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Old 10-16-2006, 10:41 PM   #1
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Question Anterior or posterior? Laminectomy or Discectomy?

Hi, I'm a newcomer to HealthBoards. After months of experiencing chronic symptoms of persistent tingling/pain and atrophy/weakness in my upper right arm/shoulder, I went for cervical spine X-rays, MRIs, EMG and CT Scan and was diagnosed by NS as having cervical spondylosis (multilevel degenerative disc disease), myeloradiculopathy, loss of normal lordosis, multilevel bone spurs, osteophytic ridging, facet hypertrophy, severe multilevel foraminal narrowing, spinal stenosis and myelopathy.

As if my life isn't complicated enough already, I now have four different NS recommendations on what procedure I should have: (1) Posterior bilateral hemilaminectomy with foraminotomy at C3 through C6 without fusion (2) Anterior cervical discectomy and fusion from C3 through C6 or possibly to C7 with instrumentation (titanium plates) and inclusion of bone morphogenic protein (3) Posterior cervical decompressive laminectomy and foraminotomy (also C3 to C6) with lateral mass plate fixation and fusion with local bone from laminectomy (4) Posterior cervical decompressive laminectomy and foraminotomy (from C2 to C6 possibly to C7) with instrumented fusion of facet joints (with rods?) and somehow using bone marrow from my spine.

I'm trying to choose between these different anterior and posterior approaches but I want to learn more about the relative pros and cons or risks and benefits, so I'd really like to hear from board members who have either direct experience as patients or other in-depth knowledge of these approaches/procedures.

Anterior or posterior approach? Laminectomy or discectomy? Fusion versus no fusion? Future problems with discs above or below? Best source of bone fusion material? Which approach is most often used currently? Which gives the best results in the long term in terms of relief from neurological symptoms with the least risk, pain, complications or loss of mobility?

 
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Old 10-17-2006, 08:50 AM   #2
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Re: Anterior or posterior? Laminectomy or Discectomy?

Ghost13 -

Sounds like you have a lot going on and docs are recommending fusion in either case.

I had a choice between docs recommending ACDF (front) and laminectomy (rear) for spinal stenosis C4-C7. I choose the doc with the rear approach partially because he was better at explaining stuff and partially because for me it made sense. I was nervous about long term affects above and below with the ACDF approach and range of motion, etc. but with fusion you will have these issues anyway. The negative with a rear approach is that they do cut into the large muscles so it does take a while to regain upper body strength -- I was surprised that I wasn't able to read in the hospital after surgery because I couldn't hold the book. Hubby had to help me dress and shower for the first week, but actually it healed faster than I thought.

Good luck deciding.

-Gloria

 
Old 10-18-2006, 08:34 PM   #3
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Re: Anterior or posterior? Laminectomy or Discectomy?

I believe anterior is less invasive than posterior, so there's less recovery time. I personally would consider anything NON FUSION before going the fusion route. Once they've removed the discs and fused the vertabrae together, there's no going back.

Somewhere in the next 5-10 years artificial disc replacement should become pretty standard practice. You'll have eliminated that option if you choose the fusion route....

There is the ADJACENT LEVEL THEORY, that I believe says once you have fusion done at one level, you increase the chance of needing it at levels above or below it, as the fusion places more stress on the remaining discs.

I had a two level anterior discectomy WITHOUT fusion at C5-6 and C6-7 eight weeks ago. It was done endoscopically, so I barely have any scar at all. When I say barely, I mean the scar is less than half the width of my pinky finger.

I have considerably less pain than I had pre surgery, although it is still a little early to tell if the surgery was an absolute complete success. And the pain that I do have now is more like a muscle soreness then it is the unbearable arm/neck pain I had pre surgery...

I wish I was further along in my recovery so that I could say hands down, absolutely without a doubt I AM COMPLETELY HEALED!!!! Still holding my breath...

In my opinion, for what it's worth, I would again consider any and all options that did NOT involve fusion first...

best of luck

BW

 
Old 10-18-2006, 09:06 PM   #4
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Smile Re: Anterior or posterior? Laminectomy or Discectomy?

