Here we go! Just found out MRI showed Herniated Disc at L4/L5 with nerve impingement

[rutman]

Thanks for the comments Dale. Interesting! Dr. Beane told me if it had just been the slight bulging of L3 disc he would not recommend surgery, but here's the question to you guys and give opinions or what you know from experience please. You could definitely tell there was a problem at the L4/L5 disc with it ruptured and the annulus slamming into the nerve--I could see the problem without the doctor telling me when I saw the MRI with the doc. Okay he goes and does this laminotomy in that area should he not go ahead and do something with that L3 that appears to be bulging a little. Dale, you mentioned it lasting 8 years or so and then mentioned about another area - maybe L3, that became a problem a year later. I hope when he's in there he can fix that area too or can anything be done on just a bulging disc? Lastly, if he just does the laminotomy on the L4/L5 disc area and does absolutely nothing to the L3 disc bulged out am I looking at going through the same problem of that one rupturing if one has become fized and then I'm relying on another disc that may be questionable? I plan to tell him fix it all, but easier said than done and of course I'm not the doctor--I can't wait till this crap is over, but reading comments it may be going on for awhile. Please advise when you all get a chance and emjoy reading the responses for sure! THX! JB

[mmglobal]

I think that everyone will be surprised by this post. Here is a most important statement that Rutman made:

Originally Posted by Rutman

I can't wait till this crap is over, but reading comments it may be going on for awhile.

That's the most important issue in the discovery process that we go through. Too many people I see never get to that realization and they make the mistake of making surgical decisions based on wishful thinking. It may be electing to do too little surgery in spite of the fact that additional areas are demonstrated to be pain generators. It may be electing to do a huge surgery, hoping to 'fix everything at once', or because 'I only want to have to do one surgery.'

There are many reasons that go into these decisions and many of them are valid or even critical decision points, but each case unique too many times I see these decisions as clearly flawed. Often they are are correct, but often they are not even close to logical or appropriate. Leaving painful levels in place because your surgeon can 'only do one level now, but I'll be able to do more later if needed' is absolutely incorrect if the level that will remain is clearly incompetent and proven to be a major pain generator. Making that same decision is absolutely correct if the questionable level is still in pretty good shape and is proven NOT to be a dominant pain generator.

These same issues can be true for people who elect to do more rather than less surgery. Electing to do a 3 or 4-level fusion because the imaging looks bad can be problematic. While I know several people with successful 3, 4 and 5-level lumbar fusions, I also know the disasters. If your spine is a train-wreck at many levels, but there is high confidence that one level is THE MAJOR problem, electing to do surgery at one level instead of 4 may offer the best chance of success. However, without the confidence about one level being the major pain generator, perhaps more surgery would be the most appropriate decision.

These decisions must be made with the full understanding that that if you and your surgeon decide to do less and it works, he's a saviour. If you do less and it fails, he's a goat. If you do more and it works, he's a saviour.... There is no template... there is no other case that will tell you what to do in your case. Your surgeon's experience is an important part of the process, but more important than what a similar case was like will be getting the proper diagnosis. Watching this process take shape in so many different arenas is quite interesting and there is a huge difference between going into a surgery with a thorough diagnosis and clear understanding what what is happening; versus discovering after the surgery that a group of symptoms turns out to be unrelated to the operated area. The outcome may be the same in some cases, but in other cases, the surgical plan changes. Making decisions with more and accurate information is better, better, better. MRI's being denied because of cost may be important for the big picture related to the cost of health care, but it is frustrating when it comes at the cost of a proper diagnosis for an individual patient.

My discussion (above) is of the extreme cases and I realize that the original thread has to do with the prospect of less invasive surgery for patients who are not too far down the degenerative cascade. However, the same issues are involved. Many people look at my history and ask if I regret my 2 discectomy/laminotomy surgeries. "We make the best decisions we can with the information we have at the time." I'd do the same thing again in the same place. I do wish that I understood more about discogenic pain and discectomy results with leg pain vs. back pain. However, at my time in the process, skipping the discectomies probably would have resulted in a multi-level fusion (which may well have been a smashing success.)

Read about Anastasia's review of her case with Dr. Zeegers: here.
He reviewed every aspect of her case in excruciating detail. Like mine, her history includes 2 attempts a minimally invasive surgery that failed. Zeegers said that he did not see a flaw in the decision making process and that attempting to salvage the disc with less invasive surgery, avoiding more invasive surgery is appropriate when one is a good candidate. These decisions are not based on wishful thinking... one has to be a reasonable candidate.

I do not agree with Dale's statement that her prior surgeries placed additional stress on the adjacent segments. I suppose it's possible that if the structure and kinematics were inappropriate, adjacent segments will break down faster... but what was the alternative? We will never know the answer to many of these questions, but we do not know the time-line of what might have happened. Our discs are going to break down. ADR will not keep adjacent segments from breaking down, but it may extend the life of the adjacent discs compared to what fusion might do. Her statement about scar tissue may be correct, but again, what are the options. Looking back I don't think that more surgery earlier in the process would have been appropriate or even an option. For many of us, looking back with 20-20 hindsight it may seem that jumping straight to the maximum surgery would have been an easier path to get to the ultimate solution, but that does not mean that the decision process was flawed or that someone in the same situation should jump straight to more surgery instead of less. We do not see the people who have the successful 'lesser' surgeries because they go back to their lives and don't come here.

I'm glad that Rutman realizes that he may be in this for a while. That knowledge will help him to take his time, learn what he can, and make informed decisions based on a proper diagnosis and an understanding of the risks / rewards of all his options... not a decision based on frustration or wishful thinking.

Sorry for the long post... I hope this helps.

Mark

[sahuaro]

Mark:
Can you clarify what you were referring to when you wrote that ADR does not protect the adjacent disks (sorry, I haven't figured out how to do the quote thing)? Did you mean that if you have DDD, the ADR won't stop that--or did you mean that as with fusion, the pressures on adjacent disks will be such that they will eventually be damaged?

[mmglobal]

sahuaro,

I did not say that ADR does not protect the adjacent discs... What I did say was:

ADR will not keep adjacent segments from breaking down, but it may extend the life of the adjacent discs compared to what fusion might do.

DDD is a process that occurred in most of us without regard to our otherwise healthy spine. Each of us has degenerated discs that occurred next to healthy segments. ADR does not guarantee that adjacent segments will not break down. I predict that in the years to come, we'll see many disappointed ADR recipients as they still suffer from adjacent level disease. ADR will be a success if the number of people who suffer from adjacent level disease is smaller than the number of people who suffer from adjacent level disease in fusion populations.

>>> Fusion does not guarantee adjacent level problems.

>>> ADR may reduce the load on adjacent levels compared to fusion, but it does not safeguard against DDD at other levels.

Mark

PS, for quotes, enclose the quoted text in (quote)text(/quote) with the () replaced by []. Bold = (b)text(/b). You may also click 'go advanced' from quick reply and use advanced formatting tags. Hover over the button with the mouse to find out what they mean. Highlight the text you want to quote, bold, underline, etc... then click the button.

[sahuaro]

Thanks, Mark, for the explanation(s).
The issue of more/less surgery hits home for me, as well.