They inject my back with lidocaine—lots of lidocaine. I’d warned them of my redheaded need for more pain medication, and yet it still surprises them that I’m able to feel things that by all accounts I should have been numbed to several injections before. But finally my back is anesthetized enough to allow the doctor to introduce needles into my spine without my feeling every part of it.
Later, Dr. Kranz would show me a video of a straightforward procedure like mine, a series of still photos from the CT scanner strung together into a stop-motion movie, captured with a foot pedal he’d tapped while his hands busied themselves with the work of placing needles in such a way that they were able to deliver an injection of the patient’s own blood to the space around the spinal cord without piercing anything that shouldn’t be pierced. “This is the spinal column, like a stack of marshmallows,” he indicated, pointing to a row of white blobs on the screen. In the next frame, a close-up of the spine at the location of a suspected leak, he pointed out a bony arch with little gaps in it. “Those gaps are where we want to go,” ideally poking the needle into a gray area just above where the CSF and spinal cord are contained by the dura. Then a flash of white appeared on-screen: contrast dye, to visualize where the blood would be injected, to make sure it would be going into the place it’s supposed to go, coating the dura rather than being injected directly into the spinal fluid. After that, the blood was injected, and the stop-motion movie captured the way it spread along and around the dura, sealing it up with blood that would, eventually, clot and plug up any holes.
This was something I would see only later, though, long after my procedure was done. From my vantage point during the procedure, with my face in the face-hole, I have only a vague sense of what’s happening at the moment, which, thanks to the fentanyl and Versed, is fine with me. I lie facedown on the table, halfway in the CT scanner, my face in the face-hole, one arm up near my left ear with a blood pressure cuff squeezing it every few minutes, the other arm up near my right ear with an IV in it for delivering the pain meds and accessing my vein for blood to use in the blood patch. Dr. Kranz explains what he’s doing as he does it, and tells me each time he places a needle. I’m alert enough to hear the difference in his tone when he’s speaking to me versus speaking to the nurses and physician assistant, when he’s noting something for my benefit or noting something for theirs. I can’t feel the needles, but each time, once they’re in and he begins injecting the blood, I feel the familiar nerve-twinging sensation of pressure building in my spine, and again have to answer the question of how much pressure is too much. It’s impossible to know. It’s an uncomfortable feeling, a feeling of wrongness, that something is absolutely not right, and so immediately I want to say “too much,” but then I worry that my “too much” might still be not enough, so I try to wait until the last possible moment of feeling that kind of twangy, jangly, reflexy feeling, like when the doctor has you dangle your leg and hits just below your kneecap to induce a kick, except that it’s that feeling on the inside of your back, along your spine, between your shoulder blades, and then between your lower ribs, and then between your kidneys, and then between your hips.
Eventually I say “too much” in each spot, and I hear the doctor note for himself and his assistants and for me, too, how my blood is spreading, how he can see it coating the dura well in each of the areas he’s injected. And then, miraculously, it’s over: My blood has been injected in the right places, has spread the way he needs it to spread. Now my back is swabbed with something cold, the blood pressure cuff removed, the face-hole returned to its mysterious hiding place. The doctor says all has gone well, that he’ll check in with me in recovery in a bit. Nurses help me roll over to lie on my back, move me to a gurney that transports me to a recovery room. Everything is ceiling and upside-down faces for a while as I float in my fentanyl haze.
Later I would read the medical account of the procedure, accessible through the patient portal online. It’s how I discovered my extra, rudimentary set of ribs.
The patient was placed in the prone position on the CT table, and a scout image was obtained for localization purposes. The patient’s IV was accessed, and 5 mL of blood was wasted. Additional blood was collected in multiple syringes under sterile fashion. Interlaminar epidural blood patches were placed using CT fluoroscopic guidance and 3.5” 22-gauge spinal needles at the levels listed below. Prior to each injection, a small amount of Isovue-M 200 contrast was injected to confirm epidural, extravascular location. Note that there is transitional anatomy, with 13 pairs of ribs, with the inferior most level representing rudimentary ribs. For the purposes of this dictation, the level of the rudimentary ribs will be designated as L1.
T9-10 (left posterior oblique interlaminar approach, 4 mL autologous blood injected)
L1-2 (left posterior oblique interlaminar approach, 8 mL autologous blood injected)
T4-5 (left posterior oblique interlaminar approach, 3 mL autologous blood injected)
L4-5 (left posterior oblique interlaminar approach, 5 mL autologous blood injected)
The needles were removed. The patient tolerated the procedure well without complication. She was taken to the recovery room in good condition.
Estimated
