λ Tony’s blog λ

L4/L5/S1/Sacro-iliac fusion

• L4/L5/S1 fusion performed 15 March 2011
• Sacro-iliac fusion performed 01 November 2011

The result of:

• The purchase and consumption of 31 medical text books on lower limb orthopaedics, neurology, neuro and spinal surgery and radiology.
• Uncountable subscriptions to medical journals.
• 18 MRIs, 4 CAT scans, 3 XRAY scans, 3 bone scans.
• 12 surgical procedures; 8 to the lower limb, 3 to the lumbar spine. 1 (successfully) minor procedure performed by myself for a medical emergency for which acknowledgement was initially refused and later accepted after surgical extraction of foreign body.
• 29 doctors
• AU$130K (total estimated)
• Having been misdiagnosed by a not-so-clever person named Dr Leigh Atkinson, including the suggestion that my chronic pain is “caused by the holy ghost.” Yes, seriously, he said this — while also in the room with a qualified medical professional (whom he called delusional in the same rant). He also claimed that I did not have Entrapment Neuropathy of SPN when I told him I strongly suspected it. I did — surgically verified by lower limb orthopaedic specialist (November 2009).
• Having been repeatedly told for nearly two years by Dr Michael McEniery, who would threaten to sue me again if I was to call him incompetent or dangerous (even though this might be my genuinely held opinion based on substantiated fact and so he would lose) that I am obsessing about a minor condition, requiring no medical intervention, and that this obsession is because of the athletic demands of myself and my coach.
• Having executed a partially-successful mission to demand immediate medical attention in March 2009 at significant expense.

I have successfully and single-handedly diagnosed:

• Entrapment Neuropathy of the Superficial Peroneal Nerve, 10cm proximal to lateral malleolus (unilateral).
• Foraminal Stenosis of the Fifth Lumbar (L5) Nerve Root (unilateral).
• Spinal instability (Spondylolisthesis) at Fifth Lumbar (L5).
• Withdrawal from morphine and oxycodone after immediate cessation.

These conditions were caused by a single acute sporting injury in July 2007. I have been treated for all.

L4,L5,S1 fusion 15 March 2011

PS: This is why I sometimes demonstrate low tolerance for stupidity and/or failure or refusal to entertain the possibility of thinking. People get hurt. No, I am not sorry.

Keeping with the spirit of recent topics, here is a letter I recently received:

08 October 2010

Dear Mr Morris,

DR MICHAEL MCENIERY

We act on behalf of Dr Michael McEniery.

Our client has provided us with a copy of your letter to Dr Lachlan Steffen dated 15 September 2010.

A number of comments within your letter are grossly inappropriate and contain defamatory imputations about our client, suggesting that he is dangerous and incompetent.

The publication of defamatory material in Queensland is actionable under section 7 of The Defamation Act 2005. Please understand that our client takes strong objection to your conduct and reserves his right to claim damages.

Our client demands that you immediately cease making any negative or derogatory comments or publications which may cause injury or loss to him. If you do not cease such conduct our client may take such action as he is advised without further notice to you.

Yours faithfully,

David Watt

…and a response…

29 October 2010

Dear Mr David Watt,

Re: DR MICHAEL MCENIERY (08 October 2010)

No.

Sincerely,

I might just leave this here:

DEFAMATION ACT 2005 - SECT 25

Defence of justification

It is a defence to the publication of defamatory matter if the defendant proves that the defamatory imputations carried by the matter of which the plaintiff complains are substantially true.

…and this too…

DEFAMATION ACT 2005 - SECT 31

Defences of honest opinion

(1) It is a defence to the publication of defamatory matter if the defendant proves that –

(a) the matter was an expression of opinion of the defendant rather than a statement of fact; and

(b) the opinion related to a matter of public interest; and

(c) the opinion is based on proper material.

Just sayin’

A friend of mine, Brad Clow, has received demands to remove one of his blog posts by a lawyer. This post contains a letter that I wrote to the Medical Health Board of Queensland in March 2009. The letter mentions the name of a doctor, from whom I have also received recent threats of legal action; specifically allegations of defamation. Brad has removed the name of this doctor.

These threats are without any legal basis at all and a cursory read of The Defamation Act 2005 makes this really quite apparent. Specifically, sections 25 and 31. Neither myself nor Brad have made any defamatory claims against Dr Michael McEniery, however, I do have honestly held opinions which are based on facts which are substantially true. These opinions and facts will be made available for public viewing after I have sought advice from legal experts. Advice in this regard is most welcome and I promise a remarkable and quite alarming story.

