Reherniation

[Gil Denis]

Reherination Microdiscetomy

Hi All

I just came home from my surgeon and the MRI results were not good
L2-L3 Bulge,L3-L4 Bulge, L4-L5 re herinated, L5-S1 no change but not much disc left, She wants to do injections at L4-L5 to try to dissolve the disc that is pushing on my nerve,"three should do it". Also suggested to do a repeat microdisctomy which may or may not work?
Also suggested to send my information to Denver for a second opinion, that does ADR!
I have four very bad levels and she thinks only one level is the pain generator,I think that there is more going on.
I am now taking the bull by the horn and sending all my information every where, any suggestions would be greatly welcome.

Mark you were correct!

Thanks
Gil

[Maria]

I had two discectomies and both rebulged. I'm pretty certain the work on L5S1 set L4 up for more rapid demise and then the work on L4 really rattled my cage so to speak. Further surgeries were recommended ~ still holding out here tho I sure was gung ho to get more opinions after the one in 2001 re getting a 3 level global fusion! So very glad I didn't do that one (have an anular tear/internal disc disruption at this level and DDD at all lumbar levels)!

Keep on getting those opinions and when you've found someone that makes the most sense to you re advice and you think you might be able to live with whatever the results are good or bad because of your choice~ then go with it.

Sorry to to read it appears you have multiple level problems however maybe it is just one or two levels that really need to be addressed and others can be left alone to best treat the situation. That'd be ideal (or nothing needing to be done would be more ideal w/no pain/probs). Good luck!

[dshobbies]

Gil,

Ouch - and only 1 pain generator out of 4 bad discs?????? It's possible but the only way to find out is a discogram, which may cause even more problems. However, the possible solutions for 1 disc vs. 4 will be different so you have to decide if the disogram is worth the risks.

I had my first discectomy/lami in 1994. S1/L5 reherniated as did L4/5- my second surgery was in 2002. Less than 1 year later I had 4 bad levels, 3 of which were pain generators. This 'disease' is call failed back surgery syndrome. It has a name because of the frequent occurrances. Though my first surgery was an emergency, knowing what I know now, I would not have had the second. Looking at successful percentages, they are not in your favor.

I also want to mention that prior to my first surgery, until the very last days, I had almost no leg or hip pain. It was mostly contained within my back, my muscles seizing tight, drastically limiting my mobility. Standing in the shower was almost impossible. Even now, L2/3 has become a pain generator, not because of nerve involvement but those damned muscles have simply had enough. So just because your MRI may not show nerve compression, you could still have significant pain.

Note to Mark - would a discogram reveal this muscle 'protective' mode?

The short of it Gil, IMHO, I wouldn't have more discectomies. Something else you may want to consider is scar tissue which might make ADRs more difficult. You have a lot to think about and I wish you a lot of luck.

Dale

[Maria]

Gil,
I had started my original post to you with the same thought in mind that Dale mentioned re not having another discectomy or at least not at the same level. I just think they're basically a prelim to more spine surgeries and or bigger surgeries down the road and maybe very shortly down the road.

Perhaps techniques have improved alot since my last discectomy so perhaps I'm being unfair or just stupid to say what I did tho I do think that my spine became far less stable after the 2nd level discectomy and set me up for further bigger surgeries which may have all been inevitable anyway.

I've had 3 discograms and I don't think they further harmed the levels injected however I had them done between 2001 and 2006. Two of them were done a year apart.

Again.. more opinions, consultations with highly reputable outstanding spine surgeons is my advice.

[Gil Denis]

Hi Maria and Dale

Thanks for your information, My Surgeon does not want to do another microdisc, instead is trying injections that may help?And to get another opinion with Dr that does ADR and has more experience I am sending all my information to the TBI today and see what they could do for me?

