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Is this severe a surgery warranted? Surgery scheduled for 4/21/00
I am a 31 year old female with a history of a L5-S1 hemilaminectomy in 1991 and L5-S1 fusion in 1993. Recently, I have experienced increased nerve pain in the buttocks and down both legs. In addition, when sitting erect, if I move my lower back slightly, I can feel the bones move.
I was originally injured while in the US Navy and as such, the neurosurgeon from the NNMC in Bethesda, MD will be performing the operation at Walter Reed AMC on Friday - two days! (If you know the doctor, please do not tell him I wrote in as I don't want him to think I doubt his opinion.) They want to perform a L2-S1 fusion - removing all but the verterbral body, use pedicle screws and rods and bone from the bone bank to fuse the area. My concern is that this seems very intrusive and would just like to know if it seems appropriate. I cannot go on with the pain I have been experiencing, which has been increasing in severity almost parabolically since Nov. 1999, so I know I need to have something done.
I pushed to have the thoracic MRI due to radiating pain I experience at around the T11-T12 level - the level at which the back brace from the second operation ended. The doctor tells me the pain I have there is reference pain, but I am not sure I agree. I just found out about the bulging disks in the thoracic region - of which the doctor wasn't aware of before. I experienced a time when I had diarrhea for about six months and now only comes once in a while. I originally thought it was due to stress, however, could that be due to the herniated disks? As well, are there any questions I should ask the doctor with regard to those disks or the surgery in general? I want to make sure I am not being a guinea pig for surgeons who are preparing for private practice.
I really appreciate any advice you can provide - I have been trying to post for the past two months and while I realize, this is the 11th hour, would still like your feedback. Following are the CT scan and MRI results.
I had a CTscan in Jan.2000 - the results are:
Clinical History: The patient is a 31 year old female with a previous L5-S1 fusion (3/93). Rule out nonunion.
Technique: 3mmx2mm contiguous axial images were obtained from the inferior endplate of L2 through S1. Sagittal images were reconstructed from the axial data.
Findings: There is no evidence of a dense bone fusion between L4-L5 or L5-S1. The patient may have transitional lumbosacral anatomy.
At L2-L3, there is a circumferential disk bulge superimposed on moderate facet arthropathy with prominence of the ligamentum flava. This results in moderate to moderately severe central bony canal and bilateral subarticular recess stenosis. The neural foramina remain patent.
At L3-L4, there is a circumferential disk bulge superimposed on moderate facet arthropathy. This results in severe central bony canal and bilateral subarticular recess stenosis. The neural foramina remain patent.
At L4-L5, there has been attempted posterior decompression. There is a circumferential disk bulge with degenerative endplate changes. Due to bone overgrowth, there is significant stenosis of the right subarticular recess. There is compromise to the traversing right L5 nerve root. The central bony canal and left subarticular recess are patent. The neural foramina are patent.
At L5-S1, there is facet arthropathy resulting in bilateral subarticular recess stenosis with compromise to the traversing S1 nerve roots. The central bony canal is mildly stenotic. The neural foramina are patent.
Impression: This patient has transitional lumbosacral anatomy. Comparison should be made with plain films should surgical intervention be contemplated. As numbered, the patient has significant spondylarthropathy at L2-3 and L3-4 resulting in significant central bony canal and bilateral subarticular recess stenosis. There has been surgery at L4-5. With bone overgrowth on the right, there is significant right subarticular recess stenosis with compromise to the traversing right L5 nerve root.
At L5-S1, there is bilateral subarticular recess stenosis.
There is no evidence of a dense anterior fusion at either L4-5 or L5-S1.
I had an MRI in March, 2000, the results are:
MRI of Thoracic and lumbar spine:
History: Back and flank pain. Attempted L5-S1 PSF after failed back surgery eight years ago. Now with severe stenosis and DJD. MRI for preoperative planning.
Procedure: Through the thoracic spine, sagittal T1 and sagittal fast spin echo T2-weighted images were obtained. Through the lumbar spine, sagittal T1, sagittal fast spin echo/dual echo T2, axial T1, axial fast spin echo T2, and post-gadolinium axial and sagittal T1-weighted images were obtained.
