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shawley 05-05-2006 07:49 AM

Calling for help
Hi I have some question I hope you can help me with . In April worker's comp sent me for a Imparment rating evaluation, there doctor took humpteen x-rays and stuff , I just got a copy of the report from their attorney's . He stated that at this time , five months following surgery that I do not have radiographic evidence or fusion between L4-L5 , he also said I will have a permanent impairment relating to my condition. I also had a CT done last month it's impression:

There has been some minimal disc space narrowing at the L5-S1
There is a 2.0cm area of subcortical cyst formation with some distortion of the inferior/posterior endplate of L5 with some loss of visualization of the cortex in this region.

Am I looking towards another surgery ? I don't understand whats going on with my back . I hope you can help me, anyone with any insight is welcome.


Shoreline 05-05-2006 02:24 PM

Re: Calling for Shoreline's help
MY best advice is no to even think about settling a comp case, at least with that kind of evdence the fusion failed. Now just because the fusion failed doesn't mean you have to redo it. It depnds on the hardware, but it is odd to have anything definitive within 5 months. It's easy to call a fusion a success if the donar bone is still sitting there but it usualy takes longer to be reabsorbed. Obviously it's already hapened so for now, whatever fixation devices they used are maintaing the disc space between L4/5 but it apears it's putting aditional stress at L5/S1.

That's not uncommon but I don't know what the best thing for you to do is, other than don't sign anything as far as future medical or even pay at this point, because the surgery failed at some point you may have to fix it if the pain isn't managable or it becomes unstable and compresses nerves or the cord.

If or when you have surgery again may depend solely on the amount of pain your eperiencing or can manage and how debilitating it is.
More surgery means worse odds of succes and likely a different aproach taken to fuse you and extend it down to your sacrum. Then you have potential fusion problem to the scarum. Can I guess they did a posterior aproach with screws and rods?

The need to have surgery is really up to you unless you mave major neurological problems going on. Hardware may keep you stable for years and more surgery may leave you in worse condition. The only time they have to do something is when you have loss of nerve function, loss of bowel or bladder control, loss of reflexes, muscle atrophy, footdrop. Symptoms like those need to be corrected or they get worse. But if your not symptomatic other than pain. The decision is tough. There is always that thought that surgery may restore your life if it's succesful.

Unfortunately odds decrease with each attempt and with every level they add. If the hardware breaks your spine can shift and compress or damage nerves or your spinal cord and leave you in worse shape than now. I couldn't make a decision for someone else although I've been told I think I know it all. LOL

THey have tried 3 times to fuse me and each time it gets longer and made my life worse. Now I have hardware from L1-S1 but there is a surgery they could try. After each surgery leaving me in more pain than I ever could have imagined, I'm not in a hurry to try something really radical like removing a couple ribs, extending it up 3 levels, and running a bar from hip to hip because my screws toggle and pull in and out of the sacrum. One facet out of 12 they placed bone has donar material left in it.

The last surgery left me bed riddn and numb from my hips to my knees untill long acting meds were finally offered. That surgery was mechanically minimal compared to what they are talking about if at some point I can't get relief and can't stand the pain or my spine slips further out of whack and damages nerves. You also have to accept what you life bhas become at some point or keep finding docs to cut if each surgery fails. Shear desperation drives folks to have 5, 7 or 9 surgeries on the same area hoping to get it right.

I'm disabled, but it's better than bed ridden, impedent or in a wheel chair with a colostomy bag which are are possble if my spine continues to shift or I could wake up from the next surgery that way. Right now I have the pain where it's manageble and I'm working on my own to rebuild my strength and core muscles to strengthen my back.

I really don't want to take the chance another surgery will leave me in worse shape, but I really don't want to live the rest of my lfe like this. :rolleyes:
So I'm takng what I've learnd in PT, sorted out the useful and am making another attempt at recovery. Since feb I started using an elyptical trasiner and have gone from 8 minutes to 50 minutes.

You are in a bad position with comp being in charge of your care. They can recomend revising your surgery if your unable to return to work the way you are and if you say no, they can cut you off and try to force you into a settlement. But that's a crappy reason to have surgery if you think you can manage the way things are or find a manageble level that you can live with.

There will always be both sides of the coin. By not redoing it now, the longer you wait, the less likely you are to have a succesful surgery. It really should come down to how stable is your spine and what are the risks and consequences if you do nothing.