Thank You Very Much

Gil

[Crystal33]

Gil,
Sorry to hear of your prolonged suffering. Did you do anything in particular to cause the reherniation? It is my greatest fear. The only survey i could find stated that 10 out of 14 reherniations were reported to be caused by a particular event such as bending and lifting or driving over large bump or pothole.

IF your main symptom/s is from recent reherniation, and is bearable, you could try some months of conservative approach, to see if your body can reduce it and hopefully ease symptoms without cost, risk and worry of surgery. A lot of reherniations are at a different place on disc. If so I guess they should be approached same as a new herniation. Maybe your MRI shows if in same spot.

Never heard of the disc herniation dissolving injection. What chemical?
These injections have potential...
Minimally Invasive Oxygen-Ozone Therapy for Lumbar Disk Herniation -- Andreula et al. 24 (5): 996 -- American Journal of Neuroradiology

This study reports outcomes for various surgical approaches to reherniation, though carried out by a spine surgery dept so they could be glossing up the reporting on their own surgeries.
[A contrastive study of treating single level recu... [Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2008] - PubMed result

A different view below.
Lumbar instrumented fusion compared with cognitive... [Pain. 2006] - PubMed result
It's hard to find good long-term independent data on ADR.

[Gil Denis]

Hi Crystal

Thank you for all that information I am trying to be as conservative as possible.

Thanks
Gil

[New-disc]

Gil,


Sorry to hear the news.

Hang in my friend!!

Please keep us all posted.

Todd

[Maria]

Hi Gil,
that was the same route I was taking re my rebulges up until 2006. My surgeries were pretty long ago and I only started getting ESIs in 2001 yet they did help greatly w/my symptoms and in the last few years I haven't had nearly the symptoms I used to have. Still all in all if I had been working still I think I would have followed thru w/ADR surgery when recommended or hybrid surgery.

Good luck w/all and keep us posted!

[Gil Denis]

HI Maria

Thank you
What is your condition today?
Did you ever have any continuing surgery?

Thanks
Gil

[Maria]

Gil,
I had my last surgery in '92 with failed back as the lingering diagnosis. Rebulged discs and had scar tissue on my S1 nerve root which was thought to be the cause of burning and pain that I had in my buttocks and legs bilat for 5 years.

Started Gabapentin in '98 and that helped greatly, started low dose Methadone in '01 and that really helped. Started ESIs in 2001 and that helped even more.

Had surgical consults from 2001-2006. Started to feel better in 2005 and decided to wait. These days I'm doing much better and it's thought that's because the L5S1 area autofused after all these years.

I still take my same dose of meds however feel much better most of the time with less flare ups that when occur last much shorter periods of time.

Still can't sit long tho and that's my major problem altho it has improved quite a bit from before L5S1 fused. Still have a bulge at L4 that's bigger than it was, worse DDD, and now facet changes which I've been told I can forget ADR now.


Right now all in all I feel much better than I have in a long time yet again~ I am medicated and still have considerable limitations. Still for the spine journey I've been thru in the last near 30 years I'd say I'm doinng pretty good.

[mmglobal]

Gil, I'm so sorry that your relief didn't last. Good luck... please keep us posted,

Mark

[ans]

Oh no. Wishing you my best Gil during this discouraging/painful time. - ans

[Gil Denis]

Hello!

In the past weeks I have had Three ESI all at the L5-S1 nerve root. She used three selected approaches to try and hit the correct spot One injection was very painful and created a large headache.
At this point I am still waiting for some relief
No reply from any Spine Centers yet and still doing research on spine conditions
I must keep moving forward

Gil

[dshobbies]

Hang in there Gil. Your day is coming. Is insurance paying for any of this or is it all you? And what doctors haven't responded to you?

Dale

[Maria]

Hi Gil,
Good luck with all this stuff. I know the road you're traveling as do many here and I certainly wish you all the best with this spine journey. Hang in there and keep going. As Dale said your day will come.

