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Confusion over which disk to operate on

painfuldyappainfuldya Posts: 17
edited 06/11/2012 - 7:38 AM in Back Surgery and Neck Surgery
Last year I had a Discogram that showed that although L5-S1 was herniated and L4-L5 was bulging my pain was coming from L3-L4, which didn't show up on an MRI as herniated or bulging. A neurosurgeon wanted to do a fusion of L5 and L4 because these are the discs that show up on the MRI as problematic. This neurosurgeon does not believe in the Discogram as a test. However, a physiatrist I saw recently thinks I should do another Discogram because the first one said that my pain was coming from L3 L4. All I know is that my back is killing me. I am new to this website. Does anyone have any advice?

Vicki
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Comments

  • Welcome to Spine-Health. You'll find a lot of info on this site as well as some great people in the forums. There's quite the wealth of knowledge here.

    I'm curious about your doctors: you say their both neurosurgeons, but are they fellowship-trained spine surgeons (these can be either ortho or neuro)? If not, I'd really suggest you find one, someone who only works on spines.

    Also, I'd suggest getting another opinion. It's common for people who have two differing opinions to get a third and see which side they're on, if any. You need to be 100% confident in your surgeon and comfortable with what they suggest. I have a fantastic surgeon, and I put my care completely in his hands with complete confidence in what he wants to do or try.

    Can you please tell us about your symptoms?

    Again, welcome to SH.
    Cath
  • I would suggest you collect a couple more opinions. The last thing you want is to have the wrong level fused. Who was it that ordered the discogram?

    It is not unheard of to find a spinal specialist who is not a fan of the discogram test. There is growing evidence to support the theory that the test itself causes discs to deteriorate more quickly. Many doctors do not routinely request one as they might have in the past.

    However, if you've had the test and it indicates the problem is at one location, it would be odd to ignore that result and operate at an adjacent segment. Unfortunately what it may mean is that both levels have some weakness and may need to be fused together
    at some point in the future.

    I would definitely get another opinion, probably several more.

    Good luck with your diagnosis.
  • Thanks so much for your reply! The first is a neurosurgeon (the one who wants to operate), the second is a physiatrist (the one who wants to do another Discogram). Both of them specialize in the spine.My symptoms are pain in the lower back especially on the left side, pain down the backs of both legs, and pain down the front of the left leg. The back pain is worse. So far only the L5 and L4 herniation showed up on my MRI but the physiatrist says I have a herniation in L3, based on film from the last Discogram. The neurosurgeon doesn't think it is significant. I am so confused! I would appreciate any feedback you have. I have already seen a bunch of doctors and I'm in a lot of pain Thanks so much
    Vicki
  • You're kidding-they actually contribute to deterioration of the disc? Where did you find this information I want to read it, I'm glad I saw your post. This would be my second Discogram within one year if I decide to have it. As for opinions, I've been to so many doctors over the past year and have gotten nowhere. Two of them told me that they couldn't help me because they don't do triple fusions, which would support your comment about an additional level having to be fused. Another two told me I only needed two discs used (ha ha only). Yet another doctor told me that I didn't need surgery and should do more physical therapy. I'm going crazy, I'm in so much pain and I don't have a life. Also, I was wondering how you add your medical history at the end of your post the way you have done in yours. Today is the first day I have used this site. Thanks so much.
    Vicki
  • I can't locate the one study that I was reading a couple days ago, but here is a link to another:

    http://www.orthosupersite.com/view.asp?rid=40067

    The problem is that the deterioration may occur years from now, not immediately.

    My situation was pretty straight-forward but even so, the opinions ranged from fusing one level, which was the majority opinion, to fusing five levels! But in my case, no one suggested options other than fusion.
  • Yes, there is a lot of controversy about the discogram. Essentially, the test shoots dye and pressure into the disc, causing pain if the disc is already damaged. Of course, if the disc is damaged, and you shoot if full of stuff, it can be damaged further. Or, in a case like mine, where the discs were totally torn through on both sides, the fluid just leaks out both sides. If there are disc fragments, they can be pushed out onto adjacent nerves. A large number of the tests are done without causing further damage, but there is always the risk. In your case, however, you do want to be very careful to get the level that is causing the pain fixed. Not much sense going in there and having all that work done and not taking care of the problem.

    I wish you the very best. I agree with Cath -- you should get another opinion from a dedicated spine doctor, preferably one who is fellowship trained.

