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Old 09-01-2009, 01:00 AM   #1
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Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Hi, I am new to this forum.

My MRI shows that I might need two to three level ACDF.

Please advise on any new treatments other than ACDF eg artificial disc.

I have read that artificial disc works well for one level but not sure on two or

three cases.

Thanks for the kind attention and advice.

Regards,

frustratedlor

 
Old 09-01-2009, 11:03 AM   #2
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Look into a new surgery called a Laminoplasty that removes the bone over the back of the spine and reshapes it to make more room and then re-attaches it. Gives the room of a laminectomy but the safety of a covered spine after wards without all the problems that go with a fusion as no fusion is done.

Had it done on 5 vertebrae and it was remarkable.

Jenny

 
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Old 09-02-2009, 09:04 AM   #3
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Hi Jenny,

Thanks for the reply and the information.

I need help to understand my MRI report. Can you kindly help to explain it in simple and non-technical English to me ?

My MRI report says that

Multifocal enhancing lesions are noted in the cervical and throacic vertebral bodies with T2W/STIR hyperintensities and faint T1W hyper/iso intensities.

There is a straightening of the cervical spine with mild loss of the C4/C5 height.

At C4/C5, there is a central disc protrusion compressing on the cord and dsiplacing it posteriorly. High signals in the cord is noted, likely to represent myelomalacia. There is also moderate bilateral exit foraminal stenosis from uncovertebral OA

At C3/C4, there is posterior osteochondral bar formation which touches the cord anteriorly. Together with uncovertebral OA, there is right exit foramen stenosis.

At C5/C6, there is posterior osteochondral bar formation which indents on the cord anteriorly. Together with uncovertebral OA, there is severe right and mild left forman stenosis.

At C6/C7, there is posterior osteochondral bar formation which indents on the cord anteriorly. Together with uncovertebral OA, there is severe left and moderate right exit foramen stenosis.

My neurosurgeon recommnds the removal of two discs from C4/C5 and C5/C6 with ACDF. However, I am worried about the cons of ACDF eg fusion does not work. Recently, I have a dental surgery and a normal person's bone below the tooth will grow back within one to two weeks but it took me three months to grow back the bone. So, I am very worried whether my bone will grow back normally and the fusion will be good and complete after the ACDF.
Will the artificial disc replacement for two levels be as good as the ACDF for two level disc removal ?

In addition, I am a kidney patient. I cannot take many of the common and effective pain medications eg Diclofenac as these medications will have adverse effects on my kidneys. I can only take some pain medications eg codine, tramadol and pregablin and these pain medications can only be taken for a short period of time and these medications have many side/adverse effects too.

Thank you for your kind attention, advice and help.

With Warmest Regards,

Frustratedlor

 
Old 09-03-2009, 04:24 PM   #4
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

I'll post my interpretation here and you'll probably get someone else giving you their interpretation on the other post. We have a lot of knowledgeable people here so what I miss they'll fill in.

1st..the differing intensities of the bone is showing that your vertebrae are not as solid as they should be and you probably have some early osteoporosis. Your spine at the neck is losing it's normal curve and the vertebrae at C4-5 is smaller than usual probably due to arthritis.

Before starting the different vertebrae, a lesson in anatomy first. You have a disk between each vertebra sitting at the front side of the vertebrae toward your throat. The spinal cord runs down through a hole in each vertebra towards the back. On each side, there is an opening(foramen) where the nerves peel off the spinal cord(like a peeled banana) and go out to the arms or throat or head or where ever. A disk that ruptures through it's outer banding can rupture forward, sideways towards the nerves or backwards towards the spinal cord. Arthritis can affect the bone of the vertebrae anywhere but usually is at it's worst at the joints..facet joints on the back and the uncovertebral joints on the sides. So now, by the numbers...

C4-5-the disk had ruptured backwards and is pushing backwards so hard on your spinal cord that is has left damage to the spinal cord visible on the MRI scan. The place where the nerves exit the vertebra is moderately closed up by arthritis from the uncovertebral joints. This was put first as the cord damage is the most important finding.