[Gil Denis]

Hi Dale and Maria

Yes I know my day will come,
I have sent Information to Dr Bitian will not accept my insurance W.C
The Texas Back still waiting
Dr in L.A. still waiting
This all has been paid by workers comp so far. As soon as I mention W.C it seems that I am denied to be seen or treated. When I spoke to my case worker about this she claimed it to be illegal?
Getting really pissed off



Thank You

Gil

[Maria]

Gil,
I don't think it's illegal for a doctor to not accept WC insurance cases or perhaps out of state WC. I know when I was trying to live in Fla. no one wanted to accept my out of state WC insurance.

There were even some practices that said they would (Pain Managment) but then turned me down at the last minute after going thru a bunch of red tape paperwork. The OSS offices just plain and simple turned me down as did Neuro docs.

Even here there are consultations with one doctor in a practice because he or she will not accept WC patients (or new WC patients) but someone in the practice will (usually they need to build up their clientele).

Don't you wish they would just at least call and tell you where you stand? I'd rather get the denial so I could move on mentally then to think someone has me on some list and just "wait"... I've heard TBI seems to keep people waiting a long time or at least I heard this in the past (like a year).

take care!

[nomorepain]

i had success with Doc Delamarter in Santa Monica, Ca. just my opiniion, but i checked him out thoroughly before my surgery, and my results are truely remarkable, if i had to go through this again, i would with him behind the wheel in a heartbeat.

[Maria]

When I first wanted to see Dr.Delamarter in '03 and WC would have auth'd it he wasn't taking WC patients at the time so I was given an appt. with another doctor there who totally blew or the office blew getting my paperwork done in time re WC's parameters so the auth for ADR (2 level) was withdrawn and I was back to square one w/WC. Had to go get a 2nd surgical opinion all over again (Mark was with me for this) and thankfully that surgeon recommended either 2 level ADR or hybrid surgery so then it took until '05 to get back to Dr.Delamarter's office and I was adament that I did not want the same surgeon that had seen me before because somehow either thru the fault of the office or the doctor or both my paperwork wasn't processed in time and I wanted an appt. with Dr.D. which I finally got.

I was then authorized to have surgery with Dr.Delamarter tho by this time started to feel better and wanted to "wait and see" if I just could get by without surgery because I didn't see the need to pursue something when I felt like I was doing OK.

So my experience with this office wasn't "all that" however they do see a volume of patients and Dr.Delamarter has one of the best surgical repuations around for ADR (and hybrid surgery) as well. I don't know if I'd see him for fusion.

I think if I were getting a multi-level fusion I'd recommend Dr.Frank Coufal in San Diego just by word of mouth with results.

Oh well.. there are plenty of people here that can give recommendations based on their surgical experiences with someone. I'm feeling pretty good with "just hanging in there" as previously posted.

Good luck~ I certainly don't recommend ignoring the pain if there is something that can be done about it and one can't function or quality of life is just not there. I waited mostly because of such a horrible second surgery outcome tho now I'm not sorry I did at all. Of course like any other spiney.. there may be more surgery in my future.

[dshobbies]

I too would trust Dr. Delamarter - however- dealing with him and his office staff can be beyond frustrating.

I started seeking a remedy with him in September '04. From January-March'05 I couldn't get a single phone call returned and finally left the message that if I didn't hear back from him, I would look elsewhere. I finally got a phone call in May and was already scheduled for surgery with Dr. Regan. I had the opportunity to calmly tell my story to Dr. D, who listened and agreed that waiting 5 months for a return phone call was unacceptable. He seemed compassionate when I explained that though he was busy, I was in pain the whole 5 months.

From what I've read, he hasn't changed.

[Gil Denis]

Hi All

Thanks for the replies.
I just received a reply from Dr B at the TBI

Mr. Denis,

Thank you for sending all of your medical records for us to review. Dr. Blumenthal has reviewed everything and wanted me to relay the information to you. He stated that you really have too many levels involved to consider artificial disc replacement. He is basically recommending the same type of surgery that has already been suggested to help the leg pain. He did say, however, that if the back pain is bad enough then you could possibly get a discogram to try to determine what levels are actually causing your pain. Let me know if you have any questions.

