Mis tlif

[Sessy]

Hi -

Does anyone have any information or experiences they would like to share about a minimally invasive TLIF? This is an option that has been offered to my husband to help with possible psuedoarthrosis at L4-5.

Also BMP was suggested. Any info on that?

Thanks!

Sessy

[jsewell]

Sessy i have had many fusions and have a really bad back. BMP is bone morphenogenic protein or spelled something like that. When they remove the disc they put in some type of litttle cage to hold bone chips that may have been created from the surgery and BMP . These things will help it fuse into a solid mass which is the goal. Some times it has worked for me and some times it has not, but i have poor bone quality. Good cluck to your husband
judy

[mmglobal]

Judy is right about BMP... proteins that promote bone growth to increase fusion rates. Upside is increased fusion rates, downside is potential for too much bone growth. See the item I posted back in 2009... this is about a new fusion technique, but there was an unexpected finding regarding BMP.

http://www.ispine.org/forum/ispine/1...-data-too.html

Is this a repeat surgery? Pseudoarthrosis implies (to me and I'm not a doctor) that this is a fusion that did not fuse.

Welcome to the forum... whatever you ultimately decide on, good luck to you and your husband!

Mark

[Sessy]

Hi - I am not always able to get on the internet, so I haven't posted more often...

This proposed surgery is a revision of a fusion at L4-5. There is one cage there. For this surgery, they would remove the cage and place a new fusion construct.

Sessy

[Ringo]

It sounds like he has had a fusion already at that level and is looking to get a revision??? In which case he might have been told he has a non-union or pseudo arthritis at that level. This can be a painful condition that allows micro-movemtent at that level and can cause discogenic pain. If he has rods and screws, they may eventually come loose or even break.

If there are no signs of loosening or broken rods, they could possibly opt to leave them in. But, to do so they would have to do an XLIF (extreme lateral inter body fusion). This is a newer procedure that is very minimally invasive and allows the surgeon to just go after the cage. It's major advantage is that it allows the surgeon to use a very large cage which improves chance of fusion and best of all you don't have to cut through the back muscles. Recovery is pretty fast as well.

BMP is commonly used these days and works well in the lower back. It is used to encourage the body to make bone. Your surgeon will probably be encouraging its use since he/she will want to do everything possible to make the site fuse properly. It is good to use in the lower back, not good to use it in the neck (cervical vertebra) because it has been show to cause over growth of bone in that region.

XLIF is a procedure that is pretty much limited to just the L4-5 level of the lower back. Great procedure but not all surgeons can do it.

It is worth asking why the last surgery failed to fuse. Sometimes, it just happens. But there are things that need to be avoided. No smoking for several days before surgery and after surgery, definitely no non-steroidal anti-inflammatory (NSAIDS like aspirin and ibuprofen unless OK'ed by the surgeon). Inflammation is needed for the bone to heal. NSAIDS will shut down the process of bone healing if taken shortly before or after the surgery. TRUST me on that one…..I have first hand experience.

One of the disadvantages of going from the back (posterior approach) is that it can be a big challenge to get a large cage into the disc-space. There are a lot of important things that get in the way. To get that thing to fuse, you need strong rods and screws, a big cage (fit tight), make the bone bleed and use some BMP, no smoking and no NSAIDS. The site must be stable and your husband needs to follow post-op instructions regarding activity restrictions closely. Take some V-D3 and some Calcium for good luck. Do a bowel prep before surgery and take stool softeners religiously after surgery until off the narcotics completely.

Sorry if I said to much. Ask me more questions if you need to. I am new to the site. I have chronic pain and need more surgery.

Make sure he takes real good care of that back after it is fixed. Back surgery will never make him good as new. He will be putting additional stress on the levels above and below the fusion site. They will take a beating and may eventually become diseased and you get the picture.

A good fusion is a wonderful thing but you need to baby it regardless of how good you feel. People that think they can go back to labor intensive jobs are fooling themselves. Even sitting for long periods of time will strain his back in ways that normally wouldn't.

