Here we go! Just found out MRI showed Herniated Disc at L4/L5 with nerve impingement

[rutman]

For anyone that has had Back Surgery this is new to me. Been in the greatest of health, but for some unknown reason had pain shooting down right leg going to front and back of calf and even on top of the foot. Excruitiating pain at times. MRI done on last Thursday and now finding out Herniated Disc @ L4/L5 with nerve impingement and bulging at L3. Please advise what if anything can be done to avoid surgery--go back tomorrow for further review as I was told on phone, but sounds like surgery to me. If anyone has any words of wisdom or comforting words please advise. All the medicines in the world have not helped since I incurred during the first part of Thanksgiving Week. Hard to walk at times. Any recommendations including telling you better have the surgery is encouraged. Thanks in advance! The Rutman

[mmglobal]

It's not an attractive prospect, marching down the road towards spine surgery. Hopefully, your spine will be good enough to recover without surgery... conservative treatment. If you must entertain surgery, please do your homework and discover all your options.

HOw severely degenerated is your 4-5? With good disc height remaining, if you fail conservative treatment, there may be minimally invasive options.

Good luck... ask away if you have questions...

Mark

[Michelle]

I've known people that have severe herniations that were treated with epidurals for years. I know more that had to have surgery, but it happens. I think that's why you have to have a lot of conservative treatment before anyone will operate, except in extreme cases. I know the idea of surgery isn't fun, but I'd say it's better than 'we don't know why you hurt-live with it!'. Good luck! I hope you get some relief.

[dshobbies]

Rutman,

You havn't posted where you live. For years prior to my surgery, I had success with flexion/distraction therapy on the Cox table. It kept me from using heavy meds, though I also led a very sedentary lifestyle. Each therapist is different and I feel comfortable only recommending one in the San Fernando Valley. It's something you might want to look into, especially without prior surgeries and scar tissue.

Good luck, Dale

[rutman]

Thanks for the feedback! Well--first I live in Danville, VA (45 miles North of Greensboro, NC) but the Spinal Surgeon that I saw today has a very good reputation, Dr. Jeffrey Beane--located on Benjamin Parkway in Greensboro, NC. He apparently was the Chief Orthopedic resident with the Penn State football team and has been practicing for awhile. Has been in the Greensboro, NC area since 1993--so if anyone knows about him please comment positively or negative. But he seemed very confident and I was pleased with his discussions with me.

Bottom line--first time I had seen MRI pictures and even I could tell what I was looking at from what I've read on spineuniverse.com Yuck! Definitely the L4-L5 is blown out and I can see where the annulus part is just smashing into the nerve--no wonder my whole right leg is going numb and weak. I was basically told yeah you can do epidurals but just a band-aid effect and doing the surgery will definitely relieve the pain. I was also told yes it could rupture again and no promises and there is possibility of scar tissue, but bottom line I would rather fix now while I'm just 42 and then prolonging and making matters worse or causing the bulging in the L3 to become ruptured as well. For those that are reading my comments do you feel that makes sense--I just feel like fixing now the best he can instead og making matters worse and not being able to move right leg at all or causing further damage. Please respond at your earliest convenience! Look forward to your responses. Thanks again! John

[dshobbies]

Please define 'fix it'. Are you talking about an adr or discectomy?

[Michelle]

I'm assuming you mean lami, since you mentioned the risk of rerupture. Correct me if I'm wrong. What you're saying makes sense to me, but then again, I've always been less afraid of surgery than a life of pain. Just me. None of us is getting any younger, and most not any healthier, so what are the benefits of waiting? It's apparently not going to get better on it's own, so you're gaining what? The off chance it might go away, with the setback of months/years of pain. (Boy, I should be a surgery salesperson! ) As long as you're willing to live with the risks (I did it, reruptured, and wound up with 2 more surgeries, but that's me), I would at the least say your reasoning sounds reasonable. Good luck!!!

[yvette]

I originally hurt mine at 19 and kept being told I was to young for surgery. I've had many years of problems and now at 36 I've been back to square one for a few years, and kept hearing I was to young (for fusion) Which made no sense to me. You think it would be easier on ya when your young, and when its killing off your quality of life waiting whats the point.

[Blairsara]

Im 25 and had ADR when I was 22. I only had the surgery when it came to the point where I couldnt walk, sit, stand, basically do anything. Physical therapy didnt work - microcurrent, phototherapy, hands on etc.... Pain killers stopped working. Basically I totally see your opinino on wanting to fix it right now, I wanted to do the same thing before too but I decided to only do it if it was absolutely necessary.
Now, I still have problems. If you want to read my post to see what's going on go to Charite ADR 2.5 yr update.
But this is a major decision, and you dont want to end up worse off than you are now. I would definitely do epidural blocks, other injections etc... before surgery. You never know, it can releave you of your pain for a long time.

