Fusion vs MicroDiscectomy with normal disc height

[longroadahead]

Was already to schedule the microdisectomy but now the dr is recommending fusion (MI TLIF) over microdisectomy after first recommending the microdiscectomy first.

The MRI for L5/S1 shows a 4mm annular disk protrusion but with a superimposed 8mm right paracentral disc extrusion disc extrusion resulting in a slight displacement of the right nerve root sleeve.

Not exactly sure how a extrusion can be superimposed on a protrusion???

My question is wouldn't both a microdiscectomy and fusion take care of the disc extrusion since I have normal disc height? Wouldn't it make sense to try the microdisctectomy first?

[dshobbies]

You’ve asked a very important question.

First, you don’t move too much from the S1/L5 space so a fusion wouldn’t affect your movement too much. Some claim to not even notice the difference.

You should also be aware that a fused disc places a burden on adjacent segments, in your case, L4/5. Since you don’t move much from S1/L5 the burden may not be enough to cause further degeneration – or it might.

A discectomy also compromises a disc. It is forever altered and can also place a burden on adjacent segments causing further degeneration at both S1/L5 and L4/5.

Most of us with fusions and ADRs started with discectomies. Failed discecomties are quite common. I also believe, and this is coming from a perspective of absolutely no medical expertise, that scar tissue can hamper an ADR but not so much in fusions.

So, IMHO, I’d start with a discectomy. It is less invasive but you must be aware, it may lead to a fusion or more. Your back, your choice.

You should also know your choice of doctors is an equally important decision. Most of the time, you have one chance to get it right.

Good luck, Dale

[cp7959]

I don't understand why a surgeon chooses Fusion over microdiscetomy as well. From the many medical WEB sites I have read if you have an annular tear the preferred surgery is fusion or ADR.

I don't really understand because if you have a herniation with an extruded disc, other than the fact of disc materiel extruded with a herniation, both have a hole (tear) in the disc. So why is a microdiscetomy OK with a extruded herniation or non extruded and a fusion for annular tear?

Yes there are other solutions out there, but the vast medical community is supporting fusion or ADR as the standard.

My surgeon explained to me that with an annular tear, if you do a microdiscectomy the hole is still there, isn't that true with a microdisectomy for a extruded herniation? Maybe with an annular tear it comes done to having DDD and it's ability to heal, versus a normal disc with a herniation?

Got me any one have the answer?

[Maria]

What I wonder about is the case that has good disc height and perhaps could have endoscopic discectomy with annuloplasty and the chance to be well with a rather minor surgery compared to something more involved even in the scope of discectomies. I realize there are probably few skilled surgeons performing this surgery and maybe few patients that fit the criteria for it however when I hear the word fusion first I tend to think "nuh uh."

Sometimes people do well for a while with discectomy vs. skipping to a fusion which might sooner set them up for adjacent level problems (even tho I think a discectomy might as well). Sometimes fusion is probably the best option (maybe ADR?)...

I really believe that sometimes we just cannot tell what will happen until it happens so it's difficult to predict which surgery is going to bring about the problems sooner. Maybe a fusion even at less mobile L5S1 would bring about it's own set a probs for a person even if it's thought to be the better surgical option. Mabye an ADR as well.

If one has enough time to get the surgical consults and go with whomever he or she thinks makes the most sense to them and gives them the best realistic opportunity for outcome then go with whomever that is and hopefully the consensus might lean towards that direction although definately not always.

What I don't like or think works are multi level discectomies at the same time. One level perhaps is Ok. Hopefully the level above doesn't have prob then gain doesn't mean they wont develop and again I'm sure much depends on surgical technique/skill plus patient's aiblity to recoup/healing abilities). I had one at L5S1 and another one (different technique) several years later at L4.

BTW I'm glad I haven't had a fusion yet and did have discectomies vs. multi level fusion. It gave my body a chance to autofuse at L5S1. Long wait tho glad I did.

[mmglobal]

If posterior annulus is so severely compromised, it may make sense to jump to the more invasive surgery rather than to first try something that stands little chance of success (because the disc is so severely compromised.) However, saying 'good disc height' seems to imply that the disc is not too severely degenerated.

With the average local surgeon, the only treatment options will be 1. nothing (conservative treatment), 2 discectomy, 3 fusion. There are other treatment options available that the average surgeon might not consider. Annular repair devices, posterior stabilization, various types of thermal annuloplasty (with discectomy) hold some promise, but its hard to know where to turn.

The problem with this decision making process is understanding how much to fear fusion. Obviously, there is huge motivation to develop alternatives to fusion, but one spine surgeon will be so very casual about lumbar fusions, while another will be adamant about not doing fusions for pain.

Tough choices.

Mark