Findings: Thoracic spinal cord is of normal signal intensity throughout. Conus ends at the mid T12 level. At T4-T5, there is a small central disk bulge. At T5-T6, there may be a small right paracentral disk protrusion. At T6-T7, there may be a small disk bulge. At T10-T11, there is a small central disk bulge. The thoracic spine marrow signal intensity is normal. Alignment is normal.
The remaining visible structures about the thoracic spine are unremarkable.
Sagittal images: The L5 vertebral body is transitional. There is a rudimentary L5-S1 intervertebral disk. Conus ends at the mid T12 level and is of normal signal intensity and configuration. No abnormal pial enhancement. Cauda equina is unremarkable. The L2-L3 and especially L3-L4 intervertebral disks are diminished in signal intensity and height, and bulge diffusely. Central disk protrusion at L2-L3 and a central disk herniation at L3-L4. At the L4-L5 level, there has been a right hemilaminectomy and partial resection posterior aspect of the L4-L5 disk. This portion of the disk enhances and is compatible with scar. Minimal degenerative endplate change at L4-L5. Marrow signal intensity otherwise normal. Lumbar spine alignment normal.
Axial images: The L5-S1 disk is rudimentary. L5 is sacralized.
At L4-L5, there has been a right hemilaminectomy. Posterior aspect of the disk space demonstrates increased T2 signal intensity and enhancement following administration of gadolinium. This is contiguous with T1 signal abnormality material in left anterior epidural space and left subarticular recess surrounding the anterior and posterior aspects of traversing left L5 nerve root. This material enhances and is compatible with scar. No displacement of traversing nerve roots. Traversing left L5 nerve root sleeve is mildly distended. Signal intensity in the anterior aspect of the L4-L5 disk is diminished, as is height. There is no evidence of fusion across the disk space. Central canal is widely patent, the left subarticular recess is narrow but not truly stenotic, right subarticular recess is mildly to moderately stenotic and the neural foramina are widely patent bilaterally.
At L3-L4, there is a central disk herniation superimposed on the broad-based disk bulge and mild bilateral facet arthropathy with narrowing of the transverse dimension between the facets. Central canal is at least moderately stenotic, subarticular recesses are moderately stenotic bilaterally, and the neural foramina are mildly stenotic bilaterally.
At L2-L3, there is a broad-based disk bulge with small superimposed broad-based central anular tear with protrusion. Central canal is moderately stenotic, subarticular recesses moderately stenotic, and the neural foramina are at least mildly stenotic bilaterally.
At L1-L2, the disk is normal. The central canal and neural foramina are widely patent.
The remaining visible structures about the lumbar spine are unremarkable.
Impression:
1. Suggestion of small mid-thoracic disk protrusions.
2. Probable transitional anatomy with L5 being sacralized.
3. Post surgical changes at L4-L5 based on spine level numbering from the dens. Scar formation in left paracentral region. No evidence of recurrent disk herniation.
4. Central disk herniation L3-L4 which may affect bilateral traversing L4 nerve roots and which causes significant central canal stenosis. Further evaluation is recommended.
5. Additional spondylotic changes causing central stenosis at L2-L3.
I was originally injured while in the US Navy and as such, the neurosurgeon from the NNMC in Bethesda, MD will be performing the operation at Walter Reed AMC on Friday - two days! (If you know the doctor, please do not tell him I wrote in as I don't want him to think I doubt his opinion.) They want to perform a L2-S1 fusion - removing all but the verterbral body, use pedicle screws and rods and bone from the bone bank to fuse the area. My concern is that this seems very intrusive and would just like to know if it seems appropriate. I cannot go on with the pain I have been experiencing, which has been increasing in severity almost parabolically since Nov. 1999, so I know I need to have something done.
I pushed to have the thoracic MRI due to radiating pain I experience at around the T11-T12 level - the level at which the back brace from the second operation ended. The doctor tells me the pain I have there is reference pain, but I am not sure I agree. I just found out about the bulging disks in the thoracic region - of which the doctor wasn't aware of before. I experienced a time when I had diarrhea for about six months and now only comes once in a while. I originally thought it was due to stress, however, could that be due to the herniated disks? As well, are there any questions I should ask the doctor with regard to those disks or the surgery in general? I want to make sure I am not being a guinea pig for surgeons who are preparing for private practice.
