ADR/Fusion -How do you know the right time?

[Ed155]

Hi,

I have a question on when is the right time to consider a Fusion or an ADR. I am 29 years old, and have become relativity inactive after a microdiscectomy for a protruding L4-L5 2 years ago. During the operation there was some difficulty moving the nerves and it caused some damage to the S1 nerve in my left leg, As I understand there was some damage to the Mylar sheath or dural tear with spinal fluid leak. 2 years on I have the following symptoms: Decreased sensory along the S1 path, Unable to do heel lifts, calf muscle atrophy, random bouts of burnings sensations in my left foot with some, muscle spams, a burning feeling in my foot, when using the bathroom or even passing wind. I put this surgical result down to bad luck as what else can you do, but the severe pain in my left leg had disappeared and been replaced by a limp and numbness (At least I am not in pain). I accepted this and moved on, until recently.
The signs of sciatica have returned to my right leg although not as severe as what prompted me to undergo the discectomy initially. Also I have noticed an increase in the bouts of random nerve pain/hypersensitivity in my left foot.  

My questions relate to the following:

1) I have had regular MRI's, one year post op and recently 2 years post op. The L4-L5 has shown further signs of degeneration and symptoms are to suggest further herniation. This leads me to believe that further surgery is a case of when not if. The L4-L5 disc has practically dehydrated and collapsed, all the other disc in my back are fine with a slight bulge and sign of degeneration to the L3-L4. Rather than wait till the pain increases should I use this time to explore my options and book in a surgery with a specialist in either fusion or ADR?

2) I realise the timeframe for nerve repair is around 18 months, however if there is still compression or has continually been compression but my body has been unable to recognise the pain indicators am I better off electing for surgery sooner rather than later? If i am to undergo a more serious operation are there any options open to me regards nerve repair during this surgical procedure?

3) I do like the sound of the ADR, in particular the Prodisc. I am unable to find any recent information on the results of osteolysis or long term effects of ion absorption in the case of metal on metal. I hear a revision surgery can be quite complex. What are your views on these implants and why are they using UHMWPE rather than PCU as in the new generation hip replacments?

4) Sorry for the long e-mail. Are there any nerves in the L4-L5 region that could be compressed that could cause villi atrophy in the digestive tract? Since my back pain I have had terrible pain and inconvenience arising from Villi atrophy and the GI's can find what is causing it? Could it be linked to pancreatic hormone regulation?

Thank you for your time, and it is greatly appreciated. You guys do a great service for those of us that are out there and in pain. Thanks for helping us understand a little more.

Paul        

[kittyluv1]

Unfortunately, degenerative disc disease is a progressive process which continues due to the wear and tear that occurs as we age.  The process can be slow or advance more quickly depending on the condition of your bone mass (osteopenia and osteoporosis are major contributors) and the amount and level of activity performed.  Obviously, any recurrent trauma should be avoided.
So nothing I know can reverse this process (or I might not have had my fusion surgery!)
I am not familiar with replacement nucleus devices, but they sound somewhat similar to an ADR.
Keep the faith --- you will eventually get a margin of relief.  Some residuals may never completely go away, but hopefully you can make adaptations that make them easier to handle.

[Ed155]

Thank you for taking the time to answer my post. Yes there is further degeneration. I guess its just a case of waiting till the pain becomes debilitating till i consign myself to further surgery. I do feel unlucky due to complications of the microdiscectomy since i had heard so many positive stories on the high success rates with low complication rates of this type of procedure. I think the complications where due to the amount of time i left it, I had pain for several years before the surgery and the nerves had become quite compressed and attached to the disc, hence the operation going on about 5 hours due to the surgeon slowly trying to pry them from the disc.

Short of a fusion or ADR, are there any other alternatives that would put a complete stop to further degeneration whilst still considered minimally invasive?

What are replacement nucleus devices?    

[kittyluv1]

Welcome to the Back and Neck Community.  Members are here to provide assistance to individuals experiencing symptoms related to possible abnormal conditions of the cervical and/or lumbar spine.  Advice given is non-professional and is based primarily on personal experiences.  Please post on the Expert Forum if additional medical advice is needed and one of the medical doctors will assist as appropriate.

I am sorry to hear of your continued health problems regarding your low back.  It is unfortunate that you sustained the complications from your initial surgery that you outlined in your post.  It can be difficult to assess the residuals from that surgery and the new symptoms you are currently experiencing.
If your last MRI was done recently, you are probably under the care of an orthopedic specialist at this time.  Without knowing the full extent of the clinical findings on MRI, you do report additional herniation/degeneration at the prior surgical level and the adjacent disc L3-L4.  The fact that your symptoms are now related to your right leg would be most likely as the remaining disc material has probably compressed the exiting nerve root at the L4-L5 level and may also involve the adjacent disc.  I do not know if the MRI showed any involvement of the spinal cord itself.
ADR or artificial disc replacement has been done in recent years to try and preserve movement of the spine which would be most likely lost if a fusion was done.  I am only aware of the Prodisc having approval for a one level repair at this time.  No two level ADR is currently being done to my knowledge.  Insurance companies vary on whether they will cover the use of ADR, as fusion remains the gold standard when dealing with DDD and herniated discs/stenosis.  That might be a consideration when you contemplate surgery at this time.
The risk of additional degeneration of the adjacent discs after fusion is possible, but the rate at which it might occur would vary based on the current status of those discs and the amount of activity being performed.  The ADR has not been evaluated for any length of time to determine if there is any significant differences noted in this rate of degeneration.  ADR has been used primarily in younger patients seeking to maintain mobility and in those who do not have any significant medical problems (cardiac etc) that might make recovery more difficult.  Hopefully, your spine specialist can review the statistics with you as they exist at this time.
You are correct in noting that  the longer the nerves are compressed the lengthier the recovery period will be and the potential for permanent damage that can not be repaired with either type of surgery should be a consideration.
I am not familiar with any connection of your spinal problems to your digestive tract other than the extent of nerve damage can produce changes in bladder and bowel control and if you are experiencing any changes in these functions it would be important to make your specialist aware of these concurrent problems.  
Deciding on surgery is a difficult situation.  You must evaluate your current status in terms of pain. effect on lifestyle/activity level and the potential success/complications that could be expected from both ADR and fusion.
Please post back with your progress and any further questions/concerns you may have.
Best wishes ----