Its L4-5, L5-1 decision time - ESP hybrid?
 

Hi, Ive been intermittently following this forum for several years now but this is my first post. The realization has set in, my discs and surrounding structures will continue to degenerate and cause ever increasing activity limitations unless corrective action is taken. In the past 9 days I have had no less than 3 ADR spine surgeon consults as to the best course of action. In a nutshell there is no perfect answer, no perfect disc, and no perfect surgeon - so Im working to reduce risk and increase likelihood of fixation and long term success.

Background: I am 44 yrs old, 6'1" 185lb and generally active. Several times a year my lower back will get triggered and I am debilitated. The pain I experience during this period is severe but localized to the lower back and last 3-4 weeks. I have been dealing with these cycles since 2011! and the aggravated cycles have become more frequent. Just recently my pain was so severe that while cautiously walking down the stairs, my back seized and I collapsed.

My L4-5 is the most likely cause of pain and instability, its severely degenerated with modic changes - see image, and a cavity at L5's top. Facets at this level are good. L5-1 has less severe degen, but still needs to go. Challenges at this level include steep sacral slope and thin/almost fused facets.

Seriously considering 2 doctors. Clavel and Illerhaus of ONZ. Interestingly they have 2 different recommendations. Clavel prefers hybrid with disc at L4-5 and ALIF at L5-1. Illerhaus' solution is ADR at both levels. Both are committed to their particular methodology, primarily due to their experience. When challenged with the alternate methodology, Dr Clavel responds why take the additional ADR risk at L5-1 when there is such limited movement in that segment. Illerhaus' response is more philosophical, "we aim to preserve motion wherever possible."

I also pressed both doctors on disc favorability for my condition. It was interesting, Dr Clavel while generally favoring ESP has had some reservations due to recent bonding complications. He surmised, a stiffer disc with no keel may have more challenges with the initial fixation. However even after understanding the cavity at my L5 endplate he was optimistic the ESP would be the best approach. He seems to favor the ESP, especially for its elastic return property. Illerhaus also seems to prefer ESP, however he indicated that my steep sacral slope of 16 deg may limit disc options to ActiveL.

Im leaning more towards the hybrid approach, and will probably talk to a couple more surgeons in the coming weeks before finalizing. So thats a bunch for a first post but any thoughts, feedback, or questions are welcome.

Why not check out the Texas Back Institute? They have great reviews and most of the studies we see are based on their work. Europe might be more "advanced" in terms of tech...but advanced tech doesn't necessarily mean most EFFECTIVE tech. ActivL for instance, might not exactly mimic our discs, but the results seem to be great. LP-ESP seems like a good disc, but is there a ton of long term data around it? not as of yet.

I'm going to dodge the question of who to talk with to get your surgery but, instead, think more about what you need to do. I'd be more critical of getting an ADR at L5S1 if your facets are already as badly compromised as you indicate. The whole marketing literature about how good modern ADRs are aside, there's a reality that it's impossible for them to have completely perfect physiologically appropriate movement and the facets can often take abuse at ADR levels. Sometimes the facets improve because using and ADR to raise the disk spacing to the correct height improves the loading on the facets. Other times, the facets are simply too bad and the improvements possible with the ADR aren't enough to help. I'd ask a lot more about that if you were more serious about the dual ADR approach.

Update.

As I never had a super clear path with ADR or fusion, I ended up doing a discectomy by Dr. Robert Eastlack in San Diego on February 8, 2023. I was told the way Dr Eastlack performs the surgery would not preclude me from doing a bigger surgery later on - so I opted to try it first.

I am amazed by the results: snowboarding 10 days later with zero pain!
Its been 7 weeks or so since the surgery, Im lifting weights, working out almost every day, and have been dumbfounded by the effective result this relatively simple surgery has produced.

Even if this procedure works for only a few years, and I need major surgery later - I think it would still be worth it.

Whats weird is that I talked to a dozen+ surgeons over many years, in Europe, TX, CA. I shared detailed XRAY, CT, MRI images with all of them, and yet I only heard discectomy viability beginning of this year. I was told discectomy is viable if you have shooting leg pain, no shooting pain - you need fusion. There is still a long way to go before efficient clear diagnosis can be performed.

Wishing everyone here finds their way. Its still very early, less than 2 months, but so far discectomy surgery has been life changing for me.

Hello abenhaim Congrats on the successful surgery ! You had a discectomy , was any bone removed (lamina) , micro-discectomy? Take care