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  • Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

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    Old 08-22-2016, 10:35 PM   #31
    gabrialo
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Thank you all for your advices.
    Since my last post, I went to see another ortho spine surgeon in early August and he told me my MRI and X-rays were not as bad as my symptoms.
    He ordered AP lumbar and pelvis X-rays and result shows I have lumbar sacral transitional vertebrae-LSTV on L5-S1 partially fused and some degenerative changes in pelvic, sacrum and SI joint. My PT said I have hyper mobility in my si joint so I am wearing a si belt all day long.
    about 4 weeks ago, I developed scatica nerve pain on my left leg with pain from left buttock to outer thigh and calf .
    My 4th toe was very numb too
    I cannot walk at all and must use a cane or walker to go from bed to bathroom, the pain is excruciating - I'm pretty house-bound!
    This is new as my leg pain has been on my right with hip pain down to outer thigh and front shin and big & 2nd toes.

    I am going back to see the first surgeon who recommend 2 levels fusion and see if I only need one since I have LSTV.
    The surgeon I saw this month said surgery will not help with my sciatica pain he told me to wait it out and he bet it will go away in another 4-6 weeks!! He said he doesn't know the cause of my pain but he said surgery will not help with the pain. I'm not sure if he's incompetent or he is right???
    So far it has been getting worse!
    I don't want to have more permanent nerve damage to wait it out, does sciatica resolve on its own?

    I'm at the end of my rope, the pain is killing me!

    I know surgery will not eliminate all the pain and numbness and most people learned to live with their "new level" of pain and numbness after surgery as you can never be your old self again! Is that true? Is that the reality of fusion surgery?

    Any advices would be appreciated!

     
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    Old 08-23-2016, 07:08 AM   #32
    teteri66
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    I read through this thread again, and a few questions have popped up. Just a few weeks ago I believe you were able to walk without needing a cane or walker. What is the difference? Has the pain increased that much? Do you have a feeling for which surgeon you prefer? Has any of the surgeons indicated you do NOT need surgery?

    My second question is do you know the condition of the L3-4 segment? Any bulging disc or facet disease here?

    I see no reason why your sciatic pain would go away in six weeks. I see no reason why it would go away at all unless or until the nerve is decompressed! One thing that few surgeons mention is that the nerve itself can become scarred when there is movement as in a spondylolisthesis. Nerves are very sensitive and do not respond well to being touched or manipulated. I would think this is a potential issue with you given the amount of movement you have between the spondy and the SI joint dysfunction. When something continually slides across the nerve scar tissue can develop...and this can cause the nerve to send of signals to the brain just like when the nerve is obviously compressed.

    What I said earlier about spine surgery in general is that it is not like other surgeries where something is removed or repaired and after the surgical incision heals, the body returns to normal. With the spine, people have expectations that after they recover, they will have the back returned to the condition it was in back in their youth. This cannot and does not happen! I think in part it is because the spine is so intricately linked to our ability to move, to bend, to twist...and because it is all so linked together and contains the nerve super highway that controls all bodily functions, feelings, movements, etc. so when one part goes out of kilter, it can have an effect on many different parts and things.

    The problem with spine surgery as I see it is the unpredictability of the outcome. Since the nerves are all in such tight proximity, it is easy to see how something could go wrong. Also there can be "surprises" that were not apparent on MRI and other imaging.

    When I had my second big surgery to add on to my L4-5 fusion, everyone, including 4 spine specialists, several therapists and the doctor giving me the spinal injections were convinced my pain was coming from L5-S1. My surgeon was very surprised when he opened me up to discover that the facet joints at L3-4 were so worn away as to be virtually non-existent. They all thought I had a small, inconsequential disc bulge at L3-4 that no one had included in any surgical plans because it was so small. Luckily my surgeon did not have a heavy surgical schedule that day so he was able to devote extra time to reconstructing that part of my spine.

    L5-S1 looked much better than expected...but since he was already operating, he made the decision to go ahead and fuse it, too. So I ended up being fused from L3 to S1. I was fused at L4-5 for two years previously. Other than a longer recovery time, physically I didn't notice much difference in terms of movement, etc. I can't twist as far as I used to be able to, but this isn't something that bothers me.

