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S1-L5 mild herniation and a "bone spur"

SteveCSSteveC Posts: 64
edited 06/11/2012 - 7:25 AM in Back Surgery and Neck Surgery
Morning All,

Thanks for reading all of this in advance. I'll start out by saying I am in shape, muscularly very strong, do weights, yoga, swim etc., don't smoke and only drink socially.

I am looking for some insight and thoughts on the next best move for me...laminectomy vs. fusion.
Two surgeons have warned me that a lam. will likely require a follow up in 5-10+ years to deal with further disc degeneration. Both have said this is required as a minimum.

One surgeon suggested fusion "now rather than later" since I do have some disc degeneration/thinning and a lam. won't address instability. I have no gross instability, but may have micro-instability (see below). He has said since my problem is S1-L5 that a disc replacement is not the best idea.

My physiatrist warned me that post-operative chronic pain was more likely following a fusion than a lam. (about 50%, versus about 15%). Not a fun prospect.

I think this frames the question: "Since stability points to fusion, is there any way that micro-instability can be assessed?" Since my initial flare up, I have often felt my lumbar/sacrum was "weak" or my hips were "unstable." I've never been sure if this was due to muscular tiredness due to other weakness/compensation or if I am (slightly) mechanically unstable. Which came first? Chicken or the egg?

Here's the executive summary:
23 months ago - searing white hot pain in lumbar/sacrum - no motion or initiating activity. Pain management worked. Chiropractic was "the old fashioned way" and did not work and on 2-3 occaisions made it worse. MRI nothing special to distinguish me from my peer group, some mild disc bulge, some mild stenosis.

4 months ago - sitting down...searing pain, body felt heavy on my back. Could only shuffle 6 inches at a time, with support. Only comfortable position was laying on my side. Had left leg drag a couple of days after, but didn't know how serious it was. Cleared up spontaneously in 3-4 days. MRI was same as before...perhaps a slight increase in herniation? Difficult for even the radiologist to be definitive.

3 rounds of epidurals - helped the pain.

1 month ago - left leg drag. Medrol dose pack, cleared up well in 1 day, 99% in 3 days. Surgical consult ordered - No need for surgery now...but be prepared in the future.

Last week - left leg drag, much worse than before. Bad enough to get an immediate consult with a surgeon and MRI. MRI showed maybe a 1mm increase in my hernaiated disc, putting pressure on the RL nerves, and a facet (?) putting pressure on my LL nerve. My physiatrist warned me that surgery was not being pro-active, it was reacting earlier, rather than later to an emergency situation "You need something done, sooner."

Thank you!
Steve
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1345

Comments

  • Don't know what others would advise, but if you can get 5-10 years without a fusion, that's the route I would take! It just takes so long to recover from the fusion surgery. Who knows, the lammy might do the trick for longer than that! Just my thoughts.
  • :) first, i want to say hi and welcome you to the forum. :H we are here to offer you support and answer what questions we can. i have had a double laminectomy and had a good recovery. it is now over 25 years later and i am having problems but nothing surgery can fix. :''( i would not reccomend a fusion if the laminectomy can do the trick. good luck and ask lots of questions and get all your answers. :? good luck and i hope to see you around the forums. Jenny :>
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  • Hi Steve, welcome to SH. You have found a great site of information and support. Have you had flexion and extension xrays to check for instability? Even these aren't absolute as far as the instability goes, but it usually the way to check for instability. I had them with result of marginal instability of my spondylolisthesis L4-5. At time of surgery, surgeon found extreme instability when he got in there. My back crunched with every little movement I made, even just standing and shifting my wieght back and forth on my feet caused grinding crunching noise in my spine. That sensation is totally gone now post fusion.
    As far as which surgery to do, only you and your surgeon can make that decision. I would recommend that you research each option thoroughly. Remember fusion patients often end up with adjacent disc disease later on requiring further fusion due to added stress on the surrounding discs. Often people start with the least invasive option first. Perhaps seek a second opinion from another surgeon to help you decide. Take care, >:D< Cali-Sue
  • I did have flexion and extension X-rays and no gross instability was noted. Although the surgeon says that micro-instabilities could play a role in my symptoms.

    I did speak to another surgeon whose attitude was "wait and see." Much as I don't want to go under the knife...3 hits of "drop foot/foot drag" in 3 months has me more rattled than the "white pain" although, dealing with that is no picnic either.

    I am leaning towards the laminectomy at this point. There doesn't appear to be any flags for instability, and prior to the first incidence of "white pain" my back felt very stable.

    But...that being said...my first physio noted some instability in my sacrum (post white pain attack)...I gave up doing laying ham curls as they hurt my lower back...I describe my back as feeling "weak" (and unstable) most often.

    Thanks again,

    Steve
  • I know it is a hard decision to make and probably even harder if you are not in constant pain.
    As has been said only you can make the final decision but you also have to look at the future. Once you have had a fusion there is a high chance that you will need further down the track as it puts more pressure on your discs above and below the fusion. So eg if you had a fusion now L5-S1, you may be looking at another one in 5-10 years.L4-5

    Or if you had the laminectony now you may still be looking at a fusion in 5-10 years but it would be L5-S1.

    Personally, if you are in great pain constantly and had definite instability then I would say go the fusion but if it is for the hernieation and you have tried everything else then why not start with the laminectomy and give it a chance.
    If you are fit and healthy as it seems you are then you have a great chance of this being your only surgery.

    Have you been having intense PT? Often that can revert the disc.

    Sorry for playing devils advocate. }:)

    Blessings Sara O:)
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  • Angelback said:
    I know it is a hard decision to make and probably even harder if you are not in constant pain.
    Exactly!