I really appreciate any advice you can provide - I have been trying to post for the past two months and while I realize, this is the 11th hour, would still like your feedback. Following are the CT scan and MRI results.
I had a CTscan in Jan.2000 - the results are:
Clinical History: The patient is a 31 year old female with a previous L5-S1 fusion (3/93). Rule out nonunion.
Technique: 3mmx2mm contiguous axial images were obtained from the inferior endplate of L2 through S1. Sagittal images were reconstructed from the axial data.
Findings: There is no evidence of a dense bone fusion between L4-L5 or L5-S1. The patient may have transitional lumbosacral anatomy.
At L2-L3, there is a circumferential disk bulge superimposed on moderate facet arthropathy with prominence of the ligamentum flava. This results in moderate to moderately severe central bony canal and bilateral subarticular recess stenosis. The neural foramina remain patent.
At L3-L4, there is a circumferential disk bulge superimposed on moderate facet arthropathy. This results in severe central bony canal and bilateral subarticular recess stenosis. The neural foramina remain patent.
At L4-L5, there has been attempted posterior decompression. There is a circumferential disk bulge with degenerative endplate changes. Due to bone overgrowth, there is significant stenosis of the right subarticular recess. There is compromise to the traversing right L5 nerve root. The central bony canal and left subarticular recess are patent. The neural foramina are patent.
At L5-S1, there is facet arthropathy resulting in bilateral subarticular recess stenosis with compromise to the traversing S1 nerve roots. The central bony canal is mildly stenotic. The neural foramina are patent.
Impression: This patient has transitional lumbosacral anatomy. Comparison should be made with plain films should surgical intervention be contemplated. As numbered, the patient has significant spondylarthropathy at L2-3 and L3-4 resulting in significant central bony canal and bilateral subarticular recess stenosis. There has been surgery at L4-5. With bone overgrowth on the right, there is significant right subarticular recess stenosis with compromise to the traversing right L5 nerve root.
At L5-S1, there is bilateral subarticular recess stenosis.
There is no evidence of a dense anterior fusion at either L4-5 or L5-S1.
I had an MRI in March, 2000, the results are:
MRI of Thoracic and lumbar spine:
History: Back and flank pain. Attempted L5-S1 PSF after failed back surgery eight years ago. Now with severe stenosis and DJD. MRI for preoperative planning.
Procedure: Through the thoracic spine, sagittal T1 and sagittal fast spin echo T2-weighted images were obtained. Through the lumbar spine, sagittal T1, sagittal fast spin echo/dual echo T2, axial T1, axial fast spin echo T2, and post-gadolinium axial and sagittal T1-weighted images were obtained.
Findings: Thoracic spinal cord is of normal signal intensity throughout. Conus ends at the mid T12 level. At T4-T5, there is a small central disk bulge. At T5-T6, there may be a small right paracentral disk protrusion. At T6-T7, there may be a small disk bulge. At T10-T11, there is a small central disk bulge. The thoracic spine marrow signal intensity is normal. Alignment is normal.
The remaining visible structures about the thoracic spine are unremarkable.
Sagittal images: The L5 vertebral body is transitional. There is a rudimentary L5-S1 intervertebral disk. Conus ends at the mid T12 level and is of normal signal intensity and configuration. No abnormal pial enhancement. Cauda equina is unremarkable. The L2-L3 and especially L3-L4 intervertebral disks are diminished in signal intensity and height, and bulge diffusely. Central disk protrusion at L2-L3 and a central disk herniation at L3-L4. At the L4-L5 level, there has been a right hemilaminectomy and partial resection posterior aspect of the L4-L5 disk. This portion of the disk enhances and is compatible with scar. Minimal degenerative endplate change at L4-L5. Marrow signal intensity otherwise normal. Lumbar spine alignment normal.
Axial images: The L5-S1 disk is rudimentary. L5 is sacralized.
At L4-L5, there has been a right hemilaminectomy. Posterior aspect of the disk space demonstrates increased T2 signal intensity and enhancement following administration of gadolinium. This is contiguous with T1 signal abnormality material in left anterior epidural space and left subarticular recess surrounding the anterior and posterior aspects of traversing left L5 nerve root. This material enhances and is compatible with scar. No displacement of traversing nerve roots. Traversing left L5 nerve root sleeve is mildly distended. Signal intensity in the anterior aspect of the L4-L5 disk is diminished, as is height. There is no evidence of fusion across the disk space. Central canal is widely patent, the left subarticular recess is narrow but not truly stenotic, right subarticular recess is mildly to moderately stenotic and the neural foramina are widely patent bilaterally.
