Any information is helpful please

[cldc2000]

My surgeon wants to do a fusion on L3-4 degenerative bone on bone disc. An artificial disc on L4-5 where I have a bulging disc. I've had a discogram done and L4-5 was a 10 out of 10. and L3-4 was a 7 out of 10. Has anyone had this surgery done. I've been off work for a year and the pain hasn't gotten better with conservative treatments. My doctor is Dr. Richard Kahmann in SB

[Jim M2]

If you're going to fuse L3-4 why not go ahead and fuse L3-5? At L4-5 the aorta splits into the illiac arteries which makes access difficult. In the event the initial surgery doesn't work out, scar tissue and difficulty accessing L4-5 raises the chance of the surgeon cutting one of the big arteries. This is why a revision or conversion to fusion is risky at L4-5. It's something to consider. I may not be giving you the best comments but fortunately for you this forum has some real experts who may weigh in.

[mmglobal]

I'd have the opposite question... why isn't the doctor considering ADR at both levels? Is it a medical question or is it a reimbursement issue? You are motivated to pursue motion preservation if possible to reduce the risk of future 'adjacent segment disease' or domino effect. Where the fusion causes increased loading to be transmitted to the adjacent segments, the longer the fusion, the greater the risk.

While the risk of revision surgery makes for in interesting discussion, it needs to be part of a comprehensive discussion of all the risks and possibilities of all the options. As part of a comprehensive discussion, it winds up not being of overriding concern. (That is easy for me to say because I'm not looking at ADR revision surgery... I do know dozens of people who have had this surgery; a few who've opted out because of the risk; and one who wanted the surgery but could not have it because of an anomalous vascular situation.

Note that L3-4 being bone on bone does not necessarily mean that it is not a candidate for ADR. It may still be mobile and if it's stable, would still be a candidate for ADR (assuming there are no other contraindications.) Sadly, the importance of perceived contraindications is inversely proportional to the likelihood of reimbursement for the ADR surgery. The less likely reimbursement is, the more important the contraindications are. Note that the perceived contraindications are different for surgeons who are highly experienced in ADR than they are for surgeons either without the experience, or without the latitude to make the medically appropriate decision. (For example, the risk management attorney at the hospital won't allow multi-level ADR because of reimbursement issues, or because the device manufacturer won't allow "off-label" use of their product by surgeons at a given experience level.)

As you can see, you have a lot to learn and difficult decisions to make.

Good luck... please keep us posted.

Mark