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View Full Version : Posterior only vs. A/P?



Confusedmom
05-30-2010, 12:29 AM
Did any of you have a choice in the type of surgery you had, i.e. posterior only or anterior/posterior? I have had both options recommended to me, and I'm wondering about the pros & cons of each. Thoughts?

spinalfusion09
05-30-2010, 01:05 AM
Well I had a posterior approach thankfully. Anterior approaches as you know are done through the front but are more complicated because they have to go through all of the stuff infront of your spine (insides). I know my doctor told me there would have to be another doctor there to do an anterior appraoch that monitors other things.
Maliha

Vali
05-30-2010, 09:21 AM
I had both A/P. There was a reason for this (anterior), but my mind has gone totally blank at the moment. (I keep falling asleep at the computer). I will ask my surgeon on Tuesday, along with goodness knows how many other questions! He did tell me that my recovery would take a little longer than if i had posterior only. My incision at the front looks the same as a caesarian incision. I had the surgery explained to me as to how and why, but figured that he (the surgeon) knew best what to do and therefore placed my complete trust in him. He did a good job!

kennedy
05-30-2010, 11:00 AM
my surgeon said if my cuvre got to 60 or 70 dergees he whould do it from the front and back i was only 7 degrees from that evether way

loves to skate
05-30-2010, 01:27 PM
My surgeon recommended A/P in my case because it would make for a much stronger fusion. He knew I wanted to be able to go back to rollerskating and be very active. Each case is different though. Maybe you need a third opinion to break the tie.:(, or at least ask the Docs why they recommend or not the Anterior in your case.
Sally

Vali
06-01-2010, 09:30 AM
I had my 12 month checkup today. I questioned him about why the anterior as i knew there was a reason for this. He said that the anterior was done for more stability. The two screws posterior would not have been adequate as the L4/5-L5/S1 discs had to be removed and replaced with cages. He said that in my case those two levels needed more stability, therefore A/P was needed.

CHRIS WBS
06-01-2010, 10:52 AM
My surgeon originally recommended anterior and posterior, two big surgeries spaced a week apart. The anterior would have been a thoracoabdominal surgery with an incision beginning at the side and down the front. This is what two other Chicago surgeons recommended for me as well. My surgeon later changed his mind to only posterior. While I probably would have gotten a better cosmetic result with both approaches, in hindsight I believe my surgeon made the right decision for me. This surgery was very hard on me and I honestly donít think I could have tolerated two big surgeries. I was initially concerned that lack of anterior might put me at higher risk for pseudoarthrosis, but thankfully that was not the case.

Susie*Bee
06-01-2010, 11:05 AM
I was also originally scheduled for both A/P and my surgeon decided a month or two prior (I don't remember now) that he could achieve what he wanted with just posterior. Sounded good to me!

Confusedmom
06-01-2010, 09:24 PM
Thanks everyone, for responding.

Vali, appreciate you asking your doc about this. I heard something about cages at my last appt., too. I will ask about it at the next visit.

Thanks again,
Evelyn

Nitram
06-01-2010, 10:37 PM
I was a/p and my surgeon echoed what others have said in that a/p is typically done for a stronger fusion as apparently you can't remove the L4/L5/S1 discs without going through the front. If I understand correctly my surgeon wanted L4-L5-S1 fused in front and back to make sure my spine had a very solid foundation. If he just went from the back those vertibrae would only be fused in the back of the spine like the rest of my vertibrae.

Rich

kt2009
06-01-2010, 10:51 PM
I had an anterior approach...my scar goes from under my right shoulder blade and then continues down and across my side... and ends right above my right hip bone. They used my rib for the fusion and this seemed the best approach. My doctor had a team with him and also a general surgeon who he always works with. The general surgeon did the opening and closing...moving all the delicate things around as he said. After the fusion, he came back and put everything back into place and sewed me up...he also threw in a hernia repair!!

