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gabrialo 04-03-2016 12:31 PM

Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Hello
I'm new to the board but I've read many articles on this message oard for the last few weeks. I've lumbar stenosis and disc bulge and herniated disc throughout my lumbar spines since 2007. I also have lupus and RA and other autoimmune diseases. The chronic pain on my lower back has been manageable until last October(2015).

I started having numbness on my big and 2nd toes on my right leg and shooting pain from right hip all the way to front of my shin, mostly intense while sleeping. When I touched top of my right foot, it will send a sharp pain to my toes. I didn't know what it was until late Jan 2016 after talking to my Rhemy. She advised me to neurosurgeon ASAP.

During the waiting I've seen an acupuncturist on my leg pain/numbness/tingling. It has helped a lot on the numbness but I still have constant tingling of my right foot and pain on my outside thigh to shin when I walk or sleep. My PCP tested out my reflexes on both ankles and knees and they were non-existent! He finally referred to see a neurosurgeon.

The neurosurgeon ordered flexion/extension x-rays and together with my June 2015 MRI, he told me I need 2 levels fusion from L4-S1. He told the surgery won't make me feel better if my pain is NOT severe but he cautioned me NOT to wait until foot drop/drag or leg weakness. I am most scarred about losing mobility and internal functions(bowel/bladder) when nerves were permanently damaged.

So I'm not sure if I should wait as my pain is not unbearable(BTW I have very high tolerance of chronic pain with years of practice!) except when I walk and sleeping. Tingling is always there but pain on leg comes and goes.

Here are what I'm doing now:
- started PT last week and my PT said my spines are very loose and not recommend to use inversion table or traction table. I was prescribed to do pelvic tilt with different modifications
- will continue my acupuncture treatments but it seems it's not as effective as when I first started???
- waiting to see a ortho. spine surgeon soon for a 2nd opinion.

my questions to my fellow spondy:
- do I have to time to wait it out?
- should I opt for 2 level fusion if 2nd opinion concur with 1st?
- what other non-invasive treatments I can try WITHOUT causing permanent nerve damage?

any advices and suggestions would be greatly appreciated.

gabby

Here are my MRI and x-rays impressions:
MRI done 6/15/2015:
L4-L5: Grade 1 anterolisthesis. Left more than right facet arthropathy.
Broad-based disc bulge and oesteophytic spurring
Mild foraminal encroachment on right more the left
Anterolisthesis and degenerative change worsened prior study

L5-S1: broad-based bulge and osteophytic spurring.
Moderate foraminal encroachment on the right mild on the left
L5 root displacement mile degree on the right

L3-L4: no neural compress seen.
Right paracentral and foraminal disc protrusion and fissure
Facet arthropathy

X rays findings done 3/11/2016:
Grade one anterolisthesis at L4/L5 in extension.
This is accentuated in flexion by approximately 4mm.
Calcific density projecting within the spinal canal/neural foramen L3-L4.
Best seen extension

teteri66 04-04-2016 08:09 AM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Lumbar spine issues are seldom considered a medical emergency...and this pertains to a grade I spondylolisthesis as well. It often remains undiagnosed for a long time and usually only gradually worsens. When mine was originally diagnosed, the surgeon told me the only solution for a spondylolisthesis was a fusion, but when I did it was up to me. There were no other treatments, surgically or conservative, that would address the problem, just things that might ease the pain for a bit...but I would still have the spondylolisthesis and ran the risk that it could slip further and worsen.

There is a general meme that says the longer a nerve is compressed, the greater the chance for permanent nerve damage. In other words, one can wait too long! However, no one knows when that might occur. (What the time frame is). On occasion a nerve can be compressed a short time and permanent damage still occurs.

So you can afford to wait unless you suddenly develop bladder or bowel issues such as sudden incontinance or you develop sudden muscle weakness such as a drop foot. Then you should call the surgeon ASAP.

I would suggest you consult with the fellowship-trained orthopedic spine surgeon. If the surgeon suggests something very different, get a third opinion. Then see who you feel comfortable with and then make a decision.

I might add that from the report, it appears that your stenosis is not bad...enough to cause pain which may feel bad, but in the scheme of things, not all that bad. No specific nerve compression is noted.

gabrialo 05-23-2016 03:36 PM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Hello teteri66,

Thank you so much for your advise and initial assessment on my condition.
I've on a acupuncture treatment and herbal supplements for the last 2 months and they seemed to help a lot initially. I also was on PT doing core strengthening exercises-pelvic tilts and etc.

