Advice on revision surgery for failed fusion

Advice on revision surgery for failed fusion

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spike
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Joined: 05/07/2011 - 3:28pm
Advice on revision surgery for failed fusion

Hi all (long post!) -

I'm new to the forum, but had lurked here before my original spinal fusion surgery to read stories and collect information. I'm 42 years old and in decent shape, but had increasing lower back pain over the last several years. After several rounds of physical therapy and epidural spine injections over the last three years, I finally had a L5-S1 posterior spinal fusion in July of 2010 due to intractable pain in my lower back and the beginning of right-side radicular pain. I was diagnosed through MRI, CT-scan and discogram as having a completely ruptured and degenerated L5-S1 disc impinging on my right-side L5 and S1 nerve roots. I also had right-side facet arthropathy causing foraminal stenosis!

It was a tough decision, but I finally did the surgery. I ended up using a neurosurgeon who had performed a micro-disketomy on a friend at work. I had the "gold-standard" posterior lumbar spinal fusion at L5-S1 with nerve decompression and removal of the right-side facet joint. The graft was a PEEK TLIF with Actifuse, some cadeavor bone and some of my bone they had removed. 4 pedicle screws and 2 rods were used to hold the single-level fusion in place. When I woke up in the recovery room I noticed that my right big-toe was completely numb and I was having worse radicular pain down my right leg than before the surgery. In addition, I had extreme pain in my right hip. Recovery was slow but I eventually returned to work (computer desk job) after 9 weeks of disability. I did 3 months of physical therapy, out of which 2 months was water therapy in a pool (highly recommend!) and 1 month with traditional land therapy. 5 months post-surgery (Dec. 2010) I seemed to be healing o.k. except for the pain in my right hip, which was not constant and only brought on by movement that engaged the hip. My NS (Neuro Surgeon) ordered a lumbar CT-scan to see if any of the pedicle screws might be touching any nerves. The CT came back negative for this, but showed that very little fusion had actually taken place. My NS did not seem worried at the time.

By March of 2011 I was on a project at work that required me to be sitting/standing through many long hours of meetings. At this point I begin to have new lower-back pain on my left side of L5-S1 in addition to the hip pain. I also felt a "tugging" feeling which I read could be the instrumentation hitting muscles. Also, I was waking up in the middle of the night with extreme muscle pain in my mid-back that would only go away if I got out of bed and walked around. My NS prescribed both Lyrica (100 mg bid) and an anti-inflammatory (Mobic). He also recommended going back to physical therapy and he also ordered another CT scan. I responded quite well to the Mobic and Lyrica and begin doing more active stretching at PT including some spinal rotation. The PT helped me get some hip mobility back, but it seemed that I was pushing myself too hard and ended up getting too sore even with the meds.

2 weeks ago (9 months post-op) I met with my neurgo-surgeon to go over the new CT scan results. He said that basically there was no difference in fusion from the December 2010 CT scan and declared that I had a "failed fusion". I reviewed the CT-scans with him and saw with my own eyes that there was very little if any fusion and basically no difference in bone growth over the Dec 2010 - April 2011 period. He had me stop physical therapy and has now recommended that I get a revision surgery since I am in worse pain now. My pain level does not require painkillers yet (Lyrica and Mobic seem to do o.k.), but seems to be getting worse. He said that the instrumentation will not last forever. Additionally, the CT-scan radiology report shows that I now have a 4mm "bulging" disc at L4-L5 and a 2mm "bulging" disc at L3-L4. Also, there appears to be scar tissue on the right side of L5-S1 (where the laminectomy was performed) persistently touching the L5 nerve. My NS is recommending that I get a 360 degree (anterior & posterior) revision spinal fusion. He wants to put a large graft with BMP material in from the anterior (front) side, redo the posterior instrumentation (thicker pedicle screws and new rods) and add new graft material in the posterior "gutter" region. He claims BMP is more aggressive in helping fusion than the Actifuse he used in the 1st surgery.

