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Old 02-04-2013, 07:40 AM   #1
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Pseudoarthrosis at C6/C7 : Ant. or Pos. revision?

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I'm at a crossroads. The decision is whether to have an anterior or posterior revision of a failed attempt at a C6/C7 fusion with a PEEK in February of 2010. I am a 56 year old male at about 155 pounds. A little history. The bad news is I have had 6 total spinal surgeries commencing in my early twenties. Three lumbar and three cervical. The good news is that those involve only three segments (one lumbar and two cervical). I've had two surgeries for a ruptured disc at L5/S1,and I underwent a successful fusion there in 2008.
As for the neck surgeries, I had surgery for a bone spur at C5/C6 21 years ago, and when that didn't work, I had an anterior fusion with autograft from my illiac crest the next year. So I made it about 18 years until 2010 when C6/C7 was collapsed and desicated.
Sorry to take so long to get to the current point, but I am almost there. I had an anterior fusion surgery at C6/C7 in Feb. of 2010 with a PEEK implant. I got some relief but not as much as I had hoped. About a year ago I overexerted myself doing work around the house (pressure washed my garage). I had a lot of pain over the next few days in neck and interscapular area, radiating into the arms with tingling in the ring and pinky fingers. One night in bed I litteraly heard a crack, and the pain got worse . The most disconcerting thing, though, has been the prgressive muscle atrophy, beginning right at the base of my neck, spreading to my traps, rhomboids , and gradually downward along my paraspinals.
I was afraid I had ruptured C7/T1, but I have since learned that herniation at that level is rarity, and , in any event, tests have shown that segment to be normal and healthy. The doc who did the attempted fusion ordered an mri and then a cat scan. He mentioned the possibility of pseudoarthrosis , but after the tests said he couldn't find anything wrong and sent me on my way. I took the tests independently to another orthopod, and to a neurosurgeon, both of whom said that they suspected pseudoarhtrosis (failure to fuse) at C6/C7. They both recommended a CT myelogram for further diagnosis. I had one per the new orthopod's order, and he confirmed pseudoarthrosis. He says if I have not fused by now, I will not. Period. I have gone the recommended conservative route for a year ( nerve blocks, physical therapy, massage, anti inflamatories, massage, pain killers), and am ready to attempt a revision.
The question is whether to redo the anterior fusion, or to leave the PEEK in place and posteriorly fuse the facets and add screws. The current orthopod is a sharp guy - trained at Mayo in Rochester and did a one year spine fellowship at Cleveland Clinic. He has been very honest and patient with me, explaining my options at revision. He leans heavily toward the posterior revision, and has told me that he would do it. I agonized over the choices, but ultimately decided that the anterior approach offered the best shot at long term success . However, when I made the anterior decision, he back pedaled and said he would not attempt it , given the limited resources at the small hospital where he has privileges and the greater risks, primarily esophageal perforation or possible larengeal nerve damage. He says that about 30% of the anterior revisions result in espohageal perforation, and that there is a 20% mortality rate among that 30%. ( I can find no literature indicating the risk is anywhere near that 30% figure, but I do not deny that is a very real concern). He wants to send me to the Cervical Spine Clinic at Georg Washington University in St. Louis, where they will have a team of docs available during my procedure to address any eventuality. I have read the CV of the Doc in St. Louis, and it is indeed impressive : chairman of dept. of orthopaedics, professor of neurosurgery, and board certified in internal medicine. He also is a pioneer in arthroplasty (artificial disc), which I have not even considered as a possible alternative.
I would appreciate your insights and suggestions. I am a tired, broken man whose life is shrinking. I hate to start from square one with a new doc, but I just don't really trust the posterior outcome , though I readily admit it is safer. But I could be persuaded otherwise. I am just worn out and don't know what to do. If you have read this far, thank you so much for your indulgence.

 
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Old 02-04-2013, 10:40 AM   #2
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Re: Pseudoarthrosis at C6/C7 : Ant. or Pos. revision?

If the Dr in St Louis is available, I would at least go there and see him and get his opinion. Discuss your concerns with him about the posterior approach. Sometimes when you are on the fence and can't decide, a second opinion will tip you one way or the other. If he also is convinced posterior is the way to approach, then you may feel better about that and will have the option of either that Dr or the one at home. This is too important to risk a bad outcome, worth a flight out of town, and then think about who you feel most comfortable with for the surgery. I understand your feeling "broken". I have had 3 back surgeries one neck fusion and know I have more to come on neck, just a matter of time. Hopefully you have a supportive person in your life that can accompany you out of town and make the trip more pleasant.

 
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Old 02-04-2013, 11:14 AM   #3
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Re: Pseudoarthrosis at C6/C7 : Ant. or Pos. revision?

<< He leans heavily toward the posterior revision, and has told me that he would do it. I agonized over the choices, but ultimately decided that the anterior approach offered the best shot at long term success . However, when I made the anterior decision, he back pedaled and said he would not attempt it >>

I'm a little confused. Should that "posterior" be "anterior"?

The doc actually said there's a 6% mortality rate for anterior revisions? I do not know that to NOT be true, but I'd be surprised if it were.

As for the specific choice of surgeries, you're way ahead of me, so the only advice I can give you is to make the best choice you can and get the best surgeon you can. At any rate, I'd go to Saint Louis even if the local doc didn't want me to. In fact, I'd go to LA or New York, if I thought I'd get a better surgeon. I could easily be wrong, but I'd guess that your choice of surgeon may well be more important than your choice of surgery.