    The surgeons letter described: disc dessication and collapse of the disc space, slight bulge to the right (my leg issues are always to the [strong]left[/strong]). Facet arthrosis and facet cyst directly over the left-sided nerve root (explains my drop left leg and the extreme "white pain" when things really go bad.) No other significant issues. He suggested laminectomy at a minimum

    I would describe my issue as discomfort in my sacrum and a feeling of weakness, but intermittant (pain only when there is a major flare - of which there have only been 2 - but they involve several weeks before they calm down). The ache/weakness can come on for obvious reasons like wrestling my son, or just from waking up in the morning. It is not debilitating, but I do have to be careful what I do, lest I feel weaker. This is the part which makes me think fusion.
    Angelback said:
    if you had a fusion now L5-S1, you may be looking at another one in 5-10 years.L4-5

    Or if you had the laminectony now you may still be looking at a fusion in 5-10 years but it would be L5-S1.
    Agreed. It seems discretion might be the better part of back surgery.
    Angelback said:
    Have you been having intense PT? Often that can revert the disc.
    The PT I had involved Pilates type exercises which are so easy for me, unless of course I am in the middle of a "weak" phase, in thich case the balance skills are way off.

    Likewise, I do yoga as often as a I can. Apart from being inflexible, like most guys, I have no problems...unless of course the back is giving me some issues. If I am, I modify significantly.

    I don't know which came first...does the nerve on the left and bulge on the right give me the feeling of weakness, or is my sacrum wobbly? One PT did notice a "tip" in my hips when doing a laying ham curl.

    Yup, it's a tough choice. I know if it was my prostate, I would be very aggressive, but my back isn't going to kill me, but it will depress me because I can't work out or wrestle my son.

    I suppose if a laminectomy and disc trim, addresses the nerve issues (on both sides), it will act as a diagnostic for instabilities as nerves will be out of the equation.

    Thanks for listening to my out loud thoughts and thank you everyone.
  • A lami takes bone away from the vertebrates. It doesn't address the bulged disc. The disc might continue to bulge even further afterwards and you will be back to square one.
    Sometimes lami's de-stabilize the vertebrates because the procedure involves cutting of ligaments, muscle.

    Fusions are really bad too.

    Real nice choices we have, huh?
    Ugh.

    How is your 4-5 disc?
    -----------------------------
    On the sunny and mild Central Coast of California

    L4-L5 endoscopic transforaminal microdiscectomy June, 2007
    L5-S1 endoscopic transforaminal microdiscectomy May, 2008
  • you can have a laminectomy and a discectomy at the same time. I know most Drs in Oz do it as a pair because often if you need one you need them both.

    Steve - let us know what you decide.

    Blessings Sara O:)
  • Like Angelback, the doctors here do the Discectomy along with the Laminectomy.

    To the original poster: If a doctor gives you more than one option, in my opinion, then fusion is NOT the way to go. Fusion should only be done as a LAST resort. It doesn't matter if you would eventually need one... It's better to put it off 5 or 10 years, than have one now then another in 5 or 10 years on top of that. Ya know? The longer you can put off a fusion, the better. Any experienced, knowledgeable, caring surgeon who is good at what he or she does will tell you that. If there is another option that is a lot less drastic than the fusion, that should always be the first attempt. It's better to start small. If the Laminectomy doesn't do the trick, it's not a major surgery, so it's not big deal if it fails... Then you know you tried, and you can go into the fusion knowing you did everything you could. HOWEVER, if you go for the fusion and it doesn't fix the problem and you end up with Pseudoarthritis, for example, you may regret it and wish you tried the Laminectomy instead. Fusions cannot be undone. Put it off as long as you can.

    I'm 22 and had to have my L4-L5 fused, and was basically told at some point even though L5-S1 is looking fine for now, I will end up with that one going and having it fused. At 22, I am hoping and praying for at least another 60 years on this earth... My L5-S1 disc is not going to last 60 years between a fused L4-L5, and a tailbone. Lol. But I had no other choice... I was risking permanent nerve damage and permanent weakness in my leg, to the point where I was tripping over it and couldn't even drive without lifting my thigh off the seat to let up a little on the gas. It's rare to need a fusion from DDD at 22, but I had tried the P.T., the Chiro, the injections, the TENS unit, the Ultrasound therapy, the MicroD, the Aquatic P.T.... And it was getting worse... And I reherniated and seriously aggravated my nerve. It was an emergency surgery... 12 hours after seeing my Doctor. That's the only reason they did a fusion for me being so young.... And I am prepared for the future... I know I will end up with more back surgeries, but if I had another option aside from fusion, I would have gone with that first...

    My fusion surgery was a MAJOR success, and I am starting to fuse ALREADY at 8 weeks post op... BUT, like Angelback said and I think someone else... Starting small is most likely your best bet... And if something is inevitable, it's inevitable... But you shouldn't throw in the towel right away just because you dread the future... Do what you can for right now... You never know what the future will actually bring.


  • Thank you all...Right now I am realling leaning towards the laminectomy and disc "trimming"

    The sugeon made the following comments (paraphrased from a letter):
    One consideration...microlaminectomy and decompression of the nerve root - the downside is that it would not address the degenerate changes at the L5-S1 level

    Now regarding fusion:
    More definitive surgery would be a min invasive L5-S1 fusion with interbody fusion and pedicle screw fixation...risks...I would favor the fusion over *disk replacement* because of the anterior approach and risks of retrograde ejaculation. In addition we do see facet arhtrosis at the L5-S1 level in what may be a small facet cyst which could not be address with an anterior approach.

    Thank you all once again.

    Steve

    PS. Final consult with the surgeon mid-December for a January op...will let everyone know how it goes.
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