    Linda
    3 level spinal fusion, L3/4, L4/5, L5/S1, November 2008. Stiff, but I can walk.
  • cath, you say you have a fantastic doctor. I don't know what the rules on this site are for giving doctor recommendations and I also don't know what city you live in. You are right though I definitely need some more opinions. Would you be able to recommend a doctor? How is this done?
  • Thanks so much for your reply. It really sounds like you've been through a lot and that you're very knowledgeable. On my MRI it shows that L4 and L5 are herniated. On the Discogram I had last year, it shows that L3 is herniated and is a pain generator. However, strangely L3 did not show up on my last MRI-it just showed L4 and L5 again.
    The neurosurgeon I went to has the abbreviation for fellow of the American College of surgeons after his name, does that mean he is fellowship trained? Otherwise I'm not sure what you mean by fellowship trained. As for the physiatrist who's doing the Discogram I'm not sure if he is fellowship trained, but he is definitely a spine specialist. I'm scared to get this second Discogram even though they are only doing L3.
    As for triple fusion, I also had a similar experience with one orthopedist-he told me I needed a triple fusion and that there was nothing he could do for me because they don't do triple fusion. He then told me that I would probably get worse and I left the office with nothing, not even a prescription for physical therapy. I wanted to die. How did you find someone who does triple fusion? I don't see anyone providing doctor recommendations on this site, and I don't know what city you live in, but it sounds like you are getting better care than I am so I'm interested in finding out who you work with. If you have anyone to recommend, doctor or hospital, I'd love to know. Is there some sort of private message feature? I don't know how this works. Thanks Linda and Hope you are feeling well today.
  • If your doctor feels strongly that you need to have the discogram, then he must feel that it will provide information that is necessary to have...so you may as well go ahead and do it. As Linda said, if it is the test that will provide the necessary information, then you need to have it. You do not want to go through all this surgery only to find out it was something else causing the pain.

    The American College of Surgeons includes surgeons from all different specialties...hernias, appendectomies, etc. It does not indicate anything pertaining to spinal specialty.

    Fellowship training is a year or two program beyond the surgical residency that a doctor must be chosen for. It is more like a mentor situation where the young doctor, who has completed medical school and a surgical residency, works alongside a seasoned specialist getting hands on experience in diagnosing, surgery and research. They are often in academic settings, but not always. Some large spine clinics offer fellowship training. It is a designation that lets the patient know that this doctor devotes all his time and attention to issues of the neck and back. In the case of an orthopedic spinal surgeon, he does not replace joints or operate on knees -- he only works on necks and backs...and with the neurosurgeon, he does not specialize in the brain and operate on backs occasionally. His whole practice will be devoted to patients who have back or neck problems.

    Older doctors may not have this training because it is relatively new -- I'm not sure when spinal fellowships originated,but certainly by the mid 80s they were in place. My surgeon is 54 and he did a fellowship in Toronto...so it's been around for awhile.... ;)
  • The board prohibits posting names of doctors, clinics, hospitals, etc. but you can write that in a PM. On the left side of each post, under the person's name there is a link that says "Send PM." Just click on that and it will open into the PM page....
  • Please see me PM to you.

    Cath
  • I am a bit confused! I have 3 problematic discs (ie bulging/herniated), but I had a discogram done recently as all my pain was on the left lower side of my back and in my left leg (ocasionally). When he injected the L5 S1 disc, I nearly shot through the roof, whereas the others caused just mild discomfort. So my understanding is that the discogram should show up the inflamed and the problematic disc that is causing your symptoms. The other 2 discs at L4 L5 and L1 S12 were obviously damaged and degenerative, but not causing my pain.

    I then decided to have ADR surgery and it has been 100% successful. I now have no back or leg pain (other than a little post op pain when I overdo it too much - I only had my surgery last month - but nothing like the previous pain).

    My operation was performed by a spinal surgeon in the UK (he specialises in spines only).

    I also understood that having a discogram has it's risks (but so does taking a tablet!), and if you want to get to the bottom of your pain source, you will have to listen to the experts. In your case there seems to be a bit of confusion though as two different people are saying different things. Can you see someone else?
  • Welcome to the board --

    I just wondered how many levels you had replaced?

    That's great you're doing so well. As you probably know, they do not implant at multi levels in the US...or at least, it is uncommon.
  • As luck would have it, the North American Spine Society met last week in San Francisco and this was one of the studies that was released:

    Modern discography techniques can lead to accelerated disc degeneration --

    If anyone is interested in reading the study, it is located here:

    http://www.orthosupersite.com/view.asp?rid=50644

    The conclusions is:

    New disc herniations were increased in the discography group as were Modic changes, he said.

    “Careful consideration of risk and benefit should be used in recommending procedures involving disc injection,” Carragee said.
  • What is scary about that is people like me. I never had a Discogram, but as you see fusions. At just past a year, yeah (sniff) a year my level C6/7 went, and now I have to get another MRI after my PT if no change because now the dang C7/T1 disk space is decreasing!! The *only* set that is "good" still is my C3/4. After reading that article, and how minimal the disk is affected (needle) it kind of bums me as a "fusion" person who has already had adjacent disk disease and another fusion - looking like 2 more surgeries in the future. :-(

    Ongoing issues... What's the phrase? Once a spiney always a spiney? Trying to keep a sense of humor as this has cost me my career - but still a sense of humor!!! Thanks Gwennie - eye opening article. :-)

    Brenda
    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
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