Interesting T-Spine Q&A

[Aaron]

Mark I thought you might find this interesting, I am still a little confused and taken back by it , but this is a well respected surgeon with lots of exp. in scoliosis of thorasic. My email to him and his answers to my question


Dear Dr. Fessler,

My name is Aaron Nelsen and I am sorry to bother you ,but I was looking over some spinal books for thorasic spine information and I saw your name and then found your email address. I am having the most confusing time with my thorasic injury. I have a T6- T7 herniation with cord impingement, tears at T5 - T8 and those levels were positive on discogram, but I don't have much radiating pain just massive pain directly over that part of spine and on the right side of Tspine. I am confused because some doctors I see say I should not be hurting from the thorasic area, while others agree that is were my pain is coming from, just surgury is to big at my age. I have been told thorasic fusions are unpredictable, only 50 % success rate, will have adjacent problems after fusion ( I thought the ribs supporting would limit adjacent degeneration ). I have had doctors tell me if this was in lumbar or cervical we would operate. Its all very confusing and along with the fact that I have done so much rehab, professional as well as on my own. I have maintained good ROM due to yoga and pilates and I follow strict rehab plans. But all I have ever gotten is short term relief. I have a couple of questions for you if time permits.

1. Would you do the VATS surgury or the open surgury if you were having T spine surgury?

No. VATS is relatively rarely used now. I have less invasive ways of taking the disc out.

2. Are the success rates that low

Success all depends on the reason for surgery. Generally, results for “back” pain, as opposed to radicular pain are not as good.


3. After 5 years is the chance of my tears healing?

I think it is unlikely that the tears are causing any of your pain. Frankly, I’ve never heard of Thoracic discography before, and I’m a little skeptical of that recommendation.

[mmglobal]

Aaron, thanks for posting. This will be an interesting dialog. As you know, I am newly VERY interested in t-spine issues because I'm dealing with them too. It's nice to see you hear, but I'm sorry you are still in it. Call me some time.

Regarding my case, I was very surprised by how discouraging the surgeon's (that I've spoken with) comments have been about thoracic spine surgery. I thought I'd be a perfect candidate for XLIF, but the top XLIF surgeon in the world (Pimenta) told me, "Mark, stay away from spine surgeons!"

Hopefully the extreme lateral access approach developed with Nuvasiv's XLIF procedure will make most VATS surgeries obsolete. However, I think this may be one of those procedures that requires an above average surgeon with plenty of XLIF experience, to stay out of trouble.

Ask your doc what he's referring to with the less invasive option. (XLIF??)

Regarding success rates, this is the same type of thing that I'd hear about my lumbar spine. One of the surgeons I saw said, "I won't do a multi-level fusion for pain. If you had a fracture, tumor, etc... I wouldn't hesitate, but I won't do it for pain." IMHO, this is what we here from only the most conservative surgeons. The other extreme, when they will not hesitate to do a fusion while they told me, "come on and do a 2-level 360 fusion and you'll be playing soccer in a year."

IMHO, success rates vary greatly from surgeon to surgeon. Excellent technician vs a just lousy carpenter makes a big difference. Even worse are the surgeons who have the capability to be the excellent technicians, but let other factors make them careless and sloppy. Even the excellent technicians have poor outcomes. They can be poor diagnoses, or you could be unlucky enough to have something that even the best diagnostician cannot properly sort out. And then, most surgeons I've dealt with have told me, "some people just don't get better. We can't explain it, but it happens."

Lumbar discography is controversial. It is much, much less controversial than it was just a few short years ago and most of the naysayers, IMHO, are completely missing the point. (I'll explain further later.)

Cervical discography is still quite controversial. The volume of the disc is so much less than a lumbar disc, many doctors believe that false positives are far too easy to generate and don't trust the test. This is even more true with thoracic discs for the same reasons... even smaller volumes.

