Re: Re: Diagnostic Block to Determine End of Fusion

[Guest guest]

,

I agree with Cam, frankly talk to Kumar about the fate of L5-S1 after a fusion only to L5, cause you'd hate to be back in there a year or two from now, having to go to the sacrum anyway. Such was my case. Ask him how many cases he has had where they went to L5, and it held for years, and there wasn't degeneration below the end of that fusion. I know he's cautious, and wants you to have the most movement as possible, but going back in a year or two later to fuse to the sacrum, when you could have the whole enchilada done now, and have it done and over, maybe worth looking at.

I know we are all individuals, and my case isn't your case, but given what I know now, I would have opted for the fusion to the sacrum from the get go. He was trying to have me have the most movement possible, and I don't fault him or me for the decision we made for a decompression/lami, but time marches on, and I have the benefit of not only seeing how my case went, but others here, and sitting where I am now, I would have pushed for the fusion to the sacrum. My case is my case, but I'm not blind to seeing just how these things work out. Fusion to the sacrum shouldn't be done lightly, but in some cases it, it plain is a good option, and while limiting in some movements which can be a pain in the butt, it can be a gift if the pain is gone, and you are able to get back to your life. Kumar is wonderful about being REAL with you, just go over with him my case, it's one to look at as an example of what you asked.

The benefit of being here is the ability to talk to patients who have been through various procedures and surgeries, and get the real 411 from them.

Kumar always puts you in the drivers seat, it is your body, and your choice, and know everyday I'm thankful for the work he did on me. An informed patient always makes a doc work, and Kumar loves when you challenge, and learn, and participate in your outcome.

Call me if you want to go over my case with you.

Colorado Springs

[ ] Re: Diagnostic Block to Determine End of Fusion

,I can't answer you on the question of the diagnotstic blocks, because I didn't have to have one, I was already fused to L4 and so extension to the sacrum was the only realy option at the time.I dont know exactly where you are fused, or even if you have said, but if I was you I would have a very frank discussion with DrKumar about the "fate of L5-S1" as it relates to your case.The flatback "surgeon gurus" have been following the issue of exactly what is likely to happen below long fusion and what the odds of inevitability of having to go all the way to the sacrum really are. The latest research abstract I can find is 2007. If I understand what I am reading correctly, (and I certainly may not...I am just a patient!)...I think 69% of the patients studied with thoracolumbar deformity who were fused to L5 developed subsequent advanced degeneration (SAD).((***<----by the way....that acronym really disturbs me!!!****))and required another fusion to the sacrum.The point being....if it was me, and the research is pointing toward needing yet another surgery being necessary in 5-15 years....I would want to have a chance to participate in the planning/thinking with the doctor, regardless of the outcome of the diagnostic block. I suppose to a certain extent people that participate in our group may be slightly more likely to have long histories with scoliosis and thus had time to find us in their quest for information....but still....I cant think of anyone who was fused to L5 and didn't have to come back fairly quickly for the LS-S1 surgery. Thats not fun.Of course....none of this may apply to you, but on the off chance that you are wondering the same thing, I figured it might help you focus your discussion with your doctor. You may even decide that you wish to have a second opinion. In my case I begged both DrRand and Boachie to tell me that they could just do a decompression, one level fusion....and they both said they could, but that I would be back in fairly short order for the whole "enchilada", and at the end of the day the recovery timelines were very similar...so why go through all that effort only to be back at the starting line? The research is pasted below. If you want more info, go to www.pubmed.gov and type in key words "scoliosis fusion fate of L5 S1" and you will have a roster of other research to dig through.Take Care, Cam1: Spine. 2007 Nov 15;32(24):2771-6.Related Articles, LinksClick here to readThoracolumbar deformity arthrodesis stopping at L5: fate of the L5-S1 disc, minimum 5-year follow-up.Kuhns CA, Bridwell KH, Lenke LG, Amor C, Lehman RA, Buchowski JM, C 2nd, B.Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.STUDY DESIGN: A retrospective long-term follow-up study. OBJECTIVE: Evaluate the fate of L5-S1 disc analyzing subsequent disc degeneration and associated risk factors for degeneration at minimum 5-year follow-up (average 9-year follow-up). SUMMARY OF BACKGROUND DATA: Two previous studies reported the results of long deformity fusions terminating at L5 with minimum 2-year follow-up only. METHODS: Thirty-one consecutive patients with an average age of 45 years (range, 20-62 years) were fused from the thoracic spine to L5 and were evaluated at a mean follow-up of 9.4 years (range, 5-20.1 year). Patients were evaluated before surgery, after surgery, and latest follow-up with radiographs and Scoliosis Research Society Patient Questionnaire-24 scores. Disc degeneration using validated radiographic Weiner grades. Grade 0 to 1 discs were "healthy" and Grade 2 to 3 were degenerated. Patients with "healthy" discs preoperative that subsequently degenerated were designated subsequent advanced degeneration (SAD). RESULTS: Two out of 31 patients had preoperative advanced degeneration of the L5-S1 disc (Weiner grade 2-3). Three additional patients had an early revision to the sacrum secondary to sagittal imbalance not thought to be related to SAD. Twenty-six out of 31 patients were assessed as "healthy discs" preoperative (Weiner grade 0-1) and were evaluated for SAD. By latest follow-up, L5-S1 SAD developed in 18 of these 26 patients (69%). Risk factors for the development of SAD included long fusions extending into the upper thoracic spine down to L5 (P = 0.02) and having a circumferential lumbar fusion (P = 0.02). Although preoperative sagittal balance was not significantly different between the "healthy" and SAD group, sagittal balance at follow-up was: C7 plumb >5 cm in 67% of SAD patients and only 13% of "healthy" disc patients (P = 0.009). There was a trend toward inferior Scoliosis Research Society Patient Questionnaire-24 pain scores at follow-up in SAD patients (average score 4.1 vs. 3.4, P = 0.13). Eleven out of 30 patients (35%) had subsequent spinal surgery with 7 of 31 (23%) having extension of their fusion to the sacrum. An additional 6 of 31 (19%) were considered for extension to the sacrum but comorbidities precluded surgery (3 patients) or the patients declined further surgery (3 patients). CONCLUSION: Advanced L5-S1 DDD developed in 69% of deformity patients after long fusions to L5 with 5 to 15 year follow-up. SAD frequently results in significant positive sagittal balance at a minimum 5-year follow-up. Long fusions to the upper thoracic spine down to L5 and circumferential fusion may further promote subsequent L5-S1 disc degeneration.PMID: 18007259 [PubMed - indexed for MEDLINE]