I met with an orthopaedic spine surgeon yesterday to get a 2nd opinion on my condition, and he concurred about my condition and basically recommended the same revision surgery as my NS. He reviewed the CT-scans too and thought he saw one of the pedicle screws slightly touching my L5 nerve and said maybe this was causing my right-hip pain (funny, my NS never saw this). Anyway, the ortho spine guy said he would be willing to do the revision surgery but also knew of my NS and said he was a good surgeon too. I asked if a bone-growth stimulator would help this late in the game and he said no.

So, here I am confused and scared about getting a 2nd surgery. I have 2 opinions that basically line up from 2 fairly highly regarded spine specialists in my area. My pain is getting worse and I can only sit at work now for 1/2 hour at a time. So, my questions for anyone out there that may have been through a similar process:

(1) Should I hold out and wait for 6 more months while in pain to see if I magically fuse over that period? Obviously avoiding a 2nd surgery would be great, but there was no delta in bone growth over the last 5 months at the fusion site. I don't smoke and kept my brace on for the first 3 months post surgery, so why didn't I fuse in the 1st place?

(2) Should I schedule the revision surgery ASAP and just go for it? Has anyone had similar 360 degree revision fusion surgery? Is the recovery period greater than what I had initially done? Are there greater risks with the anterior approach?

(3) I'm worried about permanent nerve damage to my L5 nerve (big-toe is still numb and when I stop the Lyrica I get some radicular sensations from right-hip on down). Will redoing the hardware maybe fix this or if it is scar tissue will I always have the nerve sensation?

(4) Should I seek a 3rd opinion? There is a "world reknowned" top 5% ranked ortho surgeron in my area (San Diego, CA) that my GP says is famous for fixing failed fusions. I called his office and he doesn't have an appointment for 2 more months! I put my name on a cancellation list to see if I can get bumped to an earlier appointment but have not gotten a call yet.

(5) Should I just live with the pain I have (while taking Lyrica/Mobic to maintain) and not get the revision surgery and hope that the hardware holds for a few years?

I have lots more questions and was hoping someone on this site who has been through a similar experience could share some insight. Sorry for such a long story but I thought I'd share where I'm at. I've also done a lot of research on the web and talking to friends of friends, etc., but have yet to talk to anyone who has had failed fusion. Please reply if you can shed some light on my situation through your own personal experience.

Thanks!
Mike

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sleeprgirl
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Sorry that you..

are facing a possible revision. Did your surgeon have you wear a bone growth stimulator at 5 months, when he determined you had no fusion? Also, was he not worried that the Mobic would interfere with bone growth? Have you had any steroids since surgery, or do you smoke?

My lumbar fusion history could be yours...very similar. I had no fusion noted at 6 months. My physical therapist insisted to my NS that I have a bone growth stimulator. In three months, we saw a small amount of bone growth. Three more months, more growth. At 16 months, I am finally fully fused. However, I have a tremendous amount of scar tissue around the fusion site, plus multiple bulging discs and osteoarthritis in my thoracic spine. Hence, I still have severe pain and numbness in my feet and lower legs.

I think it is a wonderful idea that you have the option to see another surgeon with wonderful credentials that is local to you...what a blessing. I have a friend on this forum that is potentially having to travel several thousand miles because of a similar situation.

All the best,

SG

virginiap
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hi Mike

I am 8.5 months post ALIF and I too am having issues with lack of fusion. My NS who performed my surgery basically removed himself from my case at 4.5 months, unlike you, my recovery has been riddled with complications. Luckily, aside from pain (same as pre op with lots of new symptoms, including nerve damage) most other complications have slowly improved.

I was lucky to find another NS to follow my case. He is suggesting posterior fix, which includes foramanotmy, 4 pedicle screws & two rods.

