144. Positioning method without imaging

[This chapter needs to be sorted out today]

Intervertebral disc herniation is no longer a problem in modern times. Early detection and early treatment can be mostly relieved by conservative treatment. Removal of the nucleus pulposus can only relieve symptoms and cannot change the changes in the bones. Maintaining the correct sitting posture, reducing the frequency of bent over and preventing strenuous exercise and labor are the key points of conservative treatment.

However, patients like the old Marshal who have severe lumbar nerve pain have severely compressed the spinal cord nerves, and only surgery can relieve the pain.

Ludwig is over 60 years old, anesthesia is risky, and surgery is definitely difficult. Although Kawei has been involved in spinal surgery, at least more familiar than external maxillofacial, lumbar disc herniation is not a common surgery in emergency surgery. To get this surgery, Kawei needs to make sufficient preparations to eliminate all possible accidents as much as possible.

Of course, before deciding on the operation, Kawei needs to do another thing, that is, the location of the lesion.

Modern imaging examinations are used to accurately locate the problem. It can be seen whether the nucleus pulposus is between the two vertebrae and where the direction is protruded, and whether the degree of protrusion is serious or not.

Imaging examinations are mainly to show the progress of the disease more intuitively, and can also eliminate some possible traps and difficulties before the operation. However, even if there is no imaging examination, relying on the lumbar nerve to control the regional distribution, the position of the old marshal's intervertebral disc herniation can be determined.

What Kawei needs to do is to position it more accurately, so he needs to do a physical examination of the waist, hips and lower limbs. At the same time, this is also a must-have content for the medical examination every year.

He held a piece of paper given by the butler in his hand, and first used a quill to roughly draw the old marshal's waist and legs. The big and small legs were divided into areas, marking the corresponding spinal cord plane, and there was a blank space on the edge, preparing to write down the corresponding pain, touch and muscle strength. [1]

"Old Marshal, I will do a complete set of examinations next." Kawei explained what he was going to do first. "It is mainly to judge where the lesion is. There is no need to make too long incisions for the operation. It only needs to be performed on this lesion position."

When the old marshal heard the inspection, he was afraid: "We still need to check? Could it be the one just now?"

Kawei smiled and said, "It's okay. Since the disease type has been determined, the next positioning examination will be much easier."

Judging from the symptoms, Ludwig has unilateral sciatica and low back pain. The straight leg elevation test is positive, which is a typical manifestation of lumbar disc herniation. Low back pain itself can roughly find the location of the intervertebral disc herniation.

Kawei has basically determined the position between L2-S1. [L lumbar vertebrae, S sacral vertebrae]

Judging from the pain position in the waist, the L1-L2 gap seems to have been ruled out, but before drawing a conclusion, checking is needed for further verification. Kawei first found the anterior and central area of ​​Ludwig's thighs and gently drew long lines with his fingernails: "How do you feel?"

"It doesn't hurt."

"It doesn't hurt. I mean, is there a difference in the feeling of the thighs on both sides?"

"No." [L1-L2 is no problem]

Kawei's hands followed the trend and went down from the medial femoral condyle to the medial ankle: "What about these? Does it feel the same?"

"It's all the same." [Medium femoral condyle = L2-L3, medial malleol = L3-L4]

"Okay, next is the outer side of the calf"

Kavi's fingers moved to his calf, and Ludwig immediately responded: "Wait, it feels different here! There is almost no feeling in the right calf!!"

"The feeling is abnormal." Kawei used some force on the outside of his right calf. Seeing that he was still shaking his head, he tentatively determined the plane position of the intervertebral disc herniation: "The outside of his calf, that is L4-L5."

Kawei made a mark on the paper, then moved his hand to the instep. Before he could ask, the old marshal knew the checking routine and replied, "I don't feel it here either."

"Where is the pain?"

"The pain can be felt, but the degree is very mild."

“There are problems with L5-S1 too”

Most of the herniated discs in ordinary people are single-shot in a single plane. The compression nerve root is only manifested as a weakening of sensory pain, and there will be no such severe sensory pain disappearance. Kawei cannot draw a complete conclusion based on simple sensory and touch. Next, we need to do some necessary reflexes.

First of all, the knee reflex, the old marshal's reflex exists. [It means there is no problem with L2-L3]

However, when doing an ankle reflex, there was an abnormality, and the ankle reflex was very weak, almost the same as it disappeared. [There is a problem with L5-S1] [2]

"Marson, try to hook your feet upwards."