It would take pages to play devils advocate for both, having surgery and not having surgery when you look at every aspect of having more surgery, what apoach are they using, using basic statistical equations for sucess given known odss for repeat surgery and the number of levels involved. The math on a revision of my 6 level failure means I go in with a 180% chance of failure. Using an antierior or global aproach, your looking at about a 60% chance of failure at a second attempt with the levels involved . But sometimes 40% chance of succes is enough if your quality of life is so horribly effected by your present condition or lack of pain control. There is all the man psyche crap to deal with when disabled and the guilt that you have to at least try for everyone other than yourself.

What's hapening pain wise and work wise with you? Is comp pushing to settle this because you can't or won't comply with any of their requests? Comp can cut you off if they don't like your decisions, but a lawyer can eventually get it reinstated with a hearing in front of the industrial commision. It's the time with no income you have to get through and if you don't have adaquate PM, it makes it tough to make a decision you may end up regretting.

How efectively is your pain being manged. If your able to return to work with the right combinations of modalities to mange your pain, I would think you have a lot of medical care of some sort in your future, so signing that away for a lump some will likely come back to haunt you. PM meds aren't cheap. spending 25K a year on PM medication isn't unusual.

What neuro symptoms have you experienced and which way are their docs leaning? You may need your own docs to dispute their recomendation whether for surgery or against it. IF someone is giving you better han 50/50 odds of succcess on surgcial revsion and extension they are blowing smoke. IMO.

Sorry about erros, sitting gets tough real fast and sometmes I don't get to edit without being knocked of the net so my first draft gets slapped up..

Sorry and Good luck, let us know what you do. Your not the first to get bullied by comp, if it hasn' happened, it's pretty much a given. You either get better and go back to work, or things get ugly.

If their docs pointed out the failure, IT sounds like they may expect you to have a go at it.If you do, ask lots of questions, what aproach and why, what hardware and why. I can't believe they even do posterior aproaches to sacral fusions. There isn't enough bone to bone contact. IMO, anterior with cages is the only logical aproach to L5-S1 fusions. You have a much larger area to fuse VS trying to get the wing tips of the much smaller facets to fuse when they barely touch.Wing tip to wing tip just doesn't make structural sense.

Using an anterior aproach means going in from the front removing the disc completely, putting 2 vented cylinders in side by side to mainatin the space, fill them with crushed bone and rhBMP11 "bone growth proteins" and try to get some solid bone growth from the large flat area to large flat area. They could do the same for L4-5. 2 level anterior doesn't sound that bad, but the failure of the first is concernng.

That's also how they would do me, but 9 levels along with all the other stuff. For me it's crazy, for you it's a posibility with no gaurentees and worse odds than the first.

Fabrashamx 05-05-2006 04:37 PM

Re: Calling for Shoreline's help
Hi Shawley, hope you can get your issues resolved and be more comfortable. Just had to say, My God Dave, I had some idea what your situation is, but I am totally humbled. The strength it must take you just to get up in the morning and keep going amazes me, I know there is always someone worse off than myself, I guess until we die theres someone in a worse situation somewhere, But I have to tell you, your taking the time to help all of us with info and some very hard won expierience is just amazing. Thank you so much, you are truely a rare and courageous person. Shawley, hope things improve for you and for Dave and for us all, But in the meantime, we have each other to lean on. Your friend, Fabby :cool:

shawley 05-08-2006 06:18 AM

Re: Calling for Shoreline's help
Dave thank you for your wisdom and willingness to help other , I sound like a little baby compared to your problems , I do take everything you say serious . Firt off I have no plan's on setteling now . Couple months ago I was ready , thank the LORD I didn't . Pain wise , I been having increasing burning and thumping down bothe legs , my back hurt's some, but no where near my feet and legs , I am taking Cymbalta and lyrica and I do have a bottle of hydrocodone to take when the pain is at it's worse .
I can walk on a treadmill but as soon as I take long steps or walk down hill I get a bad burning in my thighs, then the rest of the night is pure hell. I have problems leaning forward . I have been in therapy for 3 weeks , walking on treadmill , doing rows , squats , lat pull downs, exercise ball , back strengthing. I do this weird thing on my hands and knee's where I put my left leg straight back and my right arm out, and switch legs and arms, I hold for 2 seconds and rotate , this exrcise kills me , my feet go numb, and my leg gets really weak. The other day I was walking and stepped over a fallen tree and when I lift my leg I got this terrible pain ripping down my thigh ,it hurt for about 3 minutes , and my burning came back to my legs and feet. Maybe it is to early to tell whats exactly wrong with me . I really don't want to go through another surgery , I feel so bad for your condition , I could only imagine as many levels your fused would feel like , Thank you for taking time and helping other's

shawley 05-08-2006 07:37 AM

Re: Calling for Shoreline's help
I'm sorry I forgot to add they did my surgery through my back , uh,,I mean they cut me on my back , lol...
Thanks again Dave

Shoreline 05-08-2006 09:10 AM

Re: Calling for Shoreline's help
Hey Shawley, That crazy excercise where you lift your ight arm and left leg while balanced on the ball is called the superman, because it takes alot of core muscle strength to remain balanced while you do this.

