei needed to be fully prepared and eliminate all possible accidents as much as possible.
Of course, before deciding to operate, Kawei also needed to figure out another thing, and that was the location of the lesion.
Modern imaging examinations can accurately locate the problem. It can be seen which two vertebrae the problematic nucleus pulposus is between, in which direction it protrudes, and whether the degree of protrusion is serious or not.
The main purpose of imaging examination is to display the progression of the disease more intuitively, and to eliminate some possible pitfalls and difficulties before surgery. But even without imaging examination, the location of the old marshal's disc herniation can be determined by relying on the regional distribution of lumbar nerve control.
What Kawei wants to do is to perform a more precise positioning, which requires a physical examination of the feet, waist, hips, and lower limbs. At the same time, this is also a required part of the medical examination every year.
Holding a piece of paper given by the butler in his hand, he first roughly drew the old marshal's waist and legs with a quill. The upper and lower legs were divided into areas, marking the corresponding spinal cord levels, with blank spaces left on the edges to prepare for writing the corresponding pain, touch, and muscle strength. 【1】
"Old Marshal, I'm going to do a complete set of examinations." Kawei first explained what he was going to do. "It's mainly to determine where the lesion is. When the time comes, the surgery won't require a long incision. It only needs to be targeted at the location of the lesion." That’s it.”
When the old marshal heard about the inspection, he was afraid: "Is there another inspection? It won't be the same one just now, right?"
Kawei smiled and said: "It's okay. Now that the disease type has been determined, the next location examination will be much easier."
"As long as it doesn't hurt."
Judging from the symptoms, Ludwig suffered from unilateral sciatica and low back pain, and a positive straight leg raising test, which is a typical manifestation of lumbar disc herniation. Low back pain itself can roughly identify the location of the herniated disc.
Kawei basically determined his position between L2-S1. [L lumbar vertebra, S sacral vertebra]
L1 seems to have been ruled out based on the location of waist pain, but Carvey still hopes to use the nerve root compression range for further verification. Kawei found the front and middle of Ludwig's thighs and gently drew long lines with his fingernails: "How do you feel?"
"fine."
"Does it feel different?"
"No." [L1-L2 is OK]
Kawei's hands went down from the medial condyle of the femur to the medial malleolus: "Where are these? Do they all feel the same?"
"Both are the same." [medial femoral condyle=L2-L3, medial malleolus=L3-L4]
"Okay, next is the outside of the calf..."
"It feels different here!" Ludwig reacted immediately, "I can hardly feel anything in my right calf."
Kawei used a little force on the outside of his right calf. Seeing that he was still shaking his head, he tentatively determined the protruding plane: "On the outside of the calf, that's L4-L5."
Kawei made a mark on the paper, and then moved his hand to the instep of his feet. Before he could ask the question, the old marshal already knew the inspection routine and replied: "I don't feel anything here either."
"Not here either?"
"No."
"Where's the pain?"
"It's so small that I can't feel it."
"There is also a problem with L5-S1..."
Most intervertebral disc herniations in ordinary people are single on a single plane, and the compressed nerve root will not be so severe that the pain will disappear. Kawei couldn't make a complete conclusion just by simply feeling the touch, and he had to do some necessary reflexes.
The first thing to do is the knee jerk reflex, the reflex is there. [Indicates that L2-L3 is fine]
But when I did the ankle reflex, something abnormal happened. The ankle reflex was very weak, almost as if it had disappeared. [There is a problem with L5-S1]
"Your Excellency Marshal, try to hook your feet upwards."
"Hook your feet..."
With Kavi's help, Ludwig's right ankle dorsiflexion was no problem, which showed that the dorsiflexor muscle strength was normal [L3-L4 was no problem]. But when asked to hook his toes, he shook his head: "Only the left foot can do it, not the right foot."
"The dorsal toe extensor muscles are weakened, and there must be something wrong with L4-L5."
Relying on feeling, pain and some necessary reflex examinations, Kawei basically locked the location of the lesion, which was at L4-S1. Both intervertebral discs may have herniated. But before drawing a conclusion, he still needs to do another muscle strength test: "Your Excellency, Marshal, hold on to the edge of the table and stand up slowly."
"This is a bit difficult." Ludwig had trouble walking smoothly, but he still obeyed Kawei's request. With the help of the butler, he slowly came to the table and straightened his body, "What next?"
"Lift your right thigh." After Kawei finished speaking, he pressed his thigh with his hand. "You need to resist my downward pressure and keep your body straight."
Ludwig's movement was very difficult, but the necessary iliopsoas muscle strength was still there, and Kawei's downward force did not crush his raised thigh: "Not bad, L1-L2 will definitely be fine."
"So what's the problem now?"
"It can basically lock the position." Even so, Kawei still needs to do some necessary consultations, "During the attack, does the pain radiate directly from the waist to the thigh?"
"right."
"Does it get worse when you cough or strain to have a bowel movement?"
"sometimes will."
"After checking around, I can now conclude that it is a serious herniation of multiple nucleus pulposus, and there are problems in two places." Kawei looked at the picture and gently pressed on Ludwig's lower back, "Here, And here..."
Just a simple compression made the old marshal unbearable, and he could only barely keep silent. He wanted to move away, but the pain itself restricted many movements, and in the end he could only endure it: "It hurts too much, haven't you finished checking it?"
"Soon."