Hope I didn't say to much. Peace, Ringo

Originally Posted by Sessy

Hi - I am not always able to get on the internet, so I haven't posted more often...

This proposed surgery is a revision of a fusion at L4-5. There is one cage there. For this surgery, they would remove the cage and place a new fusion construct.

Sessy

[Sessy]

Hi All and Ringo- Thank you for your response. It is very helpful and definately not too long.

My husband had an alif surgery several years ago. He has two cages at L5S1 and one cage at L45. These are BAK cages. The one cage at L45 was not stable from the beginning, in fact, after the surgery, the surgeon told him that he had instability and might need another operation posteriorly. He had a large disc space as well and I don't think the cage was tight (large enough) enough to provide stability. I think this is maily whay he did not fuse. On following up with that surgeon though, on imaging, he said everything was ok- good to go and dismissed him after a few months. He did have pain relief for about 3 months after which the original pain returned. The films are not conclusive although a surgeon he saw recently said that he does not think he is fused there. His images do not reveal much. All looks mostly ok. MRI and CTs. As for other reasons whay he may not have fused, after that original surgery, he also had a course of steriods for nerve swelling - I think about a month or two out; I don't remember. But, really, I don't thin the whole thing was stable. He had tall disc spaces and the cages didn't really work for that. I mean they would have had to have been so big to distract the disc space that they would not fit otherwise, they would stick out the side. I don't think they even had large enough cages.

I don't know about L5S1 although it looks to me like one cage is sticking out some laterally from the vertebral body and may be compressing something as well.

This recent surgeon proposed, at L45, a minimally invasive TLIF. He said he would remove the cage by pulverizing it and then would insert another spacer and use BMP. He would then put in rods and screws. One foramen would be opened up at least. My husband has a lot of pain on the right side, so that side would be opened up I think. He would leave L5S1 alone. I am wondering how he will get the cage out. This is a major concern. The surgeon said that he had just recently performed this same surgery on a women and remove a cage this way.

I think that my husband does need a surgery to stablize everything. He is in a great deal of pain and it has gotten even worse (if that is even possible) over the last couple of years. He can't walk farther than around the house and is in constant severe pain. He health is getting worse in other areas too as a result of pain and not being mobile.

The question is: what surgeon to trust? What is the best way to do this? It is so hard. If we knew who was a good surgeon and would be able to accomplish the surgery without complications like nerve damage and so on, it would not be a question. I have to say that after the first surgery, I wonder if they really care about the patient, after all, they make a lot of money and bear no consequence regardless of how the surgery turns out. They can dismiss the patient and then you have to live with the consequences. They just go about their business - on to the next patient. Sorry, but deep down that is what I think and is a fear I have. I think they might think - well he is so screwed up now, if I botch this surgery up, who will know or care? He is screwed anyways.

We do plan on getting another opinion though. It is about one hour drive from where we live and will be very difficult. The limited ability to travel is also limiting the choices of surgeons. We have to be able to get there and my husband does not even think he can do the one hour drive to a Dr. appointment. I am planning on us staying overnight.

Sorry for the longwinded response.

Thank you so much for any and all help and support.

Sessy

[Ringo]

Your husband sounds a lot like me. To get a good fusion you need to put in a large cage and it needs to fit tight. They don't remove all of the disc. L4-5 is more difficult to fuse than L5-S1. Yes, they can grind up the old cage or break it up and take it out. Trust me, they can get it out of there. But remember, there is really no such thing as minimally invasive when you are cutting into the back and going after a cage and putting rods in. I sort of look at it as a lesser of two evils. If you keep going back in there, the chances of having a good out-come decreases. You loose a considerable amount of the muscle with each surgery…..guaranteed. The structure of the back is incredibly delicate. It is a marvel.

