Newbie :)
 

Hello all. New to the forum. Just want to introduce myself and give a little history.

1991: At the age of 19, I had a Spinal Fusion at L5-S1 using bone autograft, with no hardware. Done to address Spondylolisthesis pain due to birth defect. Pain not present until my mid-teens when I stupidly carried a friend on my shoulders for a mile. Discovered that my L5 vertebra wasn't fully formed. After conservative treatment failed, I considered surgical options. My surgeon, Dr. Michael Neuwirth, explained Spondylolisthesis can progress and cause more difficulties later in life. He said I was young and strong, so had a great chance at healing to a full recovery. So, in order to address the pain I had at that time and prevent my Grade 1 Spondylolisthesis from progressing, I underwent the fusion. Amazingly, that operation was a complete success and afforded me over 20 years of active, relatively pain-free living.

2011: Began experiencing sciatica symptoms after running long distances. Latest MRI results as of November 2011:

- The vertebral bodies are normal in height and signal intensity...The conus is normal in position and signal...

- At L1-2, L2-3 and L3-4, there is no focal disk herniation, spinal or foraminal stenosis...

- There is mild loss of disk signal at L4-5, compatible with DDD...At L4-5, there is a broad-based central disk herniation impinging upon the ventral thecal sac...In addition, there is mild facet hypertrophy with mild foraminal narrowing...

- At L5-S1, there is Grade 1 Spondylolisthesis...No evidence of focal disk herniation or significant stenosis.

EMG in December revealed no abnormalities.

2012: Sciatica mostly resolved. In mid-July, I stupidly performed twisting exercises which must have aggravated my herniation, and I began experiencing sciatica again. Started PT which began to help until I stupidly pushed the Mckenzie extension exercises too far one week ago (August 6). Increase in back pain, big set-back with PT. Today (August 12) doing much better, but still have abnormal pain and stiffness, and sciatica is still present, actually a little worse than before the set-back. Appointments with Ortho surgeon and Neurologist for early next week.

I was afraid (and still am a little) that I may have damaged my fusion with those Mckenzie extensions. I'm hoping that if I did that I'd be in much more pain and have much greater disability than I currently do. Would you agree that is probably the case? I need an updated MRI to see what's going on now. I need another EMG as well. My goal is to work with my doctors to find out exactly what/where the pain generators are in my back:

- Is my fusion still OK?
- Where are the nerves being compressed?
- Is the sciatica pain coming solely from the herniation?
- Is the foraminal narrowing contributing to the sciatica?
- How much is the facet hypertrophy contributing to my overall pain?
- How much is the L4-5 disc itself contributing to my overall pain?

I need these questions answered, so I know what I can and cannot do, and so that I can get proper treatment. If any of you know the proper diagnostic tests to get those answers, please let me know.

DDD is progressive, so I anticipate that sooner or later I will need a surgery at L4-5. I do not want another fusion if I can avoid it. My fusion has been successful, but I did lose ROM, and I'm quite confident that it hastened my DDD at L4-5. I don't want to continue the DDD cascade up my spine.

So, I'm here to learn as much as I can about artificial disc replacements. Obviously, the Spinal Kinetics M6-L is a standout, but it's so new and revision in case of a problem looks very dangerous. NuVasive's NeoDisc looks like it might revise easier, but that's only for the cervical spine as far as I can tell. Are there other lumbar adr devices I should be considering?

I want to do everything I can to delay surgery, but my research on this forum and others tells me that I don't want to wait too long to have a surgery (if it's inevitable), because the longer one waits, the more likely irreparable damage will occur to nerves and boney structures, thereby ensuring chronic pain despite surgery. I welcome any advice or insights you have on my situation.

Thanks a lot,

z :)

Zen,

Condolences on being here, but welcome. You'll find a lot of lumbar experience on here. While we're not doctors, we can take a shot at your questions; but we're better at sharing our relevant experiences.

I've never heard of a fusion "breaking" or becoming problematic because of an activity. Yes it it know to cause adjacent disc disease, as it appears to have in your case, but I rather doubt you've done anything to your fusion.

