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    Old 04-14-2017, 04:43 PM   #1
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    Questions!! Description of my procedure, spinal fusion & hardware removal

    Hi everyone. This might be long, so please bear with me.

    Last summer 2016, I had a high impact crash from a skydiving accident and fractured my L5. I had lower back surgery at L4-L5-S1 with 6 screws and 2 rods inserted. The doctors called it a spinal fusion.

    The recovery sucked. Months later, I was still in a lot of pain from post op. It felt like someone one was constantly forcing me to bend backwards and a very bad "dragging/pulling" feel on my spine. Sleeping and sitting on recliners was almost impossible.

    I decided to get the hardware removed and had the removal surgery on January 2017.

    Recovery was a lot quicker compared to the first surgery, and there is a significant amount of difference in pain level. My back feels a lot better, somedays it feels like I never fractured it. Sleeping/turning around it bed and reclining is still a problem.

    My first neurosurgeon who did the spinal fusion said no actual fusion was done and only hardware was inserted.

    My second neurosurgeon said he removed the screws and rods and put in artificial bone to fill gaps from the holes made by the hardware. He said I should bounce right back with minimal back pain, no restrictions after 6 months and no long term effects.

    (2 back surgeries done by 2 different surgeons, because of where I live and go to school)

    But during the post op visits, I didn't see my surgeon and instead saw a completely different doctor. I'm confused because the new guy said that my lower lumbar is fused and I do have a few restrictions such as participating in some sports, sexual activity(positioning) and may have arthritis at a younger age or other problems.

    Prior to the accident, I was healthy and physically very active. I absolutely love to run, rock climb and zip line. I'm scared that I might have to give it up after the recent doctors appointment. I'm only 20 years old.

    The following is a description of the procedure from my medical synopsis:

    Preoperative Diagnoses:
    1. Lumbar spondylosis
    2. L5 fracture deformity, posttraumatic, warranting stabilization L4-S1

    1. Exploration of previous fusion mass of L4-S1
    2. Hardware removal

    Patient is 20 years old female seen in the Clinic for debilitating back pain. This was referable to an L5 fracture which was treated at an outside institution with segmental stabilization. The fracture itself appears to have healed. It sounds like initial index operation, they talked about putting latter in as an internal fixator and she was advised to have the hardware removed at a later date. She is presenting to us for hardware removal. Imaging studies do not show any robust posterolateral fusion mass at L4-S1

    Description of procedure:
    The patient was taken to the the operative room... Previous fusion mass was explored. There was really no fusion mass. The lamina however decorticated. The hardwares were explanted L4-S1 and the screw holes were packed with Gelfoam. There was no instability preoperatively and so I did not feel the need to commit her to any revision instrumental fusion. There was some healing along the screws and screws themselves were quite loose. I did place some MASTERGRAFT at L4-L5 on both sides and autologus iliac crest bone marrow aspirate was obtained from the right ilium. Meticulous hemostasis was achieved and the wound was then closes...

    Can someone please explain the procedure to me?
    What is fusion mass?
    Am I fused from l4-s1?
    What does it mean if the lamina is decorticated?
    What did they do with my bone marrow?

    I know I have to avoid bending, twisting and lifting, but is that forever?
    Can I resume to be as active as before again?
    -For example, is it okay for me to go swimming, surfing, kayaking, rock climbing and zip lining again?
    Do I have a high chance of getting arthritis years down the line?

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    Old 04-15-2017, 08:56 AM   #2
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    Re: Questions!! Description of my procedure, spinal fusion & hardware removal

    Welcome to the board. Was the doctor you saw post operatively to the removal surgery also a neurosurgeon?

    I have a feeling that what the three doctors have told you is not all that different factually. It is their communication styles that may be causing the confusion. To simply things, I am going to call the surgeon who performed the initial surgery "Doctor A." The surgeon who performed the hardware removal is "Doctor B" and the one you saw most recently after the second surgery will be " Doctor C."

    Also keep in mind that this forum is not staffed by medical professionals, but it comprised of members who share information and experiences. So, this is my layman' attempt to explain your procedure to you. KI have had three lumbar surgeries including two fusions and am now fused from L3 to S1. When you get through recovering from this last procedure, you may be "fused" at L4-5, but you will not have hardware in your spine. (See below **)

    The word "fusion" is a stumbling block in that it has different meanings to different people and is used in various ways. For example, I may have a fusion surgery but if after a year it is discovered my spine is unstable at that segment, it may be because I have not fused...meaning the bone has failed to grow together to produce a solid bone mass. During the surgery certain ligaments, etc. have been removed to make it possible for the new bone to grow together, so this apart of the spine has lost its structural integrity. If the new bone cells do not grow together properly, this area will be unstable.

    Hardware is not designed to hold things together permanently. Think about a situation where someone breaks a leg or arm. The bone is set and a cast is put on to immobilize the area so the bones can knit back together naturally. If the two ends of the fracture have movement, they will not be able to knit together. Since the spine cannot be casted to the point where the bones are immobilized, hardware was invented to hold things together. Most people leave in the hardware, but it is the solid fusion of the bone graft that is important.

