Considering 3rd surgery – Minimally Invasive vs. Open ?

[Tim]

Hi all
I'm looking for some advice/opinions..
I’ve had 2 previous spinal surgeries:

1988 – 3 level laminectomy + decompression; L3-S1
2003 – 2 level ADR (Charite) L5/S1 & L3/4 – Dr Zeegers

In 2003 my pre-surgical discogram at the L4/5 level was apparently negative and although extremely degenerate was not operated on but left sandwiched between the 2 supposedly correctly operating ADR’s. Since this surgery I have suffered from continuing back and increasingly leg pain. In 2005 I had facet injections at all 3 levels with no effect presumably therefore ruling out facet involvement.
2 weeks ago I had a repeat discogram at the L4/5 level. The result was again technically negative but the disc was so degenerate that it could hold no pressure – the dye simply poured out as quickly as it was pushed in.
My consultant says this level is completely knackered and has recommended fusion at the L4/5 by means of minimally invasive TLIF with BMP + rods and screws. Interestingly although the discogram did not (at the time of injection) replicate my symptoms, from about 3 days out I started , and continue, to have a rough time – my leg pain has been particularly exacerbated. Whether this is due to the leaking dye or is a delayed response from my ‘fried’ disc I don’t really know but the consultant did seem to regard it as relevant..
A second more local consultant has also recommended TLIF at the L4/5 but this time by a more traditional open procedure TLIF with combined PLF + rods and screws and my own donor bone from hip with no BMP.
The first guy recommending the minimally invasive approach with BMP is 4 hours car ride away while the 2nd guy recommending the open procedure is only a half hour away. My question is basically do you think the theoretical advantages of the minimally invasive procedure combined with BMP warrants the lengthy post-op journey (I am planning on travelling laid out on the back seat and am worried if this will even be possible post-op!?)
The minimally invasive guy has basically guaranteed me fusion by 3 months while the open procedure guy is less optimistic but still thinks solid fusion should be achievable within 6 months.. Both have pointed out that the procedure is very unlikely to make me pain free. The minimally invasive guy said there is a 60% chance that he can halve my pain (not the best odds). The open procedure guy didn’t want to give me any figures but said he was hopeful the procedure would help. Both thought given no major complications they shouldn’t make me any worse – funny I think I’ve heard that somewhere before!!
I must admit I'm tempted by the minimally invasive approach – less muscle/ligament cutting and therefore supposedly a less painful recovery.. I am however worried by such a long post-op journey. I can’t understand why the 2nd guy doesn’t use BMP – everything I’ve read seems to suggest this greatly aids fusion. Basically on questioning he said he regards your own bone taken from the hip to be the ‘gold standard’.. I am also a little unsure as to the advantages of the additional PLF procedure as recommended by the 2nd guy – I'm guessing this is a sort of’ belt and braces’ approach to try and ensure fusion occurs.
As far as I can gather from my research both surgeons are well regarded in the patient community and by their peers although one is quite obviously more cutting edge.

Any thoughts on which procedure I should choose would be appreciated..

Money shouldn’t be the decider here (which is why I’ve placed this right at the bottom of my post..) but I might as well mention that the minimally invasive TLIF will cost me between £13-15,000 while the open approach will be free on the good old NHS (Yep you guessed it I'm in the UK). I can’t really afford the former option but as this is my third surgery it’s kind of last chance saloon and I just want to get it right.

Of course the other option is to leave well alone and put up with the limitations (too numerous to mention but with which I'm sure you’re all familiar) and the pain..

Wishing you all a pain free day.
Tim