    One more comment...usually leg pain responds much better to surgery than does localized back pain...so I don't know why that surgeon said what he did.

     
    Old 08-23-2016, 09:22 AM   #33
    gabrialo
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Hello Teteri66,
    thank you for reading my post so quickly. You are a guidance angel of this forum!
    Yes, just a few weeks ago, I was in very little pain, mostly local lumbar pain and occasionally numbness on my toes. It might have caused by overworked and stress from work end of July that it triggered the onset of sciatica nerve pain on the opposite leg, actually the left side has always been hurting due to the lower back pain.
    Yes, the pain level has been a full 10 especially when I changed position from sitting to standing or VV. the worst is getting out of bed and up the first 45 minutes in the morning. I totally cannot stand up and cannot walk as the pain is excruciating. But once it passed an hour or so, it will ease up. But then I will have to continue to rest on my bed throughout the day to avoid more sharp pain on any movements. Standing and walking can really worsen the pain. I just started water therapy over the weekend and it seems to help. At least I can move freely (slow walk) in the pool. The minute I got out of the pool, my whole back and leg gone into spasm and I have to jump into the water tub(spa) to warm up and relax the muscles.

    As far as the 3 surgeons I had seen, the first one-neurosurgeon, who recommends 2 levels fusion(L4-S1) seems to be very quick to this decision. My husband thinks he might be watching his own pocketbook.
    The 2nd one(ortho spine)is the young guy and he told me I am not as bad and can wait a bit, fusion will be a single level(L4-L5). But I saw him 2 months ago without my sciatica pain. I was in the least pain when I saw him so his physical exam might not be accurate anymore.
    The last one(ortho spine) I saw twice, is the oldest and in practice the longest.
    - First visit - told me no surgery yet, ordered the 2 new xrays , we thought he is a good & honest surgeon
    - 2nd visit 2 weeks ago with my sciatica pain - he still cannot provide any diagnosis as to what cause my new pain. he asked me to wait it out for another 4-6 weeks as sciatica will go away on its own.
    we lost faith in him as he kept saying "I don't know" on whatever we asked such as cause of pain, nerve damage, injection, etc

    So bottom line, I don't have one surgeon that I preferred or have trust in what his diagnosis and treatment plan!!
    I do have a 4th referral to see another neurosurgeon but my first apt is not until end of September. I don't know if I could wait that long! She is also been in practice longer than the first 2 but not as longer as the 3rd one.

    I looked up the MRI from 7/7/16:
    T12-L1:
    focal paracentral disc protrusion does not result in spinal stenosis or neural foraminal narrowing
    L1-L2 and L2-L3:
    spinal stenosis or neural foraminal narrowing
    L3-L4:
    mild disc bulge with right foraminal disc protusion. Facet arthropathy is also noted. no evidence of spinal stenosis or neural formainal narrowing.
    L4-L5:
    facet arthropathy and degenerative spondylolisthesis with disc bulge. the neural foramina are mildly narrowed bilaterally.
    L5-S1:
    Focal central disc protrusion does not result in spinal stenosis or neural foraminal narrowing.

    here are the results from the last 2 new xrays taken 8/2/16:
    XR Lumber Spine 2/3 view:
    Grade 1 anterolisthesis of L4 on L5. Straightening of the normal lumbar lordosis. Trasitinoal segment representing a partially scralized L5 vertebra. Rudimentary ribs at T12. Disc space narrowing at L4-L5 and L5-S1. Minor marginal osteophytosis. The vertebral body heights are maintained. No acute fracture. Multilevel facet arthropathy, servere at L4-L5. Pedicules are intact.

    XR Pelvis less than 3 views taken on 8/2/16:
    Bones: Visualized bones are intact. Bone mineralization is normal. Degenerative changes of the partially visualized lower lumbar spine are seen. There is hemisacralization of the inferior most lumbar vertebra, which articulates with the superior right sacral ala with mild degenerative changes of the articulation.
    Joints: Articular alighment is anatomic. Mild degenerative changes of the bilateral hips are present, left appearing slightly worse than right. Mild degenerative changes of the bilateral SI joints and pubic symphsis notes as well.

