Questions, concerns - at wits end

[Sandra L]

Ian,

What a dilemma

Part of me would like to explore surgery now while I'm still young and fit enough to heal correctly. It's sort of a catch 22. I can live for x amount of years and enjoy the time I have left until I get to the point where I can't exist without massive pain meds and endless bedrest, or I can take a chance on surgery now, endure a painful rehab process for a year or longer, and if everything goes well live another 20 years without too much pain.

Age is a big problem, not only is it harder to mend, but it takes so much longer. Most people my age are not as fit as we should be. I didn't realize bone density was so important in adr's, I just read here that a young guy was turned down for low density. Your bone has to grow and attach to the endplates of the device so that it is stable. Dr. Bertagnoli said he had only placed one other device in a person older than me. Thankfully I had good genes or he would have turned me down.

I'm positive my recovery would be better if I had been able to get the implants in 2004. I think Dr. B's first cervical 4-level took place about that time, so not sure I would have been able to discuss the surgery or even find gentleman . My option 5 yrs ago was fusion and the head of the spine center here said WAIT. My one regret is that I didn't think about the problem until I was told I had no choices.

The best recoveries seem to be those who get the surgery after they're sure that the degeneration is advancing but before too much other damage accumulates, facets, SI joint, etc.

annapurna's advice is right on, but when is RIGHT, the million dollar question.

Enough about me, what I'm trying to say is that you are doing the absolute right thing, research, ask questions, think and do it all over again. Choosing that RIGHT time is difficult. If you wait a little while, the devices/surgeries will have improved, the surgery is still in early stages. Insurance companies will pay, hopefully in a few years. There is also the newest trend, stem cell to regrow the disc, etc., etc.

Best wishes Ian, you're on the right track. Good luck and God bless, Sandy

[Sandra L]

Ian,

This research supports annapurna's post.

Effect of untreated degenerated disc on adjacent discs
Single-Level Degenerative Disc - Adjacent Segments FEA: J.Biomechanics 2009 Jan Epub

--------------------------------------------------------------------------------

Journal of Biomechanics
Article in Press
Copyright © 2008 Elsevier Ltd All rights reserved.

Influence of single-level lumbar degenerative disc disease on the behavior of the adjacent segments—A finite element model study

Lissette M. Ruberté a, Raghu N. Natarajan a, b, and Gunnar BJ. Andersson b

a Department of Bioengineering, University of Illinois at Chicago, USA
b Department of Orthopedic Surgery, Rush University Medical Center, USA

Accepted 23 November 2008. Available online 10 January 2009.

Abstract

The current study investigated mechanical predictors for the development of adjacent disc degeneration. A 3-D finite element model of a lumbar spine was modified to simulate two grades of degeneration at the L4–L5 disc. Degeneration was modeled by changes in geometry and material properties. All models were subjected to follower preloads of 800 N and moment loads in the three principal directions of motion using a hybrid protocol.

Degeneration caused changes in the loading and motion patterns of the segments above and below the degenerated disc.

At the level (L3–L4) above the degenerated disc, the motion increased due to moderate degeneration by 21% under lateral bending, 26% under axial rotation and 28% under flexion/extension. At the level (L5-S1) below the degenerated disc, motion increased only during lateral bending by 20% due to moderate degeneration. Both the L3–L4 and L5-S1 segment showed a monotonic increase in both the maximum von Mises stress and shear stress in the annulus as degeneration progressed for all loading directions, expect extension at L3–L4. The most significant increase in stress was observed at the L5-S1 level during axial rotation with nearly a ten-fold increase in the maximum shear stress and 103% increase in the maximum von Mises stress. The L5-S1 segment also showed a progressive increase in facet contact force for all loading directions with degeneration. Nucleus pressure did not increase significantly for any loading direction at either the caudal or cephalic adjacent segment.

Results suggest that single-level degeneration can increase the risk for injury at the adjacent levels.

Keywords: Disc degeneration; Finite element; Lumbar; Spine

[gregfin_2001]

I am also 39 an had a Micro-D 4 years ago at l5-s1. At the time I was active. I ran a marathon that year, biked and was getting into triathlons.

I was playing softball and injured myself. Reflecting, I always had back problems since I was young and the pain would go a way so I ignored my back. Not now, so I did physical therapy for 6 months with no results.

The surgery did not take, or maybe it did partially. I have found out since by another DR that I also have stenosis at l4-l5. I have not been able to run or bike, but I can walk. Every day seems to be a challenge. I can't remember is if the pain I have now is greater than before the surgery? Do I tolerate more now?

