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2 level ALIF on 35 year-old - advice?

BorderlessBBorderless Posts: 14
edited 06/11/2012 - 8:46 AM in Back Surgery and Neck Surgery
Ok, well, here's my quick story.

Played high school football and then played recreational basketball 6 days/week in college. That (and genetics I'm sure) led to disc degeneration in L5/S1 and L4/L5. In 2001 (when I was 27) I herniated L5/S1 to the point where I had so much right-leg pain I had a laminectomy/discectomy. 6 months after surgery I fell down a flight of stairs resulting in another laminectomy/discectomy in Feb 2002.

Fast forward to last year (2009).. I had an episode after playing tennis where I was again facing the prospect of a fusion which I wanted to avoid at all costs. I got through that episode which involved lots of back pain but no neurological pain in my legs. I proceeded to lose 20 pounds (I'm now 6'3" 183 pounds) and have been doing Pilates twice/week. I have a stronger core than ever.

But alas, I hurt myself again playing tennis. It's been 3 weeks since the leg pain has begun, 2 weeks since I had an epidural and now I have weakness and numbness in my left leg. I'm going to see 2 doctors tomorrow (my original and a 2nd opinion) but every previous surgeon I've consulted has told me I will more than likely have to have 2 level fusion at some point.

If I can't get off the pain meds and have the numbness go away, I'm not sure if I have a choice.

Here are my concerns and questions:

- My original surgeon who I continue to see has recommended 2 level ALIF but since I'm 35 he's concerned that in 5-10 years I may require another fusion at L3/L4 (which are perfect right now). He said he might recommend not only the ALIF but also to then flip me over and put supporting rods up to L3/L4 to proactively help reduce the pressure those discs will then receive as a result of the 2 level fusion.

Has anyone heard about this? Experience with it?

Is the concern about a (relatively young) fusion really valid? I will continue to workout and stay fit. I've now had DDD on L4/L5 and L5/S1 for over 10 years and L3/L4 and all discs above look very healthy. Will they just quickly degenerate once a fusion below is in place?

At 35 and in pretty good shape, should I expect recovery to be quicker?


  • First of all, welcome to Spine Health. This site is invaluable in helping to educate you about various spinal problems. On this forum, there are also lots of very friendly people, who will happily share their experiences and offer support to those in the same or a similar boat.

    I am not medically trained, so my thoughts are just that; the thoughts of someone who has learnt some information through the experience of having a fusion and spinal problems.

    I agree that Pilates and strengthening your core is very helpful in improving symptoms. I also obtained help in this way, but eventually needed to have fusion surgery at L4/L5 because of the structural problems with my spine.

    I was told that the discs above and below my fusion were degenerated, but my surgeon said he didn't think I needed him to treat those. He told me that a physiotherapist would advise me how to protect them, after my surgery. I must admit that I worry a bit about having problems with those levels in the future.

    You are relatively young (at 35), to be having a fusion. I would be surprised if your young age makes it any more likely that you will have trouble in the level above in 5-10 years time. Unless your surgeon thinks that you will be more active than an older person. If you play sport regularly, perhaps he thinks that will put more strain on your spine.

    As your L3/L4 disc is fine now, it seems to me puzzling to put in rods at that level to protect it.
    Wouldn't that just shift any problems up a level to L2/L3? I believe that a 2 level fusion does put more pressure on the adjacent levels than a single fusion, but stopping the movement of the level above, is almost like having a 3 level fusion, which I would think could put even more stress on the level above. I may be wrong!

    As for the recovery from surgery, it is very difficult to predict what your recovery will be like. Everyone is different, and even in the same person, different surgeries can have very different recoveries. There are people who have had a much easier recovery with a more major surgery, and they don't understand why. Having said that, it would make sense if your recovery was quicker and easier than an older person.

    I am 54 and have made a much better recovery than I was expecting. I believe that the fact that I had been exercising and walking every day before surgery helped me with my recovery. Despite that, it takes a long time and much patience is needed.

