Microdiscectomy vs. ADR vs. Nothing?

[DavidQ]

Hi all,

I herniated my l5/s1 in April 2010.

I had one epidural injection, some pt, and thought I was mostly recovered from the sciatica that had made life pretty tough for a while.

I had an occasional relapse that would involve muscle spasm in my low back, but no sciatica. Probably two times over two years, and about two weeks of limping until I was feeling normal.

Then, February 2012 I went xc skiing with a friend in washington. I thought I was careful enough, but felt things starting to tighten afterwards. By that night I was in quite a bit of pain.

I spent the next two weeks doing what I figured was the usual limp to recovery. But then as my muscles relaxed, I found myself with pretty severe sciatica. I could get around, but it is very painful to stand and walk for more than a couple minutes at a time, and I usually have to squat and rest.

My regular orthopedist who I see about my back first put me on prednisone for a week... that left me feeling VERY depressed for a few days, and no better.

I was sent to get an MRI, the report is at the bottom of my post. Looking at the pictures myself, I'm struck by how much darker all my discs have gotten in the last two years.

I just had a lumbar epidural yesterday. So far I'm feeling maybe a little bit better. I'm doing PT weekly, and working from home, stretching, and using an inversion table every day lately.

If this does not fix things, my orthopedist told me surgery is likely, a microdiscectomy to remove the herniated fragment of the disc.

I met with a surgeon who I liked very much, and will meet with him again in a couple weeks now that I've had my epidural.

My main questions for the forum:
1). How do I know if it is time for an ADR? Is it a matter of assessing my level of disability and making sure to consider that option before a fusion? Or is a loss of disc height and significant herniation enough to consider it? I realize I do not have the level of pain that many other posters report, as I'm mostly unmedicated except before bed.

2). If I do elect to have a microdiscectomy, I assume the door to ADR is still open down the road?

I feel a bit lost, as most surgeons in the US don't seem too keen on ADR until it becomes a bit more "mainstream".


Based on what I've read, I'm considering a strategy of:
1). microdiscectomy only if needed.
2). Try to stay healthy as long as possible, in hopes of ADR or stem cell therapy many years from now, when hopefully one or both of the technologies have had more time to mature.

Any comments or thoughts are very much welcome.
Thanks,

-David

My recent MRI report reads:

Impression:
Degenerative Disc Disease and facet arthropathy with retrolisthesis, l5-s1, with l5-s1 right paracentral disc extrusion/sequestration narrowing the right lateral recess, contacting and displacing the right s1 nerve root.

Findings:

There is minimal retrolisthesis, l50s1 with ddd most pronounced at this level consisting of disc dehydration, disc height loss, anterior spondylosis, and endplate marrow change. The conus medullaris terminates at a normal level and is normal in signal intensity and configuration.

L1-2 through L3-4: No focal protrusion, canal stenosis, or neural foraminal narrowing is demonstrated.

L4-5: Central protrusion is seen without canal stenosis or neural foraminal narrowing.

L5/S1: Right paracentral disc extrusion/sequestration is seen, extending inferiorly, measuring up to 1.7cm (sagittal image 8) superoinferiorly x 1.0cm mediolaterally x 1.0cm anteroposteriorly, contacting and displacing the right s1 nerve root.

[annapurna]

1) You're on the right track for making the decision about surgical options. You should also consider how fast you're getting worse. At some point the problems of conservative care will outweigh the risks of surgery in your estimation. That's when surgery is reasonable. Unfortunately, no one can tell you when that point is as it's mostly based on how you perceive risk.
2) ADR can be done after microdisectomy.

I would suggest that you start actively looking at stem cell or prolotherapy type conservative care options right now as they really only work as early stage interventions. Once the disk start showing advanced DDD, they really can't reverse things. You don't have to use them, but you should be researching them now so you know what's out there and what they could offer you.

[DavidQ]

Thanks for the reply!

I'm not sure how to assess 'worse' or 'better': My symptoms may be slowly getting better after the epidural.

I actually spent much of the last week looking at alternative treatments. Prolotherapy sounds interesting, but there seem to be a few different protocols:

One school of thought is to treat the ligaments supporting the back, and I might look more into this. Perhaps that could keep my discs in better shape if they had better support.

Another approach is to inject into the disc directly: When I mentioned this to the surgeon I spoke with last week, he was shocked. I guess for many stem cell experiments on animals, all they need to do to initiate disc degeneration is to place a needle in the disc, and remove it.

Likewise, for stem cell treatments that makes me a little nervous. Of course, if there was true regeneration that could be expected, that should outweigh the injection damage. But I'm having a tough time finding any studies done on humans for a treatment with a solid track record behind it.

