Think my 2 best options are.... Any Advice?

[longroadahead]

L5/S1

1. Microdiscetomy - With possible Anulex X-Close sutures

2. Unilateral TLIF (Right Side)

Before leg right symptoms, I had a grade 5 annular tear at L5/S1 but the MRI now shows a 8mm large disc extrusion. (actually a 4mm annular disc protruision but with a superimposed 8 mm right disc extrusion, whatever that means).

The microdiscetomy might get rid of the back pain but it might not. It is difficult to tell which pain is greater. Would almost rate the back/leg pain at 50/50 and would like them both to disappear.

Any opinions would be much appreciated....

[dshobbies]

LRA,

A fusion is pretty drastic and though no one wants to think in terms of multiple surgeries, you can still have one after the discectomy, which is far less invasive. Also, I don't know your specific circumstances but without any contra-indications, I'd consider an ADR before fusion in the first place.

I should also mention that discos often don't last (further degeneration on operated and compromised level) and can lead to further degeneration at adjacent segments. However, this is even more likely with fusion.

Can you give us more specifics, doctors, locations, age...

Dale

[longroadahead]

37 years, 185 pounds, 5'11. I am in Texas.

The ADR surgeons I have seen have mainly recommended a hybrid (fusion L5/S1 and ADR L4/5). My L4/5 MRI showed 2mm annular disc bulge with mild bilateral foramina stenosis and minimal flattening of the ventral thecal sac.

The neurosurgeons recommend mainly a TLIF (unilateral) or Microdisctectomy for the L5/S1 only and would not consider the L4/5.

Based on my research, think the hybrid is the way to go but think if I can get 5-10 years from my L4/5 the treatments available then will be better than they are now.

So that leads me down the path of just treating the L5/S1 for now. My insurance doesn't cover ADR but will cover most of the cost if done in conjunction with a fusion. I like the Kineflex but it is not FDA approved.

Will see one more surgeon next week then will try to make a decision. That will be 4 surgeons seen this year.

[Maria]

Option you mention sound that good to me. I've had 2 discectomies and they both rebulged and both within a short period of time ~ real short. One can never predict how long that option would last..you may do well you may not though most likely the disc level will rebulge and/or create more problems at some date.

Fusion. I dunno seems like if you have that at L5S1 and you already have a weakened disc level at L4 even if a small bulge chances are that level is going to have more stress on it and bulge more. Then again.. ??? who knows.

It'd be interesting to hear what maybe Dr. Zeegers and/or Dr. Bertagnoli or other surgeons of their skill/magnitude would have to say regarding your case and what they would do.

What I like about at least getting an opinion from them is they don't base it on what the FDA has approved in this country and what insurance will pay. It's based on what they think would work best for you and I believe they have everything to work with unrestricted. Although that's not to say there aren't extremely skilled spine surgeons in this country as well.

Unfortunately I know only too well how it is to have to consider what insurance will pay and/or financial constraints.

Good luck. I'm not sure my opinion counts for anything although I would only hope anyone considering spine surgery will do much better than I have with it.

[dshobbies]

If you're asking 'what would you do', I'd fuse S1/L5 and ADR L4/5. L4/5 is already compromised. The disco will further degenerate the disc which will most probably further degerenate in a very short period of time, leading to more pain and as follows, more surgery, this time with extra scar tissue.

Could the fusion and discectomy lead to several years of relief - yes. Is this probable, IMHO and based on personal experience and other posts, no.

This is your back and your decision. S1/L5 doesn't move much so fusing that space probably won't interfere with activities. But L4/5 is already bad and the chances of further degeneration, especially with the fusion below are pretty good.

BTW, if doctors don't perform ADR surgery, they're not likely to recommend it. The more honest opinions come from doctors who do it all. They won't be losing work by recommending anything and have no personal motives.

Please do your research. Minimal surgery at L4/5 will let you do it again, but just how much relief will you get and how long will it last?

Good luck, Dale

[Keano16]

Originally Posted by longroadahead

L5/S1

1. Microdiscetomy - With possible Anulex X-Close sutures

2. Unilateral TLIF (Right Side)

Before leg right symptoms, I had a grade 5 annular tear at L5/S1 but the MRI now shows a 8mm large disc extrusion. (actually a 4mm annular disc protruision but with a superimposed 8 mm right disc extrusion, whatever that means).

The microdiscetomy might get rid of the back pain but it might not. It is difficult to tell which pain is greater. Would almost rate the back/leg pain at 50/50 and would like them both to disappear.

Any opinions would be much appreciated....

1. Selective Endoscopic Discectomy with thermal annuloplasty as more advanced and powerful technique compared to micro-discectomy.

Remember: start with least invasive, finish with most invasive.

And let me just quote Plato and this year's Turkey ISMISS (International Society for Minimal Intervention in Spine Surgery) congress "moto" : “Beauty of style and harmony and grace and good rhythm depend on simplicity “

[longroadahead]

A lot to think about for sure.