It took me a little over a year longer to finally determine the correct diagnosis. I had an entrapment neuropathy of the superficial peroneal nerve 10cm proximal to the lateral malleolus causing traction injury and subsequent foraminal stenosis at the right L5 nerve root, resulting in severe neurological deficit. I also had anteromedial osseous impingement syndrome (caused by tibia/talus collision from foot drop) and four improperly installed screws causing (painful) interference in the talar joint. It is now 6 months since surgical resolution and I am left with some neurological deficit. It is not known if I will fully recover, though the treating surgeon is hopeful.

Brad’s original post, before he yielded to the legal demands, follows.

We received a copy of this yesterday evening. Please note Tony is a friend of mine and this is genuine.

To The Medical Board of Queensland,

My complaint is rather lengthy. It relates to an injury and subsequent treatment of that injury by various doctors and surgeons. I am not primarily complaining about any particular individual of the medical institution, rather, that I still have not been diagnosed and treated for my condition. I am desperately seeking diagnosis and a treatment. Some doctors may believe they have diagnosed my condition, but they have been wrong and this has been proven surgically. The best diagnosis available today is my own humble conjecture, which is terrifyingly inadequate.

On 28 July 2007, I suffered a severe inversion sprain to my right ankle. I’d suffered a few previous sprains, but this one was much worse than others. I was kicking a football rather hard when I landed incorrectly. I was not weight-bearing for about 5-6 days. During that time I was a very fit athlete playing A1-grade tournament squash and was very active with many other hobbies.

Over the following months after the injury, I tried returning to sport and I could feel I had something wrong in my ankle. I hoped it would resolve, but it didn’t. I could not put my joint into dorsiflexion due to a mechanical impingement and this resulted in muscle atrophy. Subsequently, I became very ill. Nevertheless, I pushed on with my sporting endeavours expecting my body to overcome the problem like it had many others in the past.

Eventually I conceded in January 2008 and sought help from Dr. Michael McEniery. We tried various treatments including a cortico-steroid injection and obtained MRI radiographs. Over time, this condition worsened to the point where I was forced to discontinue sport in May 2008. I have not been active since. I sought help from an orthopaedic surgeon, Dr. Greg Sterling, who prescribed a Broestrom Repair and medial arthroscopy since my complaint was mostly anteromedial.

At the time, I was very medically-illiterate and put much faith in medical doctors. I assumed a positive outcome from surgery, simply because I’d had surgery in the past for various conditions and I was always better afterward. The procedure was performed on 15 September 2008 and the medial arthroscopy revealed deltoid ligament damage which was also repaired along with the ATFL and CFL.

I wore a cast for 2 weeks and an orthodic boot thereafter. Although I was in pretty intense pain, I’d attributed this to the recent surgery and thought it would resolve. It didn’t. In October 2008, I knew I was in big trouble – I had similar symptoms to pre-operative but they were now much worse. I immediately sought help from Dr. Greg Sterling who requested another MRI but in November 2008, could see nothing wrong. He said “see you in January 2009”. The prospect of waiting so long in agony was traumatising.

Around the same time, I’d sought help from Dr. McEniery who claimed I was exaggerating my symptoms and attributing too much attention to my condition. This blatant oversight added further to my trauma – and he’d almost convinced a member of my family of these falsehoods. I was suffering psychologically and I sought immediate help from Prince Charles Mental Health Unit.

I was discharged as an outpatient but I knew I was not mentally ill – I was in incredible pain and agony from a misdiagnosis by an orthopaedic surgeon. I set out to conquer the problem myself – scared and ill-educated on the subject matter – and was faced by the foreign medical protocols and language.

As my stress levels grew, I was admitted to the Prince Charles Mental Health Unit by Dr. John Reinders under a de facto ITO. I was also forced to take anti-psychotic medication. This is because of some of the desperate language I was using, for example, “do I have to operate on myself?” and Dr. Reinders felt I may be a harm to myself.

I’d never been so low in my life. When taking anti-psychotic medication, you are very much unaware of your surroundings. It was only during a lull in the effect of the medication, that I decided I needed to get out of the hospital and do what I can for my ankle – I was convinced the doctors had erred and that this was a huge mistake. I requested a Psychiatric evaluation and was declared “in severe distress, but mentally healthy” and I was discharged.

I set about understanding ankle anatomy, conditions of the ankle and general medical protocols. I quickly learned that I had at least soft tissue impingement. Indeed, I had tissue trapped in the joint that was under permanent pressure due to the recent surgery – even when not weight bearing. This is as painful as you might imagine it to be and a little more given multiple pathologies.

