Improvized management of lumbar disc prolapse in Antarctica.

Sir,

The 27th Indian Scientific Expedition to Antarctica wintered over at Indian Antarctic Station, Maitri (70°45'S; 11°44’E) from November 2007 to February 2009 with 26 members (six scientists and 20 logistics personnel). Antarctica is physically isolated in winter; medical facilities are elementary.

A vehicle mechanic complained of sudden onset low back ache on 4th June 2008, about 5 days after returning from a 4-day-long convoy duty. The 43-year-old male vehicle mechanic, responsible for maintenance of heavy machinery and to run supply convoys to the Indian coastal camp 120 km (15 hours) from Maitri, endured heavy physical labor on hard, irregular blue ice in extremely cold (0®C -30®C) and windy conditions and icy terrain with frequent blizzards.

The pain subsided in 3 days with oral NSAIDS, local heat application and bed rest only to recur 10 days later, while attempting to lift a 50 kg sack. This time the pain was worse and radiated from the lower back down the posterior aspect of left thigh extending up to the mid-calf region with occasional episodes of tingling and numbness of the outer three toes and plantar aspect of the left foot without any weakness in the lower limbs. The pain was aggravated by coughing and relieved on lying down.

Clinical examination revealed an ectomorphic feature with loss of lumbar lordosis with tenderness in the lumbosacral region and a positive straight leg raising (SLR) in the left lower limb at about 30°; there was no scoliosis. The power, tone, sensation and the deep tendon reflexes of lower limbs were normal. Roentgenography of the lower back did not reveal any abnormality [Figure 1]. Since advanced imaging facilities were not available, he was clinically diagnosed as a case of prolapsed lumbar disc at L5-S1 with sciatica. He was resumed on oral NSAIDs, local heat application and bed rest. When he did not show any significant improvement for 5 days, online remote specialist advice was sought.

Figure 1

The X-ray Lumbosacral Spine (AP view) was taken when the patient did not respond to bed rest and analgesics and was planned to be put on traction

We decided that the patient has to be put on traction to suck in the disc protrusion and enforce bed rest.[1-3] In absence of a traction kit we improvized it. A mountaineering harness was tied around the patient's waist and a mountaineering rope was hooked to the harness using a carabiner with a 15-kg barbell weight suspended from the other end. The foot end of the bed was raised by 30° using bricks [Figure 2].

Figure 2

A mountaineering harness was secured around the waist of the patient and the loops were drawn medially from under the buttocks and secured with a carabiner to which a mountaineering rope was suspended. The barbell weights were suspended from the rope

The traction was removed whenever the patient experienced significant discomfort and for daily ablutions and meals. However, the patient was allowed to sleep without the traction. Visual Analogue Scale[4] for assessment of pain showed improvement from 6 to 2 points after 20 days and SLR of 60°. He was gradually weaned off traction. The spinal extension exercises were initiated and he was mobilized with a weight-lifting belt used as a lumbosacral support. After 3 months he was asymptomatic and uneventfully returned to his routine convoy duty and continued to be asymptomatic till 1 year.