Then starting this month, it plateaued and started to have more symptoms :
- nerve pain on my right shin gradually increased to about 15 minutes slow walking
- right toes continue to have numbness and tingling on and off
- left toes started having numbness and tingling and pain on shin which has NEVER happened since last October

I assumed these symptoms are telling me my nerve roots were pinched more in the L4-L5 and L5-S1 exits.
The 1st surgeon(neuro) said I need a L4-L5-S1 fusion and L4-L5 decompression. And I am still waiting to see an ortho.spine surgeon(6/9/16) for a 2nd opinion....I've been calling them every week for cancellation but no luck so far! Do you see the reasons for 2 levels fusion in addition of decompression?

Your post/reply said my conditions aren't very bad. Can you comment on "accentuates in flexion by 4mm" ? Does it indicate instability of my spondy? If so, does it mean it will deteriorate really fast?
Even my pain level is minimum as I stopped walking or doing anything to cause pain, but my numbness/weakness on both feet worry me very much.... should I consent for fusion surgery ASAP?

I was searching on the internet and read about this MIS procedure - transforaminal endoscopic lumbar decompression - I found this article on ncbi.nlm gov site.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4325492/
any advises on this MIS procedure or other less destructive spine surgeries for Degenerative Spondy?

Advises from you and other board members would be greatly appreciated.

thanks,
gabriela

teteri66 05-23-2016 05:37 PM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
It will come in handy to have a stronger core when you get around to having surgery. Grade I spondy is not routinely addressed with surgery. Often people just live with it. Exceptions to this are instability and increasing neurological deficit. I don't know whether you are unstable or not, but it sounds like the nerve situation is not improving.

Generally speaking, the surgeon will not do a decompression without a fusion if there is a spondylolisthesis involved.

I think I said the amount of foraminal stenosis wasn't too bad, and that nothing on the report indicates the need to have surgery immediately. You can afford to wait and shop around for surgeons, or just simply wait until the time is right. The exception to this would be if you were to develop bowel or bladder issues or very sudden muscle weakness like a foot drop.

teteri66 05-23-2016 05:47 PM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Unless some new technique has been developed to treat spondylolisthesis that I am not aware of, fusion is the only procedure that addresses it. The article you mentioned does not refer to this condition, but rather to stenosis caused by spondylosis.

gabrialo 05-23-2016 07:47 PM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Hello teteri66

Thank you so much for the swift responses.

Yes, the nerve situation is getting worse and I am very scared. I stopped walking as it hurt after 15 minutes.
I also stop using stationery bike or elliptical fearing that it will get worse.
These are the only exercises I can do last 2 months and now I have to stop!
Would you think riding stationery bike or elliptical would worsen a spondy?

I am thinking to see the 1st neuro Dr again to get more details about the 2 levels fusion and decompression he recommended. Since I was shocked during the 1st visit and didn't ask any questions at all. Now I have a list of questions I compiled and hopefully I can get answers from him.

I also heard of a new technique - Dynesys(dynamic stabilization fusion) using a flexible rods and no bone graft needed(no fusion). Has anyone heard of it?

thanks for listening to me and provide valuable advices.

thanks,
glo

teteri66 05-24-2016 07:15 AM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Usually a stationary bike is OK. Some elliptical trainers are OK too, but it really depends on the movement. I know at the club where I go there is one machine that the trainers thought I could use as it just mimicked the motion of walking. Many of them are too much like a stepper....this movement causes a shearing motion ( if you watch someone using one from the rear notice how the hip and buttocks move. You will see one side lift while the other goes down and then it reverses and the opposite side goes up....same reason why using a step ladder in recovery is sure to cause a nerve flare!)

If you type Dynesis into the search box for this board, you will find a number of closed threads that deal with this type of "fusion." Many date back to 2006, 2007 and 2008 so you see Dynesis isn't all that new. My perception is that it just never caught on...but it may be popular in certain parts of the country. I think the problem was that with nothing to stabilize the screws, they loosened, causing the need to revise the procedure.

