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Old 07-19-2011, 07:49 AM   #1
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Decision - L4-S1 Fusion or wait?

Greetings! I've been reading the boards here for sometime, gathering as much info as I can to assist me in my decision making. Here's a down and dirty of my condition.

Original injury was 12 years ago, diagnosed as a lumbar ligament strain. Treated with anti-inflammatory and muscle relaxers. Several episodes over the years where pain was caused by overworking and not watching posture while moving heavy object. Self treated with ibuprofen but never got complete relief.

Fast forward to 2008. While working out, I ruptured the L5-S1 disc but didn't know it. Since I had felt pain there before but never saw relief from self-treatment, I was convinced by a coworker to see a Chiro ([B][U]bad idea!!!)[/U][/B]. They did some manipulation and stim but the pain got progressively worse. Once I started to get numbness and tingling in the right leg/foot I figured it was a good time to see my regular doctor. They noted that I had previous issues with my lower back so they decided to send me for a MRI. The MRI confirmed DDD in the L4-L5 and L5-S1 discs and a rupture of the L5-S1 that was compressing the nerves. I had a micro-discectomy done to remove the offending disc material. The pain and numbness was gone and I felt much better. During the course of PT, I was never able to get to feeling 100%. After consultation with my neuro, he referred me to a PM doctor.

The PM did several injections to see if they offered any relief. The first injection felt good for a few days so they did another. That one lasted about a day. After another, I felt no relief. They decided to try a different location for the injections. 3 more series with no change. At this point, we decided to try RFA on the nerve roots to see if that would afford any relief. I was told it could take several weeks before seeing any improvement, but it never materialized. After several months and several PT's, I returned back to the PM to discuss my options. It was at this time that they prescribed Gabapentin for me and I got some relief from the major local pain. But I still was having pain radiating into my upper leg and would sometimes flare up down the whole leg. I had another MRI and they did another series of inter-laminar injections to see if that would calm the pain down. Needless to say, it did not.

At this point, the PM, neuro and I decided to get a discogram done to see if the pain was from the discs themselves. I didn't read the report from the procedure, but the PM told me in the recovery room that the bottom 2 discs were painful. This is where I sit today...

After reading numerous other stories of peoples back issues, I'm at a point where I need to decide if I have the fusion done or not. While my pain is not completely debilitating, it is still painful enough that it consumes a large portion of my day and I feel it's affecting my work and home life. I'm wrestling with these facts and the fact that a 2 level PLIF is a serious procedure. I worry about the recovery, both in length and pain. I also worry what effect the recovery will have on my family. Having a 2 year old daughter that I wouldn't be able to pick up or play with, and a wife that would have to take over a large portion of the home duties while I recover...

Any insight, ideas, wisdom, warnings, etc. would be greatly appreciated.

PS - Sorry for the long winded introduction, but it felt good to vent a little about my condition. Sometimes I feel like I'm whining when talking about it with family/friends...

 
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Old 07-19-2011, 09:01 AM   #2
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Re: Decision - L4-S1 Fusion or wait?

Sundedo:

I was in almost exactly the same position you describe just a few weeks ago. I had been suffering back and leg pain for years. It was keeping me from doing many of the things I wanted to do with my family and friends, but it was something I could live with. After much thought and discussion, I decided to have the L4-S1 fusion using the MIS tlif procedure.

Today marks the four week anniversary of my surgery. My back pain seems better, though it comes and goes. I think it might improve as time goes by(the incision pain is virtually gone -- just a little tenderness). However, my legs are in much worse shape right now. The numbness and parathesia have greatly increased. The worst part is my left leg, which was the one that gave me very little trouble. I know suffer from foot drop, which may be permanent. If so, I definitely made the wrong choice. Even if my pain eventually lessens or disappears completely, it won't be worth the sacrifice of my ability to walk normally or run, jog, play touch football, etc.

Things may clear up for me, but it doesn't look great at the moment. If I could go back, I'd not have the fusion. If I regain full use of my leg and the pain gets better, then I'd be a happy guy. I hope that happens.

So, my advice is this: Don't have the fusion unless life isn't worth living the way you are now. It's a major surgery with big risks and a long recovery period. If you can't enjoy life in your present condition, then it might be worth it to take the chance. Just be sure that things are really as bad as they seem. Sometimes the alternatives don't really seem important until they happen to you. Once you have this surgery, there'll be no going back. Make sure it's worth the risks. You can search around and find the postings describing my story from the place you are now to the point where I now find myself.