I'm sure you have heard of Pilates? It sounds like the excercise routine of the stars that's very popular where all these Holleywood folks like bragging about their personal Pilates trainers. That's exactly what your doing with the ball and the superman and many other core strengthing excercises. The balls are really great for this and I"m on my 4th ball so far. Even simple single knee raises while on a ball require spine stabailization, ab stabilization and a great deal of balance. Any excercise that focuses on those specific things would be considered another Pilates movement and ideal for back patients. The superman is very advanced though and may take sometime to master.

I'm sure you know the leg pain is much harder to manage and much less responsive to pain meds. But from a surgical standpoint, they are more likely able to relieve leg pain with spinal surgery than they are to relieve back pain. If there is a clear impingement than can be reduced, odds of reliveing the leg pain are better than odds of relieving back pain with addtional surgery. It's just one more part of the equation and decision you may have to make at some point. Although my fusons failed and left my back a mess, I'm very greatful my legs no longer feel like they are on fire or I'm standing in a giant bucket of ice water.

Good luck and keep us posted.
Take care, Dave

shawley 05-08-2006 09:45 AM

Re: Calling for Shoreline's help
Hi Dave , yes the leg pain seem's like it won't go away even with my percocets , I took 2 perc's to try to relieve it and I thought I overdosed on them . Just a few weeks ago I felt great , and it seem's if things are creeping up on me every week . A different spot on fire . I'm taking my w/c report to my surgeon because he told me I was slowly but fusing ? I'm tired of lies. Thanks again for your help , The superman ? Yeah that exercise is a tuff one .

Shoreline 05-08-2006 02:27 PM

Re: Calling for Shoreline's help
Hey Shawly, There is probably a little truth behind most lies doc tell us, they just don't explain wha they mean. When a disc bulges or reptures it's also dehydradting and narrowing. What eventually happens if the disc goes completely and yu end up with bone touching bone. Itr may be just on one sideand you could end up fusing cockeyed naturally from bone rubbing on bone, but hat taks alot of th disc to completely disintigrate. What usuallyhappens befor the discs completely go in the lumbar area is the vertabrea strat to take on a concave shape on the ends and those ends are th e first to touch or rub and you develop osteophytes or spurs. Once you develop enough spur and abnormal bone overgrowth it will eventuallly fuse spontaniously. I imagine he pain is pretty severe as you slowly grind your spine together to cause fusion, but this is so sure to occur that cervicle fusions are ioften done by simply removing the disc completely and bracing the neck for a few months. Cervicle vertabrea and discs are much smaller so once the disc is gone, the vertabrea touch large fla area to large flat area. If the rough the bone alittle and let it collapse, it will grow into one piece.

I'm imagining a 2 level back side fusion where you have 2 screws in each vertabre and horizontal rods. If one screw breaks, it may still keep the vertabrea apart. That's why I said you may not have to do anytihing. If the screw n the other side holds, The hardware will hold spine together. I crunc and grind alot but the remaining hardware is what allows me not to have to have any more crazy surgery. I have slippag atwhere T12 meets the fusion ad at L5-S1 because both screws are broken and pulled out of my sacrum. As long as you have one screw that's solid it can support you for a while if not indefinitely. When the screws break they can't always be removed, they often have to extend a fusion to work into an area they can place 2 fresh screws if they keep aproaching from the back. If they can back the screws out, they can simply use larger scews on a revision, but IMO going in from the front, although it has more risks and is more complicated, makes more sense to me. They completely remove the disc and replace it with 2 cages side by side at each level "the hollow cylinders they pack with bone and Bone growth proteins". It just seems like using a different aproach that gives you more bone to bone contact is more likely going to give you different results than just repeating the first method that failed with larger screws. All my work was done from the back "posterior" now I have a broken ladder built up my spine and knowing what I know now I would have looked fo an anterior aproach.

A question you hav to ask is what are you going to do different from the first surgery to ensure the best chance of fusion. Some titanuium cages/ cylynders are tapered to maintain the natural curve in your lower spine so you don't end up with another problem called flat back syndrome. He has a large choice of hardware to choose from, So you have to ask what he's going to use, what aproach if your discusing revising a fusion or replacing hardware and trying again.
The drawback of cages and an anterior aproach is if the fusion fails and the cages slip out of place it tends to be more catastrophic than a screw breaking or bending a rod. It just depends on where the cage or screw heads end up after they break or move out of position. Cages are in a position to do more damage but make more mechanical sense when looking at how they work. It gets really complicated if you consider every choice available, there are at least a dozen variables in the way a doc can do a fusion or revision.

