Summer of surgery ahead!

[on pause]

Hey
I posted a few weeks back about my situation. I have seen 3 surgeons since then, and it was a tough choice deciding what to do, as each person had a completely conflicting view of what to do!

One doctor said I shouldn't get ANY surgery, and if I did, just a lamenectomy at L4/L5. I did that back in 2003 and reherniated one of the operated on discs 3 weeks later!

Saw another doctor who said fusion at L4/L5 and L5/S1 was the only way to go and that he wouldn't even put an ADR in his dog (his exact words). He failed to mention the lasting effects of a full fusion with regards to my age, and was a difficult man to talk to, as he didn't speak unless spoken to the whole appointment! I had to mention to him which surgeries I thought were best! So certainly not my doc!

The other doctor I saw struggled for a while to come up with a plan. He said if I was over 40, it would be an easy decision, but since I'm 23 he was hesitant to do a full fusion, as it is so permanent.

Both he and another doctor he was consulting with decided on a course of action. Unofrtunately I'm not so much of a candidate for ADR at L4/L5, something about how major arteries were too close. So this May 18th I'm getting a fusion at that level, then 8 weeks later, a Prodisc ADR at L5/S1.

Its all booked, forms are signed and now the waiting game begins! I have to admit I'm pretty terrified of the prospect of 2 huge surgeries so close together, and spending my entire summer recovering. I know it won't be easy, and it's going to hurt, but I need this in order to go back to school and try to build some sort of life for myself!

Does anyone have any thoughts on what is being done?

PS. The fusion will involve some of my bone and artificial bone, so nothing is coming out of my hip

[mmglobal]

If the reason for not getting ADR is the vascular situation, I'm not sure I understand this plan.

>>> did they do a CT Angiogram to determine vascular configuration?

It sounds like the plan is for something like a PLIF or TLIF at L4-5, followed by an anterior surgery for ProDisc at L5-S1.

The vascular situation is not known for sure. Unless you've already had an anterior spine surgery, it would take a very unusual vascular situation to preclude ADR. If my undertanding is correct and if this were me... I would proceed as follows:

> do anterior surgery for planned ProDisc at L5-S1.

> while he's there, he may discover that the vascular situation does not preclude ADR at L4-5. This all depends on how easy it is to mobilize the vessels. I've probably observed over 200 lumbar ADR imlantations and have NEVER seen a situation where the vessels presented any issue in a virgin approach. (And rarely in a revision.) So, it may be easy to do the ADR at L4-5.

> if it's not easy to do the ADR, they could still do an anterior fusion with something like a STALIF cage. This does not require as much room for insertion as ADR does. If the final configuration with STALIF or other anterior device looks good, they may not need posterior surgery.

> if there was no ADR at L4-5 or if the fusion config does not seem to be sufficient, they could flip you over and do whatever posterior surgery you needed in the same OR session. (If this occurs, the doctors and hospital will all still get paid for 2 surgeries.)

Telling you that you are not a candidate for 2 level ADR completely disarms any discussion about off-label use and the related insurance or risk management issues that sometimes steer the ship instead of medical issues.

I would rather recover from one surgery instead of 2. I would rather stay away from violating the great muscles of the back if I was already having an anterior surgery... why not do it all from the front?

Please note that I'm not a doctor... just a layperson. Don't believe anything you read on the internet!

Good luck... please keep us posted.

Mark

[mmglobal]

By the way, I can't tell you how many doctors I've seen who would not do ADR on their dog... while they can't do ADR. Somehow, when they learn enough to make an informed decision about it, they start doing ADR. Actually I can tell you... it's dozens.

Mark

[Maria]

Not even on my dog.. that sounds like my OSS and what he wouldn't offer me until he started doing ADRs. Then it was offered (and already had been by others).

I can't comment on anything except to suggest getting a few more opinions. Unless you're in an emergent situation you have time and since you're as young as you are I would definately take the time to get a few more opinions even if you have to travel a bit. Find surgeons that have been doing ADR for some years now as well as fusion and get the their opinion.

When I was checking out 2nd surgical opinions (and 3rd,4th,5th and 6th) I would call the surgeon's office and ask to speak to the personal secretary or assistant and inquire if the surgeon does perform ADR and for how long/how many before scheduling an appt. I found out quite a bit of information this way and even had several surgeons call me back and speak w/me personally.

When it all got down to it all surgeons agreed on what they'd do tho by this time I was feeling better so didn't have any further surgery (I've had a very long history of back probs and 2 previous surgeries).

I think Mark is the best resource layperson there is out there because of his experience and I would definately take whatever he has to say into serious consideration and if you're so inclined contact him personally. He has been a great help to many of us here!

Good luck. Proceed w/caution and do your homework for real on this. Whatever Mark has told you please check further into. You'll probably get more information from him than any surgical consults you've had to date.

[dshobbies]

OP,

I realize you've gotten 3 opinions, 1 from a doctor who does not believe in ADRs which IMHO should be dismissed entirely, and another who only wanted to do yet another discectomy which is also not a great option. So the only opinion that's somewhat good is your ADR/fusion hybrid, done 8 weeks apart.

For me, this would not be acceptable. Both surgeries are difficult and I would not want to recoup from one only to go under the knife again. However, perhaps your doctor will consider Mark's recommendation. You might want to give him a call GPN Artificial Disc Replacement ADR . He has a lot to offer spinal patients.