If you have any questions or concerns, I'll be happy to do what I can to help you out. My thoughts are with you as you make this difficult decision.

 
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Old 07-19-2011, 10:21 AM   #3
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Re: Decision - L4-S1 Fusion or wait?

Bracer-

I just finished reading your story and it's quite similar to my own. While I find myself to be somewhat pain tolerant, it still keeps me from doing many daily activities. The biggest example would be walking. Any extended walking, other than say from the car and what not, causes the pain to flare up to the point that I can't do it anymore. Then there's the getting in and out of the car, on and off the couch, in and out of bed, etc...

But again, reading other's experiences gives me pause in having the surgery done. Sometimes the pain doesn't seem as bad. But other times it's enough to just beat me down. Could I wait to have it done? Sure. But how long and do I risk complicating my situation in doing so? These are the things I'm wrestling with right now.

I hope for continued improvement in your recovery!

 
Old 07-19-2011, 01:17 PM   #4
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Re: Decision - L4-S1 Fusion or wait?

Thanks for the good wishes. I'll take all the help I can get!

In reading your post, I see you mention potential complications from waiting. That can certainly be a determing factor. Has your doctor mentioned there being a danger in not having the fusion right away?

 
Old 07-19-2011, 02:44 PM   #5
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Re: Decision - L4-S1 Fusion or wait?

My neuro hasn't said I MUST have or MUST wait. He really left the decision up to me. He did say that the pain will most likely continue to get worse due to the disintegration of the L5-S1 disc and further degeneration of the L4-L5.

When I speak of making the situation worse, I mean possible nerve/bone damage that will be more painful and require a more extensive procedure. I'm already getting some bone grinding/popping in the L5-S1.

Last edited by Sundedo; 07-19-2011 at 02:44 PM.

 
Old 07-19-2011, 04:05 PM   #6
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Re: Decision - L4-S1 Fusion or wait?

If your read through Bracer's thread when he was trying to make his decision, you will have read what I wrote to him.

If back surgery came with a guarantee that it would turn out well and resolve all issues, or if you had a crystal ball and could tell whether you are causing further nerve damage by waiting to decompress the nerve, the decision would be easy. But, alas, no such luck.

I won't go into my spine surgery history here, but I wanted until I could not walk to the mailbox at the end of my driveway to collect my mail, and I could not stand long enough to quickly chop an onion. I finally decided to risk a third surgery when I had bought expensive tickets to see a favorite singer I had always wanted to see in concert. As the day approached, I realized it was impossible to go. Even if my husband dropped me at the door to the arena, there would not be a place to sit while I waited for him to park the car and return to me. I'd have to stand in line to get my ticket taken; it would be a long walk to my seat....What would I do if I had to use the restroom during the concert? It would be too far to walk....so I gave the tickets to a friend and decided to proceed with surgery.

I told this story to another patient in the waiting room of a treatment office.
She looked at me like I was crazy and asked why I didn't buy a wheel chair. That had never even occurred to me. I knew there was a procedure out there that stood a good chance of resolving my problems and I was going to try it rather than have to go everywhere in a wheelchair.

Every surgery is a gamble...and, as Bracer said, you have to try to weigh the risks vs. the advantages....Sometimes this opportunity doesn't present itself. Sometimes surgery has to be done. But for most spine surgeries, it is considered an "elective" surgery...and that's what makes the decision so difficult.

If you wait, you will probably get to the point where you feel you have no choice but to take the chance and have surgery. It is rare that a spine condition stays the same without worsening as the patient ages.

Just be sure that you understand that spine surgery will not restore your back to where you were before the onset of injury or pain. You may be much better, you may be somewhat better...but you will not be "good as new." You will always have an altered spine and you will need to make some adjustments in the way you move and go about your life.

I'm happy to try to answer any of your questions. I had a PLIF at L4-5,later a foraminectomy at L5 and my recent surgery a year ago was a three-level PLIF from L3 to S1 with reconstruction at L3-L4.

Consider all your options. Take your time in reaching a decision. Be sure you have found the very best spine surgeon that is available to you.

 
Old 07-19-2011, 05:58 PM   #7
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Re: Decision - L4-S1 Fusion or wait?

Teton,

I've read many of your reply's and they have given me lots of good information.

I know that no surgery will take me back to a healthy 30 year old. I also understand that each person and surgery is different. With so many factors, I only hope to gain some additional insight into other peoples decision process that I may be able to apply to my situation.

