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NECK SURGERY FOR AN ELDERLY MAN
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NECK SURGERY FOR AN ELDERLY MAN

My 84 year old father broke his neck and is scheduled for surgery.  The procedure is called "Bilateral C1 C2 instrumented fusion with allograft.  

His diagnosis is "mid c2 dens fracture and fracture involving the lateral process of C2. C1 is intact. Mild degeneration of dens which causes signifigant spinal stenosis and possible mild cord compression.  The fracture lines are still evident with no effusion seen at this time.: (from latest CT)

My question is is the surgery absolutely necessary.  He actually seems better since the injury but the doctor says the broken bone has moved and he will get worse if the surgery is not done.

Thanks!
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Avatar_n_tn
You make it very difficult for one to respond as the profile of your father lacks so much content.  At 84 I would guess he is high risk for surgery and have no idea what his other medical conditions are that would add to his risk porfile.  That would help to know.

i have learned years ago that you treat the patient and not the x-ray.  There is nothing wrong with waiting especially in light of his improved symptoms but you didn't include if he had any neurologic deficits from the fracture.

Does he have osteoporosis?

Is he wearing a rigid neck brace?

My impression is that you can wait on the surgery and make sure his Vit. D intake is atleast 800 units a day with 1200mg of Calciumcitrate daily.   His body can stabilize this fracture over time as long as he is not exhibiting signs of cord compression or neurologic deficiits.

Does that help??
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Avatar_n_tn
Thanks Cushy,

He does not have osteoporosis and has a neck brace but that is what got him into trouble because he was taking it off and picking up leaves, taking out the trash etc. He does have blood clots and was on cumaden but the doc took him off today to get ready for the surgery in a week.
The doctor said the bone moved forward since the 1st CT was done about 6 wqeks ago since he was taking off the brace  and that if it is not done he will soon experience numbness in the legs and arms.  Like i said, he is way better and up and around all the time and of course is wearing the brace 24 hours a day now.  Are you a doctor and do you really think he could go without it after hearing this?
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Avatar_n_tn
It is true that internal fixation will stabilize the fracture--surgeons think surgery and that is all they think about--waiting for the person to heal over time is not in their mentality and yes it is true if that fracture worsens bad things will happen.  He could sneeze and if the fracture is that unstable he could get severe cord compression.  So when one goes to a surgeon you have to weigh what he says--he is your father and you can think with him and come to another conclusion--it happens everyday.  you can also get a 2nd opinion in light of his improving symptoms.

I  want to add another dynamic--coumadin plays quite a role in osteoprosis--here's a quote ---"A 2006 retrospective study of 14,564 Medicare recipients showed that warfarin use for more than one year was linked with a 60% increased risk of osteoporosis-related fracture in men; there was no association in women. "  So you have that to add to the formula---one must ask if a person has a clotting problem and undergoes a very serious bone realted surgery what do think the outcome would be in light of the coumadin and its effect on normal regrowth of bone.  He of course is a high risk for clotting post op--as well as pneumonia and any other system that will be taxed as a result of the surgery.  I so often think how well he is doing now--and how stable he is NOW--and you still want to subject him to a horrendous surgery.

You must have gathered by now that I believe in the human body to tell us what to do--if he is stable and improving what is there that tells you he must have surgery.  

I have seen many CT/MRI's--with many abnormalities that technically could require surgical correction--but you treat the patient--not the xray.  I know it is an ominous sign that a fracture would worsen--but your father is not worse--just give it some time and really adhere to the use of the neck brace and try to find an alternative to the coumadin so he can have his own body stabilize the fracture and then go back on the blood thinner.

You know this conversation has a side to it where I really should not be contributing so much since I have not seen any studies and know so little about your dear father.  I guess I believe in what you feel--you are hesitant about the surgery--I wonder what you dad thinks about it and if he understands the profound risks that it entails---as opposed to just watchful waiting.

Part of my reason for me to chat with you is for you to have more information to make a more informed decision--for you to find more information--you ask more questions--you find what you need to know--you father needs to feel good about what he needs to do.  I only want to facilitate that conversation.  I have no agenda against surgeons.  You treat the patient and not the x-ray.

I wish a clear mind and open heart---David

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Avatar_n_tn
David, Thanks again, yes you are definetely right, I am hesitant about the surgery.  We have a second opinion scheduled for Friday.  The problem with my dad is he has dementia and doesn't seem to understand the gravity of his injury and what he needs to do in order for the bone to heal.  Just today again we caught him picking up leaves in the yard and again I caught him putting away the trash cans.  I yell at him and he acts like i am picking on him. Anyway, with this in mind, I am thinking the neck will never heal if he keeps doing this, we my as well do the surgery if we know he will not adhere to the requirements for it to heal.  Thanks for the headsup on the coumadin.
Greg



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Avatar_n_tn
I have another point to ponder.
If surgery is a go for your dad let's chat about it.  They will use a "allograft"--this is a bone that is taken from a dead person--it is sterilized and only provides a structure for your dad's cells to try grab ahold of and intergrate into your dad's own bone.  If your dad is a poor bone grower then this bone graft gets broken down by his body and can just turn to this pulpy mass that porvides no support--it doesnt do anything that it was originally inserted for.

