Visit with Dr. Coufal

[Jim M2]

I saw Dr. Coufal today and I thought he was pretty amazing. I showed up with no imaging or reports. I wanted to know if he had ex-planted artifical discs to confirm what I'd read on the forum. He confirmed to having perform many explantations.

As part of the examination I could not hold up my foot rigidly when he pushed against it with his hand. It slowly gave way, especially the left foot. He said the nerve from that muscle mapped to L4-5. It is a strong muscle that should easily hold up to the pressure of his hand. I recalled the last couple of MRIs dating back several years mentioned a bulge with small herniation on the left side.

I told him about my Charite complications and my self-diagnosed DDD at L4-5. He ordered a CT Scan, MRI and x-rays. He said when the new imaging is available he would use it to come up with a strategy for ex-planting the Charite. He warned that there is the risk of dealing with the scar tissue and arteries which I already knew.

I'm very impressed with his attention to detail and his reputation. I'm glad I may have this option available. I would have preferred to go with stronger meds but that wasn't happening.

[Maria]

Hey Jim
I went with my neighbor to her 6 month visit to Dr. Coufal. He did a cervical surgery for her and I believe she will be having her low back done this coming year as well with Dr.Coufal. She is extremely pleased with her cervical results so hopefully her lumbar will have equally as good results or the best possible because of the surgeon.

I would hope if and when the time comes that I need some type of spine surgery that I could utilize Dr. Coufal as well.

Good luck with your imaging and what the New Year might bring with regard to surgery and hopefully a marked improvement!

Maria

[Jim M2]

Thanks Maria,

After Dr. Coufal is done with my lumbar problems I'll be considering him for follow up with a cervical surgery.

Jim

[Jim M2]

I met with Dr. Coufal on Friday (2/7/14). The facets are severely degenerated and one facet has fragmented. There are other issues. He feels the best approach for pain reduction is to remove the L5S1 charite and fuse L5S1 with fixation on the back side, i.e. 360 deg fusion. There will be a vascular surgeon assisting. Dr. Coufal's scheduler will call me later this week so we can talk about dates.

Having a vascular surgeon assisting will somewhat mitigate the risk if one of the iliac arteries gets accidently cut but obviously it's still a risk. Another risk is associated with removal of the plates. I pointed out in the CT that there appears to be bone growth around the edge of the plate and this may make removal messy or impossible. Dr. Cougal said he will not attempt to remove the plate if it is beyond his strength to do so safely. If it takes too much of his strength it makes for an unstable situation with the risk of damaging the spinal cord or other body part. If he can't get one or both out they will stay in and he will continue to fixate L5S1 from behind.

That's it for now.

[Maria]

Hey Jim,
Wow.. that's some interesting stuff. Kind of scary to read about it but then again in his capable hands I'm sure you would have the best chance with whatever needs to be done.

Have you had a bone mineral density test done.. just wondering..

Well when do you think this will all take place or are you still thinking about it and just in case you didn't want to do it what would the outcome be or what could you be looking at?

My OSS said my facets fused at L5S1 which alleviated much of my pain at that level but then again I have had no instrumentation at that level (hardware) or fragmentation of the facets just a failed discectomy with rebulging.

Maria

[Jim M2]

I don't schedule until later this week after they see what dates are available for Dr. Coufal and the vascular surgeon.

I am ready to do this. I don't think it will address all of my pain issues but I need to start somewhere.

I should clarify about the fragmented facet. The facet is fragmented but it is only a small single piece of bone that has separated from the rest of the facet.

[Maria]

Wishing you the best with this endeavor whenever it gets scheduled with Dr. Coufal and the Vascular surgeon!

Re the BMD test.. since you're going to get what sounds like a revision surgery or at least have more hardware placed that's why I asked about the bone mineral density testing.

[Jim M2]

My insurance voided the pre-approval application after a single attempt to contact Dr. Coufal for a peer-to-peer call fell through. They say the process must be restarted. Idiots.

In the mean time I got a second opinion from a pain management doctor at Scripps in San Diego. Contrary to Dr. Coufal he felt the L5S1 facets were not necessarily a pain generator. Also contrary to Dr. Coufal he felt L4-5 could be a pain generator. Currently the medical community rarely recommends discograms but the PM felt like it would make sense in my situation to better understand L4-5 prior to a surgery.

I feel his conclusions on my L5S1 facets are incorrect mostly due to his lack of knowledge of my history. I do like his recommendation about the discogram. In fact I would like to conduct more diagnostics to better understand the pain generators. At a patient seminar in 2004 Dr. Yeuug (of DISC - Desert Instititute for Spine Care, The Leaders in Minimally Invasive Endoscopic Laser Spine Surgery fame) said he could always find the pain generator. I wonder why surgeons seem happy with only a MRI and CT.

If anyone has any thoughts I'm all ears.

[jsewell]

Jim i have only just read this thread and none of your others if they are out there.
I had some horrible pain in my thoracic region that kept getting worse, only relieved by me laying on the floor with my legs up. (it was pretty embarrassing to my kids at the airport one day) Any way i knew it was time to get something done. the MRI and cT did not show much of anything. Of course the thoracic is the most stable area . I won;t go into the whole story , but the deciding factor in the diagnosis was from a discogram which i suggested. It is a good test . It is the reason i am out of pain from my thoracic spine.
Judy

[Maria]

Per pre surgical protocol re diagnostics Orthopedic Spine Surgeons in CA that I've seen order discograms. I've had 3.