Perhaps my brain is in an overload mode. After reading soooooo much information in regards to my present condition and the different options and paths that can be taken, it really should just come down to: "Based on all the available information, will surgery give me the chance at an improved lifestyle?"

My logical brain says "Yes". As you said, it's rare for a spine condition to stay the same. So why not have it while I'm still healthy, the risk of complications is lower, and let's be honest, will probably be cheaper.

But my emotional brain says "Hold on a sec". What if my condition doesn't improve, or even gets worse after surgery? What type of advances are on the horizon that might negate the need for such an invasive procedure? Does my pain really rise to the level that it requires surgery?

After seeing this same decision being played out by so many here, I know I'm not alone in feeling this way. Again, as you said, most spine surgeries are "elective". Just how "elective" a surgery I choose or not choose is the question...

 
Old 07-19-2011, 06:39 PM   #8
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Re: Decision - L4-S1 Fusion or wait?

I'm in sort of the same boat....I have ddd and had 2 surgeries for extruded disc and now I have a slip and narrowing of the discs.....I don't know what to do either...pt didn't work (made me worse). I'm going to a dr in the city Thur for. 2nd opinion....I also have a 2 year old!! I wish u good luck!!!

 
Old 07-19-2011, 09:00 PM   #9
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Re: Decision - L4-S1 Fusion or wait?

Once you have the fusion, even if everything turns out perfectly, you then worry about the possibility of "adjacent disc disease," particularly when you are having more than one level fused. You may find, if you elect to have the surgery, that you are more careful about selecting what activities you will choose to do after you've gone through all this.

Some don't. There have been plenty of people on here who can't wait to get back to weightlifting, mountain biking, horseback riding, etc. So perhaps my age is showing...but I have modified my activities as I don't want to end up with the rest of my lumbar spine fused if I can avoid it!

The thing is...with DDD, you can pretty much assume that your discs are not going to improve...and once the degeneration starts, you end up with a lot of arthritic type changes that change the shape of the bone...which usually results in more nerve pain, not less. If you wait long enough, after a period of time the vertebrae fuse together naturally...so you'll see in medical literature where after " a certain age" DDD becomes less of a problem than it is in the 20s, 30s and 40s.

I agree with you that if you can hold out long enough, there will be some new solutions. It's just a matter of how long? I kept thinking that about six years ago, but in that time nothing has come along to replace a fusion. I even discussed the possibilities with my surgeon as he works as a consultant with two of the large spine "product" companies...and at least for my situation, there was nothing on the horizon.

You may find it helpful, if you have settled on a surgeon...and I don't know if you have made that decision yet, to make another appointment and go in and just talk with the surgeon, asking all these types of questions. I doubt he'll make the decision for you, but you should be able to get answers to most of your questions. This is one reason that consulting with several spine surgeons can be beneficial. Some answer questions better than others, and sometimes something you never even thought of to ask comes up in the conversation. I suggest you talk to both neurosurgeons and ortho spine surgeons as you may find a difference in how much surgery needs to be done.

 
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Old 07-20-2011, 05:10 AM   #10
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Re: Decision - L4-S1 Fusion or wait?

Thank you for the thoughtful response. It really did calm some of my worries.

While I was pretty active before the injuries, I know I won't be able to do all the same stuff as before. I'm ok with that. It's just the everyday activities that I would hope to be able to do without pain.

As for holding out, my interest was piqued by the thought of getting an ADR. When I discussed this with my neuro he told me flat out that he wouldn't do it. He gave several reasons, one of which is my age. Being in my lower 30's, there is a greater chance I would outlive the implant and it would have to be removed/replace or even just fused. Another reason was that ADR's haven't been proven to be any better than fusion.

The reason I was contemplating ADR was I figured, as many have, that maintaining mobility in the disc area would help to reduce the chance of issues in the adjacent discs. I brought this up with the neuro and he showed me a study that concluded that ASD (adjacent segment degeneration) is no more prevalent in patients who are fused versus those that are not. Since my L3-L4 disc looks normal and healthy on the MRI, I feel if I were to get fused, there would be no greater chance of it degenerating.

I am very comfortable with my surgeon, as he did my first discectomy. I think he sees that I am very informed on my condition and possible treatments so he doesn't try to sugar coat or blow smoke. With that said, I'm still considering getting a second opinion. But how long can that take and how hard is it? I have medical records scatters here and yon.

 
Old 07-20-2011, 08:08 AM   #11
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Re: Decision - L4-S1 Fusion or wait?