 
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Old 02-05-2013, 11:00 PM   #4
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Re: Pseudoarthrosis at C6/C7 : Ant. or Pos. revision?

Very sage advice. Thank you. I need to feel more confidence in the posterior approach if that is ultimately what I have done, and in any event the considered opinion of another seasoned professional should make me feel better about whatever choice is made. And I do have an angel of mercy - a nurse practitioner doctoral candidate at that - to help me through this .

 
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Old 02-06-2013, 06:16 PM   #5
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Re: Pseudoarthrosis at C6/C7 : Ant. or Pos. revision?

You are an attentive reader and have caught me in a bit of careless writing. No, he did not quote that 6% figure. He has told me repeatedly that about 70% of attempted anterior cervical revisions do not present espophageal complications ; conversely he says that about 30% do involve such complications (including perforations, temporary or permanent difficulty swallowing, etc. ). On my own I have read a broadbased study from a medical journal about the longterm results, good and bad, of esophageal perforations during surgeries of all kinds ( including, but certainly not limited to, anterior cevical fusion prodecures). The conclusions from that study were that there is a mortality rate of about 20%. I deduced that 20% of 30% is 6%, which now that you highlight it is not entirely accurate.

 
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Old 02-11-2013, 06:44 PM   #6
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Re: Pseudoarthrosis at C6/C7 : Ant. or Pos. revision?

Well, I received some new info that affects my decision process. A friend who is a neurosurgeon was nice enough to call me and listen. I have been told by my orthopod that the chance of esophageal damage in an anterior revision is about 30%. The neuro says he's done lots of anterior revisions and has never had that happen, although he aknowledges that it is really serious stuff if it happens. Says anecdotally in his big group of doctors it happens maybe 1 to 3 % of the time. Big difference and also consistent with what I have seen in journals. Also, he says there is a good chance the original C6/C7 segment will STILL fuse over time if the posterior procedure is done. He says this is so because the constant daily movement occurring because of the pseudoarthrosis stops once the facets are fused, thereby allowing your body to begin fusing a then still and stable segment where the PEEK is. I had never heard that until today, or if I was told that it didn't sink in. So I have some evidence that the anterior procedure may not be quite as dangerous as I previously understood, but I also have information suggesting the posterior procedure could accomplish more good than I previously understood that it could.

Last edited by 44Mark06; 02-11-2013 at 09:30 PM.

 
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Old 02-21-2013, 06:32 PM   #7
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Re: Pseudoarthrosis at C6/C7 : Ant. or Pos. revision?

Hi there...

I have never heard of those high statistics with having issues with a revision surgery.

One of the things that I STRONGLY recommend though is that if you do anymore cervical surgery, that is done by a Board Certified Neurosurgeon (Fellowship trained as well)...A Neurosurgeon is much more skilled and trained in the cervical area of the spine than Orthopedics...

I have had 3 cervical fusions (same two levels each time) C5-C6 and C6-C7. Each time they went in a different place for the anterior approach so they didn't cut through any scar tissue and the last fusion they did BOTH anterior and posterior to really shore things up. It took about 7 hours and they just use the HALO during the surgery to hold you in place and flip you over like a barbecued pig! LOL....

Obviously we never know any of this as we are blissfully sound asleep from anesthesia... But I had the nice little small holes upon waking....

Because my 2nd fusion was not done well at all and I had severe pain pretty much from the moment I woke up from that surgery, this is when I found my wonderful Neurosurgeon I have now. I did always use a Neuro but the 2nd one was just a bad luck of the draw...

So he took out what that surgeon did from the anterior, so it was pretty much like starting from scratch.

The last fusion was in Nov. 2006 and even though I have chronic pain (bone and muscle pain)...the majority of my nerve pain is all gone as well as most of the issues with radiating down my arm/hand/fingers....

You don't smoke, do you? They have now proven that this causes disc dehydration and can cause non unions for fusions as well as spine problems in general. My Neuro won't even operate on someone who smokes as he says it is a waste of time for everyone....They are happy to help people quit if they are willing...I'm lucky in that I've never had the urge to even try smoking!..

Anyway....just wanted to say that I would make sure you see at least 2-3 BC Neuros to get their opinions and then go from there. I am certainly happy that I did that last surgery!!!

 
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Old 02-21-2013, 10:05 PM   #8
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Re: Pseudoarthrosis at C6/C7 : Ant. or Pos. revision?

Thanks for the good advice. I have in fact been thinking about getting yet another opinion , but I haven't acted on it as I wonder if it would be overkill. I have heard others say similar things about neuro vs. ortho, but I suppose I have just focused on the rep of the clinic and doc instead of the specialty. As it happens, I have researched the man in St. Louis to which I have been referred, and he must be a brilliant man . He is at a university and is board certified in orthopaedics, neurosurgery, and internal medicine. The name of the clinic is "The Cervical Spine Institute," and they do only necks. We shall see what he thinks.
As to your question about smoking, the answer is no. Never have.
You have certainly been a determined soul to go through that three times. I am glad you found a doctor who helped you, and I hope I can. I do not blame any of my doctors for what has happened to me; I think they have all been accomplished , respected surgeons. Sometimes I am angry and bitter, but I do not direct it at them. Sometimes stuff just happens (or doesn't). You are an inspiration for perseverence, which I do think ultimately does get us some place good when the anger and bitterness don't.

 
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