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    Old 02-24-2004, 07:03 AM   #1
    scotty12
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    multi level fuse or opiate dependent life?

    hi all,
    i know this post is similar to my previous posts but i really cant decide what to do.im deciding if i should have the discogram.(shoreline scared me with his experience during discography).we know there is a problem (spondy)at L5-S1.year old mri shows problem at L4 and just minor bulge at L3.
    im just trying to decide if i would fuse L4-S1 as that is the probable outcome.

    my question is this and im really only looking for opinions as im aware the decision is all mine.

    i know from past experience that pain is managable.its just in the last 2 months that pain has become very bad again.tolerance to opiates may be the problem.ive been on 7.5 percs for about 8 months.currently at about 40 mg per day.it has been very hard to keep pain levels down and steady.
    i felt so good in nov and dec that i had ruled out surgery as an option at that time.

    it seems that a switch to long acting med would be needed to continue succesfull pain control
    im just trying to decide if im ready to handle the switch to long acting meds, assuming pm dr would agree to change, as im sure this will be a drastic change with both positive and negative issues that go along with LA meds or have the fusion done and hope for sucess.i no longer have leg pain so ive been told that surgery is not emergency.
    im sure many of you have been in the same situation and being on this board i think i know what most would say but let me hear it anyway...i have to make a decision very soon before i lose my mind as pain levels have been too high to function semi normally..scott

     
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    Old 02-24-2004, 10:27 AM   #2
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    Re: multi level fuse or opiate dependent life?

    Hey Scottie, Have you asked if the discogram is really neccesarry or if they can take a look and decide on lengthening the fusion at the time of the operation. I didn't mean to scare you out your wits, But it is a grueling test and will the doc not do the fusion he plans without a disco? Would he not check the suspect disc while he's fusing the one he knows is a problem?

    You left out alternative 3, Post multi level fusion with Intractable chronic pain and dependent for life. If you think you couldn't be in more pain than you are in now, I would say, sadly you are mistaken. No gaurentees with any fusion regardless of pre diagnostic testing and method used to fuse.

    There is absolutely no way to determine if a fusion is alive and growing or the donar bone is just dead and sitting there. Xrays don't show whether donar bone is alive or not, Hardware blurs and scatters future MRI's and CT's, not they they can tell f the donar bone is alive or not. There is no test to determine if a fusion is solid of not. You just find out years down the road after you doc tells you how great it looks on Xray and everythging went smooth. I was told dozens of times my fusions were succesful, right up untill the hardware snaps.

    If there is any question about the disc above, IMO it's just a matter of time untill you are back under the knife recovering from another fusion. Odds decrease with each attemopt and decrease with every level included. Statistically odds drop 20% for every level they try to fuse. First time odds are roughly 80% gong back in 2 years later at best your looking at 60% odds of success, but there are other variables. Harvested bone from the iliac crest or a rib resection vs cadavor bone, smoking, bone growth stimulators or not.

    If your gong to do this you want the best odds possble. Unfortunately I haven't run across a database of information on what fusion technique has the best outcome.

    Pedicle screws and harringtomn rods or BAK cages? Which type of hardware? I've seen several new hardware rigs with swivel heads so you don't loose range of motion, seems to me if the hardware and fusion fails, the swivel is wear the failure will occur, the weakest part of the hardware. Disc replacement at the time of fusion is another option. Posterior aproach vs Global "front and back". You really need to talk to more than one surgeon and specifically ask why his suggested method is better than any other docs method.

    It is your choice though. You can't undue a fusion, where there are micro discectomies and disc replecment that aren't as invasive to the spine and still leaves the option of fusing at a later time. The only need for doing a disco is if all you have is back pain and no radiculopothy. If you have leg pain then you don't need a disco to tell you so. IF you have nerve problems and the disc can't be trimmed without a laminectomy then the choice to fuse can be made when your on the table, and the choice of how many levels.

    If you have no neurologic symptoms then the doc is looking for the cause of your pain, is it discogenic? If it is, fusion is the way to relieve pressure on that disc, so is artificial disc replacement, which can be done without fusion. Read read read and consult with as many surgeons as it takes to ease your mind that your making the right choice as far as aproach used to relieve your pain.

    Sorry I scared you about the disco, But I went in blindly not knowing what to expect and I'm sure the other patients down the hall were wondering what the heck was going on in the radiology room I was in. If I know what was to occur I would have eaten 3 or 4 percs an hour prior , but that still wouldn't mask the pain a disco creates.

    The purpose of the test is to tell you if the pain is discogenic and to reproduce your worst pain.
    IS it Safe? "quote from marathon man"
    Good luck, Shore

    Last edited by Shoreline; 02-24-2004 at 10:35 AM.