I too sought another opinion from a ortho spine surgeon and I was very impressed with my consultation. He is top in my area and has a different suggestion for my revision. First up he did flex/ext Xrays (no one else has done this!) and unfortunately for me there is measurable micro motion within the segments, not good! He said I have some suspect anterior growth but its minimal, if at all. I am definitely unstable. He also believes that not only am I not fusing, but that I have a fibrous non union. In other words, scar tissue is growing in between the vertabre.

So between the instability and the fibrous tissue, he offered me a minimally invasive approach, Spinous process plate, bone grafts & facet screws along with the foramanotmy.

While I consider my options the OSS has me back in my brace & no BLT's, he believes that when I bend or twist the motion is aggravating the levels, causing pain and may be creating more fibrous tissue.

Ahhh, what to do???

So like you I am full of questions and uncertainties. I can't tell you what to do, Im sorry, you are going through this. I'm glad your pain levels are under control. I can say there is a fundamental difference between a NS & OSS. I really appreciated the explanation the OSS gave me and the action plan. BUT I still don't know what to do!

I am going for a 3rd opinion. I'm scared after going through such a rough recovery and failing, the thought of a re do, is a huge swallow. I am in severe pain constantly unable to work and now learning of the instability I may not have many options.

Mike, Sleepgirl mentioned the mobic, I have been told no anti inflammatory meds during fusion process. Did you ask either doctors what the chances of the magic fusion occurring if you do wait? I know another member who went into BGS at about 9 months, not sure of his outcome, he is still using it. And it worked for sleepgirl too! There is lots of info on web about non unions & BGS, do some research before you make your decision. And keep checking the cancel list with the other surgeon, get your 3rd opinion! Seeing your pain levels allow to function still and it appears there are no immediate dangers in waiting, if I were you might wait & try BGS ?? Did anyone order blood work? If not you may want to ask, its important when your not fusing to rule out possible causes.

Keep in touch & I hope some how you get that magic fusion!

V

spike
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Re: advice on revision surgery for failed fusion

Sleeprgirl -

Actually, the failed fusion was declared by my NS at 8 months post-op (sorry, my post may have been confusing on the timeline). I failed to mention that at that time my NS did take me off the Mobic since he mentioned NSAIDS can interfere with the fusion process. He has offered me a BGS since my insurance (UNH) will cover it at 9 months post-op with failed fusion. I don't smoke, but now I do remember one thing within the 1st 3 months of recovery from the surgery that my NS had ordered. Since I was having such bad hip pain, he did have IV corticosteriods injected during my post-op hospital stay to reduce inflammation. Also, about 1.5 months after when the hip was still giving me issues, he had me put on a 5-day course of an oral corticosteriod (similar to prednisone). I'm not sure if this amount of NSAID that early in the recovery process would cause the failed fusion, but it is an interesting thought.

I am happy to hear you finally fused but sad to hear that you are still in pain. Thanks for the feedback and I will say a prayer for you!

Cheers,
Mike

spike
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Re: advice on revision surgery for failed fusion

virginiap -

Sorry to hear about your failed fusion. It is interesting that you had an ALIF done rather than PLIF. From what I have read and spine doctors I've talked to, it seems that PLIF is the most popular.

My NS does flex/ext x-rays every time I visit him, but he has mentioned nothing about any visable micro-motion of my instrumentation. His theory about my soreness on my mid-back (higher up than L1-L2) is that I am having some micro-motion of my HW and the rest of my spine is working extra hard to support spine movement (funny he can't see anything on the x-rays, maybe he hasn't looked hard enough). I found that any minor spine twisting exacerbates the pain, so as I mentioned in my original post I am no longer doing my 2nd round of PT.

See my previous reply to sleeprgirl about going off the Mobic, which I am no longer taking. Since I have to wait 2 months to see the expert Ortho-spine guy, I might as well order the BGS and wear it ... it can't hurt. My NS did say that it appears I have fibrous tissue within the graft site similar to what you have. I don't know how much a BGS will help. He also said there isn't much graft material left as it has been re-absorbed into the body. But, miracles can happen and sometimes it just takes longer. Like you mention, it is worth a try with the BGS.

