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    Old 05-31-2011, 08:24 AM   #1
    colloquor
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    Different Procedures

    Hello,

    I'm a 64 year old male with cervical stenosis with cord compression at C5-C6 and C6-C7. I've had three surgical consults: 1). spinal surgeon wants to perform a laminectomy from C3 to C7 with foraminotomy, 2). another spinal surgeon wants to perform a laminoplasty from C3 to C7 with formainotomy, and 3). a neurosurgeon wants to perform a ACDF at C5-C6 and C6-C7 as well as a foraminotomy.

    Needless to say, I'm extremely confused as each procedure has its Pro's and Con's, and need to make a decision soon as my myelopathy symptoms are progressing. Originally, I was leaning toward the laminoplasty, as I'm concerned with laminectomy reducing spine stability a fair amount. Interestingly, the neurosurgeon "pitched" me the ACDF procedure. I use the term "pitched" as it actually did seem a bit like a sales pitch. Even though he too is trained in laminoplasty, he downgraded that procedure, and prefers ACDF. It sounds OK, but a bit scary due to the anterior approach. Also, since I have a congenitally narrow spinal canal, I'm wondering if in the future the stenosis will degrade at the other levels, e.g. C3 to C5, and T1, where a laminosplasty might be the best option initially and on into the future.

    Any input on this would be greatly appreciated. I apologize in advance if this is a redundant subject.

    Last edited by colloquor; 05-31-2011 at 10:36 AM. Reason: Update

     
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    Old 05-31-2011, 02:07 PM   #2
    rgsmoose
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    Re: Different Procedures

    Boy, does your situation sound familiar. I too have a congenitally narrow spinal canal and was faced with a similiar choice. One neurosurgeon wanted to do a C3-C7 laminectomy and an ortho surgeon wanted to do a C5/C6 corpectomy (it's actually an ACDCF - that's anterior cervical discectomy corpectomy and fusion). I was in a massive state of confusion, as both surgeons were highly regarded specialists. The one that preferred the laminectomy was older and said that this approach was the "gold standard", as it's been done that way for many years. The one espousing the corpectomy was a younger person that had different training, possibly meaning a more "modern" approach? In any regard, I looked at it as a mechanical issue, and since the problem was caused by an anterior segment in my spinal canal, that's where the problem should be fixed. I got the C5/C6 corpectomy and was fused C4-C7.

    All went well until the following year when I got some of the old symptoms back. I ended up getting a C3/C4/C5 laminaplasty to solve those issues. Then in another year or so I had more issues with my right arm. That led to foraminotomies at C6/C7/C8. So did I make the right decision at first? I have absolutely no way of knowing. I did my best to research both approaches and ended up getting two additional posterior surgeries when part of my original goal was to avoid a posterior approach.

    One thing to keep in mind, though -- posterior surgery is more painful both right after the surgery and also after several years. The posterior approach means going through some muscles that don't like being cut. I did not have very much in the way of pain after the anterior surgery, but I have had pain from the posterior surgeries for over 9 years now.

    I can't say much about spine stability or mobility, as the first cervical surgery was a fusion. It does limit my range of motion, but it's something you get used to. I have to be more careful when backing up the car, and have to turn my whole torso to look behind me, but that's just the way it is.

    To your specific question, I would take a look at your MRI's and see where the major issue is. Laminectomies just remove the backs of the vertebrae to create more room for the cord. If the major problem is due to disk herniations that are anterior, opening up the posterior would probably help, but maybe not as much as an ACDF??? This is the biggest question you should ask all your surgeons. That's if you agree with my logical approach of fixing where it's broken instead of the other side. I wish I had more information to give you, because I remember clearly going through your current confusion. In the end I did what I thought best from a logical approach and also considered how much I trusted each of the surgeons I talked to. That's pretty difficult to do when you're under the gun as you are, but it does have some part in the decision.

    Good luck and let us know what you decide.

     
    Old 05-31-2011, 03:50 PM   #3
    colloquor
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    Re: Different Procedures

    Thank you rgsmoose... your initial surgical consults sound like mine! My first surgical consult, a local orthopedic surgeon specializing in spine and with 33 years experience, is the one who wants to do a laminectomy from C3 to C7 and foraminotomies at a few levels. The second consult was with a spinal surgeon with 8 years experience and 250 miles from my location. He wants to perform a laminoplasty from C3 to C7 with "possible" foraminotomies. My third consult was with a local neurosurgeon, a rather young Chinese/American and chief neurosurgeon at a local hospital, who wants to perform the ACDF at C5-C6 and C6-C7, and also may perform some foraminotomies where needed.