C3-4-there is a bar like formation of bone spurs from arthritis touching your spinal cord on the front side of the cord and the arthritis in the uncovertebral joint on the right had caused the opening for the nerve to exit to be somewhat closed up.

C5-6-you have the same kind of bone spur formation here as well but this time it is making an indentation in your spinal cord. The exit holes for the nerves are again affected by arthritis in the same joints as above but this time it's severely closed up on the right and mild on the left side.

C6-7- almost the same situation with regards to your spinal cord here as in C5-6. The exit holes are again closed up but this time it's severe on the left and moderate on the right.

You need surgery. There is no mention of the width of the spinal cord but cord compression is a very serious problem that will eventually lead to paralysis. And where they have shown "severe" compression on the nerves, they too are at risk of paralysis(nerve death). An ACDF is the easiest of the spine surgeries to go through and produces the minimum amount of pain as spinal surgeries go. They remove the disks and fuse the vertebrae together with the aid of bone grafts, usually from a donor, enhanced with a product called BMP that speeds the growth of bone. Some people have reactions to BMP but it is treatable and makes the fusion take faster. And the bones are then screwed together with plates to make it even more secure while the bone grows. Once that is done, he can then remove the bone spurs touching the cord and open up the exit holes to free up the nerves.

If you don't have the surgery now, you will have to monitor any signs of loss of function and sensation in your body. Numbness, tingling, pins and needles sensations are the most common forms of loss of sensation. Loss of function includes weakness, muscles that don't work like they should(I was unable to move my legs forward very well and took baby steps), clumsiness in your hands, balance problems and the bad signs...problems with bowel or bladder function(not being able to go or can't wait). Those last 2 are an emergency as it can be permanently lost and greatly affect the quality and longevity of your life.

What is happening is that you are slowly developing paralysis either by the different nerves dying or your spinal cord dying from the compression causing the loss of blood supply. Once the blood supply is lost, you can't get it back. But the good thing is that it can take a lot of abuse before dying like that and you do have time. Ask just how compressed your cord is. The spinal cord should be between 11 and 12 mms wide. I was down to 6mms and still walking and I know someone here on the board who was down to 4mms and still kicking. But you are really taking a chance when it gets that compressed and my doc thought I was "urgent" but not an emergency. Another neurosurgeon thought I could wait a little longer. It's all up to the doc and you when to do the surgery. But I don't see anyway you are going to avoid it so you might as well do it ASAP rather than wait and risk further damage or permanent damage. I later broke 3 vertebrae in my neck and had to fight back from left sided paralysis and it is sooooooo hard. I wouldn't wish that on anyone. I will have to exercise those muscles forever and they will slowly get weaker and weaker no matter what I do.

Good luck and come back with any questions or just to say hello or give support to others. Many are going through the same thing as you.

gentle hugs............Jenny

 
Old 09-04-2009, 09:02 AM   #5
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Hi Jenny,

Thank you very much for your very helpful explanation.

Now, I understand my conditions much better.

I have my first MRI done on May, 2008 and I can hardly walk due to the pain in the legs, numbness of both hands, pain in left arm, numbness and loss of sensation of the left side of the body from chest down to leg, can no longer feel the urge to urinate ie I have to remind myself to urinate 2-3 hours later after drinking water, muscles too weak to push out the faeces. The neurosurgeon urged me to have the two levels ACDF surgery. I did not opt for the surgery as I am worried about the cons of the ACDF and the availability of pain medications for me as I cannot take NSAIDS pain medications as these medications will cause my kidneys to fail. Also, I am considering two other surgery methods ie

(1) artificial disc replacement surgery

(2) fusion of bones but with a special mechanism that enables some degree of flexibilities of the vertebraes ie ACDF with some modifications.

For some unknown reasons, my symptoms disappeared ie I can pass motion and urinate as per normal again, the legs pain are gone and I can walk again. I am fine for more than a year.