I'm sorry to hear about your situation ... facing the thoughts of a 2nd surgery is very scary, especially when you are probably facing a 360 degree like what is being recommend for me. I wake up every night in the middle of the night worrying about it and end up having to take some Xanax to get back to sleep. Fortunately I am not in as much pain as you and sleeprgirl ... the Lyrica seems to work wonders for me. I tried going off of it for 4 days last week and I was amazed at how much pain returned! I think I will order the BGS on Monday and hope I get an appointment with the 3rd OSS guy.

I hope all goes well with whatever decision you end up making. Thanks for the feedback ... it has helped! Get better and I'll say a prayer for you!

Cheers,
Mike

tamtam
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Welcome

Mike,

First let me say welcome to spine-health. As far as your non fusion and what went wrong it is hard to tell. It can be the original bone graft was to small and had to much work to do. One thing I caution you on is the use of BMP. Do yourself a favor and look up the FDA guidelines on using BMP. The one issue with BMP is if it is used wrong the situation can go from bad to worse. All my surgeries are cervical spine, I only know the guidelines from the cervical spine. When they use the product it calls all the bone growth material in your body to wherever it has been placed, and it will be gone from your body before you even check out of the hospital but the work it does is still going on. So for example if someone gets that on your nerve roots, you can see what can happen. I don't want to scare you, just do the research on it, so you understand the use. Just a note many in that area use BMP, sense the inventor of it is from that area and teaches it use.

AS far as your current situation, if your not really at risk and you can deal with the pain, I would try and wait out the opinion on the third surgeon. While I have not had a 360 lumbar fusion, I have had the 360 cervical fusion and it is a longer healing time. Another thing you might want to research with whomever does the surgery is the vascular surgeon they will be using. On the anterior approach they will need one. One surgeon says you have a issue with scar tissue and they plan on removing it, I am sure. I would find out about that scar tissue coming back, and also what type of scar tissue you will have from the anterior approach.

As far as the non-union, I also think it is important to find out the reasons why you didn't fuse. While BMP has a high success rate with fusion and may not be a issue on the revision, it still can happen. My surgeon is constantly watching my vitamin D levels along with the CRP levels. I like you was given the steriods post fusion for some severe swelling. But they had to be used as I was having a breathing issue from swelling. But that small amount should have no bearing. You might find out if they see a issue called psuedoarthrosis(sp), which is a false joint. If that is what they are seeing then a bone growth stimulator won't help.

As far as being nervous, that is natural and it completely understood. I can tell you there are many here whom have had the 360 fusion and have done well with them. Just expect the long recovery time. Just don't feel pressured till you have all your questions answered and are comfortable with your decision.

Just thought I would stop by and welcome you to spine-health. Keep us posted on how you get along.

virginiap
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Mike

Thanks for prayers!

I had been offered PLIF from a different NS prior to my ALIF.

The ALIF has been growing in popularity. The reason I went with that approach was my surgeon said recovery time would be 8-12 weeks. He also felt due to my size; I am very slender the PLIF instrumentation would not fit well in my anatomy. The OSS I saw in April agreed with this, which is why he would not suggest pedicle screws & rods for my revision. But the other NS is suggesting just that... hence my confusion! And need for 3rd opinion.

I too had my fair share of steroids post op & wonder if that aided in my non union. I only had 1 depo pack, but have had 6 epidurals & nerve root block post op. Between Dec & Apr.

I wonder if the fibrous tissue forms as a way of your body trying to protect itself?

My motion is not in the instrumentation but rather the actual segments, the vertabre themselves.

My bracing trail, past 3 weeks has provided some mechanical relief in my back. I do have follow up with OSS tomorrow, he was going to do research on a BGS for my situation,.so I'm hoping he has data either way.

