QUESTION:L5/S1 ADR or FUSION?

[Michelle Maree]

Hi Guys,
I would like to know your opinion on whether or not L5/S1 is worth putting an ADR or better off fusing? Generally speaking and in my case.

I am considering further surgery at this level after microdiscectomy and now severe DDD with back pain.With only 4.5 mm disc height in the middle and possibly nearly bone on bone at the front and back of the vertebra. I have mild facet hypertrophy on one of my three radiologist reports,but the others didnt mention it. I feel I may have some facet pain though. Not yet tested. Discs above look really healthy and plump. I have no nerve pain.
So I am trying to decide : Is ADR too risky because of limited disc height and possible facet problems? Will the extra movement cause more pain? And fusion better for me as discs above look healthy enough for now. And also L5/S1 is said to have limited motion anyway.
I would greatly appreciate your thoughts.
Michelle.

[runner]

MM,

You need to check that your facets are not a pain generator before surgery.
IMHO, ADR better than fusion at L5/S1, but I am sure there are people on here that may disagree.
If you have facet pain, fusion is better.
It all comes down to the fact that it is your choice and what your surgeon recommends and why.

[cls]

Michelle,

I considered ADR and consulted an Ortho who is very much in favor of ADR and does not like to fuse but I was precluded due to low disc height. I was on the fence with ADR anyway but this sealed the deal. After reading countless threads on those who had ADR at L5/S1 the trends did not seem positive. Overall I did not get the sense that manufacturers have come up with a device that is a long term homerun and I did not like reading the numerous accounts of facet joint problems from those who had radiographically "perfect" facet joints prior to ADR but then developed problems down the road. It is a very tough thing to decide what kind of treatment to undergo but after researching and consulting highly skilled Orthos or NSs you will land on a solution that will feel right for you. The only piece of advice that I can offer is to find a top notch surgeon who is highly skilled in whatever procedure you go with. Surgeons will perfect the procedures that they are best performing. Good luck

One size does not fit all when deciding ADR vs Fusion there are just too many factors weighing these or any other major procedure. Here are some things to consider while researching your options and talking to your doctor:
Your age and general health - Is bone density an issue? Do you have any other health issues? Arthritis?
Your surgeon - what does he/she specialize in, are they known for being a top doc in this specialty? Do you know someone who has had the procedure from this doc that can give a good reference or at least share their experience?
How active are you? - What are your expectations for recovery?
Risk tolerance - Know the risks for any procedure and determine what you can live with.
Hardware/Procedure - With ADR there are more and more devices coming out. Learn what you can about them and understand the pros and cons of each. Which one will you have and why does your surgeon choose the device? With fusion, there are different methods and hardware devices as well. If you went this route would your surgeon perform an ALIF, TLIF, PLIF or XLIF? Would you use donor bone or BMP or your own?

This is just off the top of my head, I am sure there are many more factors to consider. I'm sure others will chime in.

[dshobbies]

MM,

I agree with Runner. Fusion puts a burden on adjacent segments which can lead to further deterioration resulting in more surgery down the line. This does not mean it will definitely happen in your case.

Your choice of surgeon before deciding which way to go is a primary concern. Choosing a doctor who performs both surgeries is more likely to recommend what is best for your circumstances as opposed to what he is more comfortable with himself.

Good luck to you, Dale

[Kathy]

I have an ADR at L4/5 and had a 1 mm herniation at L5/S1 and L3/4, prior to surgery with L4/5 have a grade 4 tear. If I had to have something done on L5/S1, personally, I would have a fusion. I agree with cls, I have heard too many stories of people having problems with too much movement, when they have the lowest level done. This is just my opinion, do your research and pick what is best for you.

[Michelle Maree]

Thanks for your replies..... I am finding the decision very difficult to say the least.
Everyone seems to have a different opinion on this one. And of course it really does depend on the individual case.
I have seen 2 renowned surgeons in Melbourne that use the Charite and both of them said no and recommended a Tlif. I dont know how many they have performed but I dont think it would be many. Their reasons were because of previous surgery,scar tissue, disc height, possible facet issues. I think they like pristine conditions because they may lack the experience but at the same time they may be right in being conservative. These may well be sound contraidications. I will wait on my opinions from Germany and am expecting a completely different opinion. So who do I then trust?

I sometimes try each one on for size and imagine how it would feel in my back to have either of these procedures done. It makes me realise that I do have a certain amount of motion in that segment that I would lose with fusion. For example when you walk you seem to move quite a bit in that area from side to side albeit not as much as above.What I want to know then is Do you completely lose all movement there when you walk? And it then gets transferred above?
Then I imagine having ADR in there. I find it really hard to imagine what having the height back wold feel like and then that extra movement after so long.My back has flattened a bit over th 2 .5 years and I dont know if my facets would cope with the extra lordosis.
If it didnt cause pain then I would be right. If it did cause extra pain then I dont know how id cope.
So maybe thats my answer. I have become more and more intolerant of pain as time goes on. I am just sooo sick of it!!!!
I would dearly love to hear from anyone who has had either procedure at
L5/S1.
But welcome everyones opinion.
Michelle.

[str8shooter5]

i just had a L4/L5 front and rear fusion and so far so good!

[Maria]

Michelle,
Good going. Making up one's mind is at least half the battle! Must be a bit of a relief even if you are nervous. Please keep us posted

[melodyl]

HI Michelle,

I had a revision surgery that included fusion from L-4 to S-1 in Dec. of 2007. My surgeon is normally in favor of ADR (and since that time, did a 3 level cervical ADR for me). Because of the specific problems with my spine, he would not consider going with ADR in my lower spine. Just to be sure, I got a second and third opinion. Once I made up my mind to have it done, the sooner the better! Due to previous surgery for scoliosis, my spine is fused all the way up to T-2. I will be 48 next month. I can't say that I am pain free.....but I can tell you that (for the most part) I do NOT feel disabled. My life is full. I work and have a family and home to take care of. It took me a little while to get used to the loss of flexibility from L-4 to S-1....but on the other hand, my pain went down considerably which seems like a fair trade. I suggest that you consult with the pain management dept. of the hospital you will be having surgery in BEFORE your surgery date. For those of us who have been on narcotics for lengthy periods of time, controlling the immediate post surgical pain can be challenging. Bringing in the experts can make a huge difference. I would be happy to answer any questions you have. Good luck. Stay in touch and let us know how you are doing. Melody

[dridobits]

I'm so glad to read this post. I'm going through this also but I'm trying not to think about it too much until June when I see all the surgeons.