I also saw you live in Canada with a confusing health care system which we've heard does not always consider the patient's best interest.

But here's the thing - you know there's always a thing - fusing L4/5, especially at your age, is quite likely going to lead to futher degeneration at
L3/4. This is not a definite but a strong possibility.

I know you're anxious to get this going and put these surgeries behind you but you've pretty much got only one chance to get this right. I wouldn't be jumping into this surgery until further exploring the possibility of an ADR at
L4/5 too. You still might have problems with L3/4 down the line but the line will be much longer.

Let me also tell you I've got absolutely no medical expertise and I'm speaking only as a patient and forum reader. You must do what you feel is best for only you will live with the benefits/consequences.

Dale

[longroadahead]

I am by no means a doctor but a ADR at L5/S1 and a fusion at L4/5 doesn't make sense to me. From what I have read the L5/S1 has the least amount of movement and the safest to fuse so you would want to fuse that and have the L4/5 ADR.

Understand you have complicating factors that rule that out but the 2 surgeries so close together would not be an option for me. I would try to find a one surgery solution.

Is the L4/5 so bad that you couldn't have dynamic stablization and have the surgery all at once?

[Maria]

I had thought the same as others are stating here re fusing L4 and ADR at L5S1 which supposedly has less motion/movement so usually if hybrid is suggested it seems to be the other way around but don't know what your facets look like or other surrouding structures at those levels however you're pretty young so would imagine things should look much better on you than many of us that have been offered ADR at L4 and L5 S1 or hybrid surgery w/ADR at L4 and fusion at L5S1.

Now that being said I'm not a doctor either but have had spine problems since I was 28 and am 57 now. Have had 2 discectomies (L4 and L5S1). Have had doctors recommend 3 level fusion at L3,L4, and L5 S1.

Have had 2 level ADR recommended then when didn't to that and a few years passed my facets were a factor to not recommend ADR at L5S1 as well as no FDA approval for 2 level ADRs here in US yet.

Anyway about 6 opinions later and pretty much everyone was agreeing I didn't do anything more however Mark was of great help to me and I can't recommend at least talking to him enough. Check out the website Dale has posted.

Not trying to push you into anything however really want a young person like you to make as good a decision as you're able with surgeons that really know the newer technology and with the experience so that they can offer you what they think will really work for you vs. the only thing they might know how to do well.

And again.. not trying to nag you. Just wish things had been different when I was in my 20's and even 30's and there had been as much exchange of information available as well as access to it.

[Burr]

(He failed to mention the lasting effects of a full fusion with regards to my age.) If you could explain this sentence, I would like to know what is known about the lasting effects would be. I was never told what lasting effects might be /thanks for any info.

[mmglobal]

many people have successful fusions, but years later, they experience the domino effect. When 2 or more vertebral bodies are fused into one, with no mobility that was provided by the discs that have been removed; you run the risk of adjacent segment disease. The adjacent discs are overloaded because of the mechanics of the fused spine and a few years later, the next level needs surgery, then the next...

Note that having a fusion does not guarantee that you'll experience adjacent segment disease and having ADR or other motion preservation surgeries does not guarantee that you won't. If you believe in motion preservation you believe that you SUBSTANTIALLY reduce the risk.

[Maria]

I made my worst spinal decision based on feeling pressured re timing. My own personal experience w/getting surgical opinions over the years and I got a number of them was that a surgeon who could perform whatever was necessary w/whatever technology was confident in offering it. That is unless my own clinical findings were a contraindication which would only be known with the necessary diagnostic testing done within a certain time frame relative to planned surgery (not years before as probs can change w/short amt. of time/longer time).

The surgeons that were limited in what they offered offered what they know and or as Mark stated felt comfortable with and I sort of found that out because of the number of consults I had and who was doing what and how much they were doing of whatever surgery.

I realize you're reeling from all the input. I was too when I was getting mine. We all missed something with our spinal journey like school, work, time from life and so forth however when you make a good decision re surgery you'll thank yourself. I didn't with my 2nd spine surgery and I paid dearly for that decision for many years afterwards. I was rushed by work scheduling, insurance timing and so forth and really didn't take the time to even get a 2nd opinion on that surgery. Living w/sour grapes, regret, more pain and probs post a spine surgery can really be bad.

Actually you're still in a good place right now.. you've got options it's sounds like and you've not yet had surgery so when you're done reeling from the input, concern, fears and worry just realize you're that much more ahead of the game as you do really have time to check things out a bit further.

So many people here made excellent decisions about choosing a spine surgeon and have had outstanding results. I'm not one of them and it has impacted my life in a way that for the longest time I wished I could turn back the clock.

I'm older now and much time has passed and I feel better but believe me I do understand what you're saying and where you're coming from because I was there too in my 20's and 30's.

[mmglobal]

The idea of having surgery on the disc that's known to be bad first, then only in doing surgery on the second level if it's needed a makes a lot of sense. I misunderstood the plan and had thought that is the second surgery was simply being planned months later regardless of the outcome of the first surgery. Much better!

[Maria]

I may have misunderstood as well. Thought one surgery planned for 5/18 was fusion and second surgery to be ADR 8 weeks later at L5S1.

Maybe you meant ADR at L5S1 and surgery later at L4 if necessary?

Or maybe I just got it confused completely.. if so, my apologies!