Hi BW, This is just the kind of advice I was hoping for! I'm also very interested in the potential for artificial disc replacement and endoscopic/arthroscopic minimally invasive spine surgery, but I don't know how long I can wait or if I have problems at too many levels. I'm also very concerned about the adjacent level theory since I've heard from so many patients that it seems to hold true.

Did you have any neurological symptoms other than pain prior to surgery? Did you also have a foraminotomy done? I'm curious to know if you had two discs removed without fusion what was put into the empty spaces and how did they maintain stability? Also where did you have the endoscopic surgery done and by which surgeon? Was it done as outpatient surgery? Did you have to wear a neck brace after?

Look forward to hearing from you.

 
Old 10-19-2006, 12:20 AM   #5
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Re: Anterior or posterior? Laminectomy or Discectomy?

I would like to add a few piece of info and ask a couple questions.

1. That's a lot of levels being worked on - did you research the results of the history of hemilaminectomy with foraminotomy procedure? Is there any long term data on patient outcomes? Haven't seen many people post here on Hemi procedure in the cervical levels.

2. Don't worry about incisions, they aren't that big anyway.

3. Your diagnosis is complicated. My situation is very close to yours. I would recommend you go with doc with the most aggressive attitude with lots of experience. The reason I say this is that you can go too conservatively and end up doing multiple surgeries. I regret that I didn't go big the first time. I wish I had not been so afraid to listen to the surgeon.

4. There is data to go both ways that fusion does/doesn't affect your ultimate outcome for adjacent disease. Some researchers believe you would get it anyway when you are a complex DDD case. If you do all those levels wouldn't that eliminate the possibility of "adjacent disease"?

5. Question to BW: in a ACD without fusion, even though the surgeon doesn't use a bone graft to fill in the space left from the ACD, over time doesn't it fill in? I think i heard it fills in with scar tissue? What long term complications are known? I also think I heard its more appropriate for single and two level surgeries?

6. I am fused C4-7 and don't really notice any loss of range of motion, its trivial .

Finally, you asked for our experience. All of us here are laymen, sharing experiences, but we are a very small percentage of the total population of people that have spine surgeries. Pick the best doc and go with their recommendation, it sounds like you have 2 opinions that are very similar (#3 and 4) I would zero in on those. ACDF is the most often performed and what most say is most conservative. It might not open enough space up for you - I went that route and wish I had done it with the lami. Not sure which problem is compromising your cord, make sure you attack that problem.

 
Old 10-19-2006, 05:00 AM   #6
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Re: Anterior or posterior? Laminectomy or Discectomy?

lots of good advise given here. i am glad i found this post. my spine specialist mentions surgery then says lets wait. i think it;s becuase i am a WC injury and they wait as long as possible. dr. said my neck will have to be watched for life. have 3 luged disks, some stenosis, has effected soth arms an hands somewhat. the problem seems to be this large bone spur indenting my spinal cord and i believe a pinched nerve at the C7. dr. hasn't discussed what type of surgery he's talking about at this point but i would like to avoid fusions if at all possible as i have read and read where arthroscopic surgery to remove disks is usually takes care of spur problems. i have also never read where fusions don't cause other problems in the future with more surgeries down the raod. scares the daylights out of me to have one surgery and then another and then another.

 
Old 10-19-2006, 09:51 AM   #7
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Smile Re: Anterior or posterior? Laminectomy or Discectomy?

Hi neckpatient, Thanks for your input.

1. No I have not really researched the results of the history of hemilaminectomy with foraminotomy procedure and long term data on patient outcomes, other than do a quick Google which didn't bring up much that seemed relevent. Are you talking about going to the library and reading Journals of Neurosurgery for example, or how would you go about that kind of in-depth research? Do you have any resources or references you want to share?