Suddenly (ie nothing unusual happens), some of the symptoms re-appear last month. I feel numbness in the left arm, wrist and hand especially the left thumb, lose some sensation too, stiffness of shoulders and back, drop things at times, slight right leg pain, right knee lose support suddenly at times.

I hear cracking sound of bone, when I turn my neck and when I turn myself on bed, coming from the back and the neck.

What could be the possible reasons for the disappearance and re-appearance of the symptoms in my case ?

I have bought my MRI results CD. Dear Jenny, can you kindly tell me where to look for the width of my compressed spinal cord in the MRI results. There are many tools provided in the CD but I do not know how to use them to analyse my MRI pictures in the CD. I only know how to see the different MRI pictures and zoom in and zoom out.

Please kindly advise also how to see the seriousness of the central disc protrusion in the MRI pictures.

The width of my compressed spinal cord is not written in my MRI report.

Another question is the differing intensities of the bone is showing that my vertebrae are not as solid as they should be and I probably have some early osteoporosis, should I ask the doctor for a test of the solidness of my (neck or all)bones ?

Dear Jenny, do you know of any url link, patient's personal blog that provides a very detailed step by step guides for ACDF patients both pre-op and after-op ie what should the patient do exactly to ensure a good and complete fusion ?

Thank you very much for your kind attention, advice and help. I am very grateful for your help.

Warmest Regards,

frustratedlor

 
Old 09-04-2009, 09:59 AM   #6
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

I'm glad I could help. The width of the spinal cord is usually listed in the report or is measured on the actual film...the CD shows everything too small to get a good measurement. But your symptoms tell the story. The problems with your bladder and bowel tell you that it is very serious. You could end up this way for life if it is not attended to soon. My neighbor let a similar situation go as he had 2 surgeries and refused to go back for a third. He now wears diapers as he cannot hold his bowels at all and is permanently using a catheter for his bladder as it no longer will allow him to urinate. A future you may face if you don't have something done fairly soon. Here in the USA, bladder and bowel function disturbances are considered an emergency situation and surgery is done immediately.

The artificial disks are only used here in the USA in 1 vertebra in the neck. They are testing 2 and it is used elsewhere but my surgeon told me that they are finding that the disks start to deteriorate and leave metallic and plastic dust around the cord and they fear it will migrate into the brain. So 1 artificial disk low down in the neck is all that is permitted until the dust problem is solved.

There are systems that do allow more motion in the neck but it involves a surgery from the back of the neck to install(I have it)and the surgery is much more painful than the front surgery of ACDF. They use long rods to fuse the vertebrae and they have some give to them but I can tell you, it's not what you think. I am fused from C3 to T1, 6 vertebrae, so it is useful but it doesn't give that much flexibility. Once the bones fuse, that is that...the bone fusion takes away the ability to move, not the hardware. All it does is make it a little more comfortable so you don't have that feeling like you have a stiff rod in your back. The rods move better with the muscles but the bones are still stiff. That is the main difference. Your neck still is frozen solid.

But your problem is not a disk problem anyhow. You have disk compression as a problem in one area only(C4-5). Two other areas have spinal cord compression due to the bone spurs of arthritis(C5-6 and C6-7). An artificial disk will not help there as it is not the disk. If the only problem was at C4-5, then an artificial disk would help. But your surgeon needs to remove all the arthritis in the vertbrae of C5,6 and 7 and that may take so much bone away that you would need the fusion to prevent the vertebrae breaking. So by fusing together C4, 5 and 6 he can remove as much of the bone as needed and then clean up the bone spurs at C3 and C7. The disk at C5-6 is not bad but in order to fuse it and clean out the bone spurs, he'd have to remove it.

I believe the surgery I had, a laminoplasty, might be what you are looking for but it is done only by a few surgeons. In that surgery, they do go into the back of the neck and it is very painful for the first couple of days, but they remove the bone over the back of the vertebrae opening up the area that holds the spinal cord, break the side bones(the lamina bones), then they re-attach the lamina bones with bone sutures and prop them open with a bone graft. What it does is it makes the space for the spinal cord almost twice as big as it was so the cord can move away from the bad disk or the built up bone spurs without removing anything. The side nerves can also be opened up. No fusion is done so there is no loss of movement. I think this is what you are looking for. There is no long wearing of a neck brace and you can go back to work in a couple of weeks. I woke up with no numbness, bladder and bowel problems gone and pain and weakness gone. The problem is finding a doctor who does the surgery in your part of the world.