    My husband is strongly against any fusion surgeries as he was told by his HR director who administrated all medical leaves that the employees DID not fare well after fusion surgeries, their success rate is about 50% and even with the good 50%, they still have lot of pain(old and new) years after surgery. My husband does not want me to be rushed into any fusion surgery just to get rid of the pain.. he wants to make sure the surgery is to correct the underlying problem. But so far, none of the surgeons we'd seen seem to have a definitive diagnosis on my underlying problem.
    As you'd indicated with your experiences. Your first fusion was only on L4-L5 but still have pain after surgery, and 2 years later, you had your 2nd fusion on L3-S1. Did this 2nd fusion resolve most of your underlying spine issues? and for the last 5 years with diligent and mindful about activities and limitation, you had maintained your pain-free condition without new adjacent vertebrae diseases?
    what is your 3rd surgery? is that after the L3-S1 or before the L4-L5?

    So is it true that spine ailments normally can take more than 1 fusion to resolve? It is not the end of the world that one needs another fusion couple years later? The surgeon recommending 2 levels said if I don't do 2 now, I will need to go back in 6-12 months for the 2nd fusion on L5-S1. Since I'm partially fused on that segment, do I really need a full fusion on L5-S1? I will be seeing this surgeon this afternoon to decide if I need only 1 level instead of 2 levels.

    sorry about this long drawn reply. I hope I answered the questions you asked and hope to get more feedbacks from you and other fellow gurus.

    thanks
    glo

     
    Old 08-23-2016, 10:25 AM   #34
    teteri66
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    I will give you a quick response now as you said you have an appointment this afternoon. If I were in your shoes, And having L4-5 fused, I would go ahead and have L5-S1 fused as well. You will not notice any difference in how much you can move or bend, and with the sacralized vertebra, it will insure you are more or less lined up properly and diminish any movement between the segments that might be catching a nerve now and then.

    I have done very well with my surgeries. It did take a long time to recover from the big fusion, and I can explain why later...but I accomplished it without aggravating the sciatic nerve, so it was worth it. I can stand or walk as long as I want now...I tire before I develop any pain. The exception to this is at a museum...where after ten minutes I want to sit down!

    I do have numbness in my feet extending up into the ankles, and very little reflexes in both feet. I attribute this to waiting too long to have the first surgery, and then waiting another two years to fix L3-4, which no one thought was a problem.

     
    Old 08-23-2016, 11:35 AM   #35
    gabrialo
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Hi Teteri66,
    thanks so much for the quick response. I just read about EMG/NVC test which supposed to confirm the nerve root compression and damage. Should I ask for this test when I see my surgeon at 230pm today? Will it provide more information to determine the cause of the sciatica pain? please advise.
    thanks,
    glo

     
    Old 08-23-2016, 01:58 PM   #36
    teteri66
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Sorry, I wasn't on the board....in your case I don't know if it is necessary. It seems to me they should know what is the pain generator, and could do a diagnostic nerve block to see if it is mostly L4-5, L5-S1 or the SI joints.

     
    Old 08-23-2016, 05:16 PM   #37
    Dogtrainer64
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Hi Gabrielo, sorry you are in so much pain. I also had spondylitis and had exhausted all forms of treatment like you did. On Feb 3 this year I had a anterior posterior L3 & L4 double fusion. The reason my neurologist did this type of operation is because the successful fusion is stronger as your bone can fuse from both sides. This is a major operation which as others have stated entails a long recovery. I won't kid you, the first three months are challenging ! You have to be totally committed both physically and mentally for successful rehabilitation. I am glad your neurologist does not want you to wait. I should have had mine sooner as I developed drop foot and the nerve damage was already done. However, my gait has improved.

    At 6 months out I am very glad I had the operation. My pain has almost vanished when sitting and driving. I even was able to play golf today 😊. Hang in there, I will have you in my thoughts.

     
    Old 08-23-2016, 06:40 PM   #38
    gabrialo
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Hi dogtrainer65,
    Thanks for your post and encouragements
    Yea it's a major surgery and one has to commit physical and mentally to get a positive outcome
    I wish you best of luck on your recovery. I wish I was as brave and decisive as you are!