[QUOTE=Sundedo;4803700]My neuro hasn't said I MUST have or MUST wait. He really left the decision up to me. He did say that the pain will most likely continue to get worse due to the disintegration of the L5-S1 disc and further degeneration of the L4-L5.

When I speak of making the situation worse, I mean possible nerve/bone damage that will be more painful and require a more extensive procedure. I'm already getting some bone grinding/popping in the L5-S1.[/QUOTE]

But most elderly and many younger have discs which have degenerated fully and there is no disc space left at all and no pain. Disc degenration has little or no relationship at all to pain. Bone damage is often mentioned but I'm not sure where that takes place and is it relevant. Most with some fully degenerated discs have no nerve damage at all. Is it really true that the longer you wait if you have to have surgery that a proceedure will be more extensive or complex. I have several discs where the space is no more but symptomless. My only area that has painfull episodes is where the discs, that is in my lumbar area look intact.
James

 
Old 07-20-2011, 03:29 PM   #12
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Re: Decision - L4-S1 Fusion or wait?

That's just the point. I believe I am beginning to see some pain from some bone on bone. Add the fact that I also read that the bones can develop more spurs, or possibly fuse out of position, etc...

I'm waiting to talk with the neurological again to ask a few more questions. We'll see what comes out of that.

 
Old 07-20-2011, 04:10 PM   #13
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Re: Decision - L4-S1 Fusion or wait?

[QUOTE=Sundedo;4804562]That's just the point. I believe I am beginning to see some pain from some bone on bone. Add the fact that I also read that the bones can develop more spurs, or possibly fuse out of position, etc...

I'm waiting to talk with the neurological again to ask a few more questions. We'll see what comes out of that.[/QUOTE]

I think that's the best course of action. Make a list of questions and make sure you get them answered to the best of your satisfaction. Then, find another doctor and ask the same questions again. Yep, it's a lot of trouble to get second opinions -- but it just might be worth it. Please don't take any chances. If you need this surgery right now, then get it done by the best surgeon you can find and do it quickly. But if it can wait, then wait. Technology changes rapidly in the area of spinal fusion. And let your surgeon get a little more practice on some other patients before he gets to you.

 
Old 07-21-2011, 07:32 AM   #14
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Re: Decision - L4-S1 Fusion or wait?

I'm still waiting for a call back from the neuro, but in the mean time I had the PM docs office fax me over the discogram report. The symptoms and pain I'm having sort of make sense now. Here are some of the highlights I've gleaned from the report:

[QUOTE][I]L4-L5 discogram strongly positive for pain reproduction and is mildly degenerative
L5-S1 discogram strongly positive for pain reproduction and is moderately degenerative[/I]

From CT report:
[B]Vertebral bone [/B]- Small osteophytes at L5/S1
[B]Disc Spaces [/B]- Moderate space loss and vacuum phenomenon at L5/S1
[B]L3/4 [/B]- contrast extends toward left lateral margin likely secondary to annular tear
[B]L4/5[/B] - contrast diffuse secondary to degeneration with annular tears. Mild herniation consistent with previous MR. Mild joint hypertrophy with ligamentum flavum thickening noted. Mild narrowing of the central canal. Mild bilateral neural foraminal narrowing.
[B]L5/S1[/B] - Osteophytes. Broad based posterior disc herniation. Right paracentral disc component contacts traversing S1 nerve roots. These findings are new from previous MR. Moderate bilateral neural foraminal narrowing.

[B]Impression
[/B]Small broad-based central disc herniation at L4/5 causing mild central canal narrowing. Disc osteophyte complex at L5/S1 with superimposed broad-based central disc herniation, eccentric to the right paracentral region, with encroachment on the traversing right S1 nerve root.[/QUOTE]

I highlighted a bunch of sections on the reports so I can ask the neuro about them.

 
Old 07-22-2011, 09:34 AM   #15
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Re: Decision - L4-S1 Fusion or wait?

Just got off the phone with the neuro. He explained the reports, answered all my questions, and left me with a very good feeling. After reviewing the MRI's, CT, and discogram we determined that expectations are that a 2 level fusion of the L4-S1 discs would offer me the best chance at being pain free or greatly reduced pain. When asked about doing a discectomy on just the S1 disc, he said it wouldn't treat the majority of my pain.

We discussed the surgery (procedure, recovery, follow-up, etc.) and what I could expect going forward. As I said, he left me feeling better about the entire procedure.

Time to talk to the wife and finalize the decision...

 
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