I sought help from Dr. Andrew Wines (Foot & Ankle Orthopaedic Surgeon) in Sydney who prescribed an arthroscopic debridement. This was performed under GA on 11 December 2008. To quote his remark, “you had a chunk of tissue about the size of my finger in there”. I was immediately weight bearing post-operative and the local aneasthetic provided some relief. As a result of this anaesthesis, I was under the false impression that my troubles were over. They weren’t.

After a few days I knew I still had a severe and painful problem though I no longer had the problem of tissue impingement. It felt like I had bone impingement on dorsiflexion and I sought answers from medical literature. I eventually stumbled on Anteromedial Osseous Impingement Syndrome for which MRI radiography is inconclusive for diagnosis. I used my January 2009 appointment with Dr. Sterling to ask for a request form for a CAT radiograph and weight-bearing Xray. Dr. Sterling also made an appointment with Dr. Michael Lutz to determine if he could unravel this mysterious problem of mine.

Upon obtaining these radiographs, I saw immediately that I had a bone spur in the location of my pain. I sought assistance from Dr. Andrew Wines (again in Sydney) who agreed with me to some extent but wanted a second opinion in order to ensure he was not suffering a bias. I applaud this decision. I used my upcoming appointment with Dr. Lutz to achieve this second opinion. Dr. Lutz agreed that an open incision to excise osteophytes on my tibia may be appropriate and I was informed of the risks .

Dr. Wines performed an arthrotomic tibial ostectomy on 04 March 2009 under GA at Royal North Shore Hospital. I flew home the next day – I was weight bearing without assistance. Again, the anaesthetic provided a false belief that my problems were over.

Unfortunately, I still have the same problem I started with – I cannot put my ankle into dorsiflexion. Many doctors might attribute this to the recent surgery, but I know I am experiencing precisely the same symptoms that I have done for the last 18 months. Although the localised and extreme pain caused by a bone spur has been resolved, I still have bone impingement on dorsiflexion that is not localised. I also know that this is due to a very definite mechanical limitation, since I have had a Physiotherapist in the past attempt to push my joint past this point with intense force to no avail.

As a result of this inability for dorsiflexion, my muscles have atrophied up to my thoracic spine. Subsequently, I find breathing difficult and any position uncomfortable except for lying down. This has caused immense stress especially while I have maintained a full-time job (Computing Science Researcher) and I am considering indefinite unpaid sick leave. Unfortunately, a consequence of this is that I will no longer be able to afford regular flights to Sydney for treatment, radiographs and so on, therefore, I must continue the battle under all circumstances and despite exhaustion.

I have long maintained that my symptoms are only observable while I am weight-bearing and in an attempt at dorsiflexion. This means that surgeons who operate cannot check for resolution of these symptoms, MRI and CAT radiographs cannot exhibit them and the only weight-bearing Xray I have was not in dorsiflexion because the Radiographer would not allow it (images only per requesting doctor instructions).

Unfortunately, I still have quite a large battle ahead but I am at a complete loss with respect to how I should go about it and that is why I have written to you, my state medical authority.

Is there a radiographic machine available in Queensland that will exhibit my bone impingement while in dorsiflexion and while weight-bearing? Better still, is there a doctor who is prepared to do the hard work of figuring this problem out? I am more than willing to make many sacrifices to ensure it. These are rhetorical questions – I don’t know what the right questions are.

I am desperately seeking a diagnosis and treatment, 19 months after an initial injury and I know that my time is limited with regard to the amount of stress and pain that I can continue to endure. This is simply unsustainable.

Please advise.

Thank you for your time. Confidentiality is not requested and you may share this information with whoever you see fit.

Of the 26 medical doctors I have met in the last couple of years, about 10 of them had this question before them in some way. All of them answered “no.” I am very confident this tiny sample set extrapolates — I doubt there is a doctor who would not say no.

They are all wrong.

Entrapment neuropathy of the superficial peroneal nerve is not a common condition, but one which I had after an ankle inversion sprain. The entrapment was 10cm proximal to the lateral malleolus at the deep fascia exit behind the peroneal muscles.

In order to achieve resolution of this problem, I had to publish an essay with citations and present it to several surgeons. My citations include every case study of this condition that currently exists and several orthopaedic text books.

My insistence that this was causing a significant problem and that I also had incomplete foot drop was met with deep scepticism. After all, the superficial peroneal nerve (SPN) is a cutaneous nerve that does not supply motor control. I knew this too of course, but I had no explanation. It is the deep peroneal nerve (DPN) which supplies motor control — the guy next door. Foot drop is often caused by an entrapment below and behind the knee before the nerve splits into these two branches, but I knew this was not the cause.