2. I'm curious to know when you had your ACDF, what symptoms you had before surgery and if you still have symptoms. You say you had a C4-7 ACDF but imply that your surgeon wanted to be more aggressive - what procedure would that have been - posterior approach with laminectomies, foraminotomies and fusion, more levels or what exactly? Why did you decide against a more aggressive approach? Did you get more than one NS opinion? Do you now think you will need a laminectomy done sometime in the future, as it sounds like you still have issues?

3. My biggest concern with being aggressive is that I would close the door to future opportunities for artificial discs and perhaps the chance for a better long term outcome, as I hope to live many more years with this old neck and don't want to live in pain or be immobile. If I could get away with arthroscopic minimally invasive surgery (laminotomy and foraminotomy without fusion at just two levels) then that's a very tempting option. Then in future maybe I could get artifical discs?

 
Old 10-19-2006, 12:07 PM   #8
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Re: Anterior or posterior? Laminectomy or Discectomy?

ghost-

no foraminotomy done, not even sure what that is...

In my case- I had two herniated discs at C5-6 and C6-7 that were primarily causing INCREDIBLE pain in my RIGHT arm anytime I'd sit, stand or drive for too long. I also have bone spurs, but after a DISCOGRAM, the doctors felt it was the herniations and not the spurs that were causing my pain.

No significant numbness or tingling, just the throbbing pain primarily from my shoulder down to my elbow.

I had received relief via traction, chiro adjustments and massage therapy for almost two years. But eventually the herniations got to the point where nothing short of surgery was working.

I am 39 years old- not a young pup, but I hopefully have 30-40 years left to go- so I was reallllly apprehensive about fusion. Even after talking to several people who have found success with it. I just feel if there's any option where they don't have to actually REMOVE something, then it's worth trying, and doesn't eliminate FUTURE options...

In my case the ACD w/out fusion went like this- in my layman's terms. They went in through the right side of my neck and removed the NUCLEUS of the problem discs. They then lasered the herniations/tears shut. After that, they injected a platelet gel into the disc where the nucleus had been. The gel was used to basically PUMP the disc back up.

So they DID NOT remove the actual discs.

One of the negatives of this procedure is that they can't also remove the bone spurs. But again, the dr's felt they were not the cause of my pain. Time will tell I guess.

There too is a risk that the disc(s) could collapse, which could possibly then leave fusion as your only resort. I had a VERY SLIGHT COLLAPSE at C6-7 six weeks post op. The doctors explained it as basically like a tire that has some of the air let out of it. it still works, but it's not as strong as it once was. everyone as they age has some variance of collapse...they said further as long as the arm pain didn't return- which it hasn't- that it was nothing to worry about.

As for WHERE I had the procedure done and WHICH DR- Dr. Merrill Reuter, Advanced Orthopaedics of South Florida in Lakeland, Florida.

I live in TN, and I came across him, I believe, in another person's posting on this message board.

They charge $200 to review your MRI films etc, before determining if you may be a candidate for their procedure.

I want to emphasize that I'm STILL NOT 100% out of the woods, that I still get a little sore, and that I still get paranoid that it didn't work. But the people at Dr. Reuter's office have all said that's normal for another month or so...and further, they have been AWESOME in holding my hand through the entire process, and have been very accessible via email and phone contact.

For now- I feel a whollllllle lot better than I did before surgery. He was one of the few dr's in the country that I found that performed minimally invasive stuff AND was in network with my insurance. So it didn't cost me an arm and a leg. Plus it was a cheap flight on Southwest, and I had family in the area so I had a free place to stay.

For me it was totally worth it. If nothing else, it has given me substantial relief in the short term, and has bought me time until further advancements become the norm...

Oh- I was in a SEMI HARD neck brace for 3 weeks- I basically could only take it off to sleep. Cheated after the first week and took it off in the shower. I wasn't allowed to drive for 3 weeks. Then I switched over to a soft collar for another 3 weeks, and I was allowed to drive as long as I wore the collar. Now, no collar, no restrictions on driving or anything else- aside from using my judgement and taking it easy on doing any lifting...

