Fusion today

[mmglobal]

I'm posting this in Arthroplasty Central because this surgery is part of an ADR odyssey. Over the years, Stephen has posted as Crawler on MGH and as StephenLA on BPSG. His story is incredible. He found me in December of 03 and his was my very first online profile. After Melanie, he was my second client.

His pain response was so extreme, he had been unable to be upright for any length of time. Pain and muscle spasms would become so extreme. He had stopped walking over a year before.... literally crawling wherever he needed to go. He lived like a shut-in, venturing out only for doctor appointments. Local surgeons were divided. Half dismissed him - afraid of psych problems. The other half wanted to do a 3-level 360 fusion. We presented his case to Dr. Bertagnoli who recommended a 3-level ADR and asked for a bone density test. Horrifying news... t-score was -4.4... off the charts... severe osteoporosis.

Stephen started seeing an endocrinologist who immediately started treatments. At that time, he was simply waiting for bone density to improve... could be years, especially without weight-bearing exercise. Stephen had good disc height, so I recommended that he go to Dr. Yeung to see if SED would help resolve discogenic pain. Like others, Dr. Yeung was very leery of a patient with such an extreme response to pain, but agreed to see him. Dr. Yeung's discogram was very telling.

1. Patient was not overly pain sensitive.
2. Negative response at L2-3.
3. Positive - normal positive response, discogenic pain at L3-4
4. Positive - normal positive response, discogenic pain at L4-5
5. Outrageous positive response at L5-S1

At L5-S1, the dye ran immediately into the S1 vertebral body. Dr. Yeung described this as a fractured or separated endplate. Very rare. All the doctors I've spoken to about this confirmed that they have seen or heard of such a condition... it is very rare... it is normally accompanied by an extreme pain response.

The bad news is that this condition does not respond well to SED. So, Stephen is left waiting for bone density to improve. After 3 months of treatment, he was at -4.0. 6 months -3.7. 9 months -3.4. 13 months -3.5. Everyone was surprised by the early progress, but not by the backwards movement... it is not linear and not expected to be so dramatic. Like many things, early improvement is easy and it gets tougher as you go... especially without weight-bearing exercise.

We batted many options around. Bertagnoli would do ADR at -3.4 with vertebroplasty, but it would cost 16,000 for a stretcher ride to Germany and possible 16K for a return trip. It is unclear how quickly Stephen will be up and about, even with successful surgery. What was finally decided upon on is a partial solution. Today, Stephen will have a TLIF with cage and BMP, plus Sextant procedure for posterior support. (Regan, Cedars Sinai) This will be done only at L5-S1. We fully understand that Stephen will be left with discogenic pain at the other 2 levels, but we are hoping that resolving the worst problem will allow him to get back on his feet. He will still be a spiney and may still be disabled and on pain meds. Hopefully, he'll be like the rest of us with discogenic pain at 2 levels...able to walk, able to do things during the good times... able to do PT... able to live a better life than he has for the last 2.5 years... unable to sit upright, unable to walk, unable to do anything.

This plan preserves the anterior approach. He may need 2-level ADR on top of the fusion. He may be a good candidate for SED. We don't know what the next few months will bring, but this is the best option now. We get to resolve the worst pain generator and take stock again.

Whatever it is that you do... pray, meditate, chant, anything... muster up all the good karma you can and send it Stephen's way. He needs it. I'll keep you posted.

Mark

[Justin]

Sending my prayers Stephen...

Justin

[Mariaa]

Stephen,
My thoughts and prayers go out to you for surgical success at the L5S1 level and ability to be up and about afterwards/weightbearing so bone density will continue to improve as will the ability to function upright, and of course for pain relief!!!
This was very interesting to read in terms of approach for incremental improvement~ thanks Mark!

[ans]

To Stephen, my best.

[Fortitudine]

Hoping that all goes well for you, Stephen.

[Alastair]

My thoughts are with you Stephen

[Melanie]

Stephen:
Wishing you every success.
Thanks for sharing Stephen's story, Mark.
Melanie

[biffnoble]

Hi Stephen:

For all of us beat the odds!

Good luck!

[Pat&Robin]

Saying a prayer for Stephen, he is obviously a man of great courage and an inspiration to keep on keeping on.
Robin

[spotty14]

Stephen,
I've had you on my mind today hoping that your surgery went well and is a success. I hope this is the beginning of your ability to be up walking again. Talk with you real soon.
Mark, thanks for posting this.