[Guest guest]

Cam & ,

Thanks to both of you for the additional

information and feedback. I truly appreciate it.

I am currently fused to L4 from surgery 30

years ago at age 13. I definitely agree that once we have the results of the

diagnostic block, I need to have a good talk with Kumar on the pros and cons of

being fused to L5 or S1. I definitely don’t want to have another surgery

in a couple of years just because I chose to be fused to L5. Will being fused

to S1 mean that I won’t be able to bend at all? If I remember correctly,

there are pictures of you touching your hands to the floor. If that was

you, how long did it take you to be able to gain your flexibility back? I love

sitting in child’s pose to stretch, but I’m guessing that I wouldn’t

be able to do that afterwards if fused to S1. If the plan changes, it’s

just something I’ll have to get used to. It’s just that this wasn’t

part of the initial plan, I know I will lose a lot more movement and my mind is

still processing the possibility. Oh well, life goes on and at least I’ll

be able to walk without pain since that hasn’t happened for a long time.

Thanks again for the information and

everyone’s support!

From: [mailto: ] On Behalf Of cammaltby

Sent: Wednesday, May 06, 2009

11:05 AM

Subject: [ ] Re:

Diagnostic Block to Determine End of Fusion

,

I can't answer you on the question of the diagnotstic blocks, because I didn't

have to have one, I was already fused to L4 and so extension to the sacrum was

the only realy option at the time.

I dont know exactly where you are fused, or even if you have said, but if I was

you I would have a very frank discussion with DrKumar about the " fate of

L5-S1 " as it relates to your case.

The flatback " surgeon gurus " have been following the issue of exactly

what is likely to happen below long fusion and what the odds of inevitability

of having to go all the way to the sacrum really are. The latest research

abstract I can find is 2007. If I understand what I am reading correctly, (and

I certainly may not...I am just a patient!)...I think 69% of the patients

studied with thoracolumbar deformity who were fused to L5 developed subsequent

advanced degeneration (SAD).((***<----by the way....that acronym really

disturbs me!!!****))and required another fusion to the sacrum.