Even googling extensively for stem cells and disc regeneration, the best I could find was a MRI of a herniation that abated somewhat after stem cell injection, but the mri did not look as though the disc "regenerated" to me: The volume looked the same. The herniation was reduced, but it would seem that's much more likely due to the body's natural reabsorption of the disc material than from the stem cells?
More stem cell disc successes… | Regenexx™


Adult Stem Cell Procedure to Treat Back Pain looks like one of the more promising sites I've found, but even then, there is next to nothing listed about the results that one should expect from the treatment.

Do you happen to know of any posts from this forum, or other resources where someone has a before/after MRI of a regenerated disc thanks to stem cell therapy? I figure I'll at least wait until the current wave of clinical trials has reportable results, but I'd love to see some hopeful signs.

Originally Posted by annapurna

1) You're on the right track for making the decision about surgical options. You should also consider how fast you're getting worse. At some point the problems of conservative care will outweigh the risks of surgery in your estimation. That's when surgery is reasonable. Unfortunately, no one can tell you when that point is as it's mostly based on how you perceive risk.
2) ADR can be done after microdisectomy.

I would suggest that you start actively looking at stem cell or prolotherapy type conservative care options right now as they really only work as early stage interventions. Once the disk start showing advanced DDD, they really can't reverse things. You don't have to use them, but you should be researching them now so you know what's out there and what they could offer you.

[jss]

David,

Condolences and welcome. I ditto everything annapurna posted and add that I've observed a general theme in patients that have lost disc height; that is that they go through a variety of non-surgical treatments and end up in surgery anyway some time later. I hope that you can stave it off for a good long time.

Anything but very minor retrolisthesis is a contraindication for ADR. Most ADR manufacturers publish a retrolisthesis limit in which they believe that their device may be safely used. If/when the day for surgery arrives, I would encourage you to discuss this with your doctor.

Good luck, Jeff

[Harrison]

David,

Your strategy seems sound and conservative.

As you may know, there are actually many variants of a "microdiscectomy", all of which will likely contribute to your post-operative outcome. There are different surgical tools, techniques and of course the surgeon's skills employed in the procedure. Here's one example:

Two-year outcome after lumbar microdiscectomy versus microscopic sequestrectomy

http://www.adrsupport.org/forums/f50...2008-feb-4891/

If the spinal disc height and health is good, it may be prudent to have a consult with a highly experienced surgeon -- one who specializes in microdiscectomies.

Concurrently, keep working on non-surgical remedies. Some folks here have avoided surgery by using traction (or inversion), juicing and extreme diet improvements.

Did you have chronic back pain prior to your herniation?

[annapurna]

You're not going to find too much published research on stem cell or stem cell-like techniques. Right now it's still treated like closely held intellectual property in a research company: don't publish anything. On the other hand, the big name folks are willing to discuss their results and can offer substantiation of their results to some extent. I'd look for Dr Hauser and Dr. Adelson (Docere Clinic in Park City UT) for prolotherapy, Regenexx and Stem Cell Institute of Panama for stem cell work, and look to Europe for ACDT (I'm occasionally dyslexic with this technique; it could be ADCT). If you are interested in prolotherapy, I'd strongly suggest Adelson; he's now teaching stem cell techniques to the big names in prolotherapy.

Laura does have a before and after result for her L4-5 and C4-5 that we successfully treated with ACDT. They have partially rehydrated and have been doing well.

[OBXDave]

Originally Posted by annapurna

Laura does have a before and after result for her L4-5 and C4-5 that we successfully treated with ACDT. They have partially rehydrated and have been doing well.

I'm confused, is this you or another Laura? Is there a link to where this result is?


DQ, I'm in a similar situation not being on any pain meds but still limited in the activities I can tolerate. I am currently holding off since I am starting to slowly improve from a latest prolotherapy treatment. I also wasn't able to find any stem cell study that would justify a closer look. As for most here, its a week to week, month to month situation.

I'd definitely give prolo a try (read my other posts).

[annapurna]

My wife, Laura, and I, Jim, both post with the same screen name, Annapurna. I try to make sure we include some cue to tell people who's writing any given post if it's important.

We don't have any posted pictures from her MRIs. She received ADCT two years ago in February-ish timeframe. She checked about a year or so later and saw some reversal of the dehydration but, more importantly, the incipient neurological symptoms that were still on the edge of being detectable have disappeared entirely.

The stem cell information will probably only be available if you call the clinics. Regenexx was involved with a nasty fight with the FDA and got out of the habit of publishing anything. Stem Cell Institute was primarily working with autoimmune disorders and has recently gotten into orthopedic concerns. BTW, the first line people who will likely answer the phone at Regenexx are pretty bad. You'll have to get past them to speak with Dr. Centeno, Shultz, or Hansen before you'll get real information.