Back-out
06-01-2010, 11:46 PM
he also threw in a hernia repair!!
Hmmm. I'd been thinking about asking for a tummy tuck...:D

Debra JGL
06-02-2010, 04:26 PM
One of the docs I saw had recommended an anterior release done minimally invasively followed by posterior instrumentation - they remove disk(s). He said it would increase flexibility and could be done during the same surgery, but would increase surgery time. The other docs I saw did not think it was necessary and not enough potential addtional correction would warrant the additional risks of an added procedure. Hopefully when I see Dr. Boachie in June he'll still feel posterior only is the way to go. I figure less is more for surgery, if poss., but they're the experts and of course a good result is the goal.

Deb

jrnyc
06-02-2010, 08:08 PM
the discs can be removed from the side..and are...that is where my discs will be "cleaned out" and "spacers" (also called "cages") will be put in...IF/WHEN i have the surgery...

jess

Back-out
06-02-2010, 08:44 PM
I had three surgical recommendations, in retrospect unclear about how all would be accomplished.

At least one was for A/P separated by days (up to a week, I think)

Another wants to do me all posterior pending the judgment of his partner. Both would be working on me at the same time (hope the two sides of the tunnel meet in the middle of the mountain! :D) Now I need to see his co-surgeon.

Reading the report from a third, it appears he DOES want to do both posterior with an anterior release but cut from the side (I hadn't gotten that from our appt) - both would be done on the same day. (How could they turn me over to do both at once?)

He'd be starting at much lower levels than either surgeon above. That would mean the surgery would take less time, even though it would all be at once and only one surgeon (I do NOT want my surgeon getting all tuckered out! No kidding) . I think it's pretty clear i need A/P - the question is how it's to be approached. That's because my lumbar area is such a mess.

I have an appt to see another surgeon at the end of June. He tends to operate with the two parts separated by 4-6 weeks! Hard to imagine how I'd tolerate that! His belief is that it's easier on the body to allow for intermediate healing. So that's what I'm expecting to hear about me.

When you speak of having a choice, you must mean in which surgeon you choose, right? Don't think many surgeons actually leave it up to the pt.!

jrnyc
06-02-2010, 10:52 PM
one has a choice based on which surgeon one chooses..some do minimally invasive...some do not...
also..my surgeon gave me a choice of metals...and also is willing to try to stop at sacrum if i so wished...would go to pelvis if he thought it was unavoidable...

however, if i have the surgery..and i know it would be with him...i would take his word on metal and take his word on where to stop...i trust him....i like him....or i wouldnt have surgery with him...that's it.

jess

titaniumed
06-02-2010, 11:29 PM
The anterior surgeries are complicated surgeries and they do these "releases" due to better access to the spine. Usually this is reserved for large lumbar curves. Some surgeons feel that the success rates for fusion are better by doing this.

I had an Ileus, which is an abdominal shutdown and happens when the intestines are touched. So, I was NPO, which means nothing through the mouth, and had an NG tube. They feed you through this tube, and ended up with large gall stones a year later and lost my gall bladder. This was due to the "superfood" they feed you in the hospital. Please remember that these things donít happen too often, but can happen. They are called "complications", which everyone should be aware of before having scoliosis surgery.

My posterior was done 2 days after my anterior, so a 2 day stage. One of the things I would like to know is, how do surgeons decide the length of the stage? I donít think I would like to wait too long, to get it over with. If I remember correctly, Doodie (Julie) had a long stage. I was awakened for 2 minutes by my surgeon for "permission" to continue on with my posterior, otherwise I was out in intensive care till my posterior.

Anterior surgeries also take longer to heal from....

I had no choice, had major degeneration, diseased bone, multiple herniations, and couldnít control my pain effectively anymore. After 34 years, it was a battle I just couldnít keep fighting.

Be sure to let us know what happens. The interview process or "hiring" can be quite a process..... Its nice to have multiple surgeons in agreement on the procedure, and many will give a second opinion. Thatís why its nice to have digital x-rays to e-mail.
Ed

Back-out
06-02-2010, 11:38 PM
Ed

If I remember correctly, Doodie (Julie) had a long stage. I
It's her surgeon I'm seeing at the end of June!

Boy, you've fought a long battle, Ed. Now you're bringing hope to so many with your results and attitude.

Appreciated! :)

You seem to take it so lightly, but it's clear all your successes were hard-won. Didn't know about your gallbladder surgery*, for instance.