The point being....if it was me, and the research is pointing toward needing

yet another surgery being necessary in 5-15 years....I would want to have a

chance to participate in the planning/thinking with the doctor, regardless of

the outcome of the diagnostic block. I suppose to a certain extent people that

participate in our group may be slightly more likely to have long histories with

scoliosis and thus had time to find us in their quest for information....but

still....I cant think of anyone who was fused to L5 and didn't have to come

back fairly quickly for the LS-S1 surgery. Thats not fun.

Of course....none of this may apply to you, but on the off chance that you are

wondering the same thing, I figured it might help you focus your discussion

with your doctor. You may even decide that you wish to have a second opinion.

In my case I begged both DrRand and Boachie to tell me that they could just do

a decompression, one level fusion....and they both said they could, but that I

would be back in fairly short order for the whole " enchilada " , and at

the end of the day the recovery timelines were very similar...so why go through

all that effort only to be back at the starting line?

The research is pasted below. If you want more info, go to www.pubmed.gov and

type in key words " scoliosis fusion fate of L5 S1 " and you will have

a roster of other research to dig through.

Take Care, Cam

1: Spine. 2007 Nov 15;32(24):2771-6.

Related Articles, Links

Click here to read

Thoracolumbar deformity arthrodesis stopping at L5: fate of the L5-S1 disc,

minimum 5-year follow-up.

Kuhns CA, Bridwell KH, Lenke LG, Amor C, Lehman RA, Buchowski JM, C

2nd, B.

Department of Orthopaedic Surgery, University

of Missouri, Columbia, Missouri, USA.

STUDY DESIGN: A retrospective long-term follow-up study. OBJECTIVE: Evaluate

the fate of L5-S1 disc analyzing subsequent disc degeneration and associated risk

factors for degeneration at minimum 5-year follow-up (average 9-year

follow-up). SUMMARY OF BACKGROUND DATA: Two previous studies reported the

results of long deformity fusions terminating at L5 with minimum 2-year

follow-up only. METHODS: Thirty-one consecutive patients with an average age of

45 years (range, 20-62 years) were fused from the thoracic spine to L5 and were

evaluated at a mean follow-up of 9.4 years (range, 5-20.1 year). Patients were

evaluated before surgery, after surgery, and latest follow-up with radiographs

and Scoliosis Research Society Patient Questionnaire-24 scores. Disc

degeneration using validated radiographic Weiner grades. Grade 0 to 1 discs

were " healthy " and Grade 2 to 3 were degenerated. Patients with

" healthy " discs preoperative that subsequently degenerated were

designated subsequent advanced degeneration (SAD). RESULTS: Two out of 31

patients had preoperative advanced degeneration of the L5-S1 disc (Weiner grade

2-3). Three additional patients had an early revision to the sacrum secondary

to sagittal imbalance not thought to be related to SAD. Twenty-six out of 31

patients were assessed as " healthy discs " preoperative (Weiner grade

0-1) and were evaluated for SAD. By latest follow-up, L5-S1 SAD developed in 18

of these 26 patients (69%). Risk factors for the development of SAD included

long fusions extending into the upper thoracic spine down to L5 (P = 0.02) and

having a circumferential lumbar fusion (P = 0.02). Although preoperative

sagittal balance was not significantly different between the

" healthy " and SAD group, sagittal balance at follow-up was: C7 plumb

>5 cm in 67% of SAD patients and only 13% of " healthy " disc

patients (P = 0.009). There was a trend toward inferior Scoliosis Research

Society Patient Questionnaire-24 pain scores at follow-up in SAD patients

(average score 4.1 vs. 3.4, P = 0.13). Eleven out of 30 patients (35%) had

subsequent spinal surgery with 7 of 31 (23%) having extension of their fusion

to the sacrum. An additional 6 of 31 (19%) were considered for extension to the

sacrum but comorbidities precluded surgery (3 patients) or the patients

declined further surgery (3 patients). CONCLUSION: Advanced L5-S1 DDD developed

in 69% of deformity patients after long fusions to L5 with 5 to 15 year

follow-up. SAD frequently results in significant positive sagittal balance at a

minimum 5-year follow-up. Long fusions to the upper thoracic spine down to L5

and circumferential fusion may further promote subsequent L5-S1 disc

degeneration.

PMID: 18007259 [PubMed - indexed for MEDLINE]

[Guest guest]

Very good point, Bonnie.  I had my dad as a living example of that.  At

82 he is still living with the kyphosis given him by his Harrington

rods.

For me, age 50 seemed like the line I didn't want to cross unrevised. 

