Second guessing 3rd level - thoughts?

[Jstuckey]

I'm 4 weeks away from leaving for England. I'm starting to second guess having the "optional" level done. Here's a little background, besides my signature:
L5-S1: Facets too far gone for an ADR, so this level gets an ALIF (STALIF TT to be exact. Stand Alone Anterior Lumbar Interbody Fusion).
L4-5: M6-L ADR.
L3-4: The level in question..... Mr Boeree considers this an optional procedure - place an M6-L or do nothing to this level. There is currently (as of about 1 year ago CT scans) small focal disc protrusion. Mild facet joint arthosis. Negative pain generator per discogram.

My dilemmas:
Scarring: Although Mr Boeree places barriers for vessle protection, another surgery in the future poses risks. I either have it now, or never.
Money: I'd like to think that the extra $3000 now is a much better deal than a whole additional surgery (travel, etc) down the road. No guarantee I'd need it, but my deterioration is not localized. Cervical areas are affected too - but don't need treatment....
Recovery: I am starting to second guess the need for it mostly due to the fear of a tough recovery. What a huge surgery - 1 fusion and 2 ADRs in the lumbar area. My question: How much different would recovery be for 1 fusion + 1 ADR vs. 1 fusion + 2 ADRs. I'm considering dropping the optional level if I hear it's a huge difference. The L3-4 may stop deteriorating if the level below it has an ADR?
I know there aren't many people out there (Hooch is the closest) with this particular surgery, but I'd love to hear thoughts.
Starting to hang out on the ledge!

From a year ago:

[Cirobi]

That's a good question overall. Is the doc you're seeing able to give you a generalized idea of the recovery time difference? The first surgeon I saw when I thought all I would need was another minor procedure as well as my actual surgeon were both able to give a range of time for recovery for both one level and the possible 2nd level.

The first surgeon I saw had concerns about my L4/L5 level after seeing my MRI images, but we found out L4/L5 wasn't generating pain. I suppose, had the option been given, it could have been replaced as an optional level. As they explained to me after the discogram thing, they were only going to do the single level at L5/S1 with the hope that resolving problems at that level would help me preserve the adjacent disk since it wasn't completely busted. There's degeneration, yes, but they preferred trying to preserve the natural disk.

Does your specific procedure 100% exclude you from getting that 3rd level done later?

While it may end up being more expensive later on, if there's no serious issue with it but only a general concern, it might be worth it to just go with the 2-level procedure and maybe the extra strain from the two other damaged levels will subside enough that you don't need to think about that 3rd level for a very long time.

You might get some occasional irritation because of that semi-damaged level, but I've found it to be significantly less and fairly infrequent so I just try to be careful overall. Now... for my spine specifically... I'm interested in how much irritation my semi-damaged level has as I get further in my pregnancy. I expect pain, especially toward the end, but how much pain is where my curiosity is. I'm a little afraid but... I kind of see it as a little experiment with my own body in a way... so it becomes more interesting than frightening. What can I say, I have what's probably an odd approach to these things mentally and emotionally.

Good luck with your decision and hopefully some of my rambling helps.

~Sara

[Jstuckey]

Thanks for the thoughts.... no, another surgery down the road is not 100% unavailable, but the risks are greater if it is ever needed. I'm really on the fence! (Haven't broken the news to my husband yet that I'm reconsidering that 3rd level. Hope he continues to have patience with me!)

Good luck with your pregnancy! I have no ADR related advice there, but lots of general pregnancy experience! 3 babies, 2 born at home with a midwife - so I was all about the natural approach.

[MeggieLynn]

Hi JoeySue,

This is a tough one and it really is a hard call w/so many variables to consider. I'll be facing the same thing if and when I do my cervical area. I don't think Discograms always tell the whole story & it's hard to predict whether a particular disc will continue to deteriorate in the near or distant future. I think it depends on individual biomechanics and level/speed of individual aging processes. In regards to recovery, I don't know that doing an additional level would add all that much more in term of recovery. It's still a big surgery either way. I think it adds more in terms of risk - both during surgery neurologically and afterwards longterm in terms of subsidence or infection type issues.

What about getting another MRI/CT scan? If it showed further deterioration over the last year at that level, it might make it easier to make your decision. It would also give you information if there's anything going on above the L3-4 - This might also influence your decision.

Either way, I really like the M-6 design for its "cushioning" and its semi-constrained motion in all direction properties. I think this is really important from a functional standpoint & to protect the facets. In regards to longevity - who knows. I don't think any one expert can say how long any one artificial disc will last. Good Luck!