[Michelle]

Originally Posted by yvette

I originally hurt mine at 19 and kept being told I was to young for surgery...Which made no sense to me. You think it would be easier on ya when your young, and when its killing off your quality of life waiting whats the point.

I was told this as well. I was told it was because of the transferred pressure to surrounding discs that fusion creates. The younger you are, the longer your discs have to survive that extra pressure. And, the more active you usually are. At, least that's what I was told.
Anyway, sorry Rutman, but I'd agree you're heading down the road for surgery. It's not 100% yet until you fail a few conservative treatments, but once that happens, don't put it off. The longer you live with the damage, the harder the recovery is, and possible permanent harm. I hope an epidural or something will help but... Good luck!

[rutman]

Thanks for all the comments, but after review with MRI and this Dr. Jeff Beane out of Greensboro, NC my severely ruptured disc looks like the route of a lamitonomy NOT ectonomy. Basically will remove some of the lamina covering to relieve herniated disc off of the nerve for which even I could read on the MRI. Has anyone out there has that procedure--seems basic--but I saw that one had several surgeries after ADR including lastly putting in a ProDisc between the L4 and L5. Question is with me being an avid golfer which probably caused this problem to begin with over a 30 yr period could I end up with the same problem and should have the disc replaced or for now go with relieving the pressure off the nerve. Just food for thought, but looks like the lamitonomy will be the route within the next 2 weeks. Any thoughts here? Thanks again! John

[RoinMd]

Since most people 'recover' from a herniated disc with time, most surgeons are very reluctant to jump right to surgery. I've been living in constant pain on standing or when walking since August. I've been treated with just about everything conservative -- Lyrica, Ultram, 2 courses of oral Prednisone (the first course was like a miracle -- the second, no effect at all). I start 3 weekly injections on 12/28 which I don't hold much faith in but to get to a microscopic discectomy I've had to demonstrate that nothing works I would have given anything to have not been in pain for the last 4+ months. Good luch to you! RoinMd

[mmglobal]

The decision about which surgery to do is a very difficult one. Often, there are financial implications as people cannot afford to go back to the well again if they need a second surgery. Or they feel that they cannot afford to be disabled longer if a less invasive surgery is attempted in order to try to salvage a disc or to keep from a more invasive surgery.

I am often dealing with people who have failed less invasive attempts and are graduating to more invasive surgery. Look at my history... 2 failed microdiscectomy/laminotomy procedures before my ADR. In my case, knowing I needed more surgery earlier might have saved me 2.5 years of my life, but also might have caused me to do the wrong surgery. (I came very close to doing a 2-level 360 fusion... then a 2-level BAK fusion with NO POSTERIOR INSTRUMENTATION. Both surgeries, I believe are less desirable options than the ADR surgery I ultimately had. (Note that I am not anti-fusion... for many of us, fusion still represents the best option.)

There is an interesting discovery process as we are hurtling towards surgery. Early in the process, the prospect of 4 more months of pain seems like a hefty price to pay.... and it is. However, 3 years from now, when you look back, it will seem unimportant whether you waited and suffered for 2 months, 6 months or 10 months. What really matters is long-term relief... getting the most appropriate surgery... getting the least invasive surgery that stands a good chance of solving your problem... getting a surgery that leaves you further options if it's not successful... THESE ARE THE CRITICAL ISSUES.

Obviously, I do not intend to understate how severely our lives are affected by our problems. Our careers are on the line. Some will lose their houses. Some situations are made worse or intolerable by our horribly dysfunctional workmen's comp and insurance systems. I still submit that getting the most appropriate treatment to minimize the prospect of spending the rest of our lives in chronic pain and in a fog of depression and medications is more important than our careers, houses, etc... (I know that this is easy for me to say and I had many advantages as I went through my 5-year ordeal: most importantly, a supportive spouse and a house with enough equity to allow me to get the surgery I needed.)

Also, these decisions are not black and white. Everything is a trade-off. It's easy for someone with disc herniations, good disc height, no instability, early in the DDD process to consider getting a discectomy/laminotomy. They stand a VERY high chance of success. Success may mean getting immediate and total relief and never needing another surgery; or it may mean partial relief and staving off additional surgery for just a few years... but that is still success.

But, if you have poor disc height, huge annular tears, advanced modic changes, instability, etc... you may be putting more at risk by trying less invasive procedures... you may be causing further damage to critical elements that may limit your options later.