    I'm sure that there will be other people who will post their thoughts and experiences.

    I hope that you find a solution to your problems and do let us know how things turn out for you. :-)

  • SpineAZSpineAZ WiscPosts: 1,084
    I'd say you are at a reasonable age for a fusion. We've seen people here as young as 21 and then up into the 70's.

    You have to get a good idea of how L3-L4 looks. If it's "iffy" then you may want to consider a longer fusion.

    If he does an L4-S1 fusion from the back, I'd think if he did a 360 degree (flipping you over) would also be L4-S1. In every 360 degree fusion I've seen it's the same levels from front and from back.

    (My L3-S1 fusion involved removing old L4-S1 hardware and putting all new hardware L3-S1 in the back. I had a side incision used to place a spacer in the L3-L4 disc space to keep my back in proper alignment.L4 is right now)

    So you may want a clarification. I'm not clear how this would work so if you get more information I'd like to hear his approach and reasoning.

    Although levels above and below a fusion are at risk, once a section is fused, it helps if after surgery you follow good back mechanics.

    I had my L4-S1 fusion in 1993 and it took 17 years to have to add L3. In my case it's my vertebrae that move forward (spondylolisthesis). If not for that, I had minimal disc problems at L3-L4 and likely not enough to have caused symptoms that would have led to more surgery now.

    Part of your decision depends on how active you expect to be after. Anyone who has surgery and wants to return to extensive running, weight lifting (we've seen that), or high intensity workouts may put additional stress on any level above or below the fusion.

    The reason I've had all my surgeries is that I'll do "any surgery any time any where if it will relive any of my pain" (my kind of wacky motto).

    You have to ask yourself how much the pain and/or medications are impacting your life. This means both the active part of your life to the sedentary part as well. If you are in pain often when relaxing, out to dinner, at a friend's home just hanging out, etc then it may be an indication that surgery is a good option. You can also consider another opinion from another Orthopedic Spine Surgeon and/or Neurosurgeon. Often they have differing opinions on which approach they suggest, but if each is saying that the area needs some type of fusion then you know you've got a few experts agreeing. Personally all of mine have been done by Orthopedic Spine Surgeons (they only do spine), it's just been the best match for me in terms of approach, treatment, etc.

    Don't let it worry you that you see many posts here with ongoing problems. Keep in mind that those of us who remain on boards like this for a long time are most likely those who have wacky spines that just keep popping up with more pain and problems. There are tons of people who come here, get informatin and advice and then have surgery and we never hear from them again after recovery.

    Recovery from any back surgery can be difficult. But, it's not unbearable, in most cases if you tolerate pain medications well and take them on schedule. Often after surgery someone will take a dose and say "I don't need more" then 12 hours later they've taken none and the pain has built up to a severe level. Taking pain meds regularly in the first few weeks helps. You can get up and around more easily and more often in many cases.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • Thanks for the replies. I should clarify a bit. As I understand it, my surgeon would flip me over to put a semi rigid rod up through L3. It will not emulate the rigidness you get with a fusion but rather allow for movement freely with some added support.

    He told me the rods were not approved specifically for this purpose but he has done this in the case of 2+ level fusions on younger patients who will be more active.

    Glad to hear that many people get good results. I kind of assumed its natural for people to come here when in pain (like I did) and then go away after recovery.

    I would like to play tennis after but to be honest I would rather just feel strong enough to throw a baseball with my kids at this point.

    Thanks again for your replies.

    Is it safe to say that disc replacement is no longer considered a reasonable approach?
  • SpineAZSpineAZ WiscPosts: 1,084
    Artificial Disc Replacement (ADR) is offered on a very limited basis.

    In many insurance plans will not approve it and thus paying for it out of your own pocket may be impossible.