It would be worth looking into it when you see the spine surgeons. Regarding your shock at hearing the word "surgery" it reminded me that one of my surgeons has a policy where, if surgery is the solution, has the person come back within a week with a spouse, friend, trusted advisor. At this second appointment, he goes into all the details of the surgery he is recommending, and answers questions. He found that the shock of hearing the word "surgery" was such that the person remembered little of what was said after that point! So he just made it policy to come back in and to bring someone else along who can hear the information regarding surgery, too. At first I thought it was kind of silly, but I came to appreciate why it was a good practice.

gabrialo 05-24-2016 09:36 AM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Hello Teterio66,

Thank you so much for your response, they are right to the point.
Yes, I can see now an elliptical is NOT a good choice as it rocks/swings the hips up and down...I will definitely stop using it as I have one at home which is convenient.
I will use the spin bike at the gym but I only go there twice a week. Would spin bike be OK? I try to sit straight up and I alternate sitting and laying on the floor to peddle.

Thanks for the pointer, I'll search Dynesis and learn more about it. It makes sense that that it may cause too much movement and thus loosen the screws. How long are these pedicle screws that they screw into the vertebrae? are they 3 inches long? They sure look very scary to me. And all these hardware(screws/rods) will stay on the vertebrae for good, right? What is your opinion on BMP, I sure don't have to cut open the hip for bone graft, can the surgeon use the bone from decompression as a bone graft with BMP for the fusion material?

I also heard about MIS(min. invasive)approach that will reduce blood loss, shorten hospital stay and recovery. What is your opinion on that? So far, all the surgeons I have in mind are doing open surgery. I like to find one who are experienced with that approach as I read that it's critical that the surgeon must be very good at it.

Thank you for all your help.... I learned a lot from you and the forum.

thanks,
glo

teg01 05-26-2016 02:57 PM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Have you considered artificial disc replacement. Some spine clinics perform this. Medical universities also have surgeons that perform ADR. I also has grade 1 spondylolisthesis along with 3 degenerated disc. The lowest 3 levels in my lumbar are artificial discs. My decision to do ADR was based on avoiding the domino effect that happens after fusion. Just a thought. I hope you get some answers soon.

teteri66 05-26-2016 03:51 PM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
did you have this surgery in the US?

teg01 05-26-2016 04:46 PM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
No, I had to go to Germany for my 3-level ADR. This was in 2003 and the ADR clinical trials were still going on. There we very few surgeons that had experience with 3 levels. For the life of me I can't figure out why our spine surgeons do not perform ADR as much as they do in Europe. In Germany, ADR is the gold standard with fusions being considered as alternative when ADR is not viable.

gabrialo 05-26-2016 05:07 PM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Hello teg01,
thanks for the post. I've not heard of ADR at all. What do they replaced the discs with?
What is the success rate? Does it eliminate the adjacent disc disease(the domino effect) of fusion?

I've another question about another conversative treatment - chiropractic treatment.
I've read that degenerative spondylolisthesis(DS) should not avoid traction table, inverting machine and chiropractic adjustments. I was told by my PT that my ligaments are lax, I should not try any of those to further injure my spine. Anyone with DS could provide any insights?

thanks,
glo

teteri66 05-26-2016 07:16 PM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Yes, listen to what you were told. Spondylolisthesis creates instability and treatments like an inversion table puts too much stress on the joints and could make the problem worse...as could the other things you mention. I personally would not risk chiropractic treatment for something as potentially serious as spondy.

They still almost never do more than one level artificial disc replacement in the US. A few years ago the FDA did not approve multi level ADR. Even if you can find someone who does them, many insurance carriers will not pay. In most cases ADR is not the correct treatment for spondylolisthesis, and would not be an option. It is not the best option in this case.

teteri66 05-26-2016 07:21 PM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
I noticed that I didn't answer some of your questions. Yes hardware stays in unless there is a good reason to remove it, which would be something like an allergic reaction to it. I have my hardware from my first surgery and the screws are at least three inches, probably closer to 3.5 and they look just like the ones from the corner hardware store. Great for show and tell! The rods are about the diameter of a pencil.

teg01 05-27-2016 09:46 AM

Re: Grade 1 Spondylolisthesis L4-L5 doctor suggests 2 level fusion
 
Then benefit of ADR is quicker recovery and return to work as compared to fusion. The domino effect is a lot less likely with ADR. I had 7 great, pain-free years after my ADR. My neck on the other hand is a whole different story. I had a single level fusion c6-C7 and never got any relief. The levels above and below the fusion are a mess. Some medical insurance providers cover the ADR surgery.

Also, a competent chiropractor knows that adjustments re a contraindication for conditions such as yours.


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