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Pseudoarthrosis at C6/C7. A or P revision?

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Old 01-31-2013, 11:16 PM   #1
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Pseudoarthrosis at C6/C7. A or P revision?

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 02-03-2013, 11:15 PM   #2
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Re: Pseudoarthrosis at C6/C7. A or P revision?

Here's the condensed version. I had a failed, attempted Anterior cervical fusion at C6/C7 in Feb. of 2010 with a PEEK implant. Pseudoarthrosis. My options at revision appear to be a posterior facet fusion , or a redo of the original anterior procedure, which involves removal of the PEEK and an auto bone graft from my illiac crest . Thoughts ?

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