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Old 09-17-2012, 07:28 AM   #1
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Need some input - please!

Saw my surgeon today for a pre-surgery appointment. He had me get some "flexion?" x-rays, and another MRI before this appointment, about six weeks out from my surgery. Based on my one x-ray, he went from wanting to do a laminectomy/disectomy to a fusion. Sigh. I guess the one x-ray shows that my (I can't explain it properly) disc area doesn't move like normal people? I also have degenerative disc disease, etc. Past MRIs/myelectomy has shown S1 nerve compression (my main complaint is leg pain when standing that now has gone into my groin - is this normal?), and toes are number when I lay down. I have a disc herniation at L4-5. I don't have a lot of back pain. Just a tad when I sit for a long period of time.

I told him I wasn't comfortable with a fusion procedure. I am 36 years old. After a half hour discussion, he still agreed to do the laminectomy with the condition that a fusion might be in my future.

Here is my question: Would a fusion even help my leg pain? I know that is more a question for a doctor? But have many people here gotten a fusion for leg pain? I know he kind of wants to just take care of everything. The disc herniation, etc. But he went from a laminectomy a month ago, to a fusion.

I just don't think I can do such an invasive procedure at this point. I think I may want to go conservative. Any thoughts?

And if someone wants to share their experiences (if they had a lami first, fusion next, etc.), I am all ears.

Thanks in advance.

 
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Old 09-17-2012, 08:01 AM   #2
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Re: Need some input - please!

First of all, you need to understand that the flexion/extension X-ray was done to check for spondylolisthesis, which, apparently, you have. This is a condition where one vertebra slides over the top of the adjoining vertebra.

If you look at an x-ray of a normal spine, the edges of the vertebrae more or less line up (allowing for the natural curves of the spine). In a spondylolisthesis, you will see where it will look like there is an indentation. There are different causes for the spondylolisthesis. Sometimes it is congenital. Sometimes it comes along with the natural degeneration of the discs. It is not uncommon in young athletes who spend a lot of time with their backs in extension, like gymnastics, diving or dance...or in high contact sports like football.

Spondylolisthesis can be mild and cause absolutely no pain. It can be stable which means that there is no movement going on.

However, spondylolisthesis can also result in a spinal nerve getting pinched...and it can create instability in that segment of the spine. This creates unwanted movement which can get worse as the person ages...and it can result in nerves getting trapped.

At this point in technology, there is no way to stabilize a spondylolisthesis other than to fuse the segment so it can no longer move. Now, it may not be necessary to do it at this time...but eventually, chances are good that you will need it fixed.

It may be that the laminectomy will resolve your pain for now, but if your pain is coming from the spondylolisthesis, if the bones still have some "play" in them, it will eventually move enough that the nerve will be affected.

A fusion is almost always done because the patient has so much leg pain that he/she cannot tolerate it any longer. The reason you have leg pain is due to nerve compression that is occurring in your lower lumbar spine. You said the S1 nerve is compressed. Chances are the L4-L5 disc herniation is also compressing one or more spinal nerves which is also causing leg pain symptoms.

Each spinal nerve innervates a specific area of the body. For example, the L4 nerve runs in a particular pattern down from the lower back, slightly wraps around to the side-front of the leg, crosses over the knee cap and runs down to the big toe. The L5 nerve runs to the two middle toes and the S1, to the 4th and little toe. S1 runs down the back of the leg. Pain symptoms can happen anywhere along the pathway of the nerve, even though nerve irritation or compression is going on in the lumbar spine.

I would suggest that you get a second opinion from a different orthopedic spine surgeon or a neurosurgeon. You need more information before proceeding with any surgery...specifically how bad is this spondylolisthesis? (It is graded in quarters: Grade 1 is 1-25% slippage, Grade 2 is 26-50% slippage, Grade 3 is 51-75% and Grade 4 is the worst, 76-100% slippage.)

Since your surgeon allowed you to talk him out of a fusion, I'm guessing yours is Grade 1 which may be something you were born with and it may be stable. Grade 1 and 2 do not necessarily require surgery unless it is causing pain...pain that the patient is not able and/or willing to tolerate.

I had a similar situation when I made my first trip to the spine specialist. My PCP had assured me for a year that my pain was nothing serious. Finally I went to an orthopedic spine surgeon who immediately picked up on the Grade 1 spondylolisthesis that my PCP had missed. The spine surgeon told me that I didn't NEED surgery right away...but that if it got to the point where I couldn't tolerate the pain and it was affecting the way I lived my life, I would need a fusion. No other lesser surgery was worth doing because it would just be a temporary fix.