     
    Old 02-24-2004, 05:57 PM   #3
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    Re: multi level fuse or opiate dependent life?

    Scotty, I just wanted to tell you that I understand your fear of the discogram. I had one and it was no walk in the part. However, I have heard many people say that their's were not bad at all. I think a lot of it is how the test is done. Some docs give a mild sedative, like valium, some give you versed. That way, you are awake enough to give your impressions but the pain will be removed from memory ... still not wonderful, but certainly not as barbaric as some docs do. Why not talk with your doctor and explain how scared you are, and see if he will use versed or some other type of depressant so that it is not something you can't handle. The discogram is a really wonderful tool and can help make the decision as to whether or not surgery is really needed. As for the surgery itself, if I had one level that definately needed fusing, but another l or 2 levels that were weak, I would opt to have it all done at once, because the chances are you will end up having it done anyway at a later date. How about ADR? Have you looked into that as a possibility. It is supposed to be approved this year or early next year. I hope I have given you something to think about while you consider your options.
    Carol

     
    Old 02-25-2004, 04:39 AM   #4
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    Re: multi level fuse or opiate dependent life?

    carol,
    thanks for the pep talk.its not that i really fear having the discogram but rather will i have the surgery.im not going to go ahead with disco unless im ready for the surgery.as far as ADR is concerned,right now im not a candidate due to spondy and multi level problem.maybe once FDA approved it will be an option and i hope it is and i am able to hold out..thanks carol..........scott

     
    Old 02-25-2004, 05:02 AM   #5
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    Re: multi level fuse or opiate dependent life?

    hey shore,
    this is exactly what i meant when i said "remind me" ....in an earlier post
    "alternative 3, Post multi level fusion with Intractable chronic pain and dependent for life. If you think you couldn't be in more pain than you are in now, I would say, sadly you are mistaken. No gaurentees with any fusion"

    i know youre right,hell your living proof.im calling pain dr today to move up my appt. its very difficult to think things out clearly right now so priority #1 is getting pain levels managable again.
    i did not realize that there is no way of knowing if doner bone is growing or not following fusion surgery.scary that you know for sure when hardware finally snaps.
    im at a point now where im trying to accept that im going to have to live with this pain for a long time.i could not fathom being in worse pain then i am now and thus my indecision to have surgery done.my current situation is really starting to negatively effect every aspect of my life.my career and most importantly my wife who is losing her patience.we just had a new baby and we have a 4 year old also so although i do what i can she's got her hands full.im starting accupuncture tonite and ive started going for pschotherapy.so between the surgeon,the pain dr,physical therapy,accupuncture and psychiatry when i am home i really need to get off my feet alot of the time,and i also manage to work about 30 hrs a week.
    its not that im scared of discogram but rather my indecision to have surgery,no reason to go through discography unless im goin to go ahead with surgery.
    well,thanks again shore................................sco tt

    Last edited by scotty12; 02-25-2004 at 05:04 AM.

     
    Old 02-25-2004, 11:06 PM   #6
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    Re: multi level fuse or opiate dependent life?

    I'm in the same boat as you are scotty as far as to fuse or not to fuse.

    Last year my L4-L5 disc ruptured 90% out causing cauda equina syndrome and major nerve damage to my bladder. Needless to say i had a microdisectomy and a laminectomy to decompress the nerves and it totally took care of my burning leg pain but not my back pain.

    I too have been on one opiate or another for about 2yrs and am now on oxycontin 20mg. 3x's a day and 10mg.percocet for breakthrough. I had another MRI done in October that showed that the 10% of the disc that they were able to salvage looks as if an impending rupture is around the corner and 2 levels above it have huge herniations and my cat scan showed major tears in the ligaments and the annulus. I had a positive result on 3 levels of my discogram and my neuro has pretty much told me i need a 3 level fusion but because of my age being only 30 she's shying away from it. So in the meantime i'm doing the pain management deal and just trying to buy some time to do maybe the disc replacement once the FDA approves that material.

    I so understand the hard decision that you are trying to make for yourself as i am too. Not to mention i was just diagnosed with fibro about 3 mo. ago and am going to a Rheumatologist about possible RA and or Lupus, and all i have to say is i feel like ackkkkkkkkkkkkkkkkk lol! It sure would be nice to feel like 30 instead of 90.

    My thoughts are with ya hun
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    Old 02-26-2004, 06:02 AM   #7
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    Re: multi level fuse or opiate dependent life?

