[sperryguy]

#20738

Hi Dr C

Just an update on my TLIF L4-5 surgery (11/10/14). My lower back pain has continued to increase in what appears in almost the same spots prior to my surgery. I have been to a neurosurgeon and as explained in prior posts, he couldn’t see the fusion, though it was mentioned the devices may be blocking. He mentioned my only option after waiting another year would be revision surgery. I have been going to my PT for core training and returned to my pain doctor for facet block injections. The first set I did quite well. The second set didn’t really work. The physician said he didn’t see any real fusion (a little clouding) and my pain appeared to be coming from L5 and at the surgical site. He suggested I may be able to have an Endoscopic Facet Rhizotomy. My question is does it matter who performs the procedure(thinking a neurosurgeon is preferred)? If have tried to returned to my old physical activity and the aftershocks are painful. I have made an appointment to discuss with the neurosurgeon. I would like to discuss with the surgeon on options? If revision surgery is an option, should i consider it? Do I have options other than continued pain meds(take almost nothing since it makes me ill), continued injections? What type of surgery is an option? At 59 years old i was hoping for better improvment. My orthopedic surgeon just tells me he see some fusion arounf the facet joints, though the other doctors see almost nothing. As always, I greatly appreciate your input.

Steven

[Donald Corenman, MD, DC]

#20853

Orthopaedics spine surgeons generally have a higher success rate with lumbar fusions. 50% of the work I do is revision surgery (when the initial surgery did not work) and generally it is for pseudoarthrosis (failure of fusion).

80% of the failures originate from neurosurgeons so simply based upon that, you are probably better off with a spine surgeon to take care of this fusion failure. I understand you had a spine surgeon for your initial surgery and this failure might put you off.

If you do have a failure of fusion, a rhizotomy will not be helpful. Remember that the facets should have been ablated (removed or burred down to bone underneath) to allow for fusion. If they were not touched during surgery (and I have seen that not uncommonly), they need to be fused.

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.

[sperryguy]

#20855

Thank you again Dr Corenman.

Is it possible for you to provide a “long distance” consultation? I have ordered all my imaging studies with the corresponding reports to ascertain what exactly is happening.

Thank you again

Steven

[Donald Corenman, MD, DC]

#20856

There are certain groups that I do perform long distance consults (airline pilots and olympic athletes) but I have to be careful or I will be doing these all day and not have time to see clinic patients or perform surgery. Contact my office for further instructions.

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.

[sperryguy]

#21153

Hi Dr C

Another followup that I would like to share with the forum. After a consult with the co-surgeon(neurosurgeon),(THE MAIN SURGEON WAS ORTHO) he suspected that my pain was coming from the SI joint. I did point out that the pain was similar, though not as severe prior to my TLIF surgery. He said that this symptom is not uncommon. He recommended an SI block injections, and if successful, undergo an ablation of the SI Joint/S. I pointed out that while that may resolve the pain temporarily, its not a long term solution. The doctor did order a CAT Scan and an XRAY(flexon extension). My doctors did have a consult and explained that based on the latest CAT SCAN , the facets joint are fusing and he hopes that will continue. The two other spots which received the bone graphs have issues, one area(he said less important in the front?) was completely absorbed, thus no fusion. The area between L4/5 hardly fused. The orthopedic surgeon said not to give up hope and it still may fuse(14 months post surgery). He said if the pain continues and quality of life is still affected, he would consider revision surgery. He said it wouldn’t be as severe since all else is in place and there are many “strategies” he can suggest. He also suggested that a bone scan to see where the “hot” spots are, but that wouldn’t be until he is certain I am not getting any better. I transcribed the relevant portion of the CAT Scan :
L4/L5: Posterior fusion has been performed. Complete mature appearing fusion is not visualized. There does appear to be further fusion involving the l4/5 facet joints when compared to the prior exam. Metallic Inter-body device is again noted. Device does not appear entirely incorporated. Endplate concavity is present adjacent to the device with associated sclerotic change. Again findings consistent with subsidence and they appear slightly more prominent than previous exam.

Summarize

The pain has been increasing and any real exercise program(stepper, biking) results in severe debilitation for about a week time. I also noticed that my left leg feels increasingly weak as the moth progresses.

At this juncture I don’t know whom to believe and if the “team” is telling me the whole story. Can you help me sort this out?

Thank you again for all your help!

Steven

[Donald Corenman, MD, DC]

#21156

Based upon this report, it sounds like you have developed a pseudoarthrosis (non-fusion). It is unlikely that your facets have fused but the interbody device has not incorporated. Note the radiologist states ” Complete mature appearing fusion is not visualized”. It is still possible to gain a solid fusion but after 14 months, the law of diminishing returns has to be applied.

It is possible but unlikely that you have developed SI syndrome. This is a rare disorder and is unusual after a one level fusion. The same type of pain you had prior to surgery that is still present now indicates the fusion level is still the pain generator.

You need a new set of eyes to look at you.

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.

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