QUESTION:L5/S1 ADR or FUSION?

Michelle Maree · #1 (**permalink**) 05-22-2009, 07:53 AM

Hi Guys,
I would like to know your opinion on whether or not L5/S1 is worth putting an ADR or better off fusing? Generally speaking and in my case.

I am considering further surgery at this level after microdiscectomy and now severe DDD with back pain.With only 4.5 mm disc height in the middle and possibly nearly bone on bone at the front and back of the vertebra. I have mild facet hypertrophy on one of my three radiologist reports,but the others didnt mention it. I feel I may have some facet pain though. Not yet tested. Discs above look really healthy and plump. I have no nerve pain.
So I am trying to decide : Is ADR too risky because of limited disc height and possible facet problems? Will the extra movement cause more pain? And fusion better for me as discs above look healthy enough for now. And also L5/S1 is said to have limited motion anyway.
I would greatly appreciate your thoughts.
Michelle.

runner · #2 (**permalink**) 05-22-2009, 08:58 AM

MM,

You need to check that your facets are not a pain generator before surgery.
IMHO, ADR better than fusion at L5/S1, but I am sure there are people on here that may disagree.
If you have facet pain, fusion is better.
It all comes down to the fact that it is your choice and what your surgeon recommends and why.

cls · #3 (**permalink**) 05-22-2009, 03:47 PM

Michelle,

I considered ADR and consulted an Ortho who is very much in favor of ADR and does not like to fuse but I was precluded due to low disc height. I was on the fence with ADR anyway but this sealed the deal. After reading countless threads on those who had ADR at L5/S1 the trends did not seem positive. Overall I did not get the sense that manufacturers have come up with a device that is a long term homerun and I did not like reading the numerous accounts of facet joint problems from those who had radiographically "perfect" facet joints prior to ADR but then developed problems down the road. It is a very tough thing to decide what kind of treatment to undergo but after researching and consulting highly skilled Orthos or NSs you will land on a solution that will feel right for you. The only piece of advice that I can offer is to find a top notch surgeon who is highly skilled in whatever procedure you go with. Surgeons will perfect the procedures that they are best performing. Good luck

One size does not fit all when deciding ADR vs Fusion there are just too many factors weighing these or any other major procedure. Here are some things to consider while researching your options and talking to your doctor:
Your age and general health - Is bone density an issue? Do you have any other health issues? Arthritis?
Your surgeon - what does he/she specialize in, are they known for being a top doc in this specialty? Do you know someone who has had the procedure from this doc that can give a good reference or at least share their experience?
How active are you? - What are your expectations for recovery?
Risk tolerance - Know the risks for any procedure and determine what you can live with.
Hardware/Procedure - With ADR there are more and more devices coming out. Learn what you can about them and understand the pros and cons of each. Which one will you have and why does your surgeon choose the device? With fusion, there are different methods and hardware devices as well. If you went this route would your surgeon perform an ALIF, TLIF, PLIF or XLIF? Would you use donor bone or BMP or your own?

This is just off the top of my head, I am sure there are many more factors to consider. I'm sure others will chime in.

dshobbies · #4 (**permalink**) 05-22-2009, 06:13 PM

MM,

I agree with Runner. Fusion puts a burden on adjacent segments which can lead to further deterioration resulting in more surgery down the line. This does not mean it will definitely happen in your case.

Your choice of surgeon before deciding which way to go is a primary concern. Choosing a doctor who performs both surgeries is more likely to recommend what is best for your circumstances as opposed to what he is more comfortable with himself.

Good luck to you, Dale

Kathy · #5 (**permalink**) 05-23-2009, 01:42 AM

I have an ADR at L4/5 and had a 1 mm herniation at L5/S1 and L3/4, prior to surgery with L4/5 have a grade 4 tear. If I had to have something done on L5/S1, personally, I would have a fusion. I agree with cls, I have heard too many stories of people having problems with too much movement, when they have the lowest level done. This is just my opinion, do your research and pick what is best for you.

Michelle Maree · #6 (**permalink**) 05-23-2009, 02:35 AM

Thanks for your replies..... I am finding the decision very difficult to say the least.
Everyone seems to have a different opinion on this one. And of course it really does depend on the individual case.
I have seen 2 renowned surgeons in Melbourne that use the Charite and both of them said no and recommended a Tlif. I dont know how many they have performed but I dont think it would be many. Their reasons were because of previous surgery,scar tissue, disc height, possible facet issues. I think they like pristine conditions because they may lack the experience but at the same time they may be right in being conservative. These may well be sound contraidications. I will wait on my opinions from Germany and am expecting a completely different opinion. So who do I then trust?

