Introduction
 

Backpain started really bothering me in late 2008 and decided needed to get it checked out. Had chiropractor care, SI and Facet injections, physical therapy, acupuncture and lastly fibrin sealant injections.

Before all this started was an avid cyclist and belonged to two gyms and was very active.

CT scan showed:

L5/S1 - DD and a grade 5 posterolateral annular tear on the left, reflecting a posterolateral/lateral disc herniation.

L4/5 - Posterior grade 2-3 annulat tear and mild broad based disc bulge.

The discogram was positive for the L5/S1 but not for the L4/5.

Currently, considering a hybrid (Stalif L5/S1 and Prodisc L4/5) and am having a new MRI and DEXA next week. Then just need to make the decision.

Perhaps things have changed since I had my surgery 5+ years ago but even though L2/3 was herniated, it was not a pain generator as indicated through discography. The standard was not to replace the disc prophylactically and I have 3 ADRs below it.

Too bad because it has since become a pain generator and is beginning to limit my activities.

Your discogram tested negative for pain at L4/5 yet your doctor is planning an ADR at that level? Did I read that correctly? I'm wondering, has this standard changed - is this something only your specific doctor has decided - is it known for sure this disc will become a pain generator?

I do wish I had L2/3 done with the rest. For me this was a difficult surgery with permanent nerve damage and something I'm not going to jump into again anytime soon.

Dale

Yes. I have seen 3 surgeons now and they have all agreed that the L4/5 should be addressed with the L5/S1. Although, the final choice is up to me.

They think the disc could become a problem down the road and did test for some pain in the discogram but not enough for the Dr to rule it as a problem.

decision
 

One of the reasons I didn't want to get ADR done here in the US (there were 2 major reasons) was that on 2 out of 3 discograms L3 which had anular tear and was disrupted wasn't a pain generator. L4 and L5S1 had already had surgery (discectomies) and were definate pain genertors. First when surgical recommendations were on board since 2001 I was advised to have a 3 level global fusion. Didn't think that was a good idea re success w/multi level fusion back then.

Then in 2003 recommended to have 2 level ADR at L4 and L5S1 and then in 2005 to have ADR at L4 and fusion at L5S1. Because this was a Worker's Comp case I knew only what was auth'd would be done then WC would be looking to get rid of my case quickly, dump it without auth'ing anything else surgically or probably heavy duty pain wise (like ESIs that I used to get great relief from but are no longer auth'd).

I worried that L3 would give me more trouble if I had the 2 lower levels worked on and not that level. Also in US no vertebroplasty done and I had osteopenia and later developed osteoporosis (several years later).

At least when I got a written eval from German doctors they said based on discogram results that they'd have to do there they'd let me know if I needed a 3 vs. a 2 level procedure. Also probably would have had vertebroplasty done there.

Last but not least where the surgery finally was authorized (or with the surgeon) at one point I was told that either a 2 level fusion or a hybrid surgery could be done. I was sure that a 2 level fusion would have left me screwed up at L3 even if a hybrid surgery wouldn't.

I didn't feel like having surgery for L4 and L5S1 and having to go back and have L3 done at some later point as my past luck hasn't been good with surgery and then adjacent level probs. I had a discectomy at L5S1 and one at L4 only nearly 2 years later and while the discectomy at L5S1 was Ok the one at L4 made me much worse and I suffered the aftermath terribly for 9 years before anyone would even talk about more surgery to me and no pain meds prescribed until that point as pain management had actually become a specialty that was really working on pain control vs. just prescribing PT and biofeedback and such. Ok that might not make much sense tho I've tried to condense a long history into something short.

I see you've gotten 3 opinions and there's a concensus on replacing L4 as well. Good luck with your decision. Seems like you've done your homework re 2nd and 3rd surgical opinion.

Got another MRI yesterday and went to see another surgeon for a recommendation. It's the first MRI since I had the Fibrin injections at 3 levels. Still waiting on the report but the L5/S1 appears to be worst and is now pressing on the nerve.

His recommendation is a TLIF at L5/S1 and leave L4/5 alone. He doesn't do ADR.

So still waiting for an updated Dr's opinion from the new MRI but his initial recommendation was L5/S1 Stalif and L4/5 Prodisc based upon MRI from 2009 and 2010 Discogram/CT Scan.

I think most surgeons are likely to NOT recommend anything they don't do themselves. IMHO only fusing S1/L5 is likely to worsen L4/5.

I know a conservative approach is better but it isn't always best. Still wishing L2/3 had been addressed 5 years ago.

Dale

Did anyone say ADR L5-S1, leave 4-5 alone?

did the disco at L4-5 show the contrast extravasating into canal?

From the CT Scan last year the L4/5 there was contrast material in the nucleus pulposus and annulus fibrosis particular anteriorly.

The ADR only at L5/S1 hasn't been recommended yet. The surgeon that ordered the MRI hasn't given me an updated recommendation. Hoping early next week.

It would be great if the fibrin sealant repaired my L4/5. The surgeon today thought the L4/5 was fine. He said the Stalif wouldn't be a good option at the L5/S1 because of the nerve compression that is posterior and they would have to flip me over during surgery to remove the disc that is compressing the nerve. Don't know yet if that is true.