Good luck, Dave

BrittleBones 05-08-2006 03:46 PM

Re: Calling for Shoreline's help
[U]Quoting Shoreline[/U]: "[I]I crunc and grind alot but the remaining hardware is what allows me not to have to have any more crazy surgery. I have slippag atwhere T12 meets the fusion ad at L5-S1 because both screws are broken and pulled out of my sacrum[/I]."

Dave - I have developed lots of crunching/grinding in my cervical spine. My cervical spine is not fused, but everything else is. I try to explain to folks what it's like, but I can't really describe it. I feel like I can hear the crunching and the grinding. I know that I can feel it big-time! What would cause this? I do have a titanium cage, rods, screws, in my spine. It is especially noticeable when I raise my arms to do things like putting the dishes away, or reaching for something on a shelf which is higher than I am (and that ain't to hard to do seeing as osteoporosis has taken me from 5'4" to 4'11")! Your tenured advice is appreciated Dave - Thanks KathyMac

Shoreline 05-08-2006 10:47 PM

Re: Calling for Shoreline's help
Hey Kathy, I chrunch squeek and grind so loud my wife can hear it and the docs can feel it whethey put there hand on my back. If it were me I would be concerned that you have none to bone contact that isn't fused or supposed to occur. Fusions aere always called a asuces as long as the hardware satys in alignmant and the vertabrea stay in alignment when they do flexion and extension VRays. If something is fused, it should be solid, but the hardware alone can create great stablility. It uTakes either the breakage of hardware or enough time to pass to show reabsorption of fusion material. S

Untill this happens the surgeon hat cut islikely going to say your fine, t's just somhow echoing in you ears because of the location. Sound familiar. It's really a wait and see thing andeven if it fails, the hardware can keep things from getting worse or stable enough to put off more surgery.

The doc that keeps wringing in my head wasn't the one that wants o carve me up lke a cadavor but he said, 3 surgeries ave failed, why would you think yu would benefit from a another surgery. Each one gets longer and longer and leaves me in worse shape. I worked through the first 2, but I never recoveed from the last. I know my spine is unstable, but I'm at the point unless I shift further and have greater symptoms that compromise function.

Accepting that the crunchiing doesn't mean your head is going to fall off or that you have to have it fixed in order to get better may or may not be true.. YOu may get uch wose or you may eventually sponataniously fuse from bone on bone grinding. This may actualy be a good thing and give your neck some support.

I read about folks having 7 and 10 back surgeries and it amazes me to some degree but I understand the desperation and the hope this will be the one and the feeling of obligation to try to do anything and everything possible.

I guess alot of that is a chronic pain subject materal, How to live with intactable crunching and grinding pain and not a PM subject.

Your neck grinding means your fusion lkely didn't fuse an you have movement that doesn't show in a static picture/ Xray. It can usually be seen under floroscopy but that radiates the heck out of you, they can also do a meylo with flouro and diagnose it as failed and called it spondy if you have movement that isn't seen when your holding still for an Xray. :rolleyes: but in the absence of other signicant neurlogic damage, there isn't an absoute need to fix or gaurntee fixing it will relieve all your pain if your pain can be managed.You could end up worse or you can have surgery to refuse the area and hope for the best.

We have to live with the decisions we make. It's no like most people have just been in a M<VA and will be paralyzed if we don't have surgery. It's elective surgery in most cases. We elect to take the chance it will relieve our pain.

Sorry, I think it's funny people say I act like a know it all when they get mad at mefor pointing out the obvious. I realy don't know it all. Someone please tell me of a surgeon that will do minimually invasive surgery to fix the most damaged areas rather than redo it all and write about it in a surgical journal. I can't even imagine wanting to wake up from that surgery..