Best,

*Er, how long was it after the spinal surgery, and is this a certainty after use of a N-G tube? How long was it in? Maybe better in a PM as it's unusual, I hope. You must have had a whole different specialty evaluate you for it, right?

ADMoul
06-03-2010, 02:53 PM
Just to throw another factor in...I had a previous abdominal surgery years ago. Dr. Lonner did not indicate an a/p procedure for me which surprised me due to my large lumbar curve. I think there was concern about scar tissue from the old surgery making an anterior approach more difficult. I know if he has to do any follow-up surgery :( it would be from the front and he would bring in another doc to deal with moving organs. My corrections were not as dramatic as some, but am very happy with how I look and feel and just as glad not to have had an anterior approach. So surgical history can be another variable in this decision, too.

Confusedmom
06-05-2010, 12:24 AM
Thanks for all the feedback!

I went back to see surgeon No.1 yesterday and got this explanation for A/P:

I have a stiff, 67 degree thoracolumbar curve with peak at L1. To get more flexibility down there, they need to take out discs. They have to do this from the front, although it can be done minimally invasively. In my case, though, he doesn't think mini invasive will work because he needs to get in there and pack bone where he takes the discs out. He says he thinks packing bone from both the front and back will help fusion and correction and I will get a better long-term outcome. So, the anterior part will be done just in the lumbar spine and the posterior will go from T4 to L4.

He also said he would do this in a single day, 12-hour operation. Reason is to reduce stress for me between surgeries. His partner splits it into 2 surgeries three weeks apart to reduce the "single load" stress.

All this makes sense to me, but I'm still going to get a third and fourth opinion!

Thanks again,
Evelyn

titaniumed
06-05-2010, 02:13 AM
Evelyn

If you can get your surgeons assistants e-mail addresses, you can address specific questions easily. Phone calls do not work. This way they can answer at leisure. Give them a few days.

Ask where he will get the bone from for the grafts? If from the hip, will I have pain in that location?

Is leaving one level unfused really that beneficial? How much mobility will I gain? Would it be better to fuse all the way down to the pelvis? Will the unfused level give me problems 10 years down the road? What are the chances of a future revision surgery?

Will the anterior cut be vertical, or along my waistline?

What are some of the complications that can happen?

This will be the most important decision of your life, it deserves a few questions and some serious thought. Surgery is irreversible. You do have some time.

Ed

Confusedmom
06-05-2010, 02:07 PM
Ed,

Thank you so much for taking the time to think through questions for me! You are so kind, and these are good questions. Believe me, I am giving it serious thought.

Just thought I would mention to you that my surgeon told me Thursday that he would like to use titanium with me. So I'm thinking that after my surgery I'll change my user name to "TitaniumEv." What do you think?!

Evelyn

Debra JGL
06-06-2010, 03:05 PM
Hi Evelyn,
I was curious who is scheduled to be the surgeon for the 9/15 date, or what approach is planned? Also, what did doc #2 recommend? Sorry, if you already answered these questions in another post - I'm trying to keep up. It's great you are going to get some additional recommendations. It seems each approach carries with it different benefits and risks, and finding the one from a doctor you trust that you feel most comfortable is key. You may want to ask to how much additional correction would be gained, and how important is the anterior approach to a good fusion for you. Also, asking about any additional risks of increased operating time.

Just thoughts,
Debra

titaniumed
06-06-2010, 03:40 PM
Evelyn

Your welcome. After all I've been through, I feel that I need to help when I can. Lately, I've been very busy at work, sometimes I cannot take the time to read so much anymore. I'm recovered now, and pain free.

LOL! We have threads here about user names for scolis, and there can only be one titaniumed or titaniumev. If you choose to change, I'm fine with it, I will change my user name to Rod Stewart! LOL

"Do you like my posture, do you like my balance, come on sugar, let me know"

That was pretty bad, I know. The disco period of the late 70s was a desperate period in music.

If you look at my x-ray, you will understand.
Ed titaniumed@hotmail.com

Leanna
06-06-2010, 03:51 PM
Thanks for all the feedback!