I sometimes try each one on for size and imagine how it would feel in my back to have either of these procedures done. It makes me realise that I do have a certain amount of motion in that segment that I would lose with fusion. For example when you walk you seem to move quite a bit in that area from side to side albeit not as much as above.What I want to know then is Do you completely lose all movement there when you walk? And it then gets transferred above?
Then I imagine having ADR in there. I find it really hard to imagine what having the height back wold feel like and then that extra movement after so long.My back has flattened a bit over th 2 .5 years and I dont know if my facets would cope with the extra lordosis.
If it didnt cause pain then I would be right. If it did cause extra pain then I dont know how id cope.
So maybe thats my answer. I have become more and more intolerant of pain as time goes on. I am just sooo sick of it!!!!
I would dearly love to hear from anyone who has had either procedure at
L5/S1.
But welcome everyones opinion.
Michelle.

dshobbies · #7 (**permalink**) 05-23-2009, 06:49 PM

MM,

I know you're sick of the whole process.

Stop dwelling on this until you hear from Germany. If you get differing opinions, then you start up again but give yourself a break and don't deal with anything you don't have to.

Of course, please let us know what you hear from Germany and we'll all tell you again 'this is what I think'.

Take a break until you hear more. You deserve it!

Dale

Maria · #8 (**permalink**) 05-23-2009, 07:01 PM

This is one of the very reasons I couldn't bring myself to make a decision re surgery .. in '03 I was accepted for clinical trials to do ADR on L4 and L5S1 and then by '06 I have some moderate facet arthopathy at L5S1 and only a one level disc replacement is FDA approved so WC auth'd a disc replacement at L4 and fusion at L5S1.

I'm so freaked about fusion and the possibility of screws that I didn't have the surgery.

I have an elderly father that lives cross country that I need to be on call for and just felt that I couldn't be sure of the recovery w/fusion at any level.

Ok so I procrastinated until now and as I'm aging things aren't getting any better back there/in there!

It's a tough decision to make and I surely understand altho I do hope you won't procrastinate as long as me and can move forward with your life with a sound surgical decision. Good luck from one that understands that rather circular way of thinking..

Michelle Maree · #9 (**permalink**) 05-24-2009, 02:28 AM

Yeah, thanks. I am sorry..... I guess my anxiety is showing.
I am a Gemini and the twins are constantly fighting with opposite opinions neither one gaining the upper hand. I will try and relax untill all the data is available.
It has been an extremely stressful time for me. My partner of 18 years left me late last year. I had to sell our house which I just moved out from and now im at my parents place with my 17 year old. I have other health issues also ....so the list goes.
I am sick of the pain and want to be able to move on with my life but as we all know this surgery thing is no sure garantee of that. I think if I was older than 34 and had lived a bit more I would find it easier and not resent having to take it so slow as much. I will just have to be patient and positive a little while longer.

Thanks for your support,
Runner,cls,Dale,Kathy and Maria.

guymontag · #10 (**permalink**) 05-25-2009, 07:45 AM

I can't really say what would be best for you MM, but since I have a dodgy L5/S1 and if I had a choice of Fusion or ADR. I'd go fusion. I am way too scared of an improper placement or device failure or facet stress. Just reading about Phylly and Mark from Perth and quite a few others, I realise its complicated to get the ADR out.

I've also spoken to a few people who have had fusion at l5/s1 and they have not had much movement limitations. I emailed one lady who works on her farm all day, lifting bales of hay etc, horseriding and she's feeling great. I think the kicker is that any fusion these days must consist or removing the entire disc inserting a interbody and then using bone, preferably donor. Not excising the disc and just fusing with rods and screws will lead to a lot more pain as they disc is still leaking chemical irritant. see MartyUSA blog

http://www.ispine.org/forum/surgical...gery-over.html

I'm also now a little wary of BMP from what Mark Mintzer wrote http://www.ispine.org/forum/ispine/1...-data-too.html I honestly don't know if BMP is the problem or not. But I'd prefer if my doc didn't use it.

I'm not too concerned of adjacent disc degeneration. I wouldn't be planning to do any heavly lifting, I just want to be pain free. So if L4/L5 did degenerate, I'll deall with it then. Perhaps after another 10 years they would have improved on the ADR and you would then assess the options.

probably the hardest part of fusion is to constantly remind yourself that you are still fusing and musn't stuff up that fusion process. Its easy to forget if you are 4 months in and semi fusing and you start bending.

But as you rightly said. There is definitely no guarantees and sometimes just dumb luck can play a part.

hope you can navigate to a pain free existence Michelle.

Michelle Maree · #11 (**permalink**) 05-25-2009, 09:14 AM

Hi Guy,

Yeah, I agree with you and i have decided to have a fusion. I am too far gone for ADR. I have facet problems and Im not going to take the risk of them getting worse.
I am just waiting on an appointment with a spine ortho in Melbourne and will go ahead with it ASAP.

wish me luck,
Michelle.

dshobbies · #12 (**permalink**) 05-25-2009, 07:08 PM

Once you reach a decision you are ready and anxious to move forward. I hope you can get scheduled quickly since your relief is now just around the corner.

I wish you every luck and hope your dreams of a pain free life are realized.

Dale

runner · #13 (**permalink**) 05-25-2009, 08:42 PM

Ditto.