    Although my spinal canal is quite narrow due to congenital reasons, the most significant problem include the C5-C6 disc and the C6-C7 disc, neither of which are technically herniated, but are bulging, and compressing the cord anteriorly. The neurosurgeon pointed out that there is sufficient spinal fluid at the C3-C4 level, and at the C7-T1 level, thus he feels this is the best approach. In both cases of the C5 through C7 levels on multiple MRIs over 3 years, you can't see any spinal fluid around the cord on the anterior side. Thus, I can understand his reason for the ACDF approach.

    My overall concern, however, is with the long-term, and what you've described after having your ACDF initially, is exactly what I don't want to experience in the future. That's why I wonder if having the laminectomy, or better yet the laminoplasty, from the C3 through the C7 level is perhaps the better long-term approach. I'm a bit afraid of the laminectomy procedure due to the potential for head drop or droop. Interestingly, both surgeons who proposed the laminectomy and laminoplasty plan to leave the bulging discs alone, and just "open up more room" on the posterior side of the cord.

    I understand the posterior surgery is more painful directly post-op, as well as into the future. This is a very tough decision, as it's heightened by a recent decision by our state governor and insurance contracts for state employees, in the case, the University of Illinois. I'm essentially guided by a deadline for the decision, and this is what's most frustrating and stressful.

    Thanks again.

    Last edited by colloquor; 05-31-2011 at 04:02 PM.

     
    Old 05-31-2011, 06:42 PM   #4
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    Re: Different Procedures

    I did the laminoplasty. I did have complications but they had nothing to do with the laminoplasty but were from a previous injury that no one knew about(torn ligaments as a young child). Required extra surgery(including fusion this time) but nothing since then(4 1/2 years). But the laminoplasty fixed the primary problem of stenosis.

    I did not return to work but more because I have severe rheumatoid arthritis and it has hit C1 and 2 very badly and I am at risk of having to be fused to my skull.

    I'd try the laminoplasty as that has no fusion involved and if you need to go the fusion route, you can later. Fusions are where the problems start.

    Jenny

     
    Old 06-01-2011, 06:08 AM   #5
    Realtor09
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    Re: Different Procedures

    Good Morning!
    Just a few thoughts from my experiences. I had ACDF in 10/10 with a 3 level fusion. The surgery was a piece of cake. Three weeks out of work and felt great! 4 months later my right arm started to ache and I was starting to loose mobility. My Ortho Doc stated thet the middle fusion had failed and the donor disc was in pieces.

    April 12, 2011 I had 360 cervical fusion surgery. Which is going thru the front and the back. I was really nervous about the back part as I have heard that it was extremely painful. Even my doc said that I would not like him afterwards.

    I must say that while the posterior was "slightly" more painful, I have found that it was easy. I did have a setback when a blood vessell burst 10 days post op landing me back in surgery and back in the hospital for 10 days (5 in the ICU on a vent) BUT my neck is good. I have full range of motion and very limited discomfort. I know I may be the exception but I had full faith in God and my Doc.
    Of course it's gonna hurt it's MAJOR surgery. Take it slow, listen to your Doc and don't do anything heroic! The body needs ot heal.
    I am back to work full time and still don't lift. Not diving off diving boards or running around. I am taking it slow and LISTENING to my body!

    Hope all this helps. Wishing you all much love and healing!

     
    Old 06-01-2011, 02:45 PM   #6
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    Re: Different Procedures

    My ACDF in 2006 was very simple. I have a plethera of joint and spine problems so don't let my surgical history scare you. Perhaps come up with a standard list of 10 questions you want each surgeon to answer to you can compare outcome (1) post op recovery time (2) post op functional limits during recovery and permanent (3) Why the method they suggest is better than some of the other methods you've been told about (specifically what the other doctors have said (4) What if the procedure doesn't give enough relief, what additional procedures may be needed? ETC

    My ACDF worked but I had more stenosis so I had a posterior foraminotomy in 2008. I also wish I had pushed my first Orth Spine Surgeon to include C4 as it was "iffy" at the time. So when I had lumbar surgery I told the surgeon with the co-surgeon present "I give you permission to fix anything you find in the best way you believe possible" (so if L2 had been in bad shape I'd have been fine waking up with L2-S1 instead of L3-S1).
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    Rt thumb fusion '13. R&L thumb arthroplasty '12 ; RT TKR & Bilat CTS' 11. Fusions: L5-S1('87), L4-S1('93), C5-C7('06), L3-S1('10), C4-C5('13). C5-C7 foraminotomy '08

     
    Old 06-10-2011, 12:20 AM   #7
    mahoney67
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    Re: Different Procedures

    Wow, it sounds like we've been going through the same thing over the past few months. I have two small herniations at C4/C5. A big one at C6-7 that's compressing my cord and causing right arm weakness, just turning into pins/needles too. The first OS told me to try ESIs, if they don't work he would do a posterior foraminotomy. OK. So then I went to another OS. I was thinking I was just going to see which guy I liked better. The second guy was very sales pitchy and recommended C6-7 ACDF. He wanted to do it literally next week (June 21st). I was so confused!!!! I had an appt with a neurosurgeon this week but cancelled it. Instead I had an appt with a PA to the most renowned spine OS in the state. He prescribed new meds, told me to wait as long as I can for this to heal on it's own, and he got me a July 1 appt with that renowned spine OS. So am looking forward to what he says.