I have seen Dr. Bertagnoli and he recommended fusion with the STALIF at L5/S1 with optional prodisc at L4/5. He based this on 2009 and 2010 images and ordered a new MRI which I had. Still waiting to see if his recommendation is still the same after the new MRI.

Have filled out the forms for the consultation for SED but the $250 it cost for them to review your files for 1-10 minutes gives me pause and haven't sent them.

[Maria]

When is this used (routinely w/SED)? Criteria? It may already be here somewhere or I can google it although sounds like Keano knows much about it as I'm sure Mark does.

[mmglobal]

The SED procedure was developed by Dr. Yeung through the 90's and 2000's. It stands for selective endoscopic discectomy. There is much about it that is different from a traditional discectomy or even another endoscopic discectomy.

The 'selective' part if it has to do with injecting indigo carmine. This is like a PH indicator that stains the degenerated nucleus material as the degenerative tissue has a much more acidic PH than does healthy nucleus tissue. Because his equipment puts him INSIDE the disc with a video camera, he can selectively remove only the degenerated tissues, leaving the healthy tissues.

All references to SED procedures that I've seen (and I've had dozens of clients with SED), have been for SED with Thermal Annuloplasty. The thermal annuloplasty component (TA) is an integral part of SED. Because they are inside the disc and can see the annular tear, they have the capability to apply laser or RF energy to the 'granulation tissue' and posterior annulus UNDER VISUAL CONTROL. The granulation tissue is erratic tissue (not normally present, like erratic boulders that are carried 'downstream' by glaciers) is what causes the pain in painful discs. Naysayers for SED will say that it's like shooting a fly with a machine gun. This in an uninformed concept. I've attended the training for SED and have observed dozens of procedures. There is no shooting of machine guns. They are LOOKING directly at the tissues they are ablating. They are looking at the annular tear. Typically, when they apply energy to the annulus surrounding the tear, the annulus and the tear will shrink. If it does not go in the right direction, they can see it right away and stop. All other forms of TA that I know of like IDET and Biaccuplasty are done blind. They are cooking tissues that they can't see, so they can't be certain about probe placement and cannot see what is happening (real time or not real time.)

Unlike other endoscopic procedures, SED is ‘INSIDE OUT’. They are working inside the disc and can see what they are doing. As discussed above, not only can they be selective about the tissues they remove, but the can also see the annular tears and see what is happening during the TA step. They will be pulling herniations back into the disc, then out through the canula. The more experienced SED surgeons can safely chase sequestered herniations out into the canal area, but this is something that I would not want anyone but Tony Yeung or maybe Chris Yeung attempting on me.

SED naysayers will point to studies that tested ‘cutting’ the annulus, making a hole the size of the SED tools, then relating it to future ‘recurrant hernaiation’. This is a red herring. There is no cutting of the annulus to get into the disc with SED. They start with a needle and use a series of ‘expanding canulas’ to dialate a hole in the annulus. There is no wholesale cutting of fibers as there was in the studies that are pointed to. I’ve seen discography done on SED’d discs with the doctor able to squeeze the syringe as hard as he could with a firm endpoint and no pain. Compelete negative and sealed disc years following SED. (Read Ann C’s story on the GPN story pages.)

There is a HUGE talent factor and experience factor with SED. This is not for the average surgeon or the general spine surgeon. This is for the endoscopic specialist who does these nearly every day. I have observed surgeons with 400 procedures under their belt doing surgeries thinking that would be more than enough experience. There is such a dramatic difference between them and the guys who developed the procedures, made the early mistakes, and have thousands. I don’t know how we can assess the experience level of the other surgeons. I know of many who have purchased the systems, done the training and started doing procedures; but never stayed with it long enough to get through the learning curve…. They ultimately gave up on it. It’s not that the procedure is not excellent, it is that it takes a lot of experience and a very high talent level before you have a chance of getting good at it.

All the best,

Mark

[longroadahead]

Appreciate the very good explanation of the SED procedure and was ready to send my $250 for the SED but contacted DISC and they sent me Unitied Healthcare's policy on the procedure. Yeap, it is not covered.

On another note, finally got ahold of Dr. Scott Blumenthal's office and he thought my bone denisty scan was too low for a Prodisc. I am 37 and Bone Denisty is (1.7) - (2.4) range in L1 - L4. Could this be my underlying problem?

Say Dr. Andrew Dossett a few days ago and he said I should just have a microdisctemy and if that didn't fix the back pain he would leave it alone.

[Maria]

Mark,
thanks so much for explaining that and in terms one can easily read/understand. What would the inclusion criteria be for this procedure or exclusion? Does it depend on grade of tear/type of tear/location of tear/tear of many years vs. more recent tear/ tear unaccompanied by signficant loss of disc height??

[cp7959]

SED sounds interesting, especially since I have an Annular tear. I have a few questions if anyone has the experience to answer.

With the SED procedure, does the Dr. enter the disk from the back going thru soft tissue only or does he create a path thru bone?