"Hook the feet."

With the help of Kavi, Ludwig's dorsiflexion of the right ankle joint was also fine, indicating that the muscle strength of the dorsal extensor muscle is normal [L3-L4 is fine]. But when he asked to do the toe hooking, he shook his head: "Only the left foot can do it, but the right foot cannot."

"The muscle strength of the dorsal extensor muscle of the toe is weakened, and there must be problems with L4-L5." [3]

With sensation, pain and some necessary reflex examinations, Kawei basically locked the position of the disease, just in L4-S1, both intervertebral discs may have their protrusions. However, for safety reasons, he also needs to do another muscle strength test: "Marson, hold the table and slowly stand up."

"This is a bit difficult." Ludwig's walking was not smooth, but he followed Kawei's request and slowly came to the table with the help of the butler, straightening his body, "What's next?"

"Release your right thigh." After Kawei said, he pressed his thigh with his hand, "You need to fight against my downward pressure and keep your body straight." [4]

Ludwig's movements were very difficult, but the necessary iliopsoas muscle strength was still there, and Kawei's downforce did not crush his raised thighs: "It's not bad, L1-L2 is definitely fine."

“So what’s the problem now?”

"It can basically lock the position." Even so, Kawei still needs to do some necessary consultations, "Does the pain radiate directly from the waist to the thigh during the attack?"

"right."

“Will it worsen when coughing or when you defecate with force?”

“Sometimes.”

"After checking, we can now determine that the multiple nucleus pulposus is protruding, and there are two problems in two places." Kawei looked at the picture and gently pressed on Ludwig's back, "Here, here is also here."

The simple pressing made the old marshal unbearable, and he could only barely stop himself from making a sound. He wanted to move away, but the pain itself restricted many movements, and in the end he could only endure: "It hurts so much, haven't finished the examination yet?"

"It's almost done."

In order to fight lumbar disc herniation for many years, Ludwig has been relying on the forward drive or side curvature to avoid pain, and his spine also has side curvature caused by this strange posture. In addition, he is older and his bones are becoming more fragile, so what Kave has to consider is not only whether the surgery can be completed, but also his recovery after the operation.

The purpose of the operation is to relieve the original pain with injuries that the patient can tolerate. If the operation gets rid of the pain but brings results that are difficult to stand or cannot even take care of yourself, it is better not to take the surgery.

Since Kavi has undergone the operation, he has to ensure that Ludwig can walk like a normal person after the operation.

"The operation time may be delayed for a few days." After all, Kawei is not an orthopedic doctor specializing in lumbar disc herniation. "I need to make some preparations before the operation."

"No, no hurry." Ludwig sat back on the bed with the help of Kavi, and put on his shirt and pants with a smile. "I don't care, it's better to take your time."

“Is it good to take your time?”

"Uh, I mean, it's good to make more preparations to prevent accidents."

"I try to arrange for surgery in a week."

"When the time is determined, I will send a letter to state the time and the location of the operation. I will naturally pass by then."

This operation has been basically decided, but before that, Kawei still needed to determine whether the old marshal was willing to go to the surgical theater: "According to regulations, the hospital only requires civilians to enter the surgical theater. You are naturally different from civilians, and you can freely choose the location of the surgery and the number of onlookers."

"I'll decide the location?"

"right."

“Can you even determine the number of onlookers?”

"Yes, you can refuse to enter the surgical theater and operate in your bedroom," Kavey said. "This is the privilege given to the nobles by the Municipal General Hospital. Even if this surgery attracts surgeons from all over Vienna, I must follow this rule."

Ludwig was the commander of the entire army after all, and it was really shameful to let others watch the operation.

But the old marshal was surprised: "Hmm? What does it mean to attract all Vienna surgeons to watch? Didn't you just say that just cutting off a little thing, and cutting off a little thing is so attractive?"

"From the perspective of the surgery itself, it is just to cut off the protruding nucleus pulposus, and if necessary, it needs to be removed." Kavey explained, "But no one has done this kind of surgery yet, so many people will want to watch it up close at that time."

“No one has done it. No one has done it???”

The world's first lumbar disc herniation surgery occurred in the 1930s and 1940s in the next century, and it was still 70 years away. It was a blessing that the old marshal did not understand medical treatment. If Ignaz or Watman were standing aside, I would have felt something was wrong.

