Considering 3rd surgery – Minimally Invasive vs. Open ?

[Tim]

Hi all
I'm looking for some advice/opinions..
I’ve had 2 previous spinal surgeries:

1988 – 3 level laminectomy + decompression; L3-S1
2003 – 2 level ADR (Charite) L5/S1 & L3/4 – Dr Zeegers

In 2003 my pre-surgical discogram at the L4/5 level was apparently negative and although extremely degenerate was not operated on but left sandwiched between the 2 supposedly correctly operating ADR’s. Since this surgery I have suffered from continuing back and increasingly leg pain. In 2005 I had facet injections at all 3 levels with no effect presumably therefore ruling out facet involvement.
2 weeks ago I had a repeat discogram at the L4/5 level. The result was again technically negative but the disc was so degenerate that it could hold no pressure – the dye simply poured out as quickly as it was pushed in.
My consultant says this level is completely knackered and has recommended fusion at the L4/5 by means of minimally invasive TLIF with BMP + rods and screws. Interestingly although the discogram did not (at the time of injection) replicate my symptoms, from about 3 days out I started , and continue, to have a rough time – my leg pain has been particularly exacerbated. Whether this is due to the leaking dye or is a delayed response from my ‘fried’ disc I don’t really know but the consultant did seem to regard it as relevant..
A second more local consultant has also recommended TLIF at the L4/5 but this time by a more traditional open procedure TLIF with combined PLF + rods and screws and my own donor bone from hip with no BMP.
The first guy recommending the minimally invasive approach with BMP is 4 hours car ride away while the 2nd guy recommending the open procedure is only a half hour away. My question is basically do you think the theoretical advantages of the minimally invasive procedure combined with BMP warrants the lengthy post-op journey (I am planning on travelling laid out on the back seat and am worried if this will even be possible post-op!?)
The minimally invasive guy has basically guaranteed me fusion by 3 months while the open procedure guy is less optimistic but still thinks solid fusion should be achievable within 6 months.. Both have pointed out that the procedure is very unlikely to make me pain free. The minimally invasive guy said there is a 60% chance that he can halve my pain (not the best odds). The open procedure guy didn’t want to give me any figures but said he was hopeful the procedure would help. Both thought given no major complications they shouldn’t make me any worse – funny I think I’ve heard that somewhere before!!
I must admit I'm tempted by the minimally invasive approach – less muscle/ligament cutting and therefore supposedly a less painful recovery.. I am however worried by such a long post-op journey. I can’t understand why the 2nd guy doesn’t use BMP – everything I’ve read seems to suggest this greatly aids fusion. Basically on questioning he said he regards your own bone taken from the hip to be the ‘gold standard’.. I am also a little unsure as to the advantages of the additional PLF procedure as recommended by the 2nd guy – I'm guessing this is a sort of’ belt and braces’ approach to try and ensure fusion occurs.
As far as I can gather from my research both surgeons are well regarded in the patient community and by their peers although one is quite obviously more cutting edge.

Any thoughts on which procedure I should choose would be appreciated..

Money shouldn’t be the decider here (which is why I’ve placed this right at the bottom of my post..) but I might as well mention that the minimally invasive TLIF will cost me between £13-15,000 while the open approach will be free on the good old NHS (Yep you guessed it I'm in the UK). I can’t really afford the former option but as this is my third surgery it’s kind of last chance saloon and I just want to get it right.

Of course the other option is to leave well alone and put up with the limitations (too numerous to mention but with which I'm sure you’re all familiar) and the pain..

Wishing you all a pain free day.
Tim

[wilsonrob]

Tim,

Why wouldn't they try to decompress the nerve first thru a minimally invasvie surgery without the fusion?

Thanks

[KL Aguilar]

I have a few suggestions...get a third and a fourth opinion. And if the journey is the problem, couldn't you stay a night or two in a hotel?

I think you have to take what surgeons say about pain reduction with a grain of salt. They are just guessing.

[dshobbies]

Tim,

It's really a shame that after ungoing such invasive surgery you find yourself still in pain. We've talked about removing discs preemptively and it simply isn't very practical so you've been left with what is presumably causing your pain.

However, the fact that you've had two separate negative discograms and an obvious MRI leaves your diagnosis questionable. Getting more opinions is definitely in your best interest. Have you thought about going back to Germany for a consult with Dr. Baumbach? Though I have no personal experience with him, his diagnostic capabilities seem second to none. You might want to contact Mark (mmglobal) to put you in touch with him.

Whatever you eventually decide, I do wish you more pain-free days.

Dale

[Tim]

Hi
Thanks for the replies.

I've now had 4 opinions - 2 from respected Uk surgeons via face to face consult and 2 from Germany (Dr B. and Dr Z.) via the interweb..
They all agree that that the L4/5 is the likely culprit (either through disc pain or through mechanical pain - mechanical stenosis has been mentioned).
Regarding the discogram there is general agreement that although the disc gave a technically negative pain response it did not give a negative dye distribution. It is pretty much impossible to get a +ve pain response from a disc that won't hold any pressure. Dr Z. claimed he managed to pressurize the L4/5 in 2003 prior to my surgery, but to me the images look identical to those taken recently when there was definitely no pressurization possible.. My recent discogram has definitely resulted in a delayed marked exacerbation of all my regular symptoms - my consultant seemed to regard this as relevant. However reference to a delayed response is not something I've come across in my research - anecdotal or otherwise..
My guess is that many surgeons would not even bother to perform a discogram on such an obviousy collapsed level - In an otherwise healthy spine the pain generator would be obvious. It is, I suppose, possible that the pain is coming from the 5/S1 but there is no obvious compression at that level. There is facet degeneneration present at both the lower levels but my symptoms don't clearly fit facet problems and the facet injections gave no relief.
Yes I have considered revisiting Germany and Dr Baumbach but feel I have to draw a line somewhere. Financially this is all crippling. Dr Z. seems to agree that tha L4/5 is the likely culprit so what more will Dr Baumbach be able to bring to the table. I'm trying to cross all the T's and dot all the I's but at some stage I will have to decide to jump or live with it.. If Dr's Baumbach and Z's services were free and they lived just down the road I'd be there tomorrow!
All 4 doctors have agreed that fusion is a sensible step but they all vary on the approach and instrumentation to achieve this. The choices seem to be Open PLIF + instrumentation, Anterior lateral transpsoas approach with plate, Open TLIF + instrumentation and minimally invasive TLIF + instrumentation. I'm concerned by the damage already done to my posterior structures during my extensive and pretty destructive decompression in 1988 so am leaning towards any option which minimizes further collateral damage.

Whether my logic is flawed on any of the above I really don't know - hence my posting..

Again many thanks for your replies.
All the best
Tim

[mmglobal]

Tim, these are always such tough decisions. I don't think the 4 hour car ride is significant, but I do think the cash is. All options are in play and both surgeries are likely to have the same outcome provided fusion occurs. I'd rather get a quality old-style surgery than a mediocre 'less invasive' procedure with BMP. How one can evaluate which surgeon takes care and gets it right the first time is beyond me.

Don't let the skin incision fool you... I'm wondering if the 'open procedure' follows a similar muscle splitting path, unlike older 'open' styles of surgery. Find out the comparitive damage to the musculature. You may be surprised.

I'm sorry that you are in this situation, but I'm very hopeful for you and your family. All the best... talk to you soon,

Mark