Your husband sounds a lot like me. To get a good fusion you need to put in a large cage and it needs to fit tight. They don't remove all of the disc. L4-5 is more difficult to fuse than L5-S1. Yes, they can grind up the old cage or break it up and take it out. Trust me, they can get it out of there. But remember, there is really no such thing as minimally invasive when you are cutting into the back and going after a cage and putting rods in. I sort of look at it as a lesser of two evils. If you keep going back in there, the chances of having a good out-come decreases. You loose a considerable amount of the muscle with each surgery…..guaranteed. The structure of the back is incredibly delicate. It is a marvel.
It is your right to get the radiology reports for any MRI or CT scan or plain films. I believe a CT scan is better at picking up a non-union than an MRI. In my case, they did a BONE SCAN to look for bone growth within the disc-space. I think the bone scan is the standard for evaluating the deposition of bone within the disc-space and the lateral gutters of the vertebral column. Sometimes it is a judgment call regarding what is enough bone growth. You can also have a lot of bone growth but the bone just hasn't bonded to the adjacent vertebra. That can be hard to see when reviewing radiographic studies. Having said that, very often, you simply won't have any opacity within the disc-space which is pretty obvious that something isn't right. The cage should not migrate outside the disc-space. The radiologist will catch that, so read the radiology report. There are also little radiographic markers built into the cage. Your last surgery should have included sequential x-rays that would should the cage moving around if it is on the move. You should be able to see erosion of the bone from the cage if there is movement or flexing going on.
So you feel like you are just a cog in a wheel when you go to see the doctor. I can be very cynical when it comes to the medical system. It has sort of turned into fast food medicine (that is what I call it). The goal of the surgeon is to pick the right patient and make the correct diagnosis. Your surgeon needs to find out what the pain generator is, even if it looks obvious on radiographic study. There has been whole generation of surgical decisions made on the advent of CT and MRI. At one time it was over relied on and that was a mistake. It is only a tool to assist in the process of making a surgical decision. Your surgeon should consider putting him in a hard brace and seeing if his symptoms improve. They really need to be as certain as possible what his mechanism of pain is.
I am a bit baffled why your surgeon said he finished his surgery and the cage was a loose fit or not tight. Why wasn't it tight? That is not the goal when putting a cage in there. Cages do come in different sizes?? It might have been that the posterior approach limited his ability to put a large cage in there without damaging nerves, etc.
If you get a second opinion, you need to be sort of diplomatic about it. Have all your radiology films, MRI, etc sent and reviewed before you go to the appointment. Have a list of questions but don't ask them right away. Try to get the surgeon to elaborate freely regarding the assessment of your husband. Very often, they like to listen to themselves talk and expound upon things. When the dust settles, diplomatically ask your questions like, is the cage in the right position, was the cage too small, are the screw broken, are the screws loose, are there signs of loss of disc-height from previous films, if my rods are not broken now, what are the chances of them breaking in the future, what is the likely cause of my pain, what will life be like if I have another surgery to fix this (define a successful surgical out-come in this situation), ask them what they would do if they where in the same situation?
Note that getting a totally open conversation with a surgeon is next to impossible. They can very diplomatic in there responses because they don't want to be asked to give expert testimony in court when they would rather be working in the office. (Sorry, my cynical side is showing). Personally, I would go to a major university medical center and see a orthopedic spine surgeon that has done a FELLOWSHIP in spinal surgery. Those are the one's that have done all the difficult cases and the re-do's. Chances are, they will tell it like it is and you will get a reasonably straight answer. Out of all the things I said in this letter, that is the best advise.
Another consideration for you is a anterior approach. They can go through the abdomen and possibly get the job done that way. It is frequently done. Ultimately, you want the procedure that will give you the greatest chances of success. Some surgeons will only do what they know how to do. There are tons of different procedures.
Tell your husband that a stranger cares about him. Tell him to try and have peace in his heart. Be careful when it come depression. Chronic pain can really do a number on a persons mental status. It all brings back memory's for me. Just hang in there and try to have hope. Find a surgeon like I mentioned. They are out there. Very special people. University of Washington has some. I have been there. They were very nice people.
Stay in touch. If you have more questions or I didn't answer your questions or you just want to vent, let me know. Your husband is very lucky to have you swinging the bat for him. My wife did the same for me. I keep looking for wings coming out her back side but haven't found them yet.
Peace (I really mean that), Ringo
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