What I do now is Bikram yoga and pilates to maintain. If I am in severe pain like a year ago where I could only walk 50 feet or so is muscle activation technique

Anyway hope things work out for you.

[Linda]

Ian,
Just my 2 cents worth...have you heard about the Fibrin sealant trials? I have ProDiscs at 4 levels and if you are able to wait a couple of years you could try the Fibrin sealant and it possibly could buy you the time you need for the stem cell technology to catch up. This will be a far better solution than ADR surgery which may or may not work.
Best wishes in finding the RIGHT solution for YOU,

[maz]

Hi Ian

why did the neurosurgen say you were not a candidate for surgery? maz

[maz]

Hi ther hope you dont mind me asking how did you find out about the tenosis and why wasnt it picked up before your op? Maz

[annapurna]

Originally Posted by Sandra L

Ian,

This research supports annapurna's post.

Effect of untreated degenerated disc on adjacent discs
Single-Level Degenerative Disc - Adjacent Segments FEA: J.Biomechanics 2009 Jan Epub

This one peripherally supports the point I was making but also lets me get on my soapbox a second about finite element analysis, FEA, for the spine. The point I hoped to make was that a compromised disk can lead other problems which means that the best surgical recoveries tend to be those that come from surgeries that occur soon after the injury is deemed too bad to fix non-surgically. Basically, be sure you need surgery then go get it as soon as possible if you believe that logic.

To ponificate about FEA for a second, it's a series of approximations and models about the real thing. Because of that, the conclusions that you can draw from it really should be limited to what the author intended to prove. If you use assumption A, you can prove or disprove theory B, but it might preclude any real assessment of theories C, D, and E. If someone looks at the results and doesn't understand the assumptions in the work, you can get all kinds of screwy conclusions that mislead terribly.

The other thing to remember is that lousy work on getting the right assumptions leads to lousy results and bad conclusions. I don't have the background to review the assumptions and models and generally ask co-workers to do that when I have to deal with it at work but I've sat in on many an argument over the correct inputs to use for an analysis based on what they wish to prove. Generally, I'd suggest that you use the same yardstick we use at work: if the FEA is telling you something that doesn't make sense, don't believe it without looking for confirmation from another analysis done by somebody else. As people share models and assumptions, that isn't a guarantee of quality but it's a better bet that someone would have caught a boneheaded mistake if you have two or more teams reviewing results.

Sorry about the diatribe. I got irritated at work listening to the same logic: "the analysis said so, so it must be true," and wanted to make sure that everyone here understood that FEA can occasionally produce junk just like any other test.

[ianG]

Hey Linda, no, I haven't heard of Fibrin sealant. But I'll add it to my ever growing list of options and research it further, thanks.

Maz, the surgeon had me do some basic exercises in his office, like bend over and touch my toes, do a few push ups, things like that. Because I could do them without any real drama he 'concluded' I wasn't a surgical candidate.

Gregfin, it sounds like you and I have had similar experiences. People usually take one look at me and wonder why I ever complain. I mean, I can cycle for 25 miles and seem fit as a fiddle, so everything is fine, right?. But what people don't see are the four to six Aleve I take during the ride, the large ice pack I lay on for 60 minutes when I get home, and the sleepless nights I sweat through night after night.

I'm definitely better off than a lot of people, and for that I'm grateful.

Thanks again for the suggestions and information everyone.

- Ian

Originally Posted by Linda

Ian,
Just my 2 cents worth...have you heard about the Fibrin sealant trials? I have ProDiscs at 4 levels and if you are able to wait a couple of years you could try the Fibrin sealant and it possibly could buy you the time you need for the stem cell technology to catch up. This will be a far better solution than ADR surgery which may or may not work.
Best wishes in finding the RIGHT solution for YOU,

[benne126]

iang, i am 39 yrs old and i was with pain since 05 when i slipped with all armour on during training and hernated my l4, l5, l5, s1. exhausted all non surgical options as well.

i was on 800mg of tramadol before the surgery for a year and finally july 7 2008 i had my surgery i have to say the pain and the fallin for no reason is over but now i have to deal with new pain of nerve pain and burning that they say will go away at probably 2 yrs i had my disk replaced in heidelburg at the autopraxis clinic from dr feil here in germany.

i am dealing with this pain and they stop my meds too soon. i was doin pt for a year consideration for the surgery should be on individual basis and i am still struggling with the pain.