    So I can sympathize with you!!!! I am turning 40 in Sept and this is not where I thought I would be!!! In early April I was jogging and working out every day. Now I can't even lift my children. I just want to be normal again, and between the choices of 1) wait to see if it gets better (on a ton of pain meds and watching your arm get weaker and weaker) and 2) surgery (which is the best for me?? long term implications) I'm ready to rip my hair out!!!

    All I can say is hang in there and continue to do your research. I've been using some websites to try to figure out the best surgeons in my state. I've been doing that and word of mouth. That's how I found out about the OS I am seeing soon. I am looking forward to being in touch with you as we both navigate through this!!! I hope we both make the decision that is best for us...

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    Old 06-10-2011, 12:17 PM   #8
    colloquor
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    Re: Different Procedures

    Thanks to all of you for your input. I'm considering the ACDF procedure, but the laminoplasty procedure as well. I've already canceled one surgery, and about to cancel another, as I just don't feel "right" with the decision. According to the neurosurgeon who wants to perform the ACDF, I'm on the leading-edge of myelopathy, and only have slight symptoms even though I've had cord compression at two levels since June 2007. He said immediate surgery is not necessarily mandatory, but then again, I don't want to wait for major symptoms that will likely not be reversible. This neurosurgeon, although not aggressive per se, seemed to pitch the surgery to me as if I was buying a car! None of the three surgeons have given me the Pros and Cons of each procedure, focusing only on their procedure.

    I have another consult at Northwestern University Hospital's Spine Initiative in Chicago next week, and hope that the spine surgeon I've been assigned doesn't offer a fourth alternative, but rather offers me the Pros and Cons of laminectomy, laminoplasty, and ACDF as it applies specifically to my condition.

    The fact that our HMO terminates on June 30, and our large group is forced into a Tiered Open Access Plan effective July 1, I'm having to weigh options on the different procedures, as well as the insurance, which adds enormously to my stress level. I'm only 6 months from Medicare, and the surgeon who recommended laminoplasty actually said it's easier for him to deal with Medicare than our current HMO. Of course, our HMO co-pay for this major surgery is only $275 total, whereas Medicare will likely be around $2K.

    I know surgery is never an easy decision, but I never thought that I'd be so indecisive and flummoxed (tnx Mike Myers ) on this.

    It's all very frustrating.

    Thanks again.

    Last edited by colloquor; 06-10-2011 at 12:19 PM.

     
    Old 06-10-2011, 01:12 PM   #9
    jennybyc
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    Re: Different Procedures

    Don't rush due to Medicare kicking in. You can buy Medicare supplement insurance that will cover EVERYTHING at 100%, keep it for 1 year and then change to a cheaper supplement or Advantage program.

    Medicare Part A covers hospitals and in-patient procedures at 80% with revolving deductibles that reset every 60 days and a co-pay. Part B is the out-patient part and it also had yearly deductibles and covers at 80%. Or you can dump them and get a Part C Advantage program that is through a regular insurance company but must cover what Medicare does at a minimum.

    What I have done is go for a supplemental insurance program(Medigap coverage). They offer a whole ton of options and cover what Medicare doesn't. The government sets the outlines for the companies and they give you what it will cost to get that coverage...they go from group A up to (I think) group N policies. At least 2 of the group plans pay everything...co-pays, deductibles, everything. One even covers what a doc may charge above Medicare. Since I take a IV medication that costs me $2,500/month, I have this coverage. Runs about $270.month on top of the cost of Medicare Part B and the Medicare Drug supplement. But I pay NOT A CENT for anything including in-patient care and surgery. And you are only obligated to carry it for 1 year at a time. Then once you are through and okay, you can switch to a cheaper program that covers less if you want.

    Despite having good insurance, I ended up owing about $15,000 after my 2 neck surgeries. Amazing what they will fight over. My last trip in with Medicare and the group C plan......nada.

    If you can wait, Medicare gives you the ability to chose what you want when you need it and then change when you don't. The flexibility that we all wish we had with insurance companies but instead, they do with us.

    Jenny

     
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