    I think in your case, the initial surgeon used hardware to allow the fractured vertebra to heal properly, which it has done, according to this report from which you quoted. "Imaging studies do not show any robust posterolateral bone mass at L4-S1." Surgeon B removed the hardware. He checked out the "fusion mass" (which would be the bone cells growing between the vertebrae) and found there was nothing connecting the vertebrae. He states since there was no instability between the segments, he did not feel the need to use any new hardware. He used Gelfoam to fill up the holes left from the screw removal. He took bone marrow from your iliac crest and mixed it with a biologic bone graft material called Mastergraft. This forms a living product the texture of wet cement that the body will eventually turn into new solid bone. This was placed along the sides (but not in the disc space) at L4-5. I imagine this was done just to reinforce the fractured area and provide a little support to the vertebrae. (**If I am correct in my understanding of what you were told and what I read from the surgeon's notes, you are technically not fused as all discs are in place -- but I do not know to what extend this MasterGraft might join L4 to L5! In one of my fusions, the disc was removed at L4-5 and a cage with BMP was inserted in its place to help with fusion. In another type of fusion, the disc is left in place, and the bone graft is laid along the sides...which eventually grows and causes one segment to fuse to the next...which is what a was done in my second fusion where I was fused from L3 to S1. In your case, I just don't know what was the intent for using the Mastergraft mixed with your own bone cells at L4-5. It may be that you will end up fused at this segment but not at L5-S1.)

    In some cases, the disc between the two vertebrae would be removed and bone graft material would be inserted into a cage that would go in the space where the disc was removed. This would hold the space between the vertebrae and it would eventually grow to fuse the two vertebrae into one solid piece. This is what people commonly refer to as "fusion." You did not have this done. Your discs are intact as far as I know...(unless you didn't include that part of the report??)

    The lamina is a little bony structure that is positioned on each of the spinal vertebrae, which provides a roof for the spinal canal and protects the back of the spinal cord.

    It looks like in the first surgery this area of the lamina by the L5 fractured vertebra was was roughed up a bit ( surface area removed). This is done to expose a fresh layer of blood cells etc. to help with healing. I wouldn't think this would be causing any issues at this point.

    Some surgeons (and I have lost count but I have seen more than eight) say that once healing is complete, the back should be just as strong as before. In the case of a fusion, it takes a good 12 months for the new bone to set up and become hard and durable. After that, I guess I would tend to agree with Doctor B...that you should be able to resume your active lifestyle.

    I think you can almost count on developing arthritis as you age. I've always been told that when someone is involved in a high impact crash, be it from a car crash or a fall, the trauma from the impact causes the body to develop osteoarthritis sooner than it would otherwise. This should not be debilitating for you though, assuming you take care of yourself.

    I would advise you though to be very strict with yourself during this healing phase. It is a small sacrifice to make to try to assure that you will be able to do the active things you love going forward. Learn to be patient and learn to listen to your body. When you do resume activity, do so slowly and thoughtfully. Some activities are more stressful to the spine than others. You may find that some things may cause some back pain. You may need to wait on them until you are stronger or perhaps, you will decide the activity isn't worth it and you will move to something a little less stressful. It is hard to think of these things when you are twenty...but you will also want to be active when you are 40 and 60 and maybe 80! If you abuse your body too much now, you won't be able to kayak when you are 70!

    After you are completely healed, you will be able to bend, twist and lift again. It is best to avoid doing any movement over and over and over. And movement that involves a twisting movement at the same time that force is exerted is especially hard on the lower lumbar spine...many people rupture a disc removing a snow boot, and of course golfers often have back trouble.

    So...good luck to you. I'm happy to try to answer any questions you might have. Will you see Surgeon B again?

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    Old 04-15-2017, 06:39 PM   #3
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    Re: Questions!! Description of my procedure, spinal fusion & hardware removal

    Thank you so much for all the information!!! This was very helpful and I have a much better understanding of my procedure now!

    That was all for the report. "Doctor C," who I saw post-op, was not a neurosurgeon, but he was an orthopedic. Due to where the accident occurred, where my hometown is located, and where I go to college are all different, I had no choice but to see 3 different doctors. Surgeon B is from my hometown, so I am hoping I will be able to see him atleast once during the summer.

    For now I have no further questions. Thank you again for your response!!

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    Old 04-16-2017, 08:29 AM   #4
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    Re: Questions!! Description of my procedure, spinal fusion & hardware removal

    The difference in specialties could very well explain the slight difference in message from B and C. When I first read your post and began to reply, I wrote that when you recovered from this surgery, you would be fused. But then, the more I thought about it, the more I thought...maybe not!

    The important thing for you is to be sure your spine is stable at L4-S1. When you return home for the summer, see Surgeon B to check on this. Ask for a flexion-extension x-ray...which is fast, easy and not expensive and it will give you peace of mind.

    I would also suggest as you move forward, that you are always congnizant of what has happened to your spine, and what you've been through to get it somewhat back to the way it was prior to accident.

    Life is full of choices. There are many things you can do to keep your back healthy as you move forward--simple things like maintaining a healthy weight, good posture, structural alignment, setting your desk up ergonomically, etc. You will want to do proactive things to protect your spine so you will be able to live an active lifestyle as you age!

    This isn't something one thinks about at age 20 when being 45 seems terribly old and a lifetime away...but I assure you, the years fly by faster than you can imagine!

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