I went back to see surgeon No.1 yesterday and got this explanation for A/P:

I have a stiff, 67 degree thoracolumbar curve with peak at L1. To get more flexibility down there, they need to take out discs. They have to do this from the front, although it can be done minimally invasively. In my case, though, he doesn't think mini invasive will work because he needs to get in there and pack bone where he takes the discs out. He says he thinks packing bone from both the front and back will help fusion and correction and I will get a better long-term outcome. So, the anterior part will be done just in the lumbar spine and the posterior will go from T4 to L4.

He also said he would do this in a single day, 12-hour operation. Reason is to reduce stress for me between surgeries. His partner splits it into 2 surgeries three weeks apart to reduce the "single load" stress.

All this makes sense to me, but I'm still going to get a third and fourth opinion!

Thanks again,
Evelyn

My doctor also said he would be doing my A/P in a single day which since I have found out I have been stressing about it. Not that it is a good thing at all... but Im glad to hear someone else shares his point of view. I was worried he may have lost his marbles :) Keep us informed what your other opinons state.

Vali
06-06-2010, 08:33 PM
Evelyn, I had both A and P done on the same day. Mine took 6 and 1/2 hours to complete. I did not go to ICU as the recovery team said i came out of anaesthesia really well.

PS..My name on the Aussie forum is 'Rodverta Braefusion'!!!!!!

Leanna
06-06-2010, 09:27 PM
Evelyn, I had both A and P done on the same day. Mine took 6 and 1/2 hours to complete. I did not go to ICU as the recovery team said i came out of anaesthesia really well.

PS..My name on the Aussie forum is 'Rodverta Braefusion'!!!!!!

Vali, this is really good to hear. I think my stress level just came down a notch or two :)

jrnyc
06-06-2010, 09:32 PM
Hi Vali
wow..6 and a half?! my quotes for my surgery were more like 10 hours plus... i dont know if you had the disc "cleaning out" i need...but if you had cages, i'm sure you did..

glad you are doing well!

jess

Vali
06-06-2010, 10:33 PM
Hi Jess, i have two cages at L4/5-L5/S1, (Should put that in my signature!)so i'm guessing they did the cleanup routine. The other thing is that my incision is like a caesarian cut, maybe smaller, as i can only invision that only a bubs head could come out and nothing more, so maybe time was saved there. Also, my surgeon was assisted by another Scoli surgeon. They help each other out when they have to do these big surgeries.

jrnyc
06-06-2010, 11:16 PM
thanks, Vali...
the estimate for 10 plus was with A/P...now that it is to be minimally invasive side/back, i wonder if it would reduce the time by a few hours...or not..?
there's a question for the surgeon...who was waiting for my call last month!

jess

JenniferG
06-06-2010, 11:24 PM
Hmmm. I'd been thinking about asking for a tummy tuck...:D

:DI wondered at the time if my surgeon would nick off a mole on my back, right in the middle of my spine. But the incision passed by it, missing it by mms. I would hope if he thought it looked dangerous, that he'd take it off at the same time, but it's still there and I'm looking at getting it taken off soon. Shame, would have been nice to have avoided that little surgery.

Confusedmom
06-07-2010, 04:20 AM
Don't worry, Ed, I won't really steal your name! But I DO like Rod Stewart! Wow--that's one impressive xray.

Jess, I could be wrong, but I thought that minimally invasion (oops, that was supposed to be invasive!) actually was supposed to take MORE time than open surgery--the advantage being an easier recovery. Of course it depends on the case, I'm sure.

Debra, I'm currently scheduled with my regular ortho in Indianapolis, Dr. Dietz, but since joining the Forum have learned about other probably more experienced surgeons. I'm going to see Dr. Bridwell in St. Louis and Dr. Gupta in Chicago this month. Doc #2, another doc in Indy, recommended postponing surgery a few years to see if my curve gets up above 70 degrees. And he said if he did surgery it would be all posterior. I don't really get the point of waiting (if I have to do it eventually), since it has been steadily increasing for decades, but I am trying to sort out A/P vs. posterior. Thank you for the suggested questions!