    REC73,
    its a tough decision.i think i would most certainly agree to any other surgery but unfortunatly that is not an option for me.im sure if i search hard enough i would find a surgeon who would perform a simpler laminectimy but that really will not solve the spondy issue at L5-S1 which is the pain generator along with L4-L5 bulging w/torn annulas.im only 36 years old and my chosen surgeon has told me that pending discography im most likely looking at a fusion from L4-S1 and anything other than a single level fuse advises continued conservative treatment and pain management.i wish you luck and i agree with it would be nice to feel as young as we really are....scott

     
    Old 02-29-2004, 08:11 PM   #8
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    Re: multi level fuse or opiate dependent life?

    Scotty, I'd have to say, from your limited info, that the majority of your pain is coming from the annular tear. A discogram can confirm or deny that statement, and I would urge you to complete that test. As the one person posted, a "good" doc will give you versed for the procedure, just hopefully not too much, which would make the results invalid.
    If your pain is indeed from an annular tear, there is a new procedure called an IDET procedure which repairs the disc. (I cant at this moment tell you what the initials stand for, I'll get back to you on that) Basically what the procedure consists of is: the place a probe in your disc, superheat it and make it basically "melt", then as it cools, its a whole disc again.
    This procedure is still considered investigational, but it does show some great promise in a select few. If you have had prior surgery, or if you are having symptoms in your leg/s, you probably would not be a candidate. But worth checking out, eh?
    A multi-level lumbar fusion has a very poor success rate, and poor performance in relieving the pain you had pre-op. Do I have better suggestions for you? Nope, sorry to say I dont......yet. I'm still researching myself. I have a friend who is only 24 yrs old, with herniations at 2 levels, and tears at 2 levels. Microdiscectomy was not successful, and he is not a candidate for IDET. I'll let you know what I come up with. Not to be nosy, but what area are you in? To see if I find any docs in your area.
    Good luck!

    Last edited by Cindy Stoller; 03-03-2004 at 06:56 PM.

     
    Old 02-29-2004, 08:17 PM   #9
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    Re: multi level fuse or opiate dependent life?

    It sounds very simple, but have any of you, who are trying to avoid surgery, considered be fittied for a back brace? Bracing and medication is a viable attempt at conservative treatment. I'd love to see what meds yall are on. Remember, one med cant do it all. You need to find the right combo of meds to control your pain to a liveable level.
    Let us know how it goes, and Good Luck!

     
    Old 03-01-2004, 06:05 AM   #10
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    Re: multi level fuse or opiate dependent life?

    cindy,
    i am scheduling discogram soon.my pain dr wants me to so he can treat me.says there is not much he can do for slippage at L5-S1 but if the discs above are causing pain there are treatments (nerve blocks etc.) available.i have had the esi's already this year and currently doing physical therapy,accupuncture and ofcourse pain meds.as far as the meds go i was doing very well w/ percoset 7.5mg for many months and just recently my pain has shot up as bad as its ever been.switched to roxicodone 15mg and elavil.
    i have looked into other procedures and i have seen a few different surgeons but all suggest a fusion if pain mngmt no longer an option.all the dr's ive seen believe the main cause of pain is the spondy at L5-S1 but the disco will determine any other discs causing pain so i am going to call the surgeon this week to schedule the test.................................... ...................be well...........scott

     
    Old 03-01-2004, 01:07 PM   #11
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    Re: multi level fuse or opiate dependent life?

    Hey Suzie, IDET is not new, been around at least 12 years that i know of, No it's not FDA aproved, neither is PROLO therapy, pedicle screws, BAK cages, any of the hardware,artificial discs,Nucleoplasty whch is the new version of IDET, RFA, chemical ablation, RAC or just about anything they do to us. We are the guinea pigs for the future back pain sufferers. IF you wait for FDA aproval for the right way to do a fusion, or repair a damaged disc, you would likely grow roots. However , they make these things called waivers and informed consent. You sign you rights away, roll the dice and pray it works. Unfortunately, this is the best medicine has to offer spineys at the moment.

    They can repair the heart of a 26 week fetus but can't tell you what method to fuse the spine is most succesful. Even archiac discograms don't have an aproved method as far as using short acting anesthesia for placement of the caths.Few doc use it and if your doc hasn't n the passed he isn't gong to change his thinking because a patient is concerned about the pain. That's the whole purpose of the test.

    I've broken two completely different designed sets of hardware and neither had FDA aproval. You don't have to have FDA aproval to volenteer for these procedures. IN 4 years on the net and 11 years of back pain and surgerries, I have met 2 people whos doctor used a little versed and it made no difference. After a half dozen esi's a handful of nerve blocks 2 mgs of versed isn't going to make you forget a disco.

