1 or 2-level lumbar ADR? Need help

[kflee00]

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

[Romakis]

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.

[NJ Gene]

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.

[kflee00]

Originally Posted by NJ Gene

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