If you would like, I can ask my neurosurgeon's office if he knows anyone in your area who does the surgery as he is known world-wide. Or if you can come to the USA, I would be glad to help you make arrangements to meet with my doctor. If you are interested in coming here, I would gladly send your MRI and reports to him and see what he thinks. I believe you might be an excellent candidate.

I hope this is of help to you.

gentle hugs............Jenny

PS. I don't know if I mentioned it but I had the laminoplasty and it was great but then broke my neck 3 months later...nothing to do with the surgery.

 
Old 09-05-2009, 08:18 AM   #7
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Hi Jenny,

Thank you very much for your help. I am very greatful for your help.

I am very worried about going for the surgery for two main reasons.

(1) How to ensure that the fusion of the bones will be good and complete ?

In addition, I have read in the forum that some forumers have to go for
another ACDF surgery as short as two years later or as long as twelve
years later and there are some forumers who have to go for a few
different types of cervical surgeries.

For unsuccessful surgeries, I understand that the patients will have to
rely on daily pain medications to live.

Does that mean that we have to keep on going for surgeries ?

Are there any other alternatives ?

(2) How to find out the success rate of the neurosurgeon ? I have asked the
neurosurgeon personally but the neurosurgeon does not provide any
personal statistics. Is there any way to find out the the success rate of
the neurosurgeon ? I have tried to ask the nurses but the nurses give
diplomatically correct answers only without telling me the the success
rate of the neurosurgeon.

In addition, my neurosurgeon is a specialist on brain surgery and spine
surgery is only a sub-specialty. Will this mean that my neurosurgeon
might not have much experience on cervical surgery like ACDF
surgery and the management on the complications arise out of ACDF
surgery ?

How will a neurosurgeon with spine sugery as a sub-specialty be
compared with an orthopaedic surgeon who specialises in spine
surgery ?

Thank you very much for your kind attention, help and advice.

Warmest Regards,

Frustratedlor

 
Old 09-05-2009, 03:04 PM   #8
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Sometimes the fusions don't take either because the patient didn't keep their neck in the brace for as long as necessary or the bone just didn't grow like it should. That is why they are using this new stuff called BMP. It helps speed up the fusion of the bone. But sometimes it's the fault of the surgeon as they don't put the plates and screws in properly...they are supposed to hold the vertebrae in place until the fusion is complete. Sometimes the bone is brittle and just breaks...can't be foreseen.

But anyone on the forum will tell you that a second surgery is better than permanent paralysis which is what you are facing if the compression on your spinal cord is not relieved soon.

I always prefer a surgeon that does spine surgery all the time. A neurosurgeon who does this only part-time, is not as preferable as an orthopedic spine surgeon who does it everyday. If one is available, get a second opinion and check the doc out.

The spine is one place where experience is EVERYTHING. It is such a perilous area that you need someone who sees the interior of the neck everyday and knows what to do. Often, an orthopedic surgeon will have a neurosurgeon assist them around the spine itself so you get the 2 anyhow. Every ortho spine surgeon I've talked to does this with the neck. They will do backs by themselves but not necks. So you might be better off with the orthopedic surgeon.

I know you are scared and you have a lot of medical problems on top of it. I also have a lot of bad medical problems and almost died after the surgery to fix the broken neck. But I have experienced paralysis and it is not something I'd want anyone to go through. You don't know if it's permanent or not and the only way to find out is time and hard work. And if one muscle in a group of muscles is paralyzed, the muscles around it don't work well so they spasm and hurt. I am in pain everyday but unlike most here, I don't take pain medications. I am allergic to many of them and I can't afford to become allergic to all of them and have nothing in case I have to have surgery or get injured. So I use methods to control pain I bet you are familiar with. I've used acupuncture in the past and it works well. I meditate daily. I find the meditation works best. I try to tell people about it but most won't listen or don't want to. They like the ease of popping a pill. I prefer the deep relaxation of meditation.