Now What? A four level fusion? Holly @@#%!

I will find a solution

Gil

[Maria]

Gil,
I think the FDA still is hanging with approving one level ADR at this point or has it yet gone to 2? Anyway, it sounds like this letter is stating it appears you have too many levels involved for ADR however a discogram might help decifer which level(s) seem to be truly problematic and perhaps you'd still fit in the parameters of acceptable for ADR at fusion (hybrid surgery) if only 2 levels were truly pain generators.

Or you could just skip wasting your time here and go to another country where the FDA does not deem who is fit for surgery and who isn't based on number of levels needing repair.

Either way you'll probably need a discogram to tell determine which levels to deal or how to approach the problem.

Just keep on searching for what seems right and viable for you to get done even if it takes a momentary pause to let these words settle in. This is just one surgeon, one facility.

[dshobbies]

Discogram - yes, 4 level fusion -no it's actually contra-indicated. I know a four level ADR is drastic but it is doable - or 1 fusion at S1/L4 with 3 ADRs on top.

I would suggest moving on. My original surgery was supposed to be 4 levels or as above. Dr.s Delamarter, Regan and Bertagnoli were all considering both types of surgery so yes, it can be done.

A word about what happened to me. The discogram revealed that L2/3 was not a pain generator and nothing was done at that level. It has since become one and causes most of my current pain. As long as I'm functional, I'm not willing to go for another surgery, not even on my knee and now am wishing that level had also been done. Should you have 4 bad levels but not all are pain generators, seriously consider your options before deciding on which surgery is best for you.

Dale

[Maria]

I'm with Dale on that one re "no no". I was supposed to have a 3 level global fusion back in 2001 and I'm so very glad I didn't do that.

There were 2 major reasons I didn't want ADR done here (USA) or even a hybrid surgery and that was because my L3 disc is disrupted with an annular tear and while it wasn't a pain generator on 2 discograms it was on my first and I just was never comfortable with leaving that level alone and working below it and the other major reason for me was that vertebroplasty isn't done here for osteopenia and I have since developed lumbar osteoporosis anyway so I was concerned about subsidence potential if surgery done here w/o vertebraplasty.

Ok I guess I had my doubts altogether because between the FDA and WC I didn't think I'd be getting what I really needed done here. If I had proceeded with surgery out of the country I would lose my future medical benefits on my back with WC (am going to lose them anyway sometime as I'm being pushed to do MediCare Set Aside tho still holding out).

If I had lost my future med I'd lose my PM treatment which acutally has me pretty well stabilized re pain tho I'm having some right now which I think is L4ish.

As Dale stated weigh your options carefully and perhaps there is someone somewhere or some people somewhere with multi level fusions that are going great tho 4 sounds like too many levels to me...

[Gil Denis]

A Big Thank You To All

I am hanging by a silk thread

Just received a Email from Dr D in L.A. would like to see my profile.

Here we go again

Thanks

Gil

[Gil Denis]

Hello

Just a bump, Mark what is your opinion?

Thanks

Gil

[Crystal33]

Gil,
Don't know if u have made enquiry here. Selective Endoscopic Discectomy™
Mark rates them very highly. I like the idea of keyhole and visual approach. Combined with biologic treatment for regenerating nucleus and healing annulus would be the ultimate treatment.

Tony or Chris Yeung... DISC - Desert Instititute for Spine Care, The Leaders in Minimally Invasive Endoscopic Laser Spine Surgery...."advances in endoscopic surgical technique has allowed for successful endoscopic treatment of conditions such as Failed Back Surgery Syndrome caused by recurrent disc herniation, lateral recess stenosis, foraminal osteophytes, facet cysts, and many degenerative conditions of the lumbar spine such as degenerative and isthmic spondylolisthesis. Where the patho-anatomy can be accessed through the foraminal approach, treatment options may be possible. Biologics are also being considered for tissue healing and regeneration."