Have I helped or am I just loosing it after 7 years of something I never could have imagined.
Take care , Dave

shawley 05-09-2006 07:48 AM

Re: Calling for Shoreline's help
Thank you so much Dave , I'm going to write down a bunch of questions to ask my doctor. I'm not even sure what he's going to say when I show him my IRE report . I really don't know what to think about my fusion , why would my surgeon tell me it's fusing when it isn't ? I would tend to lean on the w/c OSS because I believe he would be out to say I was fine and to send me to work ,but he didn't . I'm just sick of this burning and thumping !!!!
Thanks again

BrittleBones 05-09-2006 09:37 AM

Re: Calling for Shoreline's help
No Dave - you're not losing it! Your answers are always helpful to me and I'm sure to most folks. I think you are right about "hearing" the noise. Because it is so high in my cervical spine and closer to my ears - it does tend to sound like wood going through a meat grinder! I didn't know that there were xrays that could be taken when you were moving. That's exactly what I think I need because the flat xrays that I had just 4 weeks ago show nothing wrong at all, yet I know when I move the bones are doing the Rice Krispie snap, crackle, pop dance. I've had flouroscapy before and a mylogram. I don't think I'd ever agree to the mylo again - but the flouroscopy wasn't bad at all when they did it before my sacral joint fusions. I don't think I would ever undergo another surgery - although all of my surgeries have actually fixed the problems, I just can't see myself taking a chance on infection like I had with my hip replacement last year. It was caused by the MRSA germ. Anyway, thanks again for your advice - you've helped alot. Take care - KathyMac

shawley 05-09-2006 12:40 PM

Re: Calling for Shoreline's help
Hi KathyMac , I was reading your post , I have that poping and crunching noise to ,my surgeon told me it was cartlidge and scar tissue moving around , I hope he's right. They did do a bending x-ray on me to see if the screws were comming out, they said they wasn't so I guess I'm lucky . Dave has been so much help for alot of people here . It's amazing how educated he is on the spine , Guess when you live it ,you learn it.

shawley 05-11-2006 07:05 AM

Re: Calling for Shoreline's help
My pain is at it's worse today , I went to bed last night, slept ok, but my feet were numb. This morning is the worse I had yet , I hate to sound like a little sissy , but I can't stand this burning and thumping , when ever I lean froward or backwards or lift my legs up high it starts , do you realize how hard it is to sit perfectly straight as long as you can ? I can't do it., I went to Wal-Mart with my wife and kid last night and my wife caught me moaning when I walked , and ask me what is wrong, I try not to let her know the real pain I'm having , but I told her it was bad . Like me she is praying I need NO surgery , but somthing needs to stop this pain. I know Dave what you said about another surgery but I need to do somthing . Has anyone of you had these symptoms ? Sorry for crying all over your screen I'm just worried to death somthing is wrong back there other than my fusion not healing. Sorry

Shoreline 05-11-2006 09:39 AM

Re: Calling for Shoreline's help
He Shawley, I understand having to do something even when the odds aren't great. IN your case it's very clear what's wrong and what needs tobe corected mechanically, it's more a matter of what aproach you want or the doc wants to take to revise the fusion.

A good te to see if stabalizing your spine will bring relief is to get your brace back out to see if that gives you some relief. I've heard some docs don't even use the braces which sounds insane but I guess they the believe so much in the hardware they count on it holdng things straight while you fuse. I can just imagine you standing trying to hide the pain. When I have my Shoulders pulled up to my ears and a slight bend in the knees my wife knows I'm miserable.

Unfortunately I'm 30 lbs heavier since my last surgery so I can't get one of my braces back out. It might be worth asking the doc if surgery is an absolute to go ahead and make you a new rigid plastic brace and let you use it untill surgery. The last brace they made me was a Turtle shell out of 2 seperate plates but the original brace was more comy and designed like a clamshell with Velcro straps closing it in the front. My doc offered to make me a new brace last year but I didn't want to loose what I have restored as far as core strength and become dependent on the brace. Giving it up after sugery was bad enough. But if you know that's the direction your going, I don't see the harm if it relieves some pain.

If you made the decsion to go for it, do the research and check out the difference between Anterior interbody fusion techniques and Posterior fusion techniques. The more informed you are now, the better you can question this doc or other consult opinions.

Spine Universe is a great site that shows you the hardware and gives you a chance to read about what's available and which way trends and data are indicating are the better aproaches to whatever type of spine surgery someone is considering. Docs tend to use the method they learned during their residency and apply it to 90% of their patients. IF an anterior aproach makes more sense to you and all one doc is offering is a posteror revsion, you can always stack several surgical consults day after day or week after week untill the method a surgeon wants to use makes sense.

I know we rely on them to use the best method, but they are really just using the best method they know. I would have a problem with some of the different methods used but those are just my opinions based on some research. I would want a doc to explain to me why his method is better than another.

Just getting by with enough meds really isn't good enough, being able to put a smile on so you can participate in some basic family function and then spending the night paying for it isn't good enough. If you have an oportunity to restore your life or even stabalize the problem so it doesn't get worse, I wouldn't dare think you're making a bad decsion.

Good luck and let me know if the brace helps, it's a petty good indicator that being stable, as in properly fused will help.
Take care, Dave

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