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Unfortunately, bone/SPECT scans are generally unnecessary as they delineate bone active but do not differentiate between healing and pseudoarthrosis. The CT scan (on a 160 slice scanner if possible) is the best indicator of fusion mass and the standing X-ray with flexion/extension is a close second.
The history and physical examination along with the imaging studies are the best indication of the current status of surgery. Diagnostic injections round out the diagnosis criteria.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.Hi Dr C
I’m not quite understanding the response. I did have a bone scan pre surgery and now 22 months out, the second scan. I have had numerous CAT scan, MRI’s , mylegram, and a number of Flexon Extensions. So the bone scan is inconclusive vs the CAT Scan? My doctors all agreed that due to the absence of clarity in the other tests, the scan should shed some light on the issue. If I had to rate the pain/uncomfortable factor, its a 3-4, and higher after some strenuous activity. My son is a PT student and showed the scan to his Professor( a noted PHD in difficult spine cases) and she indicated that a chemical reaction at this late date indicates a lack of a fusion in the surgical area. Frankly this is incredibly frustrating that this team of doctors are still scratching there heads after 22 months. I will keep you and the forum up to date after my consult tomorrow. Thank you again for everything.
Steven
Generally, bone scan is much more inconclusive than a CT scan for fusion and the MRI STIR image sequences are just as effective as the bone scan for this type of information. This is why I have not used a bone scar in three years.
The bone scan is performed by injection radioactive material that will be absorbed by reproducing bone cells. Therefore, on the bone scan, any area that has significant bone activity will “light up”. This includes a healing fusion as well as a pseudoarthrosis (bone cells are trying to heal with no success).
The CT scan is the gold standard for fusion and I would insist on a 160 slice scanner with 1mm cuts through the questionable area (you only need the scan to go through this post-surgery area and not your entire lumbar spine).
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.Hi Dr C
The surgical consult indicated that in my situation, a bone scan was not necessary(as you so accurately explained). Prior CAT SCANS and X-ray Flexion Extensions provided him with all he required to make a diagnosis. Even prior to my detailed exam, he had a good idea what is happening. Again, you nailed it, a pseudoarthrosis. His assessment is as follows:
1) Questionable Complete Fusion of the Facets Joints
2) No Fusion within the cage. As a side note , he pointed out that the type of cage that was used was too small(typically used for minimally invasive ) and had a feature that spread once installed. He pointed out that he never uses such a cage since it limits the amount of fusion material placed within the cage. He typically uses a large cage. He also prefers harvesting bone from my hip vs cadaver bone.
3) The type of TLIF that was performed was minimally invasive where the facet joint was not removed. He felt this contributed to the current issues. As per the doctor, he always removes the joint so he visualize the area.
4) He mentioned that the Mylegram indicated that I have adjacent level disease at the L5. He mentioned that the facet block injections epidurals worked so well since I have issues at that level.
5) He requires a new MRI and Flexion Extension (since the old one didn’t show me leaning enough?)I was completely blown away by the type of operation that was performed. No idea it was minimally invasive and that the facet joint wasn’t removed. As a layman, it appears I got a “Trim” vs a “Full Haircut”. He felt that the surgery should have included some of the above and if I understood correctly, removing the lamina(?) providing a better view of the nerves that are being squeezed.
His exam, and analysis took close to 2 hours and he was very through. He offered me two options, both of which are surgical. Option 1 was to clean up the L4 region. Attempting to remove the cage and replace with a larger cage and add fusion material. He would then fuse the L5 region. Option 2 would be as the above mentioned, but expose the area and relieve the pressure on the nerves. He said it is longer surgery and there is more risk. Though he has extensive experience in revision surgeries. He said typically there is a 60-70% success rate but it can certainly be higher.
Over the last two years (22 months) has been a daunting and frustrating experience. While I felt I did extensive research on this surgery(layman), it appears I was in the dark on what was actually done.
Dr C, is what i was told reasonable? This surgeon would be the third consult over the last 22 months. He was the first face to face doctor to give me a clear and concise diagnosis(aside from your self). What other questions should I ask? Mentally I am not prepared though logically revision surgery is appears to be the reasonable solution. Is option 2 the better solution or go through the less invasive option? Im so sorry for all the question. My symptoms are getting worse.
Again..thank you! Steve
It sounds like you have found a good spine surgeon.
I cannot comment on the need for an L5-S1 fusion as there are many variables that could lead toward or away from this level being addressed surgically. The least invasive path would be to leave the L5-S1 level alone and just fix the pseudoarthrosis at L4-5. If however, the L5-S1 level is very degenerative and might need to be fixed, testing can be performed to determine this such as discograms and/or selective nerve root blocks (SNRB) if there is buttocks pain as a large component of the total symptom picture and relief is gained with an injection (see pain diary).
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.Hi Dr Corenman
Its been awhile since I have contributed to the forum. A brief update. Im 27 months post TLIF L4/5 surgery. My primary surgeon finally said that there is no indication of any fusion. The nuclear scan showed activity, leading him to that conclusion. New, and disturbing symptoms, are aching, bilateral front leg pain, piercing groin pain. So severe that it causes me to fall to ground until it passes. My pain doctor indicated issues with the L3 as well as the L5. To say the least I am exhausted and leaning towards the recommended surgery of redoing the L4/5, decompression at the L5 levels. The juries out on the L3, since that is a new development. Any ideas or recommendations? As always thank you for your amazing advice
Steven
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