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Doc,
Thanks for the quuick repsonse. You correctly summarized.
You said “If there is a new herniation at L5-S1, you only need a microdiscectomy at that level since you have had only one prior microdisc surgery. If the new HNP is at L4-5, you would need a fusion.”
Please expalin the distinction you made above, between the two previous micrdistectomies. If there has been only one procedure at each level, why would a second herniation at the upper level precede a fusion ad not at the lower level?
In the meantime I will make an appointment with my neurosurgeon for an exam, MRI study, and to inquire about his experience with fuion. Thanks again.
Sorry for the confusion but there are two of you on this thread. I will list the answers individually.
To catmadni: The general rule is that three herniations at one level requires a fusion. The nerve root will not easily tolerate multiple compressions and a disc that has herniated three times will most likely herniate again. To protect the root from permanent injury, a TLIF fusion is required.
It was my understanding that you have had two herniations at L4-5 and new symptoms that could indicate a new herniation. The fragment that compressed the S1 root you indicated originated from the L4-5 level. If the L4-5 level herniates again with two prior herniations, this would require a fusion. If this level had only one prior herniation, then only a repeat microdiscectomy is required.
To PFCRANGER; The surgery that you underwent I believe was a TLIF procedure. These procedures can be performed with BMP (bone morphogenic protein). Occasionally, this protein can cause bone formation in places that are not desirable. Even a fusion without BMP can cause this bone growth. The most common area for bone to form is in the foramen of the side of the TLIF which I assume was on the side of the bone spur.
Surgery is required to remove this bone spur. Hopefully, the fusion is solid and the instrumentation can be removed at the same time. The fusion must be solid to do this however which will be noted on the CT scan performed after the myelogram.
The more procedures a surgeon completes and the more he or she learns (the learning curve), the less likely that this undesirable bone formation will occur. For the first 300 TLIFs, I had about a 1-2% rate of hetertopic ossification (bone formation where it does not belong). Now my rate in the last 400 cases has been 0.25%.
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.You are dead on correct, the osteophyte is seen extending laterally into the right inferior neural foramen and seems to impinge upon the inferior aspect of the exiting right L5 nerve root. The right side is where the fusion and previous surgeries were preformed. I will be seeing the surgeon tomorrow and i am assuming that a surgical approach will be taken. So far there is no solid fusion and its been roughly 8 months now that is another concern of mine. the doctor used morcellized allograft bone and local allograft bone was used.
Having a spur in the foramen without the use of BMP is unusual. No fusion at eight months is somewhat concerning but it can take as long as a year for a solid fusion without BMP.
The surgeon will have to remove the instrumentation on the right, remove the bone spur, neurolyse the nerve root (free up any adhesions) and replace the instrumentation. If for some reason, the screws are loose, these will have to be replaced with larger diameter screws.
Additional graft might also be used to stimulate the fusion. The surgeon might even think about using BMP in the posterolateral gutters (the area where the transverse processes are) to stimulate the fusion (assuming you also had a posterolateral fusion).
Please keep in touch.
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.Ok I will update the site tomorrow after seeing the surgeon. Thanks talk to you soon.
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