Good luck in finding a solution...

BW

 
Old 10-19-2006, 01:53 PM   #9
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Re: Anterior or posterior? Laminectomy or Discectomy?

questions for all. i have 3 slightly bulged disks, some stenosis but it seems the problem in my neck is this large bone spur indenting my cord. with all the talk about fusions/no fusions i am so confused. i understand when a disk or 2 or 3 are the problem but it seems if the disks aren't there are no answers for bone spurs. i have read where there is no point in injections with spurs and that sometimes traction and PT will move them and reduce some inflamation. any advise? as much research as i have done i still come up with no answers when only spurs are the problem.

 
Old 10-19-2006, 08:21 PM   #10
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Re: Anterior or posterior? Laminectomy or Discectomy?

I'm no dr., but I thought spurs were caused in part by disc herniations. that they were the body's way of trying to "dam" the herniation or bulge. Maybe I'm wrong...

I was also told by one dr that esi's would not help if the pain was primarily caused by spurs. A different dr ordered a discogram and he felt that my pain was caused by the herniations and not the spurs. I went with his opinion and had the herniations addressed but not the spurs. I guess time will tell...

I'm not sure what type of procedure addresses spurs and nothing else, but I do believe if they go in to do a fusion, that they can remove the spurs as well.

I hope that helps at least a little. Good luck.

BW

 
Old 10-20-2006, 06:59 AM   #11
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Re: Anterior or posterior? Laminectomy or Discectomy?

I think BW's procedure is probably one of the "best" I've seen on these boards. I hope you continue to heal. I think we all fear the future and as hard as it is to do, we can't dwell on it. I told my doc I want to hit some tennis balls - he "hemmed and hawed" but the bottom line is that he is afraid I'd trip and fall - I'm just hitting casually, not reaching for the full court - obviously there's always a danger, but I think I'm just as afraid of tripping on the treadmill.

I think bone spurs can be dealt with either during ACDF or laminectomy but I'm not sure. Laminectomy or any postior procedure is a little more difficult to recover from because of the large muscles that are cut - but in my case it really wasn't that bad and by not doing fussion now, I still have that possibility open in the future if needed (and then perhaps artificial disks or a procedure like BW's might be an option).

 
Old 10-20-2006, 07:05 AM   #12
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Re: Anterior or posterior? Laminectomy or Discectomy?

thanks all----no one seems to have spurs being the problem. i see the spine specialist again the end of nov. and will have him explain if and when i need surgery what he plans on doing. i have read my cervical MRI over and over and it says mild bulged disks in 3 areas/ no herniations and it appears chronic. but there is large spurring at the C5-6 and to a lesser degree at the C6-7 with a possible pinched nerve at the C7. will be doing light PT until i see him and since the steroid injections mess my diabetes up if they won't do any good i will not do them. have had 2 in my ankle and 2 in my shoulder through this injury that have helped but from what i'm reading they aren't much help with bone spurs. don't intend to go on insulin since i am diet controlled at this point because of work injuries.

 
Old 10-20-2006, 01:52 PM   #13
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Re: Anterior or posterior? Laminectomy or Discectomy?

Question to BW: What kind of post-surgery follow-up (X-rays, MRIs etc) have you had and do you have to keep going back to Florida for any follow-up or is everything handled in your home town? What kind of strengthening exercises have you been doing to get your neck and surrounding muscles back to normal?

 
Old 10-20-2006, 10:28 PM   #14
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Re: Anterior or posterior? Laminectomy or Discectomy?

cervical xrays every 2-3 weeks to check for disc collapse. haven't had any mri's post op. xrays done in hometown, put on cd, then mailed down to fla.

very light strengthening exercises...mainly "passive modalities"- heat/ice, massage, ultrasound, etc.

again, I want to make sure that I emphasize ard that I'm not completely out of the woods yet, still too early to tell if the procedure worked 100% without a doubt. although I do have significantly less pain than I did pre op.

good luck

BW

 
Old 10-21-2006, 04:42 AM   #15
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Re: Anterior or posterior? Laminectomy or Discectomy?