     
    Old 08-23-2016, 09:46 PM   #39
    teteri66
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    What happened at your appointment? Did you reach any decisions?

    To answer one of your questions from earlier today, I had the first fusion in Jan 2008 for a spondylolisthesis at L4-5 and severe central canal stenosis. Everything about the surgery was fine except that the symptoms I had before surgery remained unchanged. After being told nothing more could be done surgically as my MRI looked fine, I ditched surgeons to one I had know about fifteen years earlier when my husband ruptured a disc. In Jan 2009 he performed a foraminotomy at L5-S1 to try to make more space for the nerves. That worked for about a month before all my radiculopathy returned. Then I spent the next year going from one specialist to the next trying to find someone who could figure out what was causing my pain. I had the third and last surgery in June 2010.

    Your husband is right in that any time they open up your spine, it is a big surgery, and it needs to be entered into with the utmost consideration. The most important decision you will make is the choice of the surgeon.

     
    Old 08-26-2016, 09:22 AM   #40
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    I had a lamectamy a year before my major surgery. He removed bone spurs and it helped for about 9 months then I tried to bend over and pull a stuck drawer out and the pain was so bad I could hardly stand up. I went to my GP and had another MRI done and then met with my surgeon. Unfortunately he thought it was only a flare up. After many decompressions and physical therapy visits, it was not until my follow up appointment that he took my tears seriously and took a closer look at my MRI. I guess my point is to be perserverient with your Doctor about the reacurring pain. If he gives you the run around see someone else. The surgery is tough but he finally solved the problem. I can't believe your Dr just said all the hardware was fine and dismissed it. I would get a second opinion. There is one offer of advice I hate to give, but it has helped me when I overdue it. My Dr referred me to a pain clinic. I was learry as I was afraid of any opioid dependency. However, when he explained an occasional low dose of Oxecodon was safer than taking two advils, I was a little more at ease. I only take one when I need it and it does the trick. The difference is never to rely upon it!

    Last edited by mod85; 08-27-2016 at 10:36 AM.

     
    Old 08-27-2016, 06:45 PM   #41
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Hi Teteri66,
    Sorry to reply so late.

    we went to see the surgeon Tuesday and he explained why he recommended the 2 levels. He told us he cannot explain why the other surgeon recommended no surgery(the one he referred me to see). I showed him my new sciatica nerve pain on the other leg(left) and he said that is L5-S1 nerve impingement. My husband seems to agree with him on the 2 levels fusion this time around. With the new sciatica pain, this surgeon might be right all along on his recommendation of 2 levels fusion.... even though he has only 10 years practice compared to the other one with 20 years.

    They've tentatively reserved 8/30/16 for me but I can't take it as I don't have clearance from work yet. I asked if I could be rescheduled not knowing they are very inflexible on rescheduling surgery date.
    He got upset(this is our 3rd visit) and told us to see another surgeon. My husband doesn't think he wants to operate on me. What do you think? Are surgeons work like that? His coordinator told us I'm not his patient yet until he operated on me. So all the visits so far were mere consultation. Is that true? And if so, what does that mean?

    So now my options are very limited. my 4th surgeon appointment is not until end of September, and even if she agrees to do fusion surgery right away, it will be another 2-3 months wait. I need to manage my pain until probably end of the year!

    At this time, I am convinced that I need fusion surgery, mostly likely 2 levels, to avoid more permanent nerve damage. The only non-surgical treatments I have not tried are injections: facets, epidurals, etc. I know they might not work for long and do not correct the spine issues. So I don't have too much faith in them.

    I agreed 100% with you on the choice of surgeon. Since you'd seen so many during your endeavor of resolving the pain, are there any pointers and tips that you can share to locate a competent surgeon for lumbar fusion?

    any advices and feedbacks would be greatly appreciated.

    thanks,
    glo

     
    Old 08-28-2016, 09:48 AM   #42
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Oh my. Surgeons come in all stripes! I've never heard of one caring when one schedules surgery. That seems odd to me, but not knowing all the facts...who can say?