ML

[mcjagger]

I agree with meggielynn's opionion of getting another mri. I would think that it would give both you and your doctor a better idea of what is going on with your back since your last images. Just my two cents.

[annapurna]

A split the difference option is to try ADCT on L34 or a pure stem cell technique coupled with microdisectomy.

[Hooch]

Did you have a discogram with dye and CT? If the herniation is well contained and there is no or minimal annular tearing I would lean towards leaving it alone. If the herniation is not well contained and there significant tearing (you can see howfar the dye travels into the annulus) I would lean towards having it replaced.

Regardless of whiz bang adr stuff these things only imitate natural discs at best and the anterior ligament is severed (inherent instability) so you want to avoid it if you can. But the other side is important too.

Have you had a good talk to Boeree about it?

In terms of recovery I don't think there will be any massive difference, I wouldn't really let that influence your decision too much, make the decision purely on best long term outcome. The fusion will give you a good caning regardless, it is a bear of an operation.

[Jstuckey]

Thanks everyone. I really appreciate your advice.
I agree - I should have an updated CT or MRI and another consultation with Boeree about it before making a final decision on the "optional" level. He really was 50/50 on it when we spoke in the spring. Maybe he'll lean one way or another with new information.
The CT (with dye) was not extremely descriptive on that level in Oct of 2010 (and I've looked at the pics but am no good at figuring them out. The MRIs are easier to read). It only states: Posterior annular tearing. Mild broad based posterior disc bulging. Minimal facet deterioration. Mild central canal narrowing. No significant foraminal narrowing.

Thanks for the ADCT advice, too, but don't know if Boeree does that. It wasn't discussed as an option from any of the opinions I received.

And Hooch, I can always count on you for telling it like it is! The fusion part will make the whole thing suck for awhile regardless of what else happens. That part is not optional.

Since I have 4 weeks, I'll make good use of that time and get some updated pics and have one more discussion with Boeree about L3-4. THANKS AGAIN ALL. These discussions help so much!

[Maddie]

Hey Joey Sue,

Second guessing is part of the process

I had an ALIF (a stand alone PEEK cage with no hardware...is that what you are describing?) plus an XLIF at L5/S1 and L4/5 respectively. (Plus an ADR at C5/6) all in the same surgery.

I have to say that the XLIF and ADR were almost a non-event compared to the ALIF. The incision was twice the size and took much longer for recovery. The surgeon had to do some serious work at that level though, because I had a grade 2 slippage (can't spell the proper word )

Every other surgeon with whom I consulted advised getting a third lumbar level done as well, but the one I eventually went with believed that the upper level would not be an issue once the other two settled down. So far, so good. I'm pretty active now and doing well. And this is with fusions, not an ADR. I'd be in the same boat in the future, financially. So I'm really hoping this is the first and last surgery, but of course there is no guarantee. I'm getting older and there's more wear and tear...that's just life.

But if your doctor has any issues with that other level, I would go for the extra ADR. The cost is minimal now, as you say, and the recovery time wouldn't be significantly more for that extra either.

One piece of advice that helped me immensely though...ask...insist if need be...for an epidural. My pain levels were so much lower than others who had surgery at the same time, without the epidural. Mine stayed in for 24 hrs, then they had to remove it to avoid risk of infection. It was a blessing.

[Jstuckey]

Thanks so much... Never thought to ask for an epidural - I will do so! I appreciate the advice - I'm getting consistent opinions on the ALIF post-surgery pain. Sounds like a party (not).
I appreciate the comments on the additional ADR not being significant to recovery time - that's been a pretty consistent thought of others too. The surgeon didn't seem to add much time on for 3 vs 2 levels. I see huge variations in people's recovery times, but probably more due to history. I'm thinking I'll be on the easier end, as I am fully functional now. Seems like those that are more impaired prior to surgery or a history of trauma have longer recoveries.
The STALIF TT is just a specific name brand/type of ALIF (Stand Alone Anterior Lumbar Interbody Fusion - not sure what the TT stands for). It's PEEK - nothing external to the vertebral bodies - screws secure it upwards and downwards - packed with harvested bone from my pelvis (sounds like fun as well) - puts space back where I've collapsed.
Thanks again. Waiting for a reply from the surgeon if he thinks a new CT or MRI is in order. (THAT my insurance will pay for.... )