You don't have to spend the rest of your life in pain with an ACDF. Many are fine.....you just don't see them here. The people who come here are in pain and looking for help just as you are. The ones who are fine, don't post. And the vast majority of ACDF patients are FINE.

On the success rate of a surgeon, if they won't tell you, then you probably should see someone else. They are hiding something. Maybe they don't keep statistics on an individual surgery like an ACDF but they should be willing to give you some info. It sounds more and more like you should see the orthopedic spine surgeon.

I'm going to ask someone who had a good outcome to post to you..okay? She'll be able to reassure you more than I can as I didn't have an ACDF. Mine was posterior.

Hang in there and we'll get you all the info you need.

gentle hugs.............Jenny

 
Old 09-06-2009, 10:15 PM   #9
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Hi Frustratedlor - I heard via Jenny that you could use a positive outcome for an ACDF surgery. I understand the fear and apprehension that you are going thru right now. I spent a good month and about four hours a day researching my MRI results and looking for the best neurosurgeon and/or clinic to treat my problems. Fortunately my pain, numbness, and radiculopathy sent me to my PCP within one and a half months of the onset of my symptoms. My PCP immediately sent me for an MRI. Within two weeks I saw the NS and within two weeks I had the ACDF. I was extremely nervous about who to have do my surgery. Once I met the NS that did my surgery I was completely comfortable and confident in his abilities. Jenny has given you excellent information about that subject.

I had the bone spurs and arthritis that had built so much calcium deposit that the NS couldn't even see the nerve root at C5-C6. I had a very large herniation at C6-C7 that he removed as well. I chose to use cadaver bone for him to use in the fusion. I am now fused at C5 - C7 and have a plate over those three vertebrae on the front of my spine. The surgery itself is absolutely amazing. My scar on the front of my neck is about 5.0 - 7.5 cm long. It has healed very well and with no trouble. I had an added blessing in that I thought that I had rotator cuff injuries in both arms. (I played softball until 45 y.o.) I had to quit due to too much shoulder pain. Anyway, after the ACDF surgery that pain went away as well as all the original numbness, tingling, pain, and radiculopathy. I consider my surgery to be next to, if not, a miracle!!! I have great range of motion and no pain in my neck at all. I am better than eight years before surgery!!!

I would be willing to answer any other questions that you might have. IF I had to choose to do it again, I'd have it in a heartbeat.

I hope that this has given you some encouragement. Ask away if you have anymore questions that I can help you with about the ACDF surgery. Jenny knows more about everything else!!! (Actually, she probably knows more about the ACDF surgery itself than I do. She's just being modest and honest in telling you that she hasn't HAD it.

One more thing.........I'm with Jenny on the urgency of your situation. I fully believe from all my readings on the Healthboards that the longer the delay when you have numbness the less likely is a full recovery.

Stonepile
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Old 09-06-2009, 11:45 PM   #10
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Hi Jenny,

Thanks for the very useful advice.

It is great that you get Stonepile to give her experience on ACDF and it really helps to de-stress my worries.

Thank you very much for your kind attention, help and concern. I am very grateful for them.

With Best and Warmest Regards,

Frustratedlor

 
Old 09-06-2009, 11:53 PM   #11
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Hi Stonepile,

Thanks for the posting and the sharing of the ACDF surgery with me. It really helps to de-stress my worries.

Can you kindly elaborate on the matters that I need to take note of before the operation, during the hospital stay and staying at home after the operation ie the should or should not do ?

Thank you very much for your kind attention, help and advice.

With Warmest Regards,

Frustratedlor

 
Old 09-07-2009, 04:02 AM   #12
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Quote:
Originally Posted by frustratedlor View Post
Hi Jenny,

In addition, my neurosurgeon is a specialist on brain surgery and spine
surgery is only a sub-specialty. Will this mean that my neurosurgeon
might not have much experience on cervical surgery like ACDF
surgery and the management on the complications arise out of ACDF
surgery ?