Evelyn

jrnyc
06-07-2010, 05:51 AM
hi Evelyn
welllll...if it took longer than the originally estimated 10 plus hours for A/P, i'd be surprised...cause 11 hours on table is about the longest i've heard of so far! and that's a loooong time!! :rolleyes:

jess

leahdragonfly
06-07-2010, 09:01 AM
Evelyn,

I think you're right that minimally-invasive ("minimal access") frequently takes more time than traditional surgery. I think this is a fact about minimally-invasive surgery that is frequently glossed over. And that is not just for spine surgery.

The bonus is supposed to be a quicker recovery and less disruption of the surrounding tissues. It is more difficult for the surgeon, though.

jrnyc
06-07-2010, 11:04 AM
i once had arthroscopic surgery for an ankle...it was quick! very little swelling or scarring..not saying it compares, just that it was quick...and easy, compared to the old way of opening up the ankle!

when i have back surgery, i will opt for minimally invasive...or not do it! i want the least cutting/poking possible...even though i've been told (honestly) there is no such thing as completely sparing the muscles, i want them disturbed as little as can be! since i was told the (older) A/P surgery would be 10 plus hours for me, i dont see a real difference for time...i was told minimally is smaller incisions too...not that i think any back surgery will be easy!

jess

Confusedmom
06-07-2010, 01:50 PM
Jess,

If min invasive was an option for me, I would definitely consider it as well. As with all surgery, I'm sure this is the way back surgery is heading. The docs near me don't seem to specialize in it yet, though, other than anterior release (I think it's called).

Anyhow, there are many potential advantages of min invasive, so I do hope it works out for you if you decide to have surgery.

Evelyn

jrnyc
06-07-2010, 02:12 PM
i think you're right about the future, Ev..and it will probably bring other things we dont even dream of...yet... :)

wish you the best...

jess

Back-out
06-07-2010, 04:09 PM
MI is certainly easier on pt short term, and maybe in right hands LT as well, depending on what needs doing. Having had lapascopic examination of abdomen, and MI/arthoscopic surgery on three knees (two rt leg; I'm only a biped) plus MI cervical decompression for spinal stenosis...

I much researched the latter as even five yrs ago when I began, it was in its infancy, relatively. I only did it against much medical advice including 2/3 neurosurgeons apart from my surgeon, and after I'd had my surgeon well vetted by someone who'd worked with him.

That surgery only involved an overnight instead of having a regular fusion with cadaver bone and hardward, and involving much more blood loss, risk of infection and longer/more difficult recovery. For the spine, the muscles are spared more too.

I wish I could wait until this surgery got to the pt I felt comfortable having it done MI! I fear for a very complex spine like mine, it's still too risky and it seems I don't dare wait. Progression appears too rapid plus I have insurance l and helper issues. Sucks to have to make such a decision under the gun! Definitely, better to wait if one can (ie., no such worries). Research only makes things better and meanwhile other people can serve as learning tools.

I haven't forgetten that ex-basketball player I posted about. He needed SUCH heavy instrumentation put it to support his lumbar spine! I was amazed. I think MI of spine involves a bit more "invasion" than elsewhere.

The visualization needs to be so 3-D for scoliosis correction, that lumbar work especially. That's part of what I think needs to be worked out now to do a long fusion MI.

jrnyc
06-07-2010, 04:23 PM
i have degenerative disc disease, scoliosis, spinal stenosis(lumbar), rotation, arthritis of spine, listhesis, etc etc etc...it CAN be done minimally...i do not believe there is a limit to what they can now do by minimal invasive approach, and in the future it will more than likely go the same direction...the future may bring less opening of the body, i believe, and from what the doctors tell me....i wouldnt have it any other way! :)

jess

Debra JGL
06-07-2010, 06:13 PM
Hi ladies, I was very hopeful to be a candidate for minimally invasive (vats) and so I went to see Dr. Lonner in NYC, 2008. He specializes in this approach. He told me though that my spine wasn't flexible enough, due to my ripe old age of then 42. From what I've read this procedure is reserved mostly for the 20 somethings and under at this point in time. It's tricky business waiting for technology to advance, as our bodies keep on advancing too. Hopefully, one day this surgery will be alot less stressful on future scoli peeps. One thing about vats, min. inv. is that I think they deflate a lung - but then of course they inflate it back up. But, there are so many benefits that it's a great option if you have it.