[Maria]

Gil,
Re Dr.D.- if you have the opportunity to go and see him or have him review your case then I'd go ahead with that. I doubt he'd want to see it/review it if he didn't think there was something he could offer you...

[mmglobal]

Just an interesting coincidence.... Yes I do rate Tony and Chris Yeung and their SED procedure, diagnostic ability, etc... very highly. I have seen many people go to them and I believe that their style of discectomy is highly advantageous in many (but not all) cases. I also rate Dr. Delamarter and his operation very highly. There is no one with more ADR experience in the US.

Few years ago, I was observing a client's surgery with Tony Yeung in Pheonix. Across the table, the assistant surgeon said, "Hey Mark, remember me?"

With scrubs, hat, and a surgical mask, everyone looks about the same. It turned out to be Justin Field. He had been Dr. Delamarter's fellow early in my career as a patient advocate and had helped me with MANY clients. He's a great guy and a top surgeon. He has a very interesting bio. Read it here:

Justin S. Field, M.D.

All the best,

Mark

[Crystal33]

Dr Hoogland is reputed to be one of the world's best at endoscopic spinal surgery. I personally am always a little guarded when review is undertaken by a doctor about his own work, which seems to be common practice.

2008 Apr 20;33(9):973-8.
Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases.

Hoogland T, van den Brekel-Dijkstra K, Schubert M, Miklitz B.

Department of Spine Surgery, Alpha Klinik Munich, Germany. hoogland@alphaklinik.de
Abstract

STUDY DESIGN: A prospective, cohort evaluation of 262 consecutive patients who underwent transforaminal endoscopic excision for recurrent lumbar disc herniation, after previous discectomy.
OBJECTIVE: To review complications and results of the endoscopic transforaminal discectomy (ETD) for recurrent herniated disc with a 2-year follow-up.
SUMMARY OF BACKGROUND DATA: Recurrent herniation is a significant problem, as scar formation and progressive disc degeneration may lead to increased morbidity after traditional posterior reoperation. The studies published until now on recurrent disc herniation concern various operative techniques, mostly the lumbar microdiscectomy, which is still seen as the standard. The advantage of ETD could be that there is no need to go through the old scar tissue and the procedure can be performed in local anesthesia. The disadvantage may be a long learning curve for the surgeon.
METHOD: Between January 1994 and November 2002, 262 patients with primarily radicular problems underwent an ETD for a recurrent herniated disc. Two hundred and thirty-eight of these patients (90.84%) completed our 2-year follow-up questionnaire. Initial surgery of 82 patients was performed in-house, 180 external. Average age was 46.4 years. The female/male ratio was 29/71%.
RESULTS: At 2-year follow-up 85.71% of patients rated the result of the surgery as excellent or good. 9.66% reported a fair and 4.62% patients an unsatisfactory result. Average improvement of back pain of 5.71 points and 5.85 points of leg pain on the VAS scale (1-10). According to Mac Nab, 30.67% of the patients felt fully regenerated, 50% felt their functional capacity to be slightly restricted, 16.81% felt their functional capacity noticeably restricted, and 2.52% felt unimproved or worse. All patients participated in a 3-month follow-up to establish the perioperative complications. The overall complication rate was 10/262 (3.8%), including 3 nerve root irritations and 7 early recurrent herniations (<3 month). There was no case of infection or discitis. After 3 months and within 2 years, 4 patients have been treated for a recurrent herniated disc in our own center and 7 patients have been treated elsewhere, resulting in a recurrence rate 11/238 (4.62%).

CONCLUSION: ETD for recurrent disc herniation seems to be an effective method with few complications and a high patient satisfaction.

[Keano16]

Interesting thing about endocopic technique is that it has similar results world-wide by 10 different surgeons.