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  #1  
Old 04-02-2015, 04:50 PM
kflee00 kflee00 is offline
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Join Date: Feb 2015
Posts: 22
Default 1 or 2-level lumbar ADR? Need help

Hi everyone,



I’d like to thank the members who’ve shared their experiences with me during my research. My symptoms became a lot worse 3 weeks ago so I don’t think I can wait too long. But the surgeons disagree on my L5/S1 so I don’t know if I’m a 1-level (L4/5) or 2-level (L4-S1). It’s a tough decision so any input is greatly appreciated.

39 y/o M, 5’ 7”, 155 lbs
MRIs & X-rays: Current; facets not contraindicated for ADR
DEXA bone scan: Looks good
Metal allergy test: Waiting for results

Images attached:
1) MRI from 2015 (L5/S1 sagittal & axial view)
2) Pain diagram (explanation in message below)
1.jpg
2.jpg
3.jpg
L5S1.jpgPain diagram.pdf



Treatment plan (Clavel – Skype, Bierstedt – phone, TBI – email):
L4/5: All 3 agree on ADR.
L5/S1: Only Clavel suggested ADR although that’s open for discussion upon physical exam in Barcelona. But all surgeons (including Dare from UK) agree that the disc hasn’t degenerated significantly, if at all, between 2010 and 2015 (i.e. same disc height & similar nucleus degeneration).

L5/S1 diagnosis:
1) Bierstedt: Disc is healthy and wouldn’t touch it.
2) TBI: Not operating on it. Is their decision to only do a 1-level at L4/5 due to FDA restrictions? Is the Pro-Disc-L approved for 2 levels in the US?
3) Clavel: Pointed out a tiny tear to the right side annulus (3 radiologists have missed it). Says the tear & nucleus degeneration can also be contributing to my symptoms.
4) Dare: Pointed out a tiny tear as well. Waiting for phone consultation.
MRI report: Mild diffuse desiccation and slight vertical height loss with bulge eccentric to the right but no evidence of descending or exiting impingement.

Concerns about ADR at L5/S1:
1) Sacral slope & sheer load – but Clavel says that my 33 degrees slope isn’t an issue.
2) Disc doesn’t look too bad to me – I’m a little hesitant about replacing it but I also don’t want another surgery a few years down the road.
3) Do the discs usually look better on MRIs but then are actually worse when the surgeons open you up?
4) Higher risks with 2-level vs. 1-level ADR

Usual symptoms:
- Most of the pain is in the lower back and hips
- Numbness in butt (both sides) after sitting
- Sciatica pain (both legs) after sitting for 1 hour
- Cramps & burning (both feet) after standing or walking for more than 1 hour


Worst episode (3 weeks ago):
- Severe muscle spasm & unable to move for 4 hours – was in ER for 6 hours before stabilized

New sacral pain (around L5/S1) since 3 weeks ago:
- When sneezing
- When changing positions (i.e. from sitting to standing)

Thank you for reading my post – I look forward to your input. I’m just afraid of doing too few or too many levels.


Best regards,
Michael
__________________
2009 - L4/5 broad-based protrusion, L5/S1 herniation.
2010 - Lami & Discectomy at L4/5, solved most of the bilateral leg pain but still have trouble sitting.
2011 - 2013 Sitting long hrs trigger pain in back/hips/legs & severe back muscle spasm.
2015 - Symptoms became worse, can only sit a total of 1-2 hrs daily and walk 45 mins. Spend most of time in bed.
May 7, 2015 - M6 at L4/5 and C5-C7 at the same time by Dr. Pablo Clavel.
December 2015 - M6 at L3/4 & L5/S1 by Dr. Pablo Clavel.
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  #2  
Old 04-02-2015, 07:24 PM
Romakis's Avatar
Romakis Romakis is offline
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Join Date: Jan 2015
Posts: 197
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If this was me, I would do both. No way I would risk having to have a surgery twice. But of course I am not a doctor, and it will be your decision. All of us have been facing hard choices.
__________________
46yo, DDD of L4-S1. Microdiscectomy L5-L4 in 2014. L4-L5-S1 M6 ADR with Dr. Clavel - June 2015.
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  #3  
Old 04-02-2015, 09:23 PM
NJ Gene NJ Gene is offline
Senior Member
 
Join Date: Feb 2013
Posts: 376
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Have you considered a Hybrid approach? ADR at L4/L5 and fusion at L5/S1? From reading these boards, it appears that when ADR goes bad at L5/S1 (perhaps only 1% of the time), it is really debilitating. On the other hand, fusion at L5/S1 seems to be the best level for it. Due to its positioning, you are much less likely to have future issues with fusion there versus other levels.
__________________
Car Accident 2002 - Small Herniated Disc C3/C4
1998 Larger Herniation and Cervical Fusion C3/C4
2005 Herniation C4/C5 - 40 epidural steroid injections from Oct 2005, - Oct, 2007
2008 - Foraminotomy at C6/C7 on left side
Feb, 2010 - Cervical Fusion C4/C5
Dec, 2010 - Lumbar Fusion L3/L5
2013 - Bulge on C5/C6; herniation C6/C7 right side
Mar 26, 2013 - Foraminotomy at C6/C7 on right side
May 5, 2015 - ADR with Dr Blumenthal of TBI for C5/C6 using Mobi-C
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  #4  
Old 04-02-2015, 10:18 PM
kflee00 kflee00 is offline
Junior Member
 
Join Date: Feb 2015
Posts: 22
Default

Quote:
Originally Posted by NJ Gene View Post
Have you considered a Hybrid approach? ADR at L4/L5 and fusion at L5/S1? From reading these boards, it appears that when ADR goes bad at L5/S1 (perhaps only 1% of the time), it is really debilitating. On the other hand, fusion at L5/S1 seems to be the best level for it. Due to its positioning, you are much less likely to have future issues with fusion there versus other levels.
Hi NJ Gene,

I did mention L4-S1 hybrid to Clavel. He's open to not touching L5/S1 for now but doesn't seem too keen on a hybrid. I don't know if I can insist on the type of surgery I want him to perform. He says there's some motion at that level and it's important to preserve that. He also said his L5/S1 ADR patients do better than fusions.

Considering that my L5/S1 isn't perfectly healthy, I'm worried about not touching it now.
1) Will the trauma during L4/5 ADR surgery cause it to degenerate a lot quicker?
2) If I want to be semi-active after a successful L4/5 ADR, will it hurt the L5/S1?

If it weren't for my planned L4/5 ADR, the L5/S1 isn't bad enough to warrant a surgery by itself. Tough decision.


Thanks,
Mike
__________________
2009 - L4/5 broad-based protrusion, L5/S1 herniation.
2010 - Lami & Discectomy at L4/5, solved most of the bilateral leg pain but still have trouble sitting.
2011 - 2013 Sitting long hrs trigger pain in back/hips/legs & severe back muscle spasm.
2015 - Symptoms became worse, can only sit a total of 1-2 hrs daily and walk 45 mins. Spend most of time in bed.
May 7, 2015 - M6 at L4/5 and C5-C7 at the same time by Dr. Pablo Clavel.
December 2015 - M6 at L3/4 & L5/S1 by Dr. Pablo Clavel.
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