    Some people live in locales where they don't have access to a variety of surgeons. Luckily I had many to choose from and I probably went overboard in visiting many of them, and in three states. I went to a major teaching university, a private practioner and several larger spine clinics. I had two different surgeons for my three surgeries. It is a matter of finding someone you trust and feel comfortable with. I wanted someone who didn't have layers of people doing the work. I wanted to see the spine surgeon every time I went in. I wanted to know he would be the only one doing the surgery...not a PA and not a resident or fellow. These things were important to me, but wouldn't matter to some people.

    Also, if you think this last surgeon is the one for you, I would just find out from work when you are cleared to have surgery and go back and say "I can have surgery after this date. What is open in your schedule?" Maybe you work through the coordinator and just explain you couldn't commit to that one date because of your work. I would think she would understand. You cannot be that unique in that situation with your work!

    Last edited by teteri66; 08-28-2016 at 09:51 AM.

     
    Old 09-10-2016, 08:03 AM   #43
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Friend had her back screwed and bolted (fused) from S1 through L2 about 4 years ago and has been eating Soma and butalbital 3 times a day since. SHe claims that her leg pain has been eliminated but her back pain was worsened from the day of the surgery through today.
    New MRI shows L1 is slipping over L2 and anterior disc space is considerably diminished.

    I cautioned her about the original surgery and now she is thinking about going back TO THE SAME GUY ("he's so nice") and having all the hardware pulled out and replaced with a fusion from S1 through L1. She asks my advice and short of telling her to buy a time machine the best I can tell her is "Get another surgeon."

    Whenever I think of pursuing my back pain, I think of her and the feeling passes.

     
    Old 09-27-2016, 08:58 AM   #44
    gabrialo
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Hi Teteri66
    thanks for your reply. So far I've seen 4 surgeons including one last Monday-2 ortho.spine and 2 neuro.
    they are all private sole practitioners as I was limited by my medical group.

    Their recommendations split by trade:
    both ortho spine surgeons recommend L4-L5 laminectomy and fusion.
    both neurosurgeons recommend L4-S1 fusion with the last one I saw recommends 360 L4-S1 fusion.

    My PCP told me the difference in recommendation between the trade is due to their training.
    She said both will produce similar outcome-reduce leg pain and stabilize the spine
    She said it's my decision to weigh out the surgery and recovery process vs possible future surgeries of the 2 recommendations. Here are what I got, please advice if I miss any major items:
    L4-L5 fusion:
    Pros - shorter surgery, lesser pain, shorter recovery
    Cons - possible fusion surgery in 2-5 years
    L4-S1 2 level fusion:
    Cons - longer surgery, more pain, longer recovery
    Pros - may last longer and no fusion in 5-10 years

    Out of all 4 surgeons, I feel very comfortable with the last neuro as she doesn't roll her eyes at me when I asked questions such as EMG test, nerve monitoring, etc. whereas 3 "male" surgeons told me I know too much(from internet) and ask too many questions and they felt I don't trust their professional recommendation. One being the one who told me to see someone else because I couldn't commit the date they gave me.
    My husband told me to back off on my questions or I will not have a surgeon to operate on my back!

    But this last neuro recommended the most invasive surgery-360 Fusion and I think it's a overkill!
    she told me anterior to remove the disc at L4-L5 with a PEEK cage and posterior to fusion L4-S1 with screws and rods. I thought my disc at L4-L5 is not too worn-out! She said this will provide the best fusion-front and back with a sold fused L5 to the sacrum.

    So far my experience with all 3 male surgeons are they DO NOT change their recommendation once given.
    I am hoping she will consider doing a simple posterior 2 levels fusion on L4-S1, without anterior interbody cage.

    At this time, I have a choice to go with single level with an ortho. or 360-2 levels with a neuro.
    my PCP told me she will pick the less invasive(1 level) and hope for the best(last 5+ years) if she were in my shoes.

    what would you pick if you were in my shoes?
    I would love to hear your assessment and experience.

    thanks,
    glo

     
    Old 09-27-2016, 09:40 AM   #45
    teteri66
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    Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion

    Is there any concern with your other health issues like lupus and RA that there might be a problem getting the bone graft to grow and set up?

     
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