Debra

Back-out
06-07-2010, 06:59 PM
Evelyn,

I think you're right that minimally-invasive ("minimal access") frequently takes more time than traditional surgery. I think this is a fact about minimally-invasive surgery that is frequently glossed over. And that is not just for spine surgery.

The bonus is supposed to be a quicker recovery and less disruption of the surrounding tissues. It is more difficult for the surgeon, though.

To both of you, on a video-interview with U Chicago's Fessler (while he was performng an MI lumbar fusion) he said he was unable to perform a longer fusion for just that reason. Time and surgeon fatigue.

Not that it was the only reason but that it sufficed. He said in the "right, hands" (experienced) MI was quite safe but that it WAS exhausting. Said if the surgeon got too tired, it was not good for the outcome. Thus, for the time being, he was only doing limited (length) MI fusions.

One of the surgeons I consulted, would operate on me in only one day with a colleague sharing planning and surgery. I guess such collaboration isn't possible for MI surgery or else perhaps longer fusions would be possible - at least , from POV of fatigue. I have the feeling only one mind can process just what they've done in MI, even more (if possible) than in a standard fusion.

Those teeny tiny cuts must be far more pains-taking, bound to be (even) more demanding of the surgeon. Like needlepoint compared to painting.

jrnyc
06-07-2010, 08:20 PM
how were they going to do my original A/P fusion in over 10 hours??...that is a long time!! ..i am going to ask my surgeon..because i do not believe minimally invasive on me would take more than 10 hours! and i am alot older than 42! he would be doing my minimally invasive from T11-pelvis...not as long as TitaniumEd's...but as long as i want to think about! and there is NO lung deflation for lumbar......and Dr Anand never mentioned any when i saw him...i dont know about high thoracic curves...but that is a different situation....

also...mine would not be teeny tiny cuts...the doctors themselves call them "smaller"..not "tiny" ..they are smaller than traditional surgery...but certainly not teeny tiny by any means...where is this stuff coming from?...i talked to 2 of Dr Anand's patients in CA as well...

jess

sarah105
06-07-2010, 08:58 PM
Jess,
I don't know a ton about minimally invasive, but I think the confusion comes from the fact that there are really two types of minimally invasive surgery. The thoracic kind has been around for a while. I/my parents discussed it with my surgeon when I was 14ish. (I wasn't a candidate because my primary curve was too low.) The thorasic kind uses several smaller incisions and looks like it requires a deflated lung. It is a video assissted procedure.

http://www.scoliosisassociates.com/subject.php?pn=practice1010

The one you are talking about looks like it is minimally invasive for people with lumbar curves that would require A/P approach. I'm not sure, but it doesn't seem less invasive for curves like mine that only require posterior. I only needed one incision, so it seems like this approach would have been more invasive for me since it involves going in twice (I doubt I would have been a candidate anyway since my curves were higher up).

I think more people have heard of the first type (thorasic) and they assume thats what you are talking about when you say minimally invasive. I think less people are aware of the newer lumbar option.

jrnyc
06-07-2010, 09:36 PM
hey sarah
yes, i am referring to the newer available minimally invasive for lumbar..i know thoracic minimal has been around for years and years...we were waiting...some of us...for lumbar to catch up! :rolleyes:

i flew 6,000 miles (round trip) to discuss lumbar minimally invasive with Dr Anand...a well known proponent for lumbar minimal...and i asked every question in the book...then spoke to 2 of his patients...both over age 60....when i tell you i asked every question, i'm not kidding...i paid cash for the consult...i got my monies worth! i wasnt going all that way (airfare, hotel, cabs, etc!!) and not get answers! and i got them...wasnt any "teeny tiny" discussion either...the incisions are just smaller, shorter...and the surgery is less rough on the patient...if it goes right...neither of the surgeons i talked about this with said anything about their exhaustion, either....i assume they arrange things ahead of time...and my planned A/P of 10 plus hours wouldnt have been a walk in the park for any surgeon...so how much worse would minimal be than 10 plus hours...!?

i know thoracic is different than lumbar surgery...i am glad that your surgery went well and that you could get on with things in good health!

jess