It is your right to get the radiology reports for any MRI or CT scan or plain films. I believe a CT scan is better at picking up a non-union than an MRI. In my case, they did a BONE SCAN to look for bone growth within the disc-space. I think the bone scan is the standard for evaluating the deposition of bone within the disc-space and the lateral gutters of the vertebral column. Sometimes it is a judgment call regarding what is enough bone growth. You can also have a lot of bone growth but the bone just hasn't bonded to the adjacent vertebra. That can be hard to see when reviewing radiographic studies. Having said that, very often, you simply won't have any opacity within the disc-space which is pretty obvious that something isn't right. The cage should not migrate outside the disc-space. The radiologist will catch that, so read the radiology report. There are also little radiographic markers built into the cage. Your last surgery should have included sequential x-rays that would should the cage moving around if it is on the move. You should be able to see erosion of the bone from the cage if there is movement or flexing going on.

So you feel like you are just a cog in a wheel when you go to see the doctor. I can be very cynical when it comes to the medical system. It has sort of turned into fast food medicine (that is what I call it). The goal of the surgeon is to pick the right patient and make the correct diagnosis. Your surgeon needs to find out what the pain generator is, even if it looks obvious on radiographic study. There has been whole generation of surgical decisions made on the advent of CT and MRI. At one time it was over relied on and that was a mistake. It is only a tool to assist in the process of making a surgical decision. Your surgeon should consider putting him in a hard brace and seeing if his symptoms improve. They really need to be as certain as possible what his mechanism of pain is.

I am a bit baffled why your surgeon said he finished his surgery and the cage was a loose fit or not tight. Why wasn't it tight? That is not the goal when putting a cage in there. Cages do come in different sizes?? It might have been that the posterior approach limited his ability to put a large cage in there without damaging nerves, etc.

If you get a second opinion, you need to be sort of diplomatic about it. Have all your radiology films, MRI, etc sent and reviewed before you go to the appointment. Have a list of questions but don't ask them right away. Try to get the surgeon to elaborate freely regarding the assessment of your husband. Very often, they like to listen to themselves talk and expound upon things. When the dust settles, diplomatically ask your questions like, is the cage in the right position, was the cage too small, are the screw broken, are the screws loose, are there signs of loss of disc-height from previous films, if my rods are not broken now, what are the chances of them breaking in the future, what is the likely cause of my pain, what will life be like if I have another surgery to fix this (define a successful surgical out-come in this situation), ask them what they would do if they where in the same situation?

Note that getting a totally open conversation with a surgeon is next to impossible. They can very diplomatic in there responses because they don't want to be asked to give expert testimony in court when they would rather be working in the office. (Sorry, my cynical side is showing). Personally, I would go to a major university medical center and see a orthopedic spine surgeon that has done a FELLOWSHIP in spinal surgery. Those are the one's that have done all the difficult cases and the re-do's. Chances are, they will tell it like it is and you will get a reasonably straight answer. Out of all the things I said in this letter, that is the best advise.

Another consideration for you is a anterior approach. They can go through the abdomen and possibly get the job done that way. It is frequently done. Ultimately, you want the procedure that will give you the greatest chances of success. Some surgeons will only do what they know how to do. There are tons of different procedures.

Tell your husband that a stranger cares about him. Tell him to try and have peace in his heart. Be careful when it come depression. Chronic pain can really do a number on a persons mental status. It all brings back memory's for me. Just hang in there and try to have hope. Find a surgeon like I mentioned. They are out there. Very special people. University of Washington has some. I have been there. They were very nice people.

Stay in touch. If you have more questions or I didn't answer your questions or you just want to vent, let me know. Your husband is very lucky to have you swinging the bat for him. My wife did the same for me. I keep looking for wings coming out her back side but haven't found them yet.

Peace (I really mean that), Ringo

[Maria]

I don't know if your husband was tested for his BMD (bone mineral density) but before undergoing another fusion or revision even if that hasn't been tested (and typically I don't believe it is in males) it'd be worthwhile to be tested for as males can also have osteopenia and osteoporosis. If one has a certain degree of osteoporosis (like moderate to severe) that may be a consideration in more surgery such as fusion.

Good luck to your husband with whatever is done. Maria