In order to fight against lumbar disc herniation for many years, Ludwig has been relying on forward body or side bending to avoid pain. The spine also bends sideways due to this strange posture. Coupled with the fact that he is older and the fragility of his bones has increased, Kawei has to consider not only whether the operation can be completed, but also his postoperative recovery.
The purpose of surgery is to relieve the original pain with damage that the patient can tolerate.
If an operation gets rid of the pain but makes it difficult to stand or even take care of yourself, it is better not to have the operation.
"I'm afraid the operation time will have to be postponed for a few days." After all, Kawei is not an orthopedic surgeon who specializes in lumbar disc herniation. He still hopes for a smooth operation. "I need to make some preparations before the operation."
"No rush, no hurry." With Kavi's help, Ludwig sat back on the bed and said with a smile, "I don't care, just take your time."
"Take your time...is that good?"
"Well, I mean it's good for you to be more prepared to prevent accidents."
"I'll try to arrange surgery for you in a week."
"When the time is determined, I will send you a letter stating the time and location of the surgery. I will naturally go there when the time comes."
The operation has basically been decided, but before that Kawei still needs to confirm whether the old marshal is willing to go to the surgical theater: "According to regulations, the hospital can only require civilians to enter the surgical theater. As the marshal, you can choose the location of the operation."
"Shall I decide the location?"
"Yes," Kavi said. "Even if this operation will attract surgeons from all over Vienna to watch, I must abide by this rule."
After all, Ludwig was the commander-in-chief of the entire army, so it was really shameful for others to watch the operation. But what he said just now made the old marshal feel strange: "Huh? What does it mean to attract surgeons from all over Vienna to come and watch? Didn't you just say that you just cut off something?"
"From the perspective of the surgery itself, it only removes the protruding nucleus pulposus, and if necessary, removes the lamina." Kawei explained, "But no one has ever done this kind of surgery."
“Nobody did it…Nobody did it???”
...
The world's first lumbar disc herniation surgery occurred in the 1930s and 1940s of the next century, which is still 70 years away from now. It's also a credit to the old marshal that he doesn't understand medical care. If it were Ignatz or Waterman standing aside, I'm afraid something would have felt wrong.
They have never heard of lumbar disc, L, S, or nerve root compression.
The old marshal was a little surprised by Kawei's age and the uniqueness of the operation. He needed to make further judgments on the difficulty of the operation, which meant that he needed to think about it again.
But based on the way he walked and the level of pain, he probably wouldn't be able to bear it for a few days. Moreover, the operation was also a good opportunity for him to escape the war. One operation could keep him in bed for half a year, perfectly avoiding the scheduled war time between Prussia and Austria.
So Kawei knew very well that no matter what the outcome was, as long as he had an 80% success rate, the old marshal would definitely agree to the operation.
The problem now returned to Kawei's own hands. This operation was not skilled for him, and it did require some practice. This was the first time Kawei was eager to dissect a dead body after traveling to Vienna.
Fortunately, the spine is different from the abdominal viscera. Even if the corpse is stored for a longer period of time, it will not be a big deal. As long as the bones are not broken, it can simulate the appearance during the operation.
However, the carriage that took him away from the manor did not return to the Municipal General Hospital. Instead, it bypassed the Ring Road and went to the Graze Hospital in the southeast.
Kawei performed more than half of the peasant woman's surgery yesterday. From his own point of view, she can be regarded as his own patient. Since he is his own patient, Kawei must understand the postoperative recovery situation.
This applies even if the person does not live in the Municipal General Hospital.
The maternity ward is full of women who are expecting or have given birth, and the babies are crying one after another. It is already very noisy once in a while. Living here is simply torture.
But compared to the dirty and crowded environment of the Municipal General Hospital, Graz Hospital charges higher hospitalization fees. At least the environment is spacious and there are not so many rats. The beds are surrounded by curtains to ensure the privacy of the patients. .
The peasant woman lives near the gate.
As soon as Kawei entered the door, she saw Dr. Orji pressing her belly, and soon a faint cry came to her ears: "Stop it, you'll be fine soon."
"Teacher Orgi."
"Huh? Kavey, how come you have time to come here..." Orji followed the post-cesarean care requirements stipulated by Kavey and pressed back and forth on his stomach several times. "This is It’s for your own good, so you can clear out the dirt in your belly.”
Kawei initially judged that the peasant woman had gynecological inflammation, which caused adhesion of tissues around the pelvic cavity.
Adhesions hindered the progress of the operation and even almost killed her. Chronic infection after the operation would further affect the postoperative recovery of the incision. After the operation, Kawei asked Orgi to take off the rubber tube of the infusion bottle, cut several small holes and put them in the incision for continuous drainage.
Although the rubber tube is not as strong as the metal drainage tube, it can be well hidden under the skin of the abdominal cavity.
If there is leakage from the incision, it will flow out through this rubber negative pressure drainage tube, ensuring that the inside of the incision is dry enough: "How is the wound? How much fluid is drained from the incision?"
"The incision is quite good." Orgi was in a good mood. "The drainage fluid is not much. I am going to remove the tube today."
"very good?"
Kawei didn't believe it. The sterile environment was so poor and the body was suffering from chronic infection. Logically speaking, it would be good if the incision could not collapse, and the amount of fluid to be drained should not be small.
But when Orji tore off the dressing, what Kavey saw was indeed a dry cut.
There was no liquid at all in the drainage bottle on the side.
It could be said that the farmer's wife's incision was the best postoperative incision he had ever seen.
－－－－－－Digression－－－－－
This chapter is a bit messy today. Let me sort it out after I take a shower.