    Why would you be curious about the meds some of us are on Cindy, you obviously have an opinion, lets here it, I have 3 different braces and aside from a little relief and loosing all muscle tone if you become dependent on the brace, it is an option, not a cure. Most of us seek cures untill there is nothing else to try except pallitive care.

    I take 150 mgs of methadone a day and up to 120 mgs of morphine, not that what I take has anything to do with how Scot or or anyone else handles the pain they have been delt. .

    Scott, I admire your desire to be cured and wish you every bit of luck. My intent was never to scare, but to pass along knowledge about this procedure. I was given the basic description you were and was never told the intent of the test is to reproduce your worst pain. Take some Roxi before you go in for the test. There is no way oral meds could blur the outcome. If you know your tolerant to the roxi a little Versed won't hurt you and they have the means to reverse things if you have a problem.

    Good luck, I think the spring is probably the best time for surgery, when it warms up you will be ready to start walkng and rebuilding the strength you loose while in a brace for 3 months.
    Good luck, Shore

     
    Old 03-02-2004, 05:29 AM   #12
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    Re: multi level fuse or opiate dependent life?

    SHORE,
    you think it would be ok to take my roxi before the test?i was kinda planning to but wasnt sure if it would hinder the outcome of test.you didnt scare me,i would rather not be in the dark as far as what to expect from procedure.although im going ahead with discogram im not rushing into surgery.im getting it done so i know how many levels i would have fused but more so because the outcome will assist in treatment for any other pain generatores besides the slippage.
    i must say that switching to roxi has helped so much.my pain levels came down the same day i switched meds and im not watching the clock nearly as much.the elavil really helps with sleep also.im giving it one last shot before deciding on fusion.im going to lose some extra weight and now that the weather is warming up i walk alot and have started a more aggresive stregnthening regimen.i dont expect a miricle but atleast if i get into the best phy. condition atleast i gave it my best shot and im sure recovery would be alot easier. ................scott

     
    Old 03-02-2004, 05:56 AM   #13
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    Re: multi level fuse or opiate dependent life?

    Hey Scott, Having taken Oxycodone for months and knowing the nature of the test I would most certainly take somethng for pain prior to the test. You really can't mask shredded disc pain when they inflate it with die. THere is no point in making it evn worse by going in without having taken your normal pain meds. Don't take more than your used to taking but enough to take some of the edge off.

    After they inflate your discs they turn you every which way they can on the table, they have hand pegs so they can invert you and watch for the die running and you do get turned and tilted in every direction. The last pictures they took on me were standing and after 45 minutes and having 5 discs inflated I was unable to stand. I mean I went in cold, no meds, not knowing what to expect at all. I figured it would be similar to a meylo gram but there is no camparison.

    IF the doc does want to sedate you, which is very unusual and more likely to skew the test results, do tell him you took your normal meds, It shouldn't prevent them from using somethng like Brevatol if they were planning on it anyway. Sedation just isn't as common as some posters are suggesting. I wouldn't mention the meds I took unless specifically asked, Then minamilize the relief you get from the meds anyway. It won't change the results at all unless the roxi just flat knocks you out. Which I really doubt.

    Oral meds really aren't going to mask the results of this test. IF you have one known bad disc, one suspect disc, then they will start at a higher level where they don't suspect a problem to see what your resoponse is to the pain of having a healthy disc inflated, It's no treat but nothing like having a blown disc being inflated.

    They placed 3 steel caths into each disc before injecting the die, just having the caths placed is rough because it's hard not to go through a nerve at some point and it does lite you up. The topical numbing agents don't even get close to reaching the depth needed to numb a nerve root or disc, so that liitle bit of marcaine or Novacaine really isn't much help. Make sure you have pain meds for after the procedure and a driver to get you home.

    If you develop a spnal headache be sure to report it imediately, there is no reason to suffer from having your dura nicked and loosing spinal fluid, when that happens you brain sets down on your skull when your upright and there is no describng that headache. You may have experienced it during an esi or other fun needle procedure but it can be fixed rather easily with a blood patch should they nick the dura,or you loose fluid some other way. They do the insertions with flouoscopy so hopefully you won't experience any problems from a misguided needle.

    I'm sure part of the reason why my experience was so terrible was because I had 5 discs done at the same tme. 3 bad ones and a test disc above and below. The test discs were no treat but nothing compared to a bad disc. I have read and heard that these are essential tests but It just seems that there has to be a more humane way to test for discogenic problems or pain. But this is what they have for now.
    Good luck, Shore

     
    Old 03-02-2004, 07:54 AM   #14
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    Re: multi level fuse or opiate dependent life?

    Thanks bud,im looking foward to it........scott

     
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