With the endoscope entering the disk thru an access point other than the tear, does this create another week spot in the disk in which another tear can form?

How long does the SED last, is it a short term fix, what are the long term results?

And the $$$$ question, how much? I'm sure my BCBS insurance isn't on board with this.

Thanks in advance.

[mmglobal]

I think that most insurance providers will not fund SED. Having said that, I still think it's odd that a spine center will go out of it's way to tell a patient that another center's procedure is not covered. I would check with the SED provider. As I said it may not be covered, but I would not depend on the info received from a competitor.

Anyone considering SED should contact the SED doctors for inclusion criteria. From my memory (which cannot be trusted), discs with grade V tears are not good candidates. Discs with severe collapse and loss of disc height are not good candidates. Classic discectomy candidates are good candidates for SED. This leads me to the conclusion that if you are a good candidate for one, you stand a good chance for all of the procedures, whatever the 'twist' they add in addition to the traditional discectomy. Having said that, I believe that the thermal annuloplasty as the twist, gives SED a chance to deal with discogenic LBP that most other discectomy techniques don't. If I could go back and redo my 2000 and 2001 discectomies, I would do SED.

How long will it last... depends on how lucky you are. IMHO, if you get a few years out of it, you win. More and you win big. Like all discectomies, there is a substantial chance that success will last only a few months. The recurrant herniation story is very common. Even so, the alternatives (adr and fusion) are to be avoided if possible... so IMHO, good candidates for discecomy should try it first instead of opting for the bigger surgery first. If you fail that (like my wife did... her endoscopic discectomy was a great success, but only for 3 months) you are unlucky and lose the bet.

Mark

[mmglobal]

Access for SED is like most endo discectomies... it is through the soft tissue and follows the path of the discogram needle. They use expanding canulas... increasing diameter tubes to convert the needle stick into an opening large enough to accomodate the scope.

Even though they use the needle path for the scope, the may still have to remove a small amount of bone to clear the scope. THIS IS WHERE ALL MISS PROCEDURES ARE NOT CREATED EQUAL. I have several clients who thought they were getting MISS procedures that would preserve their later ADR option, but the surgeon removed too much bone, basically removing a facet, and destabilized the system so that ADR was no longer an option.

You must discuss this with the surgeon in advance and be certain that he understands and is experienced enought not to just do it the easy way... but to get it done the right way. In one of these cases, it was a complete surprise when the patient discovered 6 months later that a facet had been removed. So much for MISS for him.

Mark

[zfontana]

I would just fix it with fusion and be done with it.


Anthony

[cherylstewart67]

there are surgeon that only know one thing fusion and they won't tell you what the other options are. think about why for yourself...but me personally if they can't give me more than one i dont trust them anymore. if i had had a computor at the time i would have done more reserach, but i trusted my doctor. he failed to tell me what all was out there!

[Maria]

I really dislike hearing only one option is available to me. It might be true at this point (my age and how long I've let things go however if someone can give me a good reason physiologically/structurally/or medically why I'd not be a good candidate for other options that carries more weight but I dislike when surgeons discount one thing over another just because they don't or can't perform a certain surgery. That's not being considerate of the patient's true needs and I too say walk away and think about this while looking to get more opinions from surgeons that might perform fusion and ADR or at least be open to the idea and or suggest other options.

[cherylstewart67]

Originally Posted by Maria

I really dislike hearing only one option is available to me. It might be true at this point (my age and how long I've let things go however if someone can give me a good reason physiologically/structurally/or medically why I'd not be a good candidate for other options that carries more weight but I dislike when surgeons discount one thing over another just because they don't or can't perform a certain surgery. That's not being considerate of the patient's true needs and I too say walk away and think about this while looking to get more opinions from surgeons that might perform fusion and ADR or at least be open to the idea and or suggest other options.

i do not understand how in good concience a doctor would not tell you what else is out there, but mine didn't. keeping information from someone is the same as lying to me. i cant go back now though. but moving forward i pray there are other options...

[dshobbies]

My first disco/lami was an emergency and I don't think there were many other options in 1994 anyway. However, I trusted that same doctor in 2002 to do another great service to me when the next level went south. He performed another disco/lami knowing it would probably fail and involve yet another level. He knew the odds and the other remedies out there, whether he believed in them or not. He was not 'legally' obligated to tell me about them because ADRs were not yet FDA approved. Second surgery failed within the year.

This doctor was highly respected in his field and considered a top surgeon. My anger has subsided over the years but had I realized some doctors serve themselves first, I would have done my own research or at least, get a second opinion.

Currently, a good friend, whose back has been getting worse over the years, was ready to go for her doctor recommended 4 level lumbar fusion. Blue Cross denied the four level but approved a 2 level. She didn't call me because she knew she'd get an earful- but then why would she just follow her surgeon blindly? Her husband had a successful dicso/lami 15+ years ago and is pushing her toward surgery. But a 4 level fusion?????? What kind of doctor is he, a sadist? I gave her the names of Dr. Regan and Delamarter for second opinions. Stay tuned.