I'm still healthy now that I am 50, but also glad not to have the

likelihood of revision hanging over me.

Sharon

Bonnie wrote:

Hi Cam,

 

The article said, " 19% were considered for extension to the

sacrum but comorbidities precluded surgery".  Just the possibility of

that would be reason enough for me to want the whole shebang at one

time.  I wasn't given the choice as it was clear I needed surgery all

the way to the sacrum, but I think that as we age, we need to consider

whether we will be up to major surgery in several years, or not.  You

just don't know what may get in the way of having the surgery you need

at a later date.

 

Bonnie

[Guest guest]

Bonnie,

"It may not be pretty, but I can do it." That is one of the best statements I've heard! I love it! It really gives incentive to all of us with any struggle we have, to keep on trying to reach our goals.

A big thank you to both you and Cam for your very inspirational advice.

Jeanne

[ ] Re: Diagnostic Block to Determine End of Fusion

Cam,

You said, "It goes without saying that everyone is different, some have bodies more flexible than mine going in to surgery....but throwing up my hands and accepting how I was 6 months after revision was never an option for me and that attitude has paid results...painstakingly slow though it has been!One of my favorite sayings to myself is that "It's not forever, it's just for now". I feel that the inferred "how long" question this implies is really in my sphere of control and it motivates me to challenge myself."

To that I have to add my own favorite sayings: Never give up, and keep trying. I really live by these, especially with respect to medical issues. I know it's hard to believe, but at 11 and 1/2 years post revision and 68 years old, I am still gaining flexibility. If you had told me 2 years ago that I would now be able to pick up that package of ham from the floor, I would not have believed you. (Remember that package of ham?) It may not be a pretty sight, but I can do it. Stretching exercises have helped, a lot.

Bonnie

[Guest guest]

In 1996 my fusion was extended from L3-4 to L4-5. I had 14 good years before having to be fused to the sacrum. I am very thankful that I had that time. I knew that I would eventually wear out theL5-S1 disk and then have to have additional surgery. I would still do it the same way if I had it to do over again. Again, we're all different. This is my two cents worth!

D

Re: [ ] Re: Diagnostic Block to Determine End of Fusion

,

I agree with Cam, frankly talk to Kumar about the fate of L5-S1 after a fusion only to L5, cause you'd hate to be back in there a year or two from now, having to go to the sacrum anyway. Such was my case. Ask him how many cases he has had where they went to L5, and it held for years, and there wasn't degeneration below the end of that fusion. I know he's cautious, and wants you to have the most movement as possible, but going back in a year or two later to fuse to the sacrum, when you could have the whole enchilada done now, and have it done and over, maybe worth looking at.

I know we are all individuals, and my case isn't your case, but given what I know now, I would have opted for the fusion to the sacrum from the get go. He was trying to have me have the most movement possible, and I don't fault him or me for the decision we made for a decompression/lami, but time marches on, and I have the benefit of not only seeing how my case went, but others here, and sitting where I am now, I would have pushed for the fusion to the sacrum. My case is my case, but I'm not blind to seeing just how these things work out. Fusion to the sacrum shouldn't be done lightly, but in some cases it, it plain is a good option, and while limiting in some movements which can be a pain in the butt, it can be a gift if the pain is gone, and you are able to get back to your life. Kumar is wonderful about being REAL with you, just go over with him my case, it's one to look at as an example of what you asked.

The benefit of being here is the ability to talk to patients who have been through various procedures and surgeries, and get the real 411 from them.

Kumar always puts you in the drivers seat, it is your body, and your choice, and know everyday I'm thankful for the work he did on me. An informed patient always makes a doc work, and Kumar loves when you challenge, and learn, and participate in your outcome.

Call me if you want to go over my case with you.