Neuosurgeons order myelograms. I've had 2. I leaked spinal fluid both times and ended up in the hospital for a week post procedure with severe h/a. No blood patch given per each Neurosurgeon's decision.

That was as far back as 2006. I don't know if that's changed at all with regard to the difference between Neurosurgeons and Orthopedic surgeons pre surgical diagnostics so you may want to check that out for yourself.

Good luck with getting the ball rolling again re insurance BS.

[Jim M2]

Judy,
So the L4-5 is the disc in question. On the first office visit Dr. Coufal pointed out there was strength lost in my left foot (holding the foot up) which usually maps to L4-5. On a follow up visit after new imaging came in he felt like the L4-5 had good height. He didn't want to deal with it. He is willing to explant the Charite at L5S1 and convert it to a fusion. I certainly wouldn't mind doing a discogram to get to the bottom of it. I'm certainly not in a position to make demands of an outstanding surgeon like Dr. Coufal but I'd certainly like him to give more consideration to the L4-5.

Maria,
Both PMs told me discograms give suspect results plus they can cause damage to healthy discs. They are seldom performed anymore. If I could get a discogram I hope they would agree to test only one level. I know the healthy levels give a baseline of sorts but I don't want damage to L3-4 and above.

[Maria]

Even back then I didn't have the disc above L3 tested (or rather a test healthy disc). L3 had an annular tear and on first discogram was not concordant for pain. L4 and L5 already had surgery and were both painful with L5S1 being the worse (It wasn't tested the first time because the OSS that did that one said he "knew" it was shot).

2nd time L5S1 was included because I was told it had to be.
3rd time it was L3, L4, and L5 (so discs that were shown on MRI to be problematic) but trying to find out if L3 was painful or not...

First time I had pretty significant pain even after the procedure but 2 days later felt much better than I had in quite a while which lasted a month at least.

2nd time I got Marcaine in the disc spaces post procedure.
3rd time I got an ESI directly after the procedure.

I've not sought any surgical spine consultations (thankfully) since 2005. I wonder if discograms are still being obtained prior to various spine surgeries in Europe? Anybody?

[Jim M2]

Maria,
I'm glad you mentioned the Marcaine in the disc spaces post procedure. The last time I had a discogram I was very agitated afterwards. If I am successful making my case for a discogram I'll negotiate the Marcaine up front. I have an appointment with my PM doctor one week from today (5/20/14).

[Jim M2]

For a number of different reasons I've decided to cancel the ADR explant for now. I want to study my situation longer and possibly have some more diagnostics. I'll start another thread to get everyone's input on my evolving symptoms.

[Maria]

Sounds very reasonable to me especially with a degree of concern or doubt regarding pain generators (or any part of the proposed surgery). Good luck Jim.

[mmglobal]

Jim, I'm glad that you will wait until you are more certain about your path. In the absence of issues that make this urgent or emergent, you can decide later to move forward with the 'maximum' surgery... but you can't undo it. Better to be sure.

All the best,

Mark

[Tim]

Hi Jim

In an earlier post from this thread you mentioned that "Dr. Yeuug (of DISC - Desert Institute for Spine Care, The Leaders in Minimally Invasive Endoscopic Laser Spine Surgery fame) said he could always find the pain generator".
I was wondering if you ever took this any further?
I ask because I'm in a similar'ish position to you in that I suspect my L5/S1 Charite level may be the cause of (or at least a large contributing factor towards) my continuing problems (low back pain and bilateral leg pain with pain worse in the lateral calves). In my situation the doctors don't seem to want to consider this because they can't see past my degenerate L4/5 which is pretty uniquely sandwiched between my 2 ADR's at 5/S1 and 3/4..
In the UK there's a guy called Martin Knight who specialises in Minimally invasive Endoscopic Laser surgery pretty much like Dr Yeung. His techniques don't seem to carry much credence with the rest of the 'spine surgical community'. I managed to have a brief telephone conversation with him and he said he could use a procedure called spinal probing to detect the level of my pain generators. The procedure is apparently carried out in an aware state under light sedation and I believe is commonly used as an intraoperative diagnostic tool during some MISS procedures..
Details of the procedure can be found at the following links;
Spinal Probing
Diagnosis
Spinal Probing & Discography - Spinal Foundation

I wonder if Dr Yeung might suggest a similar diagnostic procedure in your case.
I have not moved forward with this yet (partly due to the fact that the main stream surgical community seem sceptical of this particular surgeon and are seemingly unaware of this technique, + it's pretty expensive) but would be interested to know what Dr Yeung might suggest for you…
I don't know if Dr Yeung is the type who'd have a brief conversation on the phone or via email or if you'd actually have to visit to get any idea of how he'd propose to find your pain generator - after all he does claim to be able to "always find the pain generator"
Just throwing it out there….

Wishing you well
Tim

[Jim M2]

Hi Tim,

No, I haven't taken up diagnostics with Dr. Yeung. Initially I'll be dealing with my pain management doctor on 6/24 to see what he might be able to do. This is mainly due to convenience. I don't know if or when I would contact Dr. Yeung. It is interesting but unfortunate to see you dealing with similar symtoms.