According to your 2011 radiology report you have "broad based disc herniation" and "mild facet hypertrophy with mild foraminal narrowing". Your report doesn't say if such is the case, but those two often team up to compress the root nerve as it exits the spinal column; in your case at L4/5. That foraminal narrowing is a common cause of sciatica; but only diagnostic tests can determine if that is probably the sole cause of your sciatica. A discogram and/or an epidural steroid injection is often used to determine if the disc is the pain generator. I don't now what test is used to test the facet.

There are many lumbar ADRs, but the M6 and ProDisc get the most attention on this site.

I would encourage you to defer surgery as long as you can. As you've noted, waiting too long can result in permanent nerve damage and damage to other structures. Unfortunately it is often not possible to know when too late is until you've waited too long.

Good luck, Jeff

Jeff,

Thanks a lot for your reply. I'm relieved to hear your opinion about the integrity of my fusion. Each day that passes I'm a little more confident that you are correct. I would imagine I'd have to do something extremely violent to my back to destroy a 20 year old fusion, and Mckenzie exercises probably do not qualify. :) You know how it is when panic sets in, though.

I've read, and had it confirmed to me by my PT, that mild foraminal narrowing and mild facet hypertrophy happens to many people as a natural consequence of aging and are often asymptomatic. Upon reviewing my MRIs, I do not recall my ortho surgeon indicating foraminal narrowing was compressing nerves. However, I take your point, and that's why I must insist that my doctors help me confirm what the pain generators are. Perhaps a new MRI will reveal more narrowing (I hope not). Do you think the broad-based central disk herniation impinging upon the ventral thecal sac alone can cause sciatica?

Thank you for mentioning a discogram and/or an epidural steroid injection as methods to determine if the disc is a pain generator. I will ask my ortho surgeon about them tomorrow.

I understand it's hard to know when to pull the surgery trigger. I suppose if I do not improve (or if I worsen) within a year of PT and other conservative methods, I will very seriously consider surgery. My fusion wasn't only about relieving pain; it was about preventing further damage. I plan to take the same preventive approach at the L4-5 level, but I do not want to rush into it prematurely.

ADR revision seems to be a very big concern for people in this community and rightfully so. Am I correct in assuming there really isn't a lumbar ADR in existence yet which wouldn't be terribly traumatic to revise if necessary?

The other thing I was wondering is would a minimally invasive partial microdiscectomy to remove the part of the disc pressing on the nerve, and a foraminotomy to widen the foraminal openings (if necessary), be indicated for a patient with DDD? Or, would that just weaken the disc thereby speeding up the compression and damage?

Thanks again,

James (zenmunk)

While it is possible to break a fusion, breaking a twenty-year old fusion would likely be a fairly traumatic event of sufficient significance that you wouldn't be questioning what happened. A simple flexion-extension xray can, should you still be worried, confirm that your fusion is still fused. It might miss a hairline crack, just like a x-ray could miss a hairline fracture, but it's not likely to miss anything else.

A discogram might be worth investigating the condition of L4-5 by itself to see how much, if any of your pain comes from the disk. Facet injections are a possible diagnostic tool but my memory suggests that they can be confusing to interpret when you have a potentially painful disk working in conjunction with damaged facets.

You might consider your combination of a microdisectomy and a foraminotomy together with some of the investigational stem cell techniques to see if you can restrengthen the disk after the microdisectomy and buy time.

I disagree with Jeff's comment about putting off surgery for the longest possible time. Far too often, that's interpreted to mean that nothing should be done until the last possible moment: when the patient isn't able to think coherently and is pressured to do something as fast as possible. I'd suggest that you plan now to have surgery. Figure out what you'd do and what would be the bet to address your current condition. Once you have it figured out, sit down and work through the risks and benefits and decide what kind of shape you'd need to be in to be willing to get the surgery. Don't actually get the surgery until you're happy with the decision and have reached the point where the risks and benefits are correctly balanced for you but don't put off the thinking until your time pressure limits your options.

annapurna,

Thanks a lot for your reply. I will suggest the flexion-extension xray to my doc tomorrow regarding my fusion. I'll also ask that the radiologist pay special attention to my fusion when I get my next MRI. However, I do agree with you and Jeff that it's unlikely I've damaged it considering all I did was Mckenzie extensions. I was applying pretty good pressure, but not straight-armed with all my might or anything extreme like that; just with my elbows lifted a little off the floor. Regardless, I'll make sure I check into it thoroughly.

