Reasonable2012

Thanks for the response. I concede that without the additional scan we must speculate. As you indicate, the existing pattern (which is consistent to include data points of hip and arm and L1-L4) of reduced density the closer you get to L5-S1, is not something one would have expected sans scan.

No idea why the L5-S1 is not included in the scan; maybe surrounding bone structures interfere with it’s accuracy? Perhaps that would be wise, to have the PCP request an additional scan of L5-S1, if it is possible?

The MRI does suggest one other puzzling thing. It apparently shows evidence of *both* bilateral fractures plus not having bilateral fractures! As mentioned before, there is apparent rotation of the I guess it is neural foramina, relative to the vertebral body, that suggests fracturing. There is also much degeneration of the facet joints, which evidently is not expected in the case of bilateral fractures, because the facets then are not load-bearing.

Am wondering if the degenerative changes occurred *before* the fractures happened. Or possibly, it is some sort of chronic stress fracture that allows the neural foramina to rotate a tiny amount but is held from separating by muscle and ligament. Then, the fracture poorly heals (and so is load-bearing but with less structural integrity due to the splaying out and “play” in the joint), only to fracture again and rotate some more, when put under stress…vicious cycle. In this way, there is some degree of load bearing, plus there is a lot of inflammation and a chronic fracture process.

It sounds from your responses that you are ruling out the calcium borrowing from such a condition as being a significant factor in causing this loss of bone density. In other words, you would expect to see far less impact to density over a 2-year period then for what that could acount, and especially the pathological mechanical forces at L5-S1 would overshadow the density-sapping effects of chronic inflammation and chronic fracturing. Is that correct?

I am working now to set up the endocrinologist consult, and for sure will post the findings. Had another surgeon say that the MRI-indicated stenosis of my lower back was, “impressive.” Can add “puzzling” to the list of adjectives that are both disconcerting and intriguing at the same time, when they come from leading doctors.

*Kudos* for the intellectual honesty and scientific curiosity to want to explore the issue rather than gloss over it for it daring to challenge a standard model.

Note the before-crash MRI showed no spondylolisthesis, mild stenosis, and no disc degeneration. I am working on the current evidence-based model that the crash started a degenerative cascade.

Cheers,

Richard

May have misspoke. When I asked if there was a better procedure to the hybrid approach that was able to *repair* the spondylolysis and spondylolisthesis, I know the spondylolysis cannot be repaired at this point in the traditional sense, since the disc is already degenerated.

What I more accurately meant, is can the tear of the fibrous pannus be repaired in the sense of it being structurally stabilized and maybe closed to some degree?

Hey, by the way, ran into someone at a Starbuck’s. She was a professional athlete back in the day, and has clearly been around the block a few times regarding back pain. Like me, she was in a vehicle crash that caused injury to her neck and lower back. She has tried meds, chiro, acupuncture, and evidently is in regular contact with some sort of support group or network of people that all have back issues. Punch line is she recommended me to the Steadman Clinic in Vail. She seems like a credible recommendation to me.

Know it is off topic, but will call your office and talk about if you folks finanacially work with CICP (such as courtesy discount) and would be willing to do the procedure at Poudre Valley Hospital (they recognize the CICP program and are an excellent facility). Am also wrestling with Wyom Work Comp to get them to include it in my claim, but it took months after the crash for me to figure out was injured and something new and its extend, and so it is an uphill battle.

Getting to my main question for you. Have learned a bunch since the last posts. Have a followup MRI this week to see if the condition has visibly progressed in terms of degrees neural foramina has spread acutely (should be at nearly 90 degree angle relative to horizontal edges of the associated vertebrae but mine was at 129 degrees in September, what is it now?). Also want to see if spondylolisthesis and stenosis have progressed. Disc is already completely black/dead.
Have some worrisome symptoms now in neck, arms, and legs from the two injury sites. Much pain too.

In researching the whole lumbar fusion issue it opens up a can of worms. There are a bunch of ways to do it, lots of studies, yada yada. Posterior single-level fusion is clearly the safest/cheapest/easiest. But it does nothing to repair the tear in the fibrous pannus that is the root structural failure, right????
The ALIF is far more dangerous/expensive/harder but it is best at repairing the distance between vertebrae, right?? It also can at least to some degree, reduce the spondylolisthesis and prevent it from progressing in the future!!!! That is HUGE. Can the posterior procedure repair the spondylolisthesis????

I cannot determine if ALIF is able to repair the fibrous pannus…can it?????? That is the million dollar question to me.

And of course I have seen the hybrid procedures that do BOTH. They instrument posteriorly AND they do the ALIF. That seems to give the best structural support. Would you agree? I saw a study out of Hong Kong that showed exceptional results, with many seeing excellent results after an extended period, able to even return to hard manual labor. Is it reasonable to have fairly high hopes of excellent results for such a procedure (of course take all of your communications through this forum based on the info as presented herein, and for educational purposes only, per your disclaimer).

Do you folks do this procedure?

If so:
*Can you specify the hardware manufacturers? and models used?
(Not all hardware is created equal.)
*Is muscle removed in either the posterior or anterior procedure in
such a case? I had muscle removed for the posterior cervical
laminectomy and it of course created an asymmetry in strength and
motion. That would be quite problematic in lumbar region.
*I know there obviously is a loss of motion and the subsequent
additional wear/tear on above and below. But overall there should
be much more structural support and stability after the procedure.
Correct?
*In what other areas, if any, would there be a loss of natural
integrity and strength after the procedure (there are always
trade-offs).
*Is there an approach you would recommend that is even better in
terms of ability to repair spondylolysis and spondylolisthesis and
create (if successful) trouble-free stability and structural
support of that unstable region, with greater long-term success
and likelihood of being able to regain much quality of life?

Cheers,

Richard Warner

Reasonable2012 post=3396 wrote: Thanks again for the followup and clarification! Appreciate your efforts to go above and beyond and make time for people in this way. Also appreciate your apparent expertise in this specialized area.

Regards,

Richard