Spine surgery is something that should be avoided. With spine surgery less is better. Decisions should be based on knowledge and an understanding of all your options... not just hearing what you want to hear from a doctor that wants to do surgery. When I returned from Germany last week, I rode to the airport with a cancer surgeon who just had apparently successful endoscopic surgery with Dr. Hoogland at the AlphaKlinik. He said something that I wrote down for my list of quotes:

Desperation is not a good consultant!

One last note: When we are looking at the less invasive procedures, do what you can to preserve future options. I've had multiple clients who had minimally invasive discectomies but graduated to needing ADR. Sadly, they discovered that what they thought was a minimally invasive discectomy because it was done endoscopically as an outpatient procedure, actually removed all or too much of their facets and disc replacement was no longer an option. So, if you are having less surgery, which is best if you are a good candidate, make sure that you are with someone who has an eye to the future and will not burn your options unnecessarily.

Mark

[yvette]

I don't know why they work for some people, and some they don't. The ones that i have had didn't change anything.

[dshobbies]

I just wanted to add my two cents into this pot. After rupturing my disc back in 1994, I was in so much pain and disability, I would have done anything to fix it immediately... and did. And this surgery, a disco and lami, worked for 8 years, until the pressure on the adjacent L4/5 became too much and I had a second surgery. Less than 1 year later, I was in trouble with L3/4.

Looking at the statitistics, there seems to be an 80% success rate with first surgeries, which drops to 50% for a second and then all the way down to 5%. I know a woman who has had 11 surgeries and is now in the fusion stages.

In '94, an adr wasn't really an option for me. It was in 2002 but I had never heard about it and was never told about it.

Now the point, these surgeries caused further DDD on adjacent discs. The scar tissue made the chances for my ADR surgery less successful. If an ADR was available (to me) in 1994, that might be the end of my story. Would I have gone for such a drastic procedure when something far less invasive was available to me? I don't know. But as long as you're lucid, you should have all this available information to help you make an that 'informed' decision.

Could you be entirely successful with a lami... sure. Will you? Who knows. Will an ADR solve your pain more permanantly? Again, an unknown. You should just know that the decisions you make today can impact the decisions you might have to make tomorrow.

I do wish you every luck and a pain free 2007.

Dale

[rutman]

Thanks for the comments Dale. Interesting! Dr. Beane told me if it had just been the slight bulging of L3 disc he would not recommend surgery, but here's the question to you guys and give opinions or what you know from experience please. You could definitely tell there was a problem at the L4/L5 disc with it ruptured and the annulus slamming into the nerve--I could see the problem without the doctor telling me when I saw the MRI with the doc. Okay he goes and does this laminotomy in that area should he not go ahead and do something with that L3 that appears to be bulging a little. Dale, you mentioned it lasting 8 years or so and then mentioned about another area - maybe L3, that became a problem a year later. I hope when he's in there he can fix that area too or can anything be done on just a bulging disc? Lastly, if he just does the laminotomy on the L4/L5 disc area and does absolutely nothing to the L3 disc bulged out am I looking at going through the same problem of that one rupturing if one has become fized and then I'm relying on another disc that may be questionable? I plan to tell him fix it all, but easier said than done and of course I'm not the doctor--I can't wait till this crap is over, but reading comments it may be going on for awhile. Please advise when you all get a chance and emjoy reading the responses for sure! THX! JB

[mmglobal]

I think that everyone will be surprised by this post. Here is a most important statement that Rutman made:

Originally Posted by Rutman

I can't wait till this crap is over, but reading comments it may be going on for awhile.

That's the most important issue in the discovery process that we go through. Too many people I see never get to that realization and they make the mistake of making surgical decisions based on wishful thinking. It may be electing to do too little surgery in spite of the fact that additional areas are demonstrated to be pain generators. It may be electing to do a huge surgery, hoping to 'fix everything at once', or because 'I only want to have to do one surgery.'

There are many reasons that go into these decisions and many of them are valid or even critical decision points, but each case unique too many times I see these decisions as clearly flawed. Often they are are correct, but often they are not even close to logical or appropriate. Leaving painful levels in place because your surgeon can 'only do one level now, but I'll be able to do more later if needed' is absolutely incorrect if the level that will remain is clearly incompetent and proven to be a major pain generator. Making that same decision is absolutely correct if the questionable level is still in pretty good shape and is proven NOT to be a dominant pain generator.

These same issues can be true for people who elect to do more rather than less surgery. Electing to do a 3 or 4-level fusion because the imaging looks bad can be problematic. While I know several people with successful 3, 4 and 5-level lumbar fusions, I also know the disasters. If your spine is a train-wreck at many levels, but there is high confidence that one level is THE MAJOR problem, electing to do surgery at one level instead of 4 may offer the best chance of success. However, without the confidence about one level being the major pain generator, perhaps more surgery would be the most appropriate decision.