I'll mention the facet injections and investigational stem cell techniques to my doc as well. Those suggestions plus Jeff's are really helpful. It's so much better to go into a doctor's office informed. Thank you.

Would you agree that one year of conservative treatments which yield no relief is enough time before pulling the surgery trigger? I'm already one month into this latest back pain/sciatica flair-up. That gives me 11 more months to try various techniques (which may include partial microdiscectomy and foraminotomy) to buy myself more time as you say. However, if they fail, I think it may be wise to consider ADR, or fusion as an absolute last resort, to give me the best odds of preventing permanent damage/chronic pain.

And I'll ask you the same questions I asked Jeff:

Do you think the broad-based central disk herniation impinging upon the ventral thecal sac alone can cause sciatica?

Am I correct in assuming there really isn't a lumbar ADR in existence yet which wouldn't be terribly traumatic to revise if necessary?

Thanks again,

James

Would you agree that one year of conservative treatments which yield no relief is enough time before pulling the surgery trigger?
I would say that this is the wrong way to ask the question. One week of conservative care with a quickly degenerating spine that is damaged in a way that conservative care can't reverse is too long. Look at how quickly you're degenerating and how much of your life you're losing. Basically, pile up the risk and benefit columns and don't worry about specific timelines. Try conservative techniques that sound promising but ask how quickly you should expect to feel a difference. Hold them to that and be the critical decision maker when you think about what you want to do.

Do you think the broad-based central disk herniation impinging upon the ventral thecal sac alone can cause sciatica?
Can it, yes. Is it likely, you'd have to look at the dermatome map and ask yourself if the pain you're feeling matches. Also, understand that a spasming muscle in area one can pinch a nerve leading to area two and make it feel like area two is the origin of the pain.

Am I correct in assuming there really isn't a lumbar ADR in existence yet which wouldn't be terribly traumatic to revise if necessary?
I believe you to be correct. If you're worried about revision, that's all the more reason to think about your idea of microdisectomy or conservative care. The investigational stuff are things you'll have to hunt down on your own, beyond what standard care within the US will offer. You can ask your doc but don't be surprised if he disparages it or is unaware of it.

James,

I'll ditto Jim; a herniated disc protruding into the spinal column can cause sciatica. On this site we've seen MRI's where the spinal cord is pinched to half its diameter, but the patient's symptoms are few and mild. We've seen others where a bulging disc barely effaces the thecal sac, but the patient is in debilitating pain. Everyone is different and only tests can tell what is causing your sciatica.

The way Dr Zigler at TBI explained it to me, the problem in explanting a lumbar ADR has more to do with anatomy and scar tissue from the first surgery. He explained that a surgery leaves a lot of scar tissue and it leave many structures adhered to structures to which they don't naturally adhere. This can make re-accessing a lumbar level a life-threatening procedure.

Jeff

Thank you, Jeff & Jim.

Is that why some surgeons elect to use a blood vessel guard when doing ADR surgery? And, does that protect the vessels during implantation, explantation or both?

Do you know any doctors worldwide who are involved in investigational stem cell techniques to restrengthen the disks?

Could a foraminotomy disqualify a patient ADR surgery down the road?

James, it may or may not -- much of that depends on your unique spinal health, the surgeon, their skills and expertise. As well, some docs may "cherry pick" patients.

Harrison,

Thanks for your reply. Tomorrow, I'll ask my neurologist if a foraminotomy could disqualify a patient for ADR surgery.

I met with my ortho surgeon today. I tried to get in as many questions and concerns as possible (I had a lot of them), but it's always hard, because these specialists are always in a rush. He had me do some range of motion movements to check for pain, and neurological movements to check for nerve pain and weakness. He said I passed all the tests well.