Every time you go in for a procedure, you open yourself to more risk...there is always the risk for infection. Then the risk of things like development of scar tissue, and things like RSD or even arachnoiditis increase the more times the same area of the spine is operated on. So there are some valid reasons for trying to avoid multiple surgeries if possible.

Since fusion is a big surgery it is important to get more than one opinion as to its necessity.

 
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Old 09-17-2012, 08:18 AM   #3
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Re: Need some input - please!

Thank you so much. Very useful. I have gotten three opions prior to going to this pre-surgical visit. This one was a kick in the teeth though. Thought I would/was always consideirng the lami, and now I have to think of having a fusion done.

Again, you always give the most informative advice. Thanks again.

 
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Old 09-17-2012, 09:15 AM   #4
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Re: Need some input - please!

Teteri,

Got my x-ray report to give you an idea. No "Grade" is indicated, but here is what it says:

"Lateral views, in neutral, flexed, and extended positions, show the lumbar vetebral bodies to be normal in stature and alignment. The L4-% disc space is mildly narrowed. The other disc space are normal in width. The bones are normally mineralized. No instability is evident between flexion and extension, although range of motion is limited."

So, not sure...

 
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Old 09-17-2012, 09:35 PM   #5
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Re: Need some input - please!

Well...that doesn't sound like you have spondylolisthesis. I think it would indicate if you did and this says the vertebrae are in alignment.

No instability is evident between flexion and extension, although range of motion is limited."

So you're not very flexible, but your spine is stable.

This report doesn't explain (at least to me ) why the surgeon recommended fusion. I jumped the gun and assumed it was due to spondy, but that doesn't appear to be the case.

I think you need to speak to him again and find out why he recommended fusion.

 
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Old 09-18-2012, 06:43 AM   #6
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Re: Need some input - please!

Quote:
Originally Posted by teteri66 View Post
Well...that doesn't sound like you have spondylolisthesis. I think it would indicate if you did and this says the vertebrae are in alignment.

No instability is evident between flexion and extension, although range of motion is limited."

So you're not very flexible, but your spine is stable.

This report doesn't explain (at least to me ) why the surgeon recommended fusion. I jumped the gun and assumed it was due to spondy, but that doesn't appear to be the case.

I think you need to speak to him again and find out why he recommended fusion.
My guess (and only a guess) is that to avoid delaying the inevitable? I keep reading that the laminectomy CAN comprise the stability of the spine. I also have deg. disc disease at L4-5 and a bit of stenosis, so maybe he is just trying to avoid all kinds of surgeries for me? As I said in a previous post, he will do the lami/disectomy, and of course, I will tell him, and he will do the least invasive amount he has to do to get rid of my leg pan, but that is all my guess.

Thanks again.

 
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Old 09-18-2012, 07:03 PM   #7
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Re: Need some input - please!

I just had a fusion. I suggest a second or third opinion, see different types of drs but be prepared to get different opinions, at least I did. I am THRILLED with my fusion. I wanted to die from the leg pain pre-op, I'm SO much better now, I have no regrets except I wish I did it years ago when told rather than waiting until now, when I seriously injured it worse. Good luck!
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Last edited by moderator2; 09-19-2012 at 05:50 AM.

 
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Old 09-19-2012, 07:08 AM   #8
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Re: Need some input - please!

Quote:
Originally Posted by workinmom572 View Post
I just had a fusion. I suggest a second or third opinion, see different types of drs but be prepared to get different opinions, at least I did. I am THRILLED with my fusion. I wanted to die from the leg pain pre-op, I'm SO much better now, I have no regrets except I wish I did it years ago when told rather than waiting until now, when I seriously injured it worse. Good luck!
Thanks for your reply. Here's the thing, I got three opinions - two from neuros, and one from an ortho, all suggested a lami. Then, I go in for my pre-surgery appointment after some pre-op testing, and he changes his mind from a lami to a fusion cause of an x-ray. However, I don't have instability according to the x-ray. So, I guess I start all over and get more opinions?

Threw me for a loop.

 
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Old 09-19-2012, 03:48 PM   #9
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Re: Need some input - please!

I've only recently had a double.fusion so I am not able to answer, but many on here have had multiple.procedures who should reply whe have had both done, etc that can give you more to think about. Good luck in.whatever you choose!
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