To fuse or not to fuse

[annapurna]

Hello everyone,

I haven't posted for awhile, but have sure enjoyed reading everyones' threads - ya'll are great. I'm currently struggling with symptomatic facet arthritis at L5/S1 and at L4/L5. So far, radiofrequency neurotomy has not been successful, although, I might consider trying it again.

The annoying part of all of this is that I have a very well-placed Charite at L5/S1 that has done great for almost five years next month. Additionally, a discogram perfromed last month showed a nice, healthy, and pain-free disc at L4/l5.

So, the question for the group is whether it's time to give up on motion preservation and starting planning for a double-level fusion, or continue with pain management in hopes that something better will be developed soon. My pain is certainly not extreme right now, although it is definitely limiting.

My biggest concern with waiting is the lack of any promising new technologies for the facet joints. There are lots of different ADR's available, as well as dynamic stabilization devices, but nothing that specifically addresses the facet joints other than TOP's, TFAS, AFRS, and Zyre. I can't really see any really effective facet arthroplasty devices being available anywhere in the world for at least ten years (darn). Maybe I'm being too pessimistic?

Any suggestions? Thanks.

Best to All,
Laura

[Maria]

Laura,
I don't know really what level of pain you live with since my level of activity is so much less than yours and with medication I fare pretty well most of the time while not working, not sitting much, and not doing anything too strenous, really just walking for exercise tho good distances "for me."

Ok, to fuse 2 levels or not.. I know the way I'm going I may find myself at a 3 level fusion since I keep putting off surgery and maybe damaging surrounding structures but my fear with fusing several levels is this:

1) will that predispose L3 to problems even tho it's symptom free now
2) will you have SI joint probs once you've a 2 level fusion at L4-5 and L5-S1

I only know the reservations I have for myself with multilevel fusion is the same as this and even worried with just addressing L5S1 with fusion and L4-5 with ADR (leaving my disrupted but per 2 discograms symptom free L3 alone).

You see I feel the pain meds are worth it in terms of being able to function more comfortably. I certainly didn't expect to even reach this level of ease with the same level of pain meds and no recent ESI since last October.

This is after 6 years on same dose meds and ESIs that were given every 3-4 months up until the last one.

Waiting game or multilevel fusion/surgery... probably I'm not the one to ask as I'm so avoidant..

[annapurna]

Thanks Maria,

Your comments are always caring and insightful. I had totally forgotten about my symptomatic sacroiliac joint. It's almost as painful as the facet joints - and proveably so by diagnostic injections.

I also like your comments about the value of drugs in permitting one to function more fully. Right now, the "activities" that cause most of my pain are sitting at my desk at work and driving. Oddly enough, walking - and even hiking - tends to ease my arthritic symptoms. I feel very encouraged to give the stronger pain management drugs a good, honest try before I start to get "desperate" and think that I need to do something hasty. After all, I can quit taking the drugs, but I can't undo a double-level fusion.

Thanks again!!
Laura

[ans]

A: Another factor is that your pain mostly can be managed and that you are able to exercise which to me is a huge deal. I can't believe the distances you've ridden.

I also am concerned about the domino effect of a fusion and wonder if there can be a pre-emptive ADR put above the fused level to avoid disc degeration - at the beginning of the domino process.

Good luck - Allan

[Maria]

Laura,
It's none of my business although if you don't mind I'm just wondering what a normal day in your life is like and what type of exercise you are able to do, distances biked, hiked and so forth?

I only ask to try and get an idea of how screwed up I am!!!!

Today I went to work for my Veterinarian, I'm doing Accounts Receivable work on delinquent files and 4 hours of work standing and sitting was really beginning to bug me.. I wanted to lie on the floor for a few with knees to chest but since the Vet and others would walk into this office that houses 3 I decided against it.

At least I'm able to bring my dog with me... but realistically it helps me to see that I'm doing better than I used to be but so far from what my normal used to be. If I had a relax the back chair with lumbar and cervical support and things positioned the way I need them (like a quad almost) I think I could work well all day long.

I feel the need to be a biped tho~

** here's an addendum to my post~ Ok, I was at the Vet's office from 11a.m. to 3p.m. and stood much of the time. Took one doggie walk w/Lola so that was a break. Walked a mile plus last night and had 0 backache. But my neck is bothering me quite a bit. In fact, I have to keep moving my head and cracking my neck sort of... and my back feels pretty good this morning after my long walk last night!

[annapurna]

Maria,

I seem to be like you in that sitting and standing are painful, while walking and (for me) vigorous exercise can actually relieve or at least not cause pain. I've summarized my typical pain level vs. activity and duration as of right now:

driving a car: < 1 hour = 3-5, > 1 hour - 5-7
sitting at my desk: < 1hour = 2-4, > 1 hour 3-4
walking: < 1 hour 2-3, > 1 hour 0-2
standing: < 1/2 hour 2-3, > 1/2 hour 3-4
fast hiking on flat ground or downhill: < 1 hour 2-3, > 1 hour 0-2
vigorous uphill hiking with a pack: < 1 hour 0-2, > 1 hour 0-1

Unfortunately, in our automobile-intensive, automated world, we do lots of sitting and standing and very little walking. Because of this, I have lots of "functional" limitations in that I can't drive for much more than an hour, and have trouble sitting at my desk or standing around observing a process at work. On the flip side, crawling around under a piece of machinery at work, running up the side of a mountain, and spriting through the airport with all of my luggage on my back (in a properly-fitted pack of course) typically relieves at leat some of my pain.

Guess I'd do better as a "hunter-gathered" than an engineer.