At L3-L4, there is a central disk herniation superimposed on the broad-based disk bulge and mild bilateral facet arthropathy with narrowing of the transverse dimension between the facets. Central canal is at least moderately stenotic, subarticular recesses are moderately stenotic bilaterally, and the neural foramina are mildly stenotic bilaterally.
At L2-L3, there is a broad-based disk bulge with small superimposed broad-based central anular tear with protrusion. Central canal is moderately stenotic, subarticular recesses moderately stenotic, and the neural foramina are at least mildly stenotic bilaterally.
At L1-L2, the disk is normal. The central canal and neural foramina are widely patent.
The remaining visible structures about the lumbar spine are unremarkable.
Impression:
1. Suggestion of small mid-thoracic disk protrusions.
2. Probable transitional anatomy with L5 being sacralized.
3. Post surgical changes at L4-L5 based on spine level numbering from the dens. Scar formation in left paracentral region. No evidence of recurrent disk herniation.
4. Central disk herniation L3-L4 which may affect bilateral traversing L4 nerve roots and which causes significant central canal stenosis. Further evaluation is recommended.
5. Additional spondylotic changes causing central stenosis at L2-L3.
Name : Ramesh Rajan
Age/Sex : 19 years/Male
Address : Jalgaon ,Maharastra, India
H/O Vehicular accident on 20/01/2000 at 4:15 AM .
Examined by a CTVS ,Orthopaed ,Neurosurgeon and a general surgeon for probable injuries ,and was found to have sustained following injuries :
1] # of Right Scapula
2] # Rt leg bones[ Tibia ,Fibula]
3] Head injury in form of cerebral Oedema and Concussion
4] Rt shoulder area aalong with right arm and forearm had a huge heamatoma and contusions all over
5] Right arm had no pulsations distal to axillary artery
6] Upper limb had no motor or sensory activity
7] The muscles were rigid and displaying features of early ischemic contracture
An emergency angiography was performed to ascertain the site and extent of injury ,Total disruption of axillary artery beyond the clavicle and some collateral flow into distal axillary artery was found
Axilla was explored immediately under General Anesthesia ,there was total fragmentation of axillary artery with loss of a segment close to 2 inches in length ,A Saphenous vein graft was harvested from the left leg and an interposition graft was placed to restore the continuity of axillary artery with 6-0 prolene. Satisfactory distal flow was achieved distally .Two relaxing fascial incisions were made on forearm
Treated with antibiotics ,anti-inflammatory ,diuretics ,osmotic ,steroids ,anticonvulsants and H2 receptor antagonists along with immobilization of right upper and lower limb,
Patient was kept in ICU with stable dynamics and was treated by respective consultants for head injury and bone problems
Patient took discharge on request after few days for treatment at a better center ,Postoperatively he had no satisfactory sensory and motor function after mobilization
21/2/2000 NCV Study was performed
1] SAPS from right median ,ulnar and radial nerves were absent ,SAPS from left median nerve showed normal latency ,amplitude and conduction velocity
2] CMAPS from right median and ulnar nerves absent ,CMAPS from left median nerve were normal
3] On proximal stimulation right deltoid ,triceps and biceps did not reveal any potential ,left deltoid revealed normal potential
Impression : This study is suggestive of Brachial plexus [Upper+Lower]involvement on right side
03/03/2000
MRI Of Cervical Spine
Perivascular intermediate signal intensity lesion surrounding the axillary artery in the region of axilla which has probably engulfed the cords of brachial plexus ? Perivascular Fibrosis
14/3/2000
CT Myelo
Undisplaced fracture occipital bone extending up to the posterior lip of foramen magnum
The cervical spinal cord and the subarachnoid space appear normal
21/3/2000
EMG And Nerve conduction studies done 2 months after involvement showed evidence of a right brachial neuropathy involving c5 to t1 segments of the axonal degenerative type with no evidence of regenerationyet in any of the nerves [post-ganglionic neuropathy]
As compared to previous study done on 21/2/2000 there was no improvement
In the mean time patient was treated conservatively and was being reassured
EMG AND NCV studies were repeated at another center same day I:e 21/3/2000 and showed findings suggestive of neurtemesis of the Rt Brachial plexus at the level of cords involving the Rt Median ,Rt Ulnar ,Rt Radial ,Rt Axillary and Rt Musculocutaneous nerves
On 4/4/2000 Exploration of cords of brachial plexus was done and Medial and posterior cord fibrosed adhesions were found
Fibrosis and adhesions were removed or posterior and lateral cord ,but medial cord could not be separated from the fibrosed mass and it seemed engulfed in fibrosis
Queries:
What should I do now? How much recovery in motor and sensory
functions can I expect? Is there any other operative procedure to
relieve the cord and improve my condition? Can you suggest a center where this type of surgery can be performed in USA? Since I have to come from India please indicate approximate cost of treatment?