Now--they put this dead bone into your dad and then put him back on coumadin post-op---do you have any idea what little sense that makes??  One must ask these kinds of questions of those that practice this kind of medicine--it makes no sense to me--please see if it makes sense to you and your dad.

I still think if you go ahead with this surgery that you get a vit. D level and see if it is too low to facilitate the absorption of calcium.  If it were low it would be indicated for him to have a regimen of 55,000 units of Vit D weekly for 8 weeks--I would find out if he was low on Vit D even if he doesnt go with the surgery---you want to do all you can to get as much bone to form around this fracture site.

There--I finally got this off my chest and hope it is some help--David
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Avatar_n_tn
Thanks, after the 2nd opinion Friday I will get back to you,,,,Greg
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Avatar_n_tn
David,

You won't beleive this. The second doctor said no way for surgery.  He said that some healing has already taken place and that since the spine had already moved that it probably wouldn't line up anyway considering his age and all the other things you talked about.  The doctor also said he knew the dr that gave the 1st opeinion and that he was young and wants to operate on anything that moves.Thanks for your help and we are so glad we got a 2nd opinion.

Greg
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Avatar_n_tn
David,

New news. The second dr calleed back and said after looking at the new film he ordered yesterday that he changed his mind and recomends surgery.  he said there is an unstable fracture that has def moved since the last CT.  Said he could pick up the soap in the shower and it would kill him or at least paralyze him for life.  Now what do you think?
Greg
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Avatar_n_tn
It amazes me that you would still be asking me my opinion after all that you have been thru.  As you can appriciate I am just in such a disadvantage as I have no idea what the studies are that your 2nd doc is referring to.  You now have two opinions with what--20 years of experience between them--yes the young dude has got some huge boat payments and wants to cut as that is all he is trained to do---now you get this 2nd doc and he is older and sees both studies and says its UNSTABLE.   I agree that if it is that unstable that any benign movement could cause it to shift and cause drastic neurologic complications---well you dont need me to tell you what to do in that scenerio.

Okay--he is 84--not a very good candidate for surgery---not a good bone grower--must be put on a medication post-op that inhibits bone growth--what else is there--oh yes--non-compliance with all your efforts to assist him post-op his dementia is going to make your life hell.  He is already causing a great deal of stress in your life without having surgery--just think of the stress of an incision---a bone graft from a cadaver--the stress on an old system that is prone to clotting---even a healthy person would have a risk for bloood clots post op with this very complicated surgery.  I have seen my share of bone grafts turn to mush and the outcome was **** poor.

I am going to just say as a human with a heart for quality of life for you --your family and all involved--including your father---just because we can do a surgery doesnt mean it must be done---the bone will fuse with time--unless the fracture is so bad that the body isnt able to bridge the fracture gap and heal--then the decision is made.  I am just in favor of watchful waiting.  Again I hav no idea how unstable this fracture is.

The issuse of sudden death in an 84 is ever prresent despite the fracture Greg.

His quality of life is compromised with the dementia--surgery is really not something that I think will improve it--do you??

I want you to know I am speaking from my heart and am really being frank with you.  I dont take telling you these things very lightly--these are stressful times for you.  Time is on your side.

I appriciate you keeping me in this decision making process and respect your position--I am just available to chat and be a support Greg--I have no motive other than to listen and then give some feedback.

Keep me informed---David
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Avatar_n_tn
The doctor yesterday said that he must have the surgery.  I guess the new x ray and MRI says the bone is broken in two places and very unstable.  They are bringing in a team of specialists for the surgery.  We like this new doctor way more.  He is older and really doesn't want to do it but says we have to.  I believe this guy David.  I hope he is right.  I will let you know its tomorrow morning.

greg
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Avatar_n_tn
David,

You won't beleive this. The surgery was a huge success (so far).  The new doctor brought in 2 of his med school  buddies and they said it was the easiest and most fun surgery they have ever had.  My dad came out of the surgery chirpy and talking like he was 20 years ago.  He even said his hearing was back..Can u believe that.  Today he is not so chirpy.  His voice box is all garbled from the surgery and he cant swallow but otherwise we are very happy....Greg
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Avatar_n_tn
It is so kind of you to keep me appraised of your dear father's status.

You sure have been thru a great deal these passed few weeks and i can tell you are upbeat and encouraged by the results of the surgery.  I am relieved that it has gone so well and wish for a great recovery and a whole lot of bone growth to stabilize those fracture sites.

David

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634315_tn?1223816356
hey
u seem pretty smart.  can u comment on me??  here is my story.
i had a SCI in May.  had numbness from neck down. recovered fully.  had two surgeries.  july c1 c2 fusion with cadaver bone and wire.  wire slipped. surgery again with rods wire and screws holding bone graft in place--posterior approach- hurt like hell.  

i am now 12 weeks post op.  i have been out of neck brace for 2 days and was weaning prior to this.  i have minimal felxion and extension of head and i limited left to right motion.

how much can i expect to get back?  my head feels like one of those bobble heads. how long to build muscles up again?  any suggestions how-- tried the loose towel thing, scarf for extra support?  

how stable do u think these rods wires screws are??  stable enough to get my bones to start fusing--saw on xray two weeks ago.

how would i know if my hardware moves??  would i feel it? symptoms?

thanks in advance for your reply
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634315_tn?1223816356
BTW
i was dx with os odontoideum when i had x ray and ct done.  had no idea i even had it.
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