Hope this gives you another point of reference in asessing your own situation. Maybe we're more similar than we are different.

Best,
Laura

[fuzzy]

Laura,

Your pain profile sounds much like me. continuous no load moving, flexing actually reduces pain for me and any static load increases pain. Sitting and standing being the big one and holding an accelerator pedal is really bad on my back and foot.

May I ask, what is the situation with your back, do the facets cause this pain? I would stay away from fusion.
How was it before the charite, did it improve your situation (for a while?)?

[Maria]

Laura,
You are much better off than me re pain and no use of meds!

Sitting an hour or more can escalate to quite a pain level like 7-9.
Standing in one place for more than 30 mins can escalate anywhere from a 3 -an 8.
Bending over repetively can bring on a "have to lie down think my back is out type of spasm"

By far the absolute worse is sitting and I don't know how well surgery would address that issue and not bring on a whole host of other symtoms..

Oh yes, just packing can kill me and land me in bed prior to a trip ~ running about in the airport is fine w/o wearing my backpack tho as that would be a big showstopper for my spine.

Hiking.. haven't tried it but am thinking I will in San Diego~ more hilly terrain there and at least I can do some uphill climbing and reeducate my spine to that and see how it holds out. Got so used to flat terrain here in LA county and while able to walk quite well, I'm still by far not as in shape and able to get around as you w/or w/o backpack!

Truthfully if your pain levels are that low and not keeping you flat in bed or nearly bedridden or unable do do anything you love, maybe just readjusting your activity level and modifying how you perform your duites at work will change the course of action you think you are have as an only option and allow you to wait a bit longer for a better solution..

Keep us posted on your thinking as your engineering mind is a good one to have functioning on the forum and especially DRUG FREE (at least for now)!

[ans]

A: As someone who used to work out - a lot, I'd give anything to do what you do. I would be very cautious in risking losing this, for your psychological/physiological health - despite your immense pain problems. - Allan

[annapurna]

Maria and Allen and everyone - thanks so much! When you're feeling like you're going downhill, it's very easy to think that you MUST do something in order to be like "normal people". Some of this stems from our odd pain patterns, i.e. walking around reduces pain while sitting in a chair and "taking it easy" increases it. You don't know how many times I've said that I have spine problems and been offered a wheelchair at the airport when what I really need is to either lay down or walk briskly. It seems SO difficult for people to understand that I can't drive a car long distances (and where I live, EVERYTHING is long distance), but I can hike up a mountain.

You all have made me realize that I've been contemplating a double-level fusion in large part because of "peer pressure" - darn, and I complain about teenagers being silly. THANKS!!

By the way, I definitely DO take meds, just not the "heavy duty" ones yet. I cannot even begin to sleep without my tizanadine and sometimes a tramadol. I now have to take tramadol every other week or so at work if it's a long "sitting day". Luckily, not being on them around the clock, I'm hoping not to tolerance any time soon.

I also like the idea of modifying the activities that HURT. Up until now, "activity modification" meant giving up the things like hiking and skiing that DON'T hurt very much - how silly! Why not rearrange my work schedule so that I'm out on the floor more observing processes and take frequent breaks and walks when I'm at my desk writing reports or analyzing data? My plant consists of lot of buildings spread out over a seven mile square area out in the desert for heaven's sake - I can take a beautiful walk right out the door of my office. Next year my state will be gettin a commuter rail that will, hopefully, will allow me to quit doing so much driving when I need to get to a big city (and save gas to boot). Biking and/or walking short distances also reduces painful car-time and keep me trim as a plus.

Life will probably never be "normal" for me in that there will alway be things that I cannot do without pain. At the same time, irreversible surgical decisions should not be made lightly - especially given the rapid advance of new technology. Facet replacement devices may be five years away, but, five years isn't really that long if one's pain is well managed and one can exercise and do things that are meaningful to oneself.

Thanks again for straightening me out. Ya'll are wonderful!

Best,
Laura

[Maria]

edited as necessary

[annapurna]

I agree completely Maria!

For someone with some significant spine issues, I'm doing quite well. My problem is, I allow myself to feel pressured to be 110% healthwise - maybe because I live in a very young community? I have SO many friends and family members who just can't understand that I cannot sit in a coach airplane seat for five hours, cannot drive across the state in one day, and cannot sit at a desk uninterrupted all day. My family is still giving me grief about getting an ADR as they think that if I would simply give up walking - the one thing that doesn't hurt - I would be just fine. Either that of they accuse me of being a malingerer and using my spine problems to justify a "lazy" lifestyle, i.e. only working 40-50 hours per week instead of 80-100 hours.

Your perspective really helps me to put all these comments and accusations in their place. I think that I need a self confidence spine much more than I need a physical spine, so to speak. You've helped me grow one. Thanks very much.

Best,
Laura

[ans]

Hi Laura,

I had another repetitive dream that I was hiking/backpacking in the mountains and in a tropical forest. I can't even carry a pack with water which is heavier. Then the dream shifted to me being in the wild (well, chaparral shouldn't count!) with my rolling daypack over uneven terrain and how lame this was b/c I couldn't get anywhere. I might risk surgery precisely to get back to this and especially to work out for not doing so is dangerous.

I take tramadol every day and munch NSAIDs a lot - hoping that Prilosec will protect my stomach lining. Sometimes I take Vicodin which is gross.

You're high powered and subject to v. high expectations. I'm glad you're grateful more for what you have. Running uphill like how Reinhard Messner used to train!!

Wishing you well, Allan

[Maria]

Laura,
I sent a pm