They have never heard of lumbar discs, L, S, and nerve root compression.

Kawei's age and uniqueness of the operation surprised the old marshal, and also interfered with his decision. He needed to make further judgments on the difficulty of the operation, in other words, he needed to consider it again.

According to Ludwig's previous appearance when he walked and the degree of pain in his waist and legs, he would probably let go if he couldn't last a few days. Moreover, the operation was also a good opportunity for him to escape the war. One operation allowed him to rest in bed for half a year, perfectly avoiding the original combat time between Pu and Austria.

So Kawei knew very well that no matter what the result was, as long as he still had an 80% success rate in his hand, the old marshal would definitely agree to the operation.

The problem now comes back to Kawei himself. This operation is not proficient in him and does require some practice. This is the first time Kawei has been desperate to dissect a dead body after traveling to Vienna.

Fortunately, the spine is different from the abdominal internal organs. Even if the body is stored for a longer time, it will be fine. As long as the bones are not broken, it can simulate the appearance of the operation.

Before doing the surgical exercises wholeheartedly, Kawei still needs to settle down.

The carriage carrying him off the manor did not return to the Municipal General Hospital, but bypassed the Ring Road and went to the Gretz Hospital in the southeast.

The second half of the peasant woman's surgery was completed by Kawei yesterday. In his eyes, this can be regarded as his own patient. Since he is his own patient, the postoperative recovery situation is something Kawei must understand, even if he does not live in the Municipal General Hospital.

The obstetric ward of Grez Hospital is not much higher than that of the Municipal General Hospital, and it is full of women who are waiting for delivery or have given birth.

The baby's crying sounds come one after another, and it's already very noisy when you hear it occasionally. Living here for a long time is simply torture.

But compared to the dirty and crowded environment of the Municipal General Hospital, Graz Hospital charges a higher hospitalization fee. At least the environment is relatively spacious, there are not so many mice, and there are curtains around the hospital bed, ensuring the privacy of the patients.

The peasant woman lives near the gate.

As soon as Kavi entered the door, he saw Dr. Orgi pressing her belly, and a weak cry came from his ears: "Hold on, it'll be fine right away."

"Teacher Orgi."

"Hmm? Kavi, why are you here for free?" Olgi pressed his stomach back and forth several times according to Kavi's post-cesarean section care requirements. "This is for your own good, so that the dirt in the stomach can be drained."

Kawei initially judged that peasant women had chronic gynecological inflammation, and it was the prolonged and unhealing inflammation that caused adhesions to the tissues around the pelvic cavity.

Adhesion hindered the process of the operation and almost killed her, and after the operation it would further affect the recovery of the incision after the operation. Before the final incision suture, Kawei asked Orgi to take down the rubber tube of the infusion bottle, cut several small holes into the tube and put them into the incision for continuous drainage.

Although the rubber tube is not as strong as the metal drain tube, it can be hidden well under the abdominal cavity. [5]

If the incision seeps out, it will flow out through this rubber negative pressure drainage tube, ensuring that the inside of the incision is sufficiently dry.

However, even if you make enough preparations, modern medical care still has no choice for the microorganisms that reproduce in your body. Kawei came here just to see if there is anything that needs his own help. Because in his experience, peasant women are infected with both sides and vertical, but it is just a difference in severity.

"How is her wound? How much fluid is draining from the incision?"

"The incision is pretty good." Orgi was in a good mood. "There is not much liquid drainage. If nothing unexpected happens, I will be ready to pull out the tube today."

“Good looking?”

Kawei didn't believe that the sterile environment during the operation was so poor, and the operation time was delayed for an hour and a half. The peasant woman had a chronic infection in her body and excessive blood loss during the operation. Logically speaking, the incision can ensure that there is no collapse of the line, and it is God's blessing to avoid too much fluid.

No matter how you think about it, you shouldn't be "good looking".

But when Olgi lifted the gauze strip covered above the cutout, what Kawei saw was indeed a dry and intact suture cutout. The sutures were tightly matched, and the pinholes did not seep out, and no liquid was seen in the drainage bottle next to it.

Kawei has had many cesarean sections, which should be the best postoperative incision he has seen so far.

Today this chapter is a bit messy, wait for me to take a shower and get it done slowly
Chapter completed!