A marcaine/steroid injection into the SPN entrapment site immediately (within seconds) relieved some amount of foot drop. This too, was met with scepticism (?placebo), but I was adamant — there was an effect including a functional improvement.

An entrapment neuropathy of the superficial peroneal can cause foot drop by extending the nerve, and placing traction on the L5 nerve root. This will result in the expected fibrillation of the foot extensor muscles. Further, this is an extremely painful and distressing condition resulting in symptoms that can be very distracting from the actual etiology.

I am not a medical expert, just an independent thinker who owns too many medical text books.

Hello everyone,

Many of you know I have been battling health problems for the last 2 years subsequent to a sporting injury. After a total of six surgical procedures, my most recent about 3 weeks ago, I am glad to be almost completely cured. Today I lodged a formal complaint to the Medical Health Board of Queensland against six doctors (coincidentally, the same number of operations — there were a total of 19 doctors mentioned).

As a result of the aforementioned, I haven’t written in a while, so I plan to return to my usual from now on.

I thought I’d write a little about a pervasive problem on the Scala mailing lists. Specifically, the misunderstanding of the purpose of static typing. Of course, there will always be lots of myths and proponents willing to ensure their survival, however, I am a strong believer that education is the only means by which we can advance the software development industry, despite the task often appearing insurmountable (ala Scala mailing list).

Some discussions recently on the Scala mailing list include the relationship between scala.Option data type and null and another discussion about documentation and types that are once-inhabited such as forall a b c. (a -> b) -> (b -> c) -> a -> c

I thought I’d propose a small piece of code and leave any potential insights unstated so as not to destroy anything for the observer. There is a Haskell version toward the end.

I propose the following data type:

trait MyOption[+A] {
  // single abstract method
  def cata[X](some: A => X, none: => X): X
}

Astute observers will notice that the cata method is similar to a combination of the map and getOrElse methods on scala.Option. This topic has also arisen on the Scala mailing list in the past. In other words, I could have written this:

trait MyOption[+A] {
  // two abstract methods
  def map[X](f: A => X): MyOption[X]
  def getOrElse[AA >: A](a: => AA): AA
}

…and I’d have a data structure that is exactly the same as the previous one. What may not be obvious is that MyOption is also exactly the same as scala.Option. The correct term for “exactly the same” is isomorphic. Yes, this is despite not using case classes or subclasses — coincidentally, another area where much mythology is prevalent.

I could also write construction functions that are akin to scala.None and scala.Some:

object MyOption {
  def none[A] = new MyOption[A] {
    def cata[X](s: A => X, n: => X) = n
  }
 
  def some[A](a: A) = new MyOption[A] {
    def cata[X](s: A => X, n: => X) = s(a)
  }
}

As an exercise, I propose filling out the Option API, however, using the single abstract method cata and the none/some constructor functions for additional convenience. I promise you it can be done and that anything scala.Option can do, MyOption can do also (and vice versa), since they are isomorphic.

trait MyOption[+A] {
  // single abstract method
  def cata[X](some: A => X, none: => X): X
 
  def map[B](f: A => B): MyOption[B] = error("todo")
 
  def flatMap[B](f: A => MyOption[B]): MyOption[B] = error("todo")
 
  def getOrElse[AA >: A](e: => AA): AA = error("todo")
 
  def filter(p: A => Boolean): MyOption[A] = error("todo")
 
  def foreach(f: A => Unit): Unit = error("todo")
 
  def isDefined: Boolean = error("todo")
 
  def isEmpty: Boolean = error("todo")
 
  // WARNING: not defined for None
  def get: A = error("todo")
 
  def orElse[AA >: A](o: MyOption[AA]): MyOption[AA] = error("todo")
 
  def toLeft[X](right: => X): Either[A, X] = error("todo")
 
  def toRight[X](left: => X): Either[X, A] = error("todo")
 
  def toList: List[A] = error("todo")
 
  def iterator: Iterator[A] = error("todo")
}
 
object MyOption {
  def none[A] = new MyOption[A] {
    def cata[X](s: A => X, n: => X) = n
  }
 
  def some[A](a: A) = new MyOption[A] {
    def cata[X](s: A => X, n: => X) = s(a)
  }
}

If you get stuck, the answer is base-64 encoded below, however, I encourage you to follow the types and to the extent that there may be ambiguity, follow the existing Scala API specification for scala.Option. If need be, please ask questions. Best of luck!

