To fuse or not to fuse

[annapurna]

Hello everyone,

I haven't posted for awhile, but have sure enjoyed reading everyones' threads - ya'll are great. I'm currently struggling with symptomatic facet arthritis at L5/S1 and at L4/L5. So far, radiofrequency neurotomy has not been successful, although, I might consider trying it again.

The annoying part of all of this is that I have a very well-placed Charite at L5/S1 that has done great for almost five years next month. Additionally, a discogram perfromed last month showed a nice, healthy, and pain-free disc at L4/l5.

So, the question for the group is whether it's time to give up on motion preservation and starting planning for a double-level fusion, or continue with pain management in hopes that something better will be developed soon. My pain is certainly not extreme right now, although it is definitely limiting.

My biggest concern with waiting is the lack of any promising new technologies for the facet joints. There are lots of different ADR's available, as well as dynamic stabilization devices, but nothing that specifically addresses the facet joints other than TOP's, TFAS, AFRS, and Zyre. I can't really see any really effective facet arthroplasty devices being available anywhere in the world for at least ten years (darn). Maybe I'm being too pessimistic?

Any suggestions? Thanks.

Best to All,
Laura

[Maria]

Laura,
I don't know really what level of pain you live with since my level of activity is so much less than yours and with medication I fare pretty well most of the time while not working, not sitting much, and not doing anything too strenous, really just walking for exercise tho good distances "for me."

Ok, to fuse 2 levels or not.. I know the way I'm going I may find myself at a 3 level fusion since I keep putting off surgery and maybe damaging surrounding structures but my fear with fusing several levels is this:

1) will that predispose L3 to problems even tho it's symptom free now
2) will you have SI joint probs once you've a 2 level fusion at L4-5 and L5-S1

I only know the reservations I have for myself with multilevel fusion is the same as this and even worried with just addressing L5S1 with fusion and L4-5 with ADR (leaving my disrupted but per 2 discograms symptom free L3 alone).

You see I feel the pain meds are worth it in terms of being able to function more comfortably. I certainly didn't expect to even reach this level of ease with the same level of pain meds and no recent ESI since last October.

This is after 6 years on same dose meds and ESIs that were given every 3-4 months up until the last one.

Waiting game or multilevel fusion/surgery... probably I'm not the one to ask as I'm so avoidant..

[annapurna]

Thanks Maria,

Your comments are always caring and insightful. I had totally forgotten about my symptomatic sacroiliac joint. It's almost as painful as the facet joints - and proveably so by diagnostic injections.

I also like your comments about the value of drugs in permitting one to function more fully. Right now, the "activities" that cause most of my pain are sitting at my desk at work and driving. Oddly enough, walking - and even hiking - tends to ease my arthritic symptoms. I feel very encouraged to give the stronger pain management drugs a good, honest try before I start to get "desperate" and think that I need to do something hasty. After all, I can quit taking the drugs, but I can't undo a double-level fusion.

Thanks again!!
Laura

[ans]

A: Another factor is that your pain mostly can be managed and that you are able to exercise which to me is a huge deal. I can't believe the distances you've ridden.

I also am concerned about the domino effect of a fusion and wonder if there can be a pre-emptive ADR put above the fused level to avoid disc degeration - at the beginning of the domino process.

Good luck - Allan

[Maria]

Laura,
It's none of my business although if you don't mind I'm just wondering what a normal day in your life is like and what type of exercise you are able to do, distances biked, hiked and so forth?

I only ask to try and get an idea of how screwed up I am!!!!

Today I went to work for my Veterinarian, I'm doing Accounts Receivable work on delinquent files and 4 hours of work standing and sitting was really beginning to bug me.. I wanted to lie on the floor for a few with knees to chest but since the Vet and others would walk into this office that houses 3 I decided against it.

At least I'm able to bring my dog with me... but realistically it helps me to see that I'm doing better than I used to be but so far from what my normal used to be. If I had a relax the back chair with lumbar and cervical support and things positioned the way I need them (like a quad almost) I think I could work well all day long.

I feel the need to be a biped tho~

** here's an addendum to my post~ Ok, I was at the Vet's office from 11a.m. to 3p.m. and stood much of the time. Took one doggie walk w/Lola so that was a break. Walked a mile plus last night and had 0 backache. But my neck is bothering me quite a bit. In fact, I have to keep moving my head and cracking my neck sort of... and my back feels pretty good this morning after my long walk last night!

[annapurna]

Maria,

I seem to be like you in that sitting and standing are painful, while walking and (for me) vigorous exercise can actually relieve or at least not cause pain. I've summarized my typical pain level vs. activity and duration as of right now:

driving a car: < 1 hour = 3-5, > 1 hour - 5-7
sitting at my desk: < 1hour = 2-4, > 1 hour 3-4
walking: < 1 hour 2-3, > 1 hour 0-2
standing: < 1/2 hour 2-3, > 1/2 hour 3-4
fast hiking on flat ground or downhill: < 1 hour 2-3, > 1 hour 0-2
vigorous uphill hiking with a pack: < 1 hour 0-2, > 1 hour 0-1

Unfortunately, in our automobile-intensive, automated world, we do lots of sitting and standing and very little walking. Because of this, I have lots of "functional" limitations in that I can't drive for much more than an hour, and have trouble sitting at my desk or standing around observing a process at work. On the flip side, crawling around under a piece of machinery at work, running up the side of a mountain, and spriting through the airport with all of my luggage on my back (in a properly-fitted pack of course) typically relieves at leat some of my pain.

Guess I'd do better as a "hunter-gathered" than an engineer.

Hope this gives you another point of reference in asessing your own situation. Maybe we're more similar than we are different.

Best,
Laura