Hi ghost, sorry i missed your question couldn't be on computer yesterday much. Answer to your question, sorry its long.

Pre surgery DX: congenital stenosis, herniated discs at 4-5, 5-6 with
significant osteophytes causing moderate right foraminal narrowing at multiple
levels, reversal of lordosis, spondylosis, degenerative disk disease with
movement on flexion, good above C4, C6-7 early stage ostephyte
ridging at C6-7. some effacement.

Pre-surgical pain: severe Right radicular pain, chest pain, blades, shoulder, arm,forearm, wrist. No neck pain. Some cramping/freezing forearm and numbness in middle finger. Go to emergency room and get knocked out kind of continuous pain.

Surgeries : one 12/04 ACDF C4-6 and second ACDF on 05/06 adding C6-7. Plating and donor bone and hard collars after for about 8-10 weeks.

Confirmed findings via EMG

First surgery opinions sought: 3 (1 ortho/spine, 2 NS) recommended surgeries: 2 (ortho and 1 NS) agreed on ACDF (clean up osteophytes and stabilize and fix lordosis) wait on 3rd level and stenosis till later. One NS recommended more agressive immediate treatment, posterior lami with acdf all levels same time.

I picked ACDF C4-6, Complete resolution of all symptoms by 8 weeks after surgery 1. Nine months later full symptoms returned including left side symptoms. This time Pain around 6-8 vs. 10 plus before first surgery.

After PT and injections, Second surgery opinions: 2 (1 ortho/spine, 1 NS) recommended surgery - same as first time. 1 said acdf, 1 said lami with acdf. My C6-7 continued to ridge. Because of success with surgery 1, I chose acdf again instead of the lami which scared me. And I was told I probably had future surgery within 10 years to deal with stenosis as I age. Body doesn't agree and now it looks to be within 12 months. Makes me
wonder if I had done Lami, with the 3 level ACDF procedure combined as recommended by 3rd opinion in the very beginning, maybe I would be in a better spot.

Pain has returned, more arthritic with routine bouts of severe radicular, chest, and blade pain. Stenosis is feeling worse and also causing problems. Finger numbness is improved but there, cramping is improved but there, I manage to stay stable by limiting activity, rest periods, drugs, and injections.

What I feel I learned from experience:

1. THe best pain management for the nerve root compression were cervical selective nerve root blocks, ESIs did nothing. SNRB Doesn't fix them, but does calm down the inflammation in there a bit.

2. BW noted some of info I know about bone spurs. The body grows bone spurs in reaction to the bulges/herniations. It can also be normal aging, from instability, movement, or the DDD and shrinking discs, the body trying to stabilize.

3. Artifical discs aren't going to make bone spurs better and even if they drill
spurs out, they can grow back. Who knows if they won't figure out how to reverse acdf's in the future anyway with inserting artificial disks. They can drill out bone spurs, etc. why can't they figure out how to drill out the fusion?
Ask doc about your ostephytes, are these significant or minor? Should you expect more based on what they see on MRI. Mine keep growing everywhere and they get big fast.

4. When you have so many problems you need to do something that
helps stabilize the neck.

5.

6. If you have ridge in central canal, lami is in your future i think they would tell you, even if you dn't do it now.

When comparing your case try to compare to cases that have similar
problems. BW is having a good experience and that is terrific. I will pray he has an outstanding outcome- but I don't think his case sounds like yours. BW has been good at sharing and also pointing out he isn't out of the clear. Advise that you don't convince yourself on a procedure based on a case that isn't like yours.

I've been around the board for 2.5 years, most cases that sounded like yours, did go the route of Lami and/or ACDFs. You can look in the old posts and read stories. Some are still here lurking, they don't post all the time.

Don't mean to offend anyone, BW you sound great. Just sharing what i experience and have read over time.

Last edited by HBMod07; 10-22-2006 at 11:56 AM.

 
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