This mysterious body of ours

Yesterday Peter had left ureteric colic and called me at 3am.  I admitted him to Mt Alvernia and pumped him full of pain killers.  That sorted him out until morning.  My survival in the competitive world of Singapore private practice appears to be secure.  If only I am to be called upon regularly to supply non-core pain services to all my friends. 

Surely pain management extends to the coverage of acute pain.  Ureteric colic is known to be one of the strongest pain sensations felt by humans (being worse than childbirth, broken bones, gunshot wounds, burns, or surgery).  Peter, you have been through this, you don't need anesthesia for your sebaceous cyst.

Returning home at 4am, I was not allowed into the bedroom unless I had a shower.  I knew I could not sleep if I had a shower at 4am, so I slept on the couch.  Within an hour I was displaced from the couch by a sister in law who had come in to mop the floor.  Yes I live in a strange household, where floors are moped at 4am.  I migrated to the floor and sank into a deep slumber - with a strong will - displacing all impure thoughts and a cold hard floor. 

Four hours came and went - the pillow had migrated to my chest and I was ensconced in a very pleasant semi sentience.  Reluctantly I made my way through morning ablution and raiment to take on daily vicissitudes. 

Why am I making a song and a dance about sleeping on the cold marble floor?  First of all I have always believed that a cold floor sucks warm qi from one's body and disrupted the bodily humors.  Second, I have grown accustomed to sleeping on soft surfaces.  Thirdly, as a rule, I never wake up refreshed sleeping on conventional surfaces.

A neuroscientific explanation calls for:
a. Reticular activation results from an uncomfortable sleeping surface.
b. Sleep induction requires greater frontal lobe inhibition to block reticular activation.
b. Greater frontal lobe activity makes for refreshing sleep.

An explanation based on humors calls for:
a. Over activated (I was kept awake from 1 to 4am) sympathetic system creates unbalanced humors.
b. The equilibrium is restored by the flow of Qi from this overheated system into the cold hard floor.

Advice to on call doctors - sleep on the floor when you return from a call. 



 

You don't find anything unless you look for it. We treat patients, not the scan

Furthermore, you never look for it unless you know about it.
Today my considerate friend Dr Keith Goh, knowing my interest in backpain asked me to see a patient in Mt Elizabeth Medical Centre.  The overweight, 53 year old wife of the former Transport Minister of an Island in the Indian Ocean came in a wheelchair.  She used to be an active businesswoman until a year ago.  She has hypertension and diabetes and is on insulin injections.  She had a 3 month history of severe left sided low back pain with numbness in the foot, although everything started 9 months ago.  She can barely do housework or climb one flight of stairs now, and has been in and out of hospitals since January this year.  Recently she has started to have pain in the upper back and neck stiffness. In my clinic she laid on the couch as sitting aggravated the pain.  Her MRI scans suggested a neck problem.  But with careful problem oriented probing, it turned out that her problems are related to something else.

She had exquisite tenderness of the left S-I joint (sacro-iliac joint)   The Faber test was positive on the left side.  The rest of the examination did not show any signs which could be attributed to spinal cord or nerve root compression.  The straight leg raising on either side was painless up to 70 degrees.  The left foot numbness was subjective and felt over all 5 toes and non dermatomal in distribution.  She had no limb length discrepancy.

The differential diagnosis of S-I joint dysfunction include the following
a. trochanteric bursitis
b. piriformis syndrome
c. myofascial syndrome
d. lumbo-sacral disc bulge or herniation
e. limbo-sacral facet joint syndrome
f. lumbar radiculopathy
g. cluneal nerve entrapment
f. stress fracture of the sacrum

The cervical spine MRI showed fairly severe OPLL(ossified posterior longitudinal ligament) and buckling of the ligamentum flavum of C67. The lumbo-sacral MRI showed facet joint arthropathy with narrowed neuroforamina at L5-S1. 

This lady has left sacro-iliac joint dysfunction.  The left foot numbness can be attributed either to diabetic peripheral neuropathy or even referred pain from the S-I joint problem.   The left foot numbness and the interscapular pain is likely to be myofascial pain.  An altered musculoskeletal dynamics in response to S-I joint instability can certainly result in myofascial pain.

The diagnosis is clinched by injection of the S-I joint.  If any joint fluid is obtained it will need to be sent to the lab for cultures.  If pain is indeed relieved by an injection of anesthetic and steroid, other pain generators can be excluded.  Such injections are not to be belittled as I have cases who derive relief from pain for up to half a year from one such injection, long after the anesthetic had worn off.    Surgery to fuse the joint should be reserved for intractable cases. 

I will only treat the cervical problem if she develops signs of cervical cord compression. 