    From what I've read ADR is offered for those with one level problems and in the lumbar spine I thought I had seen that it's not available at the L5-S1 level. The L5-S1 joint is very unique. If you look for a picture of the spine you'll see how it's a unique position and shape. I think ADR is only available in specific spine situations and is not widely available yet.

    The long term success of ADR isn't yet known. In some ways it's like a knee replacement. Generally a total knee replacement lasts 15-20 years in an active young adult. It's not easy, but it's do-able to re-do a total knee replacement. I think a failed ADR could be harder to fix and then may require a fusion at that time.

    If you are interested in an ADR you can certainly ask and the surgeon should let you know if you are even a candidate (before having to worry about insurance)
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • ok.. went to my doctor today.

    Spent a bunch of time with him. I have very little pain left in my leg but I still have numbness down the outside of my lower leg and I have some weakness in my big toe (can't hold it up when pushed on).

    The part I left out from above is that on Thursday of last week I was in so much pain (away from home) that I really had no idea how I was going to be able to fly home. I loaded up on Percocet and muscle relaxers and he prescribed a medrol dose pack (steroid).

    What I learned today is that his opinion is that there's a good chance that the steroid is acting as a super anti-inflammatory and that's why the leg pain has gone away. He thinks there is a good chance that once the steroid is out of my system (my last dose is tomorrow) that the leg pain could return. If that's the case, he recommends I have the fusion immediately.

    The specific procedure he is recommending is a 2 level fusion at L5/S1 and L4/L5. He would go in from the front (Anterior?). He also said that because my herniation is towards the rear there is also a chance that he won't be able to retrieve the herniated matter from the front and he may have to flip me over and go in from the rear in addition to the ALIF.

    The other indication that would cause him to recommend the 2 level ALIF is if the numbness does not subside in "a couple of weeks". He said that's a sign that the nerve is dying and if we wait too long we reduce the chances of the numbness and weakness of ever going away.

    So I feel like I'm getting closer and closer to having to have the surgery. He's quite confident that it would be a success. His definition of success is that my back and leg pain go away completely. I asked him why he's so confident and he told me that 85-90% of fusions actually fuse (success) and that the majority of those that don't are smokers, diabetics or morbidly obese. In a perverse way that kind of made me feel better as I never smoked, I'm not diabetic, at 6'3" and 183 pounds I'm in pretty good shape and I'm relatively young at 35. So not to jinx it but the prospect of no (or little) back and leg pain is really tempting.. even though he warned me that this is serious surgery and it won't be fun at all. He told me the first 2 days are miserable even with morphine.

    Definitely have mixed feelings now.. I obviously want to avoid surgery but also wish I could get this behind me.. I still feel like if this episode goes away it's just a matter of time until I re-aggravate it...
  • SpineAZSpineAZ WiscPosts: 1,084
    I've been where you are, when you travel and you get there okay but you fear the ride back. We have to fly to Michigan for Thanksgiving and it's already giving me anxiety though my doctor has said he'll give me something like valium to help me relax. If I'm in pain, and I tense up and get a bit of anxiety. And I never get on a plane without my actual prescription bottles (for my own supply and protection in case anyone should ask what I'm carrying).

    Surgery can be a hard decision because as we all agree, spine surgery is not easy. The doctor may be right about the steroids, they are used as an anti-inflammatory and sometimes once they are out of our system or the affect wears off the symptoms come back. That's when I knew I had to do my neck surgery as the ESI had stopped working. Occasionally if the nerve is just irritated and there is no disc or spine problem then steroids my help enough to avoid other treatment.

    A 360 fusion (anterior through the front and posterior through the back) is actually much more common than it was years ago. I like that he wants to take care of everything he finds so he tells you it may be anterior and posterior. That's a sign that he's looking at the problem as a whole and not just one symptom or one problem. And a two level fusion seems to address everything he's seeing right now. If you are confident in him as the right surgeon and you trust in what he's saying, take his advice to heart.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
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