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  #1  
Old 06-03-2014, 02:11 PM
drewrad drewrad is offline
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Default ALSO CONFUSED, Clavel v. Bierstedt Clashing Diagnosis

Or perhaps I should say clashing prognosis since the bad discs are agreed upon(mostly). Clavel thinks he may need to go up one higher level than Bierstedt.

So, here's my latest round of email exchange:

From Yolanda(Clavel):

Quote:
Dear Andrew,
Quote:

I’ve checked with Dr. Clavel about your questions. Please find his comments below:

Staliff will not be used for the L5-S1 fusion. An anterior lumbar cage + plate is a construction that offers proven better biomechanincal stability.


We use the pyramid anterior lumbar plate and the sovereign anterior lumbar cage. Both from medtronic.


Grafton as our bone graft substitute to fill the cage.

From Bierstedt:

Quote:
Andrew, we rediscussed your case.

Our neurosurgeons Drs Bierstedt and Illerhaus recommend a 2 level disc replacement with the M6 device. Subsidence as mentioned by Dr. Clavel is not our experience, nor is the angulation shown at L5/S1 contraindicative for disc replacement.

We also do not agree that the chiseling for keel preparation of the M6 increases implant subsidence. The new implant generations only require small keels (not damaging the corticallis, ie natural vertebral endplates) as opposed to the previous generations eg Prodisc.

We understand that is conflicting your decision in regards where to go for surgery. We respect Dr. Clavel and his opinion. He has a very good reputation, good ethical principles - we just do not share his opinion fully, ie conclude that the dextra scan results or sacral angulation is a "deal breaker" for dual disc replacement.

Eventually it is your confidence that guides you.

Both surgeons have the goal for an optimal surgical outcome. Precsion, accuracy and experience matter together with the best postsurgical follow up, complication management and rehabiltation.

Very kind regards

Malte Petersen"

Both great neurosurgeons, but two vastly different approaches. Its like Rodan clashing with Godzilla. You don't know which one wins in the end.


Clavel's approach. Fixation of the L5/S1 with a Sovereign PEEK cage filled with bone graft and Activ L over the adjacent level(perhaps two). Or, wait, build up calcium stock and in a few months go for M6 instead.

Bierstedt's approach. Go for a bottom two level M6 now. Doesn't agree about either subsidence risk or the need to fuse the bottom segment.


That's tough. I want the pain to go away, but I want the right long term solution.

Stability in my case is also something that may be what Clavel is going for since I'm a multilevel DDD and he wants to ensure that the upper levels aren't thrown off like the leaning Tower of Pisa later on down the road. Lost a slight bit of mobility, but then allow the muscles to rest on a solid foundation. Throw in ADRs above and retain enough motion. Make sense?

Comments welcome. Please, fill in the space below. Your thoughts are why I'm here and most of you have great research of your own.
__________________
Weightlifter since 12 years old, now mid-40's and figuring out this wasn't such a good idea.

Chronic back pain started in 2010 while shrugging weights that a 40 yr. old shouldn't even try.

MRI in 2012 showing L4/L5, L5/S1 herniations and L2/L3 bulge.

L5/S1 taking on new shape, chronic sciatica, etc.

DEXA bone scan performed 5/7/14 showing mild osteopenia.

Surgery performed July 9th, 2014, Dr Clavel, hybrid three level lumbar.
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  #2  
Old 06-03-2014, 02:32 PM
drewrad drewrad is offline
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Default

To provide further clarity on the information exchange, here is an email from Clavel a week before this.

Quote:
Dear Andrew,

Please find Dr. Clavel's comments on your e-mails below:


"We have seen a couple of cases of subsidence on osteopenic patients. This may not have been the experience of other surgeons.

We could still perform the surgery in July if we use the Activ-L disc, since
with that disc we are not chiselling.

If he wishes that we use the M6L, he should follow an at least 6 month
treatment to improve his bone calcium stock. Then have a new dexa scan.
L5-S1 is to be fused due to the high sacral slope and pelvic incidence."

So, there is disagreement about the chiseling as well as sacral slope(pelvic incidence).

It seems the sacral slope is becoming more of an issue now on the radar of ADR neuros. I wonder why.