IMHO, lumbar discography can still be unreliable. I've seen false positives and false negatives. I've seen perfectly done tests yield completely ambiguous results. I've seen poorly done tests that yield results that seem determinative, but are unreliable because of the way the tests were done. (Remember that I've personally had 3 multi-level lumbar discographies, with and without sedation. I've had multi-level cervical discography without sedation. I've been in the OR, usually holding the patient's hand for > 50 discographies. Without the in-person experience, I've been involved in > 500 cases.)

All of the problems associated with discography allow the non-believers to question the validity of all discograms. Having seen the problems with discography, I believe that they are not the be-all, end-all test that must always be believed. Discography results simply add to the available information and the EXPERIENCED doc will have a sixth sense that lets him know how much weight to give the results. This is why it is important for surgeons to do their own discography, or at least know the doctor who does the disco very well.

A few surgeons use interoperative discography that gives them a great deal of data that allow them to do a more effective decompression (even though it lacks the pain response of a normal discography.)

Regarding, "will the tear heal": from my experience (and tapping so many surgeon's brains about this issue), some will and some won't. There are some physical reasons that some may not heal. These include the size of the tear or the incompetence of the rest of the annulus / severity of the DDD, the possibility for "interpositional" disc nucleus tissue that remains poking through the tear. The interpositional tissue can keep the tear from closing and also "wick out" the caustic disc juices that can cause a lot of nerve pain.

From the extensive dialog we had regarding Diane's case, paraphrasing what the doctors told us: "while many will have the disc herniation be reabsorbed and the tear close on it's own, the early responders are the lucky ones. By the time you get to be 2 - 3 months out if you are not improving, your chance of being one of the lucky ones are very low.

BTW, I have a disc bulge at T7-8, but we don't believe that is implicated in my pain syndrome.

Good luck Aaron... please keep us posted. All the best,

Mark

[mmglobal]

Aaron, I hope you don't mind, but I gave the post a more descriptive title.

[Keano16]

New surgical technique invented in WOORIDUL SPINE HOSPITAL yesterday.

Ji-Sung Kim, neurosurgeon from Wooridul Spine Hospital invented a new treatment for herniated thoracic discs: ossification of ligamentum flavum.

"In most cases, surgeons usually do the open thoracotomy and discectomy for ventral decompression & total laminectomy with (or without) posterior fusion. Posterior alone surgery is another option.

However, I introduce new surgical technique - simultaneous 360 degree decompressive surgery using VATS. Patient's myelopathy symptoms much improved after surgery."

[Aaron]

http://www.google.com/url?sa=t&sourc...K6J7TQ&cad=rjt

This link shows some of Dr. Pimenta procedures such as XLIF for thoracic.
Color kind of annoying but good pictures.

Edited by mmglobal to correct link error.

[mmglobal]

Corrected link for above post:

http://www.google.com/url?sa=t&sourc...K6J7TQ&cad=rjt

[Aaron]

Sorry bout that, I should have checked it to verify that it linked correctly.
Thanks Mark.

I just recieved another email from Dr. Fessler and I asked if XLIF was what he was using and he sent:

XLIF/DLIF is probably not the best option for a herniated thoracic disc. I use a minimally invasive transforaminal discectomy technique, unless the disc is calicified. Then the XLIF/DLIF techniques is probably better. You could look up minimally invasive thoracic discectomy to get information on it.
I am not sure if that means he would do a discectomy on it first or if you actually fuse it through those means. I am still looking that up, just got email from him.

There are very few Dr. I email about Thoracic issues that even take time to respond. Dr. Fessler and Dr. Perin both have emailed me immediatly after my email to them. Frankly, I am very appriciative to see it.

P.S. Yea Mark thats cool, the title of the post sounds better now

[Aaron]

Just had epidural steroid injection friday and it seems to have helped so far. The first I had did nothing, but they put some medicine next to my tear at T5-6 and my herniation at T6-7. The first time it was only at herniation.

I asked this doctor about tears and he said tears are a huge part of his practice and often are more of pain generators than herniations are.
He is the team physician for the Texans football team, the houston astros and other sports in Houston area.

See what happens.

[mmglobal]

That's great news if you get a clear positive response and can be more certain about your pain generators.