These decisions must be made with the full understanding that that if you and your surgeon decide to do less and it works, he's a saviour. If you do less and it fails, he's a goat. If you do more and it works, he's a saviour.... There is no template... there is no other case that will tell you what to do in your case. Your surgeon's experience is an important part of the process, but more important than what a similar case was like will be getting the proper diagnosis. Watching this process take shape in so many different arenas is quite interesting and there is a huge difference between going into a surgery with a thorough diagnosis and clear understanding what what is happening; versus discovering after the surgery that a group of symptoms turns out to be unrelated to the operated area. The outcome may be the same in some cases, but in other cases, the surgical plan changes. Making decisions with more and accurate information is better, better, better. MRI's being denied because of cost may be important for the big picture related to the cost of health care, but it is frustrating when it comes at the cost of a proper diagnosis for an individual patient.

My discussion (above) is of the extreme cases and I realize that the original thread has to do with the prospect of less invasive surgery for patients who are not too far down the degenerative cascade. However, the same issues are involved. Many people look at my history and ask if I regret my 2 discectomy/laminotomy surgeries. "We make the best decisions we can with the information we have at the time." I'd do the same thing again in the same place. I do wish that I understood more about discogenic pain and discectomy results with leg pain vs. back pain. However, at my time in the process, skipping the discectomies probably would have resulted in a multi-level fusion (which may well have been a smashing success.)

Read about Anastasia's review of her case with Dr. Zeegers: here.
He reviewed every aspect of her case in excruciating detail. Like mine, her history includes 2 attempts a minimally invasive surgery that failed. Zeegers said that he did not see a flaw in the decision making process and that attempting to salvage the disc with less invasive surgery, avoiding more invasive surgery is appropriate when one is a good candidate. These decisions are not based on wishful thinking... one has to be a reasonable candidate.

I do not agree with Dale's statement that her prior surgeries placed additional stress on the adjacent segments. I suppose it's possible that if the structure and kinematics were inappropriate, adjacent segments will break down faster... but what was the alternative? We will never know the answer to many of these questions, but we do not know the time-line of what might have happened. Our discs are going to break down. ADR will not keep adjacent segments from breaking down, but it may extend the life of the adjacent discs compared to what fusion might do. Her statement about scar tissue may be correct, but again, what are the options. Looking back I don't think that more surgery earlier in the process would have been appropriate or even an option. For many of us, looking back with 20-20 hindsight it may seem that jumping straight to the maximum surgery would have been an easier path to get to the ultimate solution, but that does not mean that the decision process was flawed or that someone in the same situation should jump straight to more surgery instead of less. We do not see the people who have the successful 'lesser' surgeries because they go back to their lives and don't come here.

I'm glad that Rutman realizes that he may be in this for a while. That knowledge will help him to take his time, learn what he can, and make informed decisions based on a proper diagnosis and an understanding of the risks / rewards of all his options... not a decision based on frustration or wishful thinking.

Sorry for the long post... I hope this helps.

Mark

[sahuaro]

Mark:
Can you clarify what you were referring to when you wrote that ADR does not protect the adjacent disks (sorry, I haven't figured out how to do the quote thing)? Did you mean that if you have DDD, the ADR won't stop that--or did you mean that as with fusion, the pressures on adjacent disks will be such that they will eventually be damaged?

[mmglobal]

sahuaro,

I did not say that ADR does not protect the adjacent discs... What I did say was:

ADR will not keep adjacent segments from breaking down, but it may extend the life of the adjacent discs compared to what fusion might do.

DDD is a process that occurred in most of us without regard to our otherwise healthy spine. Each of us has degenerated discs that occurred next to healthy segments. ADR does not guarantee that adjacent segments will not break down. I predict that in the years to come, we'll see many disappointed ADR recipients as they still suffer from adjacent level disease. ADR will be a success if the number of people who suffer from adjacent level disease is smaller than the number of people who suffer from adjacent level disease in fusion populations.

>>> Fusion does not guarantee adjacent level problems.

>>> ADR may reduce the load on adjacent levels compared to fusion, but it does not safeguard against DDD at other levels.

Mark

PS, for quotes, enclose the quoted text in (quote)text(/quote) with the () replaced by []. Bold = (b)text(/b). You may also click 'go advanced' from quick reply and use advanced formatting tags. Hover over the button with the mouse to find out what they mean. Highlight the text you want to quote, bold, underline, etc... then click the button.

[sahuaro]

Thanks, Mark, for the explanation(s).
The issue of more/less surgery hits home for me, as well.