Runner

str8shooter5 · #14 (**permalink**) 05-26-2009, 12:30 AM

i just had a L4/L5 front and rear fusion and so far so good!

Maria · #15 (**permalink**) 05-27-2009, 08:26 PM

Michelle,
Good going. Making up one's mind is at least half the battle! Must be a bit of a relief even if you are nervous. Please keep us posted

melodyl · #16 (**permalink**) 05-27-2009, 11:53 PM

HI Michelle,

I had a revision surgery that included fusion from L-4 to S-1 in Dec. of 2007. My surgeon is normally in favor of ADR (and since that time, did a 3 level cervical ADR for me). Because of the specific problems with my spine, he would not consider going with ADR in my lower spine. Just to be sure, I got a second and third opinion. Once I made up my mind to have it done, the sooner the better! Due to previous surgery for scoliosis, my spine is fused all the way up to T-2. I will be 48 next month. I can't say that I am pain free.....but I can tell you that (for the most part) I do NOT feel disabled. My life is full. I work and have a family and home to take care of. It took me a little while to get used to the loss of flexibility from L-4 to S-1....but on the other hand, my pain went down considerably which seems like a fair trade. I suggest that you consult with the pain management dept. of the hospital you will be having surgery in BEFORE your surgery date. For those of us who have been on narcotics for lengthy periods of time, controlling the immediate post surgical pain can be challenging. Bringing in the experts can make a huge difference. I would be happy to answer any questions you have. Good luck. Stay in touch and let us know how you are doing. Melody

dridobits · #17 (**permalink**) 05-28-2009, 03:25 AM

I'm so glad to read this post. I'm going through this also but I'm trying not to think about it too much until June when I see all the surgeons.

Cindylou · #18 (**permalink**) 05-28-2009, 01:11 PM

Michelle, you've received alot of helpful insight from all these folks. Bottom line, wait for the Germany results so you have more "muscle" for your decision making. It sounds like you have had major life stressors on top of the pain issues, and that is not an easy path to navigate. I personally have had a fusion at L6-S1 (I have an extra vertebra) last July. I also have 3 lumbar discs above the fusion. My decision was mostly a no brainer due to my pars defect and facet issues at that level. I have to say I do not notice much restriction physically with it. About the only thing that comes to mind is when I am standing and lifting a leg to put on my panties, sometimes I have trouble on one side, lifting my leg high enough to step through the hole. That's about it. Good luck Michelle. You'll come to the right decision.

Michelle Maree · #19 (**permalink**) 05-30-2009, 09:20 AM

I just heard word back from stenum after sending them my information and they are recommending the Maverick ADR. This is probably because on MRI my facet joints dont show anything wrong except mild hypertrophy.
I have decide to make sure first before going ahead with the fusion and will get a facet block booked for 12th June. I think id best make sure.

Michelle.

Michelle Maree · #20 (**permalink**) 06-15-2009, 09:16 AM

Hi,
I just wanted to update and also VENT!.

I went to have a facet medial branch block on Friday. I didnt go off my oxycontin untill the morning (I probably shouldnt have had any the night before but decide to so I could sleep). So consequently i wasnt at the 5/10 pain or over (I was about a 3)which I needed to be for the block.
So at the last minute the doctor decided to give me a facet injection instead. And apart for the first few hours while the anaesthetic was still working it has been far more painfull than before and I am now having pain radiating into my hips that I never had before!
I am so angry for allowing him to change the procedure at the last minute. I would much rather have paid for the medial branch block that wouldnt have shown anything than something that has caused more pain.
I have had this procedure once before and they were in and out really quick, very professional, but this guy was digging around with the needle for ages and his bedside manner sucked. I have a good pain threshhold but I was screaming out and now feel worse and am on more pain medication than before. I hope this isnt permanent damage.

Thanks, I needed to get that off my chest.

Michelle.

Oh, and I definately know where my face joints are now!

dshobbies · #21 (**permalink**) 06-15-2009, 05:56 PM

With any medical treatment, your choice of doctors is a primary concern. Sometimes I'm actually shocked at the treatment I receive for something considered relatively simple. Multiply that by the complicated nervous system and you have room life altering medical errors. Choose carefully.

Gil Denis · #22 (**permalink**) 06-16-2009, 03:20 AM

Hi Michelle

Fusion is forever ADR is unknown.

I think You have a tough choice

Motion preservation is the best to do but will it last?

All the Best
Gil

phylly · #23 (**permalink**) 06-16-2009, 04:03 AM

HI Michelle,
I had two ADR's put in and then needed a Revision surgery to take them out and fuse. Everyone said I looked like a great candidate for ADRs. The last surgery was a killer but I am doing well although not totally pain free. My facets also looked great on my MRI but I did have some facet hypertrophy. My original doctor said that this would get better with a double level ADR. You have a hard decision to make but ADR's are not always as wonderful as everyone says. I think getting many opinions is good way to go. I hope that everything goes well for you.
Phylly