Considering a 3-Level Hybrid Surgery

[Kerry F]

Hi Everyone,

I'll be as concise as possible:

Dr. Blumenthal at Texas Back is proposing a hybrid surgery--a fusion at L5-S1 and L4-L5, and a new disk (Charitee) at L3-L4. The problem with my back is in my signature (below).

This was following a discogram that showed no pain at L2-L3, significant pain at L3-L4, and severe pain at L4-L5 and L5-S1. I'm a 36 year old male who used to be very active physically when this started back in 2002 (pretty much out of the blue)--ran 5 miles a day, lifted weights, etc.

I've tried everything I can think of--physical therapy, facet & steroid injections, IDET, and chiropractic visits. Chiropractic visits give temporary relief, but that's about it.

I know that none of this is ideal, but neither is taking a ton of pain meds just to get out of bed and go to work; and feeling like any minute you're going to have to quit your job.

This is obviously the biggest decision I'll probably ever make regarding my health, so any advice would be much appreciated. Thanks.

[Harrison]

Hi Kerry,

Sorry for the obvious questions here, hopefully they will help and you’ve already thought about them:

- There is an old adage is that everyone has bulging discs – so why replace them if they still work, right? Are they the pain generators? It’s ironic that L2-3 has the annular tear, but generated no pain in the discogram study!? What the heck? But this segment sees lots of torsion: twisting, stresses; so if it is diseased and desiccated, replacement makes sense. How degenerated is it?

- How diseased/desiccated are the other spinal discs? Dark on the MRI? Described by the radiologist?

- How are your facets at various levels? Degree of arthritis at each? Their stages?

- Instability is a big risk for ADR, so fusion at 4-5 seems to make sense.

Any way, Dr B knows his way around the spine and has been doing ADR since 2000 with various disc replacements. Did you discuss these questions with him?

These are some challenging issues for sure, so it is wise to wrestle with them carefully and patiently. I hope this helps…

[Hooch]

Hi,

It's a tough one. I saw your posts, know u need something done, but 4 levels a lot of them won't want to touch you.

The difficulty with that discogram is sometimes you get false positives and negatives. You have a lot of pathology at l2/l3. If the tear is big enough a discogram can't generate pressure, so no pain, but I'd like to think your surgeon is wise to that. The big worry is that l2/l3 is either already a pain generator, or won't take much to become one post-op, aside from all the other difficulties with multi level surgery outcomes.

Have you got any other opinions from surgeons willing to operate? I just had an operation with Nick Boeree, it may be worth getting an opinion from him even if you have no intention of having the surgery done overseas (they don't have to know). I'd probably have a crack at Bertagnoli, and maybe Pimenta as well, he seems to save himself for difficult cases and he may take an interest.

If I was in your situation and was financially sound, I'd hunt up multiple opinions from the more surgically aggressive surgeons and make my decision off that. I'd probably ignore for the moment surgeons who say do nothing as that in all probability means live with significant disability and all the financial and personal problems it creates.

I'd take a pro-disc over a charite if facing the 2 fda approved options, but again I'd like to think your surgeon has his reasons.

[jss]

Kerry,

Condolences on your condition.

I think that Hooch gives some very good advice; that is getting multiple opinions. Hopefully they will all converge on the same treatment.

I have a question... Is Dr Blumthenal's prescription for one ADR and two fusions based on insurance limitations? Does he prefer multi-level ADR, but forced into a hybrid because your insurance company won't pay for it?

Good luck, Jeff

[Kerry F]

To all of you, it means a lot to me for you to comment on my situation. This has pretty much taken over my entire world. I’m hanging on for dear life to not have to quit my job (and lose my insurance policy) because of the mind-numbing pain. Thanks again.

Rich,

Those are great questions. How do I learn this information? The only things I have in my possession are the films and the radiologist's summary. Who can I engage to go through all the nuances of my condition? Dr. B is great, but I’m not sure he has the time to have an exhaustive discussion of my condition. I am in complete agreement with you that knowing this information is important for me to learn—to make the best decision I can make.

Hooch,

Thanks so much for taking the time to discuss this with me. You’re correct when saying that many surgeons do not want to discuss solutions with someone in my situation. No, I haven’t had any other surgeons that are willing to operate comment on my situation. I’ve had two surgeons take one look at me and think that my condition isn’t that bad (looks are deceiving). I’m 36 years old, eat right, and stay in good condition. It’s very discouraging to hear that someone can’t do anything because you have too many levels at work. What did you have done with Dr. Boiree? Where is he? Do I submit my films online and make a phone appointment. I’m truly a rookie with all this stuff. I can look him up online and call his office. I’ll do the same with Dr. Bertagnoli and Dr. Pimenta. I’m somewhat financially sound (within reason). However, if my insurance doesn’t help (Aetna), I think I may be out of luck.

JSS,

Those are great questions that I’ve sent via email to the person in charge of my case. My main question was what are the pros/cons (if money and FDA approval weren’t an issue) of 2 fusions and 1 new disk, 1 fusion and 2 new disks, or 3 new disks?

Here is a question for all:

Are there minimally invasive surgical options for someone with my condition? It just seems like something to pursue before doing something more permanent. I have an appointment

[DAnn]

Kerry,
Please keep us posted on your decision and your findings. I'm in a similar situation with a recommended hybrid surgery. I think mine might be related to mild lesthesis at one level (the fusion). ADR at the next level up.

I hope everything works out for you and your questions are answered and you end up with a great outcome.

DAnn

[Hooch]

Hi Kerry, sorry I missed your post.

Let us know how it turns out. Re. minimally invasive, not in the true sense of the word, surgery will no doubt involve interbody fusion and disc replacement.

Once you've done the physio and the steroids the rest is mainly bs.

Good luck.

[Kerry F]

Hooch and DAnn,

I have my follow-up appointment (following new MRIs on tailbone, lumbar, and upper spine last Friday) with the Minimally Invasive Spine Institute (MISI) here in Dallas this coming Thursday.

While I don’t know the future, my guess is that they’ll suggest some kind of surgical procedure on L5/S1—after all, this is what they’re in business for, right? I also have an appointment with Dr. Blumenthal on Monday, the 21st, to go over all of my questions (some of which you guys suggested I ask).

It’s going to be very interesting if the MISI suggests some kind of procedure. It will be very tempting to try this before having something more permanent (especially a fusion) done to me. My concern, however, with this solution is that they’re only going to address one of the disks. Even with insurance, it may turn out to be somewhat pricey; and I’m not sure I have the resources to go through with a more permanent procedure with Dr. Blumenthal (assuming this is still a possibility) if this doesn’t work.
Hooch,
I notice you had a fusion at L5/S1 and a new disk at L4/L5. Are you happy with it? Did it meet your expectations?

Thanks again everyone, you’ve been very helpful. I will definitely keep you posted on my journey.

[Hooch]

I'm still recovering, you need a good 6 months to come back from a fusion.