Age/Sex : 19 years/Male
Address : Jalgaon ,Maharastra, India
H/O Vehicular accident on 20/01/2000 at 4:15 AM .
Examined by a CTVS ,Orthopaed ,Neurosurgeon and a general surgeon for probable injuries ,and was found to have sustained following injuries :
1] # of Right Scapula
2] # Rt leg bones[ Tibia ,Fibula]
3] Head injury in form of cerebral Oedema and Concussion
4] Rt shoulder area aalong with right arm and forearm had a huge heamatoma and contusions all over
5] Right arm had no pulsations distal to axillary artery
6] Upper limb had no motor or sensory activity
7] The muscles were rigid and displaying features of early ischemic contracture
An emergency angiography was performed to ascertain the site and extent of injury ,Total disruption of axillary artery beyond the clavicle and some collateral flow into distal axillary artery was found
Axilla was explored immediately under General Anesthesia ,there was total fragmentation of axillary artery with loss of a segment close to 2 inches in length ,A Saphenous vein graft was harvested from the left leg and an interposition graft was placed to restore the continuity of axillary artery with 6-0 prolene. Satisfactory distal flow was achieved distally .Two relaxing fascial incisions were made on forearm
Treated with antibiotics ,anti-inflammatory ,diuretics ,osmotic ,steroids ,anticonvulsants and H2 receptor antagonists along with immobilization of right upper and lower limb,
Patient was kept in ICU with stable dynamics and was treated by respective consultants for head injury and bone problems
Patient took discharge on request after few days for treatment at a better center ,Postoperatively he had no satisfactory sensory and motor function after mobilization
21/2/2000 NCV Study was performed
1] SAPS from right median ,ulnar and radial nerves were absent ,SAPS from left median nerve showed normal latency ,amplitude and conduction velocity
2] CMAPS from right median and ulnar nerves absent ,CMAPS from left median nerve were normal
3] On proximal stimulation right deltoid ,triceps and biceps did not reveal any potential ,left deltoid revealed normal potential
Impression : This study is suggestive of Brachial plexus [Upper+Lower]involvement on right side
03/03/2000
MRI Of Cervical Spine
Perivascular intermediate signal intensity lesion surrounding the axillary artery in the region of axilla which has probably engulfed the cords of brachial plexus ? Perivascular Fibrosis
14/3/2000
CT Myelo
Undisplaced fracture occipital bone extending up to the posterior lip of foramen magnum
The cervical spinal cord and the subarachnoid space appear normal
21/3/2000
EMG And Nerve conduction studies done 2 months after involvement showed evidence of a right brachial neuropathy involving c5 to t1 segments of the axonal degenerative type with no evidence of regenerationyet in any of the nerves [post-ganglionic neuropathy]
As compared to previous study done on 21/2/2000 there was no improvement
In the mean time patient was treated conservatively and was being reassured
EMG AND NCV studies were repeated at another center same day I:e 21/3/2000 and showed findings suggestive of neurtemesis of the Rt Brachial plexus at the level of cords involving the Rt Median ,Rt Ulnar ,Rt Radial ,Rt Axillary and Rt Musculocutaneous nerves
On 4/4/2000 Exploration of cords of brachial plexus was done and Medial and posterior cord fibrosed adhesions were found
Fibrosis and adhesions were removed or posterior and lateral cord ,but medial cord could not be separated from the fibrosed mass and it seemed engulfed in fibrosis
Queries:
What should I do now? How much recovery in motor and sensory
functions can I expect? Is there any other operative procedure to
relieve the cord and improve my condition? Can you suggest a center where this type of surgery can be performed in USA? Since I have to come from India please indicate approximate cost of treatment?