The diagnosis of S-I joint dysfunction does not end here.  We will have to check for ankylosing spondylitis, crystal arthropathy and S-I joint infection.  

The moral here is - assess the patient before looking at the scan images.  If we treat only pictures, our patients will be disappointed - in us.

An Unusual cause of headache

I really enjoy working in the private setting.  There is the opportunity to directly impact my patient’s outcomes without going through intermediaries, fellows, trainees and residents.  What I like about Pacific Health Medical Centre is that it is such a well known and respected centre, staffed by so many high quality professionals.  If there is a complex problem requiring a multi disciplinary approach, I can access some of the best doctors and dental surgeons in the country just within the same building, with a phone call.  If I utilise high quality professionals to help patients and make sure that happens, then everybody wins.   

We have just discharged a patient from Mt Elizabeth today.  This 50 year old gentleman flew in from Solo in Indonesia to seek treatment for severe headache.  He had a left homonymous hemianopia and mild papilloedema but no other fundal lesions.  The brain scans showed multiple enhancing brain lesions, some hemorrhagic and encased in a calcified covering.  The largest lesion was in the right parietal region of the brain.  Radiologists wisely pointed out that this could be due to a parasite infesting the brain.

There are many parasites that can infest human brains but in recent times, food hygiene and public sanitation have all but eliminated such diseases from our society, except in immune compromised individuals.  Even so, contact with cats, ingestion of uncooked meets should always be carefully looked for in the history.  The commonest cause for a weakened immune system in this day and age is HIV infection.  In patients with HIV infection, the cause of a toxoplasma infestation is most often due to a reactivation of an infection which happened long ago.  There appears a threshold at which such reactivation occurs and that is when CD4 counts drop below 200cells/micro liter.  CD4 is a protein found on the cell surface of certain cells in the blood.(the T lymphocyte).  The HIV virus needs to bind to this protein in order to enter the T-cell.  As more T cells are infected, less T cells will manifest CD4 on their cell membranes.  The lower the CD4 counts drop, the weaker the immune system.  

However if all investigations prove to be negative, the patient will have to be subjected to a brain biopsy.  We know that lymphoma of the brain can present with multiple lesions.  This was something which the patient and I were reluctant to do.

What was the outlook for this patient if this turned out to be a cerebral lymphoma?  Not too good I am afraid.  With aggressive treatment, 70% of HIV patients with cerebral lymphoma were dead by 2 years.  

What was the outlook for this patient if this turned out to be HIV with toxoplasmosis?  Its actually quite good, much better than cerebral lymphoma.  He would have to take anti-Toxoplasma medications for the rest of his life for Toxoplasmosis in immunodeficient patients often relapses if treatment is stopped. Immune reconstitution significantly reduce the risk of recurrent infection.  HIV treatment with HAART (highly active antiretroviral therapy) will reconstitute the immune system. Nowadays the outlook is not hopeless.  

My patient's blood tests showed a high toxoplasma antibody titers and a positive HIV test. Breaking the news to the patient was not easy.  I softened the blow by gathering them in a private quiet room, speaking to them in a calm monotone and expressing a lot of hope in the treatment that will ensue.   The wife, I am surprised to say, took it calmly.  She remained supportive of the patient throughout this crisis.  Naturally, she had to be counseled and tested as well.   

As for me, what appeared at first instance to be a patient with a headache, turned out to be something very very different.  You could say, far in the periphery of pain management. Which leads me to again to express my appreciation for being in a center where each member of the team is so readily accessible. 

My name is Dr. Matthew Tung MBBS FRCS (Surgical Neurology)

I am a brain surgeon. What I do is brain surgery, so for instance when a brain tumour or a blood clot is discovered, I operate on the brain to remove clots or excise tumours. No patient ever comes to me saying I have a brain tumour, so I work closely with general practitioners, neurologists, and other physicians.  


I also manage chronic pain.  Treating chronic pain patients who often do not have any other treatments to turn to is often a challenge.  The tools I use to treat them include nerve stimulators.  We place these electrodes in various parts of the body, usually along bones of the nervous system, peripheral nerves, spinal cord or even the brain in some cases, so that we can block pain signals and provide pain relief when other treatments have failed.  The peripheral nerves are the connections between the spinal cord and these extremities, the muscles, the skin, bringing motor information out to the limbs to guide and control movement but also bringing sensory information back to nervous so that patient can be aware of pain touch pressure or nature of movement etc.  The peripheral nervous system has enormous powers of healing, for regeneration and for repair.  I cannot heal a spinal cord injury, a stroke in someone’s brain but I can heal a peripheral nerve injury, and patients can make a phenomenal recovery whereas in other parts of the nervous system that is not really possible.