He doesn't think my fusion was damaged. He doesn't think I'm anywhere near needing a surgery at this time; not even a partial microdiscectomy to remove any disc material which may be compressing/irritating the nerves. He doesn't think I need a follow-up MRI or x-rays at this time to check on the fusion and the condition of my L4-5 segment. He said that if the neurologist wants to give me another EMG, then that couldn't hurt to see if the test detects any nerve damage, but he couldn't detect any during his examination. I didn't like hearing that he didn't want another MRI, not because I enjoy the test, but because I just want to be sure I'm not degenerating faster than he thinks I am. Doctors don't have x-ray vision; they are limited regarding what they can detect in someone's back.

He said that I will just have to tolerate the pain and sciatica when they occur (they will inevitably flair-up from time-to-time), and that I should work hard with my physical therapy to strengthen my back and core muscles, and try to avoid activities which put a lot of pressure/pounding on the lower back, like running for long distances.

I'm glad his examination didn't turn up anything serious. However, just tolerating back pain and sciatica feels wrong. I mean, of course I have to tolerate the pain when it comes, but other than the physical therapy aren't there other conservative pain management treatments I can get? I didn't get a chance to delve into that with him. I have a follow-up appt in 3 months.

Tomorrow, I'm going to ask the neurologist about getting another MRI; maybe he'll agree to order one. I'll also ask about my options for pain mgmt. outside of physical therapy.

Lastly, there is a new therapy that's being used to treat DDD (Jim alluded to it earlier in the thread) which is what I have at the L4-5 lumbar vertebra. Basically, they take stem cells from your bone marrow or fat tissue and inject them into the diseased disc with the hope that it will repair itself, either arresting or retarding the degeneration.

One of the doctors doing it is Tim Davis out of L.A. If you know of any others, please let me know. Check out this short video about it. I very well may contact Dr. Davis and see if I'd be a candidate for such a procedure. It's meant to treat early DDD which is what I currently have, but it won't stay that way forever. If it worked, then it could buy me a lot more time before I'd need to have any kind of surgery. I didn't get a chance to ask the ortho surgeon about it, but I will ask the neurologist tomorrow.

Thanks,

James

Disqualification for adr
 

Hi James,

I explicitly asked my surgeon (from Cedars Sinai) that question before my foraminotomy and he said absolutely not. I know that is a contraindication for clinical studies, but hopefully not in the other instance!

keep in mind, as others have mentioned, that MRI findings DO NOT = symptoms. if you're having intolerable symptoms, push for a discogram to confirm (or even refute) the disc as a pain generator and then assess your options.

hard to say if you'd benefit from epidurals if your pain generator isn't identified.

hi
 

honestly, i dont see what the rush is into have the surgery. in case of your first one, yes that made sense. I was in the same boat as you. i had a two level DDD and my first surgeon told me to tolerate it as much as I can and to focus on strengthening my trunk muscles. I however still decided to get a microdisectomy at although it did alleviate my symptoms, i ended up getting a spinal infection that was terribly traumatic. you can always get an ADR a year later down the line after exhausting all conservative options.

if your doctor feels surgery is not necessary, i would trust him.

there isn't a data out there that is over 20 years old regarding aDR. and even if there were, the sample size is so small that you cant conclude anything effectively from it.

have you tried prolotherapy?

The rush isn't to have surgery. The rush is to make sure you start the investigation and understand your options for surgery before pain and disability limit your ability to do the research. Surgery shouldn't happen until you have a fully thought out answer but you shouldn't delay the research until you're too disabled to hunt down the necessary information. If, for instance, your local doc says that the best neurologist for doing EMGs is a two hour drive and you've put off any decision making until you're unable to sit for more than 10 minutes at a time, you're going to be making your decision without the best information possible. Is it critical? Probably not, but little compromises will add up to lead to a poor decision. If nothing else, you need to be confident enough that you have time to walk back out of a surgeon's office, refusing to work with him/her, if you have a bad feeling. If you wait until you're desperate, you might accept a compromise that you'll regret later.

This is true for current ADR styles. The Charite has been in use for almost 30 years. That sample size and lifetime is a reasonable indication of the concept of an ADR. Beyond that, it's how much of the individual ADRs' marketing literature to believe.