Colorado Springs

[ ] Re: Diagnostic Block to Determine End of Fusion

,I can't answer you on the question of the diagnotstic blocks, because I didn't have to have one, I was already fused to L4 and so extension to the sacrum was the only realy option at the time.I dont know exactly where you are fused, or even if you have said, but if I was you I would have a very frank discussion with DrKumar about the "fate of L5-S1" as it relates to your case.The flatback "surgeon gurus" have been following the issue of exactly what is likely to happen below long fusion and what the odds of inevitability of having to go all the way to the sacrum really are. The latest research abstract I can find is 2007. If I understand what I am reading correctly, (and I certainly may not...I am just a patient!)...I think 69% of the patients studied with thoracolumbar deformity who were fused to L5 developed subsequent advanced degeneration (SAD).((***<----by the way....that acronym really disturbs me!!!****))and required another fusion to the sacrum.The point being....if it was me, and the research is pointing toward needing yet another surgery being necessary in 5-15 years....I would want to have a chance to participate in the planning/thinking with the doctor, regardless of the outcome of the diagnostic block. I suppose to a certain extent people that participate in our group may be slightly more likely to have long histories with scoliosis and thus had time to find us in their quest for information....but still....I cant think of anyone who was fused to L5 and didn't have to come back fairly quickly for the LS-S1 surgery. Thats not fun.Of course....none of this may apply to you, but on the off chance that you are wondering the same thing, I figured it might help you focus your discussion with your doctor. You may even decide that you wish to have a second opinion. In my case I begged both DrRand and Boachie to tell me that they could just do a decompression, one level fusion....and they both said they could, but that I would be back in fairly short order for the whole "enchilada", and at the end of the day the recovery timelines were very similar...so why go through all that effort only to be back at the starting line? The research is pasted below. If you want more info, go to www.pubmed.gov and type in key words "scoliosis fusion fate of L5 S1" and you will have a roster of other research to dig through.Take Care, Cam1: Spine. 2007 Nov 15;32(24):2771-6.Related Articles, LinksClick here to readThoracolumbar deformity arthrodesis stopping at L5: fate of the L5-S1 disc, minimum 5-year follow-up.Kuhns CA, Bridwell KH, Lenke LG, Amor C, Lehman RA, Buchowski JM, C 2nd, B.Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.STUDY DESIGN: A retrospective long-term follow-up study. OBJECTIVE: Evaluate the fate of L5-S1 disc analyzing subsequent disc degeneration and associated risk factors for degeneration at minimum 5-year follow-up (average 9-year follow-up). SUMMARY OF BACKGROUND DATA: Two previous studies reported the results of long deformity fusions terminating at L5 with minimum 2-year follow-up only. METHODS: Thirty-one consecutive patients with an average age of 45 years (range, 20-62 years) were fused from the thoracic spine to L5 and were evaluated at a mean follow-up of 9.4 years (range, 5-20.1 year). Patients were evaluated before surgery, after surgery, and latest follow-up with radiographs and Scoliosis Research Society Patient Questionnaire-24 scores. Disc degeneration using validated radiographic Weiner grades. Grade 0 to 1 discs were "healthy" and Grade 2 to 3 were degenerated. Patients with "healthy" discs preoperative that subsequently degenerated were designated subsequent advanced degeneration (SAD). RESULTS: Two out of 31 patients had preoperative advanced degeneration of the L5-S1 disc (Weiner grade 2-3). Three additional patients had an early revision to the sacrum secondary to sagittal imbalance not thought to be related to SAD. Twenty-six out of 31 patients were assessed as "healthy discs" preoperative (Weiner grade 0-1) and were evaluated for SAD. By latest follow-up, L5-S1 SAD developed in 18 of these 26 patients (69%). Risk factors for the development of SAD included long fusions extending into the upper thoracic spine down to L5 (P = 0.02) and having a circumferential lumbar fusion (P = 0.02). Although preoperative sagittal balance was not significantly different between the "healthy" and SAD group, sagittal balance at follow-up was: C7 plumb >5 cm in 67% of SAD patients and only 13% of "healthy" disc patients (P = 0.009). There was a trend toward inferior Scoliosis Research Society Patient Questionnaire-24 pain scores at follow-up in SAD patients (average score 4.1 vs. 3.4, P = 0.13). Eleven out of 30 patients (35%) had subsequent spinal surgery with 7 of 31 (23%) having extension of their fusion to the sacrum. An additional 6 of 31 (19%) were considered for extension to the sacrum but comorbidities precluded surgery (3 patients) or the patients declined further surgery (3 patients). CONCLUSION: Advanced L5-S1 DDD developed in 69% of deformity patients after long fusions to L5 with 5 to 15 year follow-up. SAD frequently results in significant positive sagittal balance at a minimum 5-year follow-up. Long fusions to the upper thoracic spine down to L5 and circumferential fusion may further promote subsequent L5-S1 disc degeneration.PMID: 18007259 [PubMed - indexed for MEDLINE]

________________________________________

PeoplePC Online

A better way to Internet

http://www.peoplepc.com