Keep in touch & let me know if you get the BGS & if it helps. Tamtam made some interesting statements in her post about the BGS, which I will bring up with my doctor tomorrow. She also mentioned the vascular aspect of the ALIF, which is very important as the anterior approach requires a skilled surgeon to actually do the approach & close, as well as monitoring you throughout the surgery.

Good luck Mike! I know how stressful this is, I too worry & have trouble getting it out of my head.

You are right, miracles do happen, god bless!

V

sleeprgirl
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Steroids

No one can predict how steroids will effect each one of us. I have severe adrenal insufficiency and developed Cushings syndrome from one Medrol dosepak two years ago before we understood just how fragile my adrenal function was at the time.

The body secretes around 20mg of cortisol a day. It can need much more than that during time of stress, whether emotional or physical, and normally functioning adrenal glands can usually manage to cover those needs.

For instance, Kenalog is used frequently for epidural injections. A typical dose for ESI is 40-80mg. If you were replacing your daily cortisol, the dose of Kenalog would only be 0.8 mg. If you are taking a 4mg Medrol dosepak, the first day of the regimen is 24mg of Methylprednisolone. If you are replacing your your daily cortisol, you would only take 0.8mg.

As you can see, the dosage of both dosepak and epidural injections are quite high. This is not low dose steroid therapy. Steroids are necessary in many situations, but they are not benign. I've seen them save lives, but they do contain risks, so we all must be well informed about these risks and listen to our bodies for adverse effects.

When I had no fusion at 6 months, steroids were a concern of mine. I also had to look at hormonal imblances, vitamin/mineral difficiencies, etc.

Good luck with your bone growth stimulator. So hope that it works for you.

SG

TheRelaxer
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Jeez, I just joined the

Jeez, I just joined the site, and going through the forums, I have seen a lot of failed spinal fusions. My older brother got one maybe five years ago, and it was terrible for him. He was a huge scar down his back and recovery was at least two months. Now he doesn't even feel much better. A year ago I started having pain in my lower back and my doctor said fusion was probably in order. I definitely do not want to do that though! I've been looking at these minimally invasive practices in Tampa Florida where I live, and have seen some good things from the Bonati Institute. They have a high success rate and the procedure is revolutionary. I also looked at Laser Spine Institute in Tampa, but I've read a lot of negative things on the Internet about them. There is an article on Bloomberg news pertaining to them that makes me never want to be in their vicinity. My brother and I are going to go to Bonati and see if he has any advice for me and if he can help my brother with his failed fusion. I'm nervous; never had any sort of surgery before!

MLT01
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Soory to hear you have a failed Fusion...

I actually had a revision on Oct.29th. I will be honest the revision was a tough recovery. I had a 360 done in August of 09 and mine failed to loose hardware and a non union.

I go tomorrow for my 6 month checkup with a CT SCAN to see how things are going...I'm a little nervous seeing that I still have pain. Hope things work out for you

Maria

spondylolisthesis at L4-5; stenosis,
Lumbar surgeries 1999 L4-L5
Lumbar staph infection 1999-2000"
Meningitis x5 in 1999-2001
Brain shunt 2000"
Brain shunt removed 20001"
ALIF/PLIF fusion 8/5/09
Failed fusion and Failed Hardware
PLIF Fusion scheduled for 10/29/10

Emily
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I am very nervous about my revision..

I am scheduled for a two-stage 360 revision next week. Because the cause for my not fusing is an infection, I don't really feel I have much of a choice here.

Is the recovery for an ALIF with posterior revision too very tough? I had a hellish time after my PLIF a year ago, but am now totally unable to function at all. So anything that will help get me less pain and more function is ok now.

My feeling is that the longer you wait for a fusion that is just not going to happen (because the fusion environment is wrong, the alignment wonky) or all of the dozens of reasons that some fusions fail, the more out of shape you'll be and the harder the recovery.

Anyone with experience to share?

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