I was told it was stress on the implant over the lifetime of the implant. Sheer forces present at L5/S1 that are not present at discs above that.
__________________
Weightlifter since 12 years old, now mid-40's and figuring out this wasn't such a good idea.

Chronic back pain started in 2010 while shrugging weights that a 40 yr. old shouldn't even try.

MRI in 2012 showing L4/L5, L5/S1 herniations and L2/L3 bulge.

L5/S1 taking on new shape, chronic sciatica, etc.

DEXA bone scan performed 5/7/14 showing mild osteopenia.

Surgery performed July 9th, 2014, Dr Clavel, hybrid three level lumbar.
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  #3  
Old 06-03-2014, 05:48 PM
FranklySir FranklySir is offline
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Join Date: Jun 2013
Posts: 177
Default Logic under duress

Drew,

The experiance of or the lack thereof of an incidence does not make the argument true or false. Logic should prevail.

Many have had contradictory diagnosis by surgeons. For me fusion3 level or lamidisco 3 level. I took the second most conservative approach and 2 level L3-5 ADR. L5 S1 was gone and almost fused anyway. Sacral slope too steep for ADR. Pain free baby!

Now is when you need calmness of mind. You have done the conservative approach so I would think the only question in your mind would be do I RISK!! Regardless of one or the other surgeons unprovable response about subsistence or lack thereof do I risk the rest of my life with problems, if you can hold on for 6 months. In either case your bone density would be better for either surgery from or by any surgeon. Same goes for the slope thing. Im 6 moths out and I can see with how htings have adjusted and why the shear angle could be a problem. Remember you are the one that has to live with the outcome. You actually answered your own question as well above. Foundational. No leaning tower. Use logic albeit very difficult right now to do so.

There is a difference between wanting the pain to go away and needing to stop or eliminate any more nerve damage if that applies. Maybe ask yourself that question and you might come up with the answer.

Heck worst case, if you wait, you can use the time to get in the best shape possible so you bounce back quicker.

Lastly, none of the options presented are ever going to be optimal but rather the best estimate in fixing you. Logic dictates you add NO more to that unknown equation.
F
__________________
Lumbar issues 18 yrs
herniations lumbar L3-5 multiple Epis etc etc
Annular tears L3-5 cauda equina
Cervical herniation symptoms 2011
C5-7 M6C by Dr Clavel on June 5 2013
L3-5 M6L by Dr. Clavel on 12.18.13
Living life instead of living the condition
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  #4  
Old 06-03-2014, 09:05 PM
phillyjoe phillyjoe is offline
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Join Date: Jan 2013
Posts: 251
Default dexa

Not to confuse you further,but you asked for comment, don't count on increasing your bone density in only a few months, unless you have seen a specialist . And consider that you have to keep it strong if you get adr , meaning that you better determine the cause of low bmd now. I can tell you that after hitting the obvious culprits,and finding no cause,these endocrinologists just throw pills and forteo injections at you,all of which I have declined. I have been at the density game for 5 yrs, the only saving grace is that I wasn't able to get prodisc because of low bmd, and thus might someday see m6 implants come my way
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  #5  
Old 06-04-2014, 04:38 PM
drewrad drewrad is offline
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Join Date: Jan 2014
Posts: 629
Default

Yeah, Frank, for me I wouldn't say its about nerve damage at this point. I have full bladder & bowel as well as sexual function. My legs are strong. I just have pain and stiffness. Sometimes cold feet.

There's pro and con with each approach. Just trying to weigh them and see. I can't predict the future but wish I could.

Philly, there is a polymer disc like the M6 that doesn't have keels. The lp-esp. I'm researching it. Not too many doctors use it and I don't know why, but it looks like it would address the issues about spinal stability better than even the M6.
__________________
Weightlifter since 12 years old, now mid-40's and figuring out this wasn't such a good idea.

Chronic back pain started in 2010 while shrugging weights that a 40 yr. old shouldn't even try.

MRI in 2012 showing L4/L5, L5/S1 herniations and L2/L3 bulge.

L5/S1 taking on new shape, chronic sciatica, etc.

DEXA bone scan performed 5/7/14 showing mild osteopenia.

Surgery performed July 9th, 2014, Dr Clavel, hybrid three level lumbar.
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