How will a neurosurgeon with spine sugery as a sub-specialty be
compared with an orthopaedic surgeon who specialises in spine
surgery ?

Frustratedlor

You just don't want to do a CERVICAL SURGERY with someone who is not a specialist on cervical surgery. You never want to do a surgery with somebody who is only a sub-specialist, period. I wouldn't.

Also, recommended here somebody who has done at least 10,000 cervical surgeries. Not a new surgeon.

Why cannot you find a neurosurgeon who is specialised ONLY on neck surgeries?.

Last edited by nochange; 09-07-2009 at 09:31 AM.

 
Old 09-07-2009, 01:43 PM   #13
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

frustratedlor - I am happy to hear that my success story was able to help relieve some of your fear. It is a major and very serious surgery, but if you find a neurosurgeon who has lots of experience doing ACDF surgeries with a great success rate and you feel comfortable with him/her, then that's about the best scenario you can end up with, I think.

There is a thread at the top of the Spinal Cord Disorders board that is a list of things for you to think about when you go home from surgery or even before surgery they might help if you are experiencing enough disabilities.

Just from going back and reading your previous posts with Jenny it appears that you have some very disturbing symptoms going on. I agree with Jenny and hope that you can quickly find a neurosurgeon who does the ACDF routinely and one with which you are comfortable. As far as I can tell, each neurosurgeon handles post-op their own way. In all of my research the type of neck brace, length of time you have to wear one, and even possibly if you have to wear one at all varies from surgeon to surgeon. I had to wear a soft neckbrace for about three weeks. I've seen some people with ACDF not have to wear one at all. I've seen and think this is probably true in my case that the use of the soft neckbrace in the case of ACDF is more to remind the
patient to be careful than for anything else. (There may be plenty of people who disagree with me, I don't know.) My neck felt very stable immediately after surgery.

I did have some restrictions about how to move my neck and also about how much I could lift. Essentially for the first week I was asked not to lift much of anything. After my first week post-op visit I was allowed to lift five pounds. After my month check-up I was allowed to lift 25 lbs. I don't know how much driving you do in singapore, but we are not allowed to drive while in a neck brace in the US and so that is something that you have to take into consideration.

I was on morphine while in the hospital. I stayed for two days. I went home with a prescription for pain and one for a muscle relaxer. I only used them for about three days and quit taking them. All my pain was gone! (Numbness and muscle spasms too.)

My husband made sure that I followed the rules and I really didn't do much of anything except take care of myself for about three weeks. He wouldn't let me do much of anything. Not everyone may be in that situation and so going thru the list I mentioned that is on the spinal cord disorders board will help you out alot!

Hope this helps. Any other questions feel free to ask.

Stonepile
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Old 09-07-2009, 09:30 PM   #14
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Hi Nochange

In Singapore, the government gives 50-65% subsidy if the patient opts to be become a subsidized patient. However, a subsidized patient cannot choose doctors ie the subsidized patient has to be treated by the doctor assigned by the government/hospital.

To choose a specific doctor, a patient needs to pay market rate ie no subsidy plus a margin of gain made by the hospital.

For a ACDF surgery and all the tests and consultations, it will cost about S$50,000 (US$30,000).

With Warmest Regards,

Frustratedlor

 
Old 09-07-2009, 09:37 PM   #15
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Re: Advice on new treatments other than ACDF for cervical stenosis with myelopathy

Hi Stonepile,

Thanks for the informative reply.

I am glad to hear that you only need to take the pain medication for 3 days after the hospital stay.

I was worried that I might have a problem on the pain medication for me as I am a kidney patient and the use of many pain medications can make my kidneys to fail.

Thank you very much for your kind attention, help and advice.

With Warmest Regards,

Frustratedlor

 
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I have been diagnosed with a Cervical Myelopathy Braveheart07 Spinal Cord Disorders 46 12-22-2007 03:04 PM




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