I hope your surgery works out well.
CCF Neuro MD
CCF Neuro MD
thanks for the comments.
CCF Neuro MD
CCF Neuro MD
Sorry to hear of your troubles. I hurt my back at work in Jan.
2000. I have whet to about 4 different doc.
all but 1 have said surgery. I am to have yhe surgery on May
the 30th. The same surgery as you are to have. Never had any surgery on back at all. I am very scared. I don't know what to expect. I don't have any words of wisdom for you just a prayer for you. Hope that everything goes well. Please let me know how you are doing. E-mail ***@****
2000. I have whet to about 4 different doc.
all but 1 have said surgery. I am to have yhe surgery on May
the 30th. The same surgery as you are to have. Never had any surgery on back at all. I am very scared. I don't know what to expect. I don't have any words of wisdom for you just a prayer for you. Hope that everything goes well. Please let me know how you are doing. E-mail ***@****
Sorry I may not have gotten back to you in time. Before I had my surgery I talked with numerous patients who had the pedical screw implants. NOT ONE was without serious residual pain or nerve defect. Therefore I decided to have fusion using material from the bone bank. From what I understand, obtaining the graft from the thigh is the most painful and slow healing part of the operation. 8 years later, I am still pain free and have resumed full physical activity. Everyone must make their own decision, but beware of the rod/screw implants.
thanks for the comments.
CCF Neuro MD
CCF Neuro MD
Freddy,
Did you have screws inserted and if so, it sounds like you may have had problems, can you share them with me?
I had a fusion of the L5-S1 seven years ago and that did not take. In that operation, they only used grafted bone from my hip. (Which, incidently, when they took that bone, they must have clipped the nerve going through there becuase if you touch the left side of my scar, I feel it on the right side of my hip.)
At the time, the screws weren't FDA approved.
When I saw the current docs, they basically told me that I was titanium deficient. I don't think they can do a four or five level fusion without using instrumentation. Plus, since the fusion didn't take the first time, I would think they would be cautious. I have heard recommendations both ways. The basic story was that the success of the screws depends on the skills of the surgeon inserting them. If they are used correctly - they are great. If not, you will have problems.
The doctor told me that the screws and rods are really to provide support for the time it takes the donor bone to fuse and then going forward it is the fused bone that actually should carry the load. He agreed that without the fused bone, the screws would come loose and I would have problems. If they don't use the screws, since they are taking all the bone out except for the verterbral body, there will be nothing to support my back and it will be like jelly.
I am definitely interested in your experience though - it's never too late to ask the doctor more questions.
Carolyn
Did you have screws inserted and if so, it sounds like you may have had problems, can you share them with me?
I had a fusion of the L5-S1 seven years ago and that did not take. In that operation, they only used grafted bone from my hip. (Which, incidently, when they took that bone, they must have clipped the nerve going through there becuase if you touch the left side of my scar, I feel it on the right side of my hip.)
At the time, the screws weren't FDA approved.
When I saw the current docs, they basically told me that I was titanium deficient. I don't think they can do a four or five level fusion without using instrumentation. Plus, since the fusion didn't take the first time, I would think they would be cautious. I have heard recommendations both ways. The basic story was that the success of the screws depends on the skills of the surgeon inserting them. If they are used correctly - they are great. If not, you will have problems.
The doctor told me that the screws and rods are really to provide support for the time it takes the donor bone to fuse and then going forward it is the fused bone that actually should carry the load. He agreed that without the fused bone, the screws would come loose and I would have problems. If they don't use the screws, since they are taking all the bone out except for the verterbral body, there will be nothing to support my back and it will be like jelly.
I am definitely interested in your experience though - it's never too late to ask the doctor more questions.
Carolyn
Just my two cents worth. You DO NOT want any screws in your back. If you do have the operation, stick with the bone bank/fusion route.