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For Haskell users:

{-# LANGUAGE RankNTypes #-}
 
-- Data.Maybe
newtype Option a = Option { cata :: forall x. (a -> x) -> x -> x }
 
-- Just
some :: a -> Option a
some a = Option (\s _ -> s a)
 
-- Nothing
none :: Option a
none = Option (const id)
 
-- fmap
map' :: (a -> b) -> Option a -> Option b
map' f m = error "todo"
 
-- (>>=)
flatMap :: (a -> Option b) -> Option a -> Option b
flatMap f m = error "todo"
 
-- fromMaybe
getOrElse :: Option a -> a -> a
getOrElse = error "todo"
 
filter :: Option a -> (a -> Bool) -> Option a
filter m p = error "todo"
 
-- mapM_
foreach :: Option a -> (a -> IO ()) -> IO ()
foreach m f = error "todo"
 
-- isJust
isDefined :: Option a -> Bool
isDefined m = error "todo"
 
-- isNothing
isEmpty :: Option a -> Bool
isEmpty m = error "todo"
 
-- WARNING: not defined for None
-- fromJust
get :: Option a -> a
get m = error "todo"
 
-- mplus
orElse :: Option a -> Option a -> Option a
orElse m n = error "todo"
 
toLeft :: Option a -> x -> Either a x
toLeft m x = error "todo"
 
toRight :: Option a -> x -> Either x a
toRight m x = error "todo"
 
-- maybeToList
toList :: Option a -> [a]
toList m = error "todo"
 
iterator = error "bzzt. This is Haskell silly."

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I’ve had two operations on my right ankle and both have failed to correctly diagnose and address the underlying symptomatic complaints that have existed for over 18 months. I am now aware of what the correct diagnosis is, verifiable with historical and radiographic evidence and repeatable symptomatic observations.

The surgeons are cautious given that I’ve already used up two of my available surgery cookie quota and hesitant to go again. This is despite having an exact pinpoint of where the problem is and published literature of what procedure is required. I simply have no rational explanation for this and, if it weren’t for my discomfort, it would leave me in awe.

The diagnosis is anteromedial osseous impingement of the right ankle visible on CT, verified by a radiologist and repeatable on dorsiflexion. This has come about from repeated trauma and in particular, a grade 3 inversion sprain in July 2007. I require a resection of this excess ossification.

I am asking (begging) my international audience for recommendations of a surgeon who is willing to perform this procedure as soon as possible in any part of the world. I suspect, only because I have no other explanation, that there is some bureaucratic restriction preventing me from making progress with surgeons here.

Suggestions please?

Pan-pan medico Pan-pan medico Pan-pan medico.

I’ve been stuck in my house for weeks. Help!
http://ankle.tmorris.net/

July 2007

• Right ankle sprain
• Fifth life-time occurrence
• X-Ray reveals no fracture (Royal Brisbane Hospital)
• Zero weight bearing for 6 days

January 2008

• Certain movements cause swelling and discomfort
• Movement is restricted in bending the knee with the foot flat on the ground (name?) — can get the knee vertical with the tip of the foot, but no further
• MRI ordered by local GP (see below)
• Radiography report is unremarkable and states no anterolateral abnormality (even though the pain is posteromedial?)

February 2008

• Local GP administers cortico-steroid injection. Due to the swelling, the exact site of the pain cannot be accurately located. Since swelling has stopped (I have ceased rigorous activity), I estimate that the injection missed by about 2cm.
• Improvement over the following 3 weeks and flexibility increases, just a little (I can get my knee 3cm passed the tip of my foot vertically)

May 2008

• Ceased all sporting activity, in particular squash (3 times per week, including A1 grade competition)
• This was due to this injury and one other; scapholunate ligament tear resulting in instability

June 2008

• Subcutaneous atrophy from steroid injection begins to subside
• Further injections are advised against by local GP
• Arthroscopy of the wrist for scapholunate ligament repair (Dr. Peter Rowan, BOSMC)

July 2008

• Wrist Arthroscopy has failed (reconstruction pending?)
• HELP!

04 August 2008 (update)

• Appointment with Greg Sterling on 30 September
• YAY! 57 sleeps to go

Photos

• Taken 2 August 2008
• Red mark denotes site of impingement
• Note atrophy below the mark

MRI

Radiographer Report (Transcribed)

Images (DICOM)

All DICOM images (tar.gz) 71MB

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Images (PNG)

All PNG images (tar.gz) 23MB

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