Dear Carolyn:
Alot depends on your use of the back, rehab, maximizing correct lifting and posture, minimizing axial load, etc. I would do as little surgery as possible based on the types of lesion. Since we see over 30% of our population without back pain and having disc buldges I would be alittle concerning about just doing something in the spine because of what may happen (but I haven't seen the problem, so my comments are tinted). I think I would agree with the term extreme. I am a minimalist unless the situation is called for so my views are also scued.
CCF Neuro MD
Alot depends on your use of the back, rehab, maximizing correct lifting and posture, minimizing axial load, etc. I would do as little surgery as possible based on the types of lesion. Since we see over 30% of our population without back pain and having disc buldges I would be alittle concerning about just doing something in the spine because of what may happen (but I haven't seen the problem, so my comments are tinted). I think I would agree with the term extreme. I am a minimalist unless the situation is called for so my views are also scued.
CCF Neuro MD
The second opinion I got was fairly informal - it's hard to find a neurosurgeon on short notice - you are all in high demand and some are very picky as to who they will treat. His opinion was that the surgery was warranted, but the recommendation of fusion from L2-S1 seemed a bit extreme. While I trusted his opinion as to whether the surgery was warranted, his experience level was not grand and there is no way I would allow him to open me up. From what I understand, this surgery is extremely difficult and only surgeons with a lot of experience should even attempt them.
Nonetheless, when I mentioned this "extreme" opinion to my surgeon, his response was that while going to L3 is warranted, they wanted to go to L2 because the disk appeared dark on the films and there would most likely be problems down the road at that level. He was going to make the final determination once he opened me up.
My new concern is with the bulges in the thoracic level. While I know you do not have a crystal ball, do you think that these will eventually herniate? Is there a chance that I will not need surgery in the future? I am 6'3" tall - weight is appropriate for my height and would eventually like to have a family. What is your future prognosis - and please be brutally honest. I would rather know to prepare so that, in spite of the limitations on my life, I will go forward with a positive attitude.
Thank you for responding so quickly, Carolyn
Nonetheless, when I mentioned this "extreme" opinion to my surgeon, his response was that while going to L3 is warranted, they wanted to go to L2 because the disk appeared dark on the films and there would most likely be problems down the road at that level. He was going to make the final determination once he opened me up.
My new concern is with the bulges in the thoracic level. While I know you do not have a crystal ball, do you think that these will eventually herniate? Is there a chance that I will not need surgery in the future? I am 6'3" tall - weight is appropriate for my height and would eventually like to have a family. What is your future prognosis - and please be brutally honest. I would rather know to prepare so that, in spite of the limitations on my life, I will go forward with a positive attitude.
Thank you for responding so quickly, Carolyn
Dear Carolyn:
Sorry to hear about your back problems. The things that catch my eye is the significant central canal stenosis at L3-L4 and the presence of foramen stnosis. I would place alot of blame of your radiating pain to the disc buldge compromising the cord. What did the second opinion suggest? (I hope that I am NOT your second opinion, as without actually seeing the films and doing the exam I am somewhat handicapped). Certainly, what is proposed will help the central canal stenosis but the other problems will be problematic. I think I would see if there is the possibility in the military to get another opinion. The NIH is filled with excellent neurosurgeons and another opinion should not hurt the ego of your military surgeons. It may be that they are correct and you need such an invasive surgery to correct the problem. But, I would seek at least another opinion from someone not involved in the military (if possible).
Sincerely,
CCF Neuro MD
Sorry to hear about your back problems. The things that catch my eye is the significant central canal stenosis at L3-L4 and the presence of foramen stnosis. I would place alot of blame of your radiating pain to the disc buldge compromising the cord. What did the second opinion suggest? (I hope that I am NOT your second opinion, as without actually seeing the films and doing the exam I am somewhat handicapped). Certainly, what is proposed will help the central canal stenosis but the other problems will be problematic. I think I would see if there is the possibility in the military to get another opinion. The NIH is filled with excellent neurosurgeons and another opinion should not hurt the ego of your military surgeons. It may be that they are correct and you need such an invasive surgery to correct the problem. But, I would seek at least another opinion from someone not involved in the military (if possible).
Sincerely,
CCF Neuro MD
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Two of the largest studies on Alzheimer’s have yielded new clues about the disease
