Second opinion appt.

[SpineTime]

I have an appointment this coming Monday (11/07/2011) with Dr. Ganocy in Los Angeles. He's the surgeon I wanted to see to begin with, but my insurance co. sent me to another doctor first. That was fine with me, as I figured I see what the first guy had to say.

I'm a little bit anxious/nervous/excited about this appt. I want to make sure I ask all the questions I have, but I think it was Linda who said it's best to let the surgeon guide the meeting? That makes sense. I have my list of questions jotted down, but I need to organize them a little better. Mostly what I'm dreading is the drive into L.A. I hope the traffic won't be horrid.

Also, I plan to ask this, but maybe someone here can help me understand a little better, beforehand. In all my reading, I haven't come across one big thing, which is, how does the surgeon decide exactly what to do in each case? Is there some sophisticated software program they use, entering in your x-rays, CT, MRI, etc, and it helps calculate everything? Or is it much less technical than that? I'm just wondering how they decide what to do in order to get the angles right and get balance in all planes so as to (hopefully) avoid flatback syndrome, PJK, or other problems. Could someone explain how they do this or point me to where I might read more about it? TIA!

Lisa

[LindaRacine]

Hi Lisa...

Nope, no surgery in the box. I'm sure there are dozens of different ways that doctor decide on which levels, what approach, coronal and sagittal balance, shoulder asymmetry, etc. There's actually a lot of literature to help surgeons decide these things. In terms of flatback, I think most surgeons use a Jackson table (or perhaps something similar), that allows them to approximate a good lordosis. They also use intraoperative radiographs.

Regards,
Linda

[Pooka1]

You could ask these surgeons that question and then post the answers because I am sure many here would like to know.

Our surgeon seemed to use the bending radiographs to decide on lowest (and perhaps highest) instrumented vertebra and to verify that a compensatory curve is not a structural one.

There are probably a million criteria out there that surgeons can choose from in deciding all the aspects of a fusion.

[mabeckoff]

How did your appt go?

[Elisa]

My son had xrays, an MRI as well as a thorough examination by Dr. K before his surgeries/traction. I asked him what he thought the length of the fusion would be and he indicated it would 'probably' be from T2-L2 but at the time of his second surgery/fusion he had decided to go from T4-L2. I think the surgeon makes his final decision once he sees for himself what is going on with the spine.

[SpineTime]

Hi Lisa...

Nope, no surgery in the box. I'm sure there are dozens of different ways that doctor decide on which levels, what approach, coronal and sagittal balance, shoulder asymmetry, etc. There's actually a lot of literature to help surgeons decide these things. In terms of flatback, I think most surgeons use a Jackson table (or perhaps something similar), that allows them to approximate a good lordosis. They also use intraoperative radiographs.

Regards,
Linda

Surgery in the box! That made me laugh. I'm glad to hear there is a lot of literature for surgeons.

I think what made me wonder if there was some sort of software that let them plan the surgery was when I heard about the SpineAssist robot http://www.youtube.com/watch?v=ijkS_sjPkCo In fact, I think you were the one who posted a link about SpineAssist. Do you know if it's "catching on" and becoming popular? I think it's so cool! I'm fascinated by all this stuff. Partly I think it's my way of coping with it, by learning as much as I can, but really a lot of it is just that I find it interesting.

Also, I read a long, detailed article about flatback syndrome, which I almost wish I hadn't read. What struck me in the article was something about how there is such a wide range of "normal" for the degree of lordosis in any individual, that it can be hard for the surgeon to know how much lordosis to give that particular patient. Yikes.

Now I'm going to have to go read up on the Jackson table... fun!

Lisa

[SpineTime]

You could ask these surgeons that question and then post the answers because I am sure many here would like to know.

Our surgeon seemed to use the bending radiographs to decide on lowest (and perhaps highest) instrumented vertebra and to verify that a compensatory curve is not a structural one.

There are probably a million criteria out there that surgeons can choose from in deciding all the aspects of a fusion.

I will ask the question and do my best to remember the answer and post it, but I make no promises. LOL My memory is much better if I've read something than if I hear it in conversation. I will try to take notes. My husband is coming with me too, and his memory is much better than mine. Hopefully he remembers the things I don't.

Yes, I think the bending radiographs are very informative for them for deciding which levels to fuse.

As far as what surgeons choose, I think so much of it must have to do with the surgeon's training, what they were taught, and then what they've personally experienced over the years, in doing surgeries.

Lisa

[SpineTime]

How did your appt go?

Hi Melissa,

The appt. will be this coming Monday, November 7, the same day as your surgery. I hope all goes well for you! I'll be thinking of you as I'm (probably) sitting in traffic, inching my way into L.A.

BTW, do you know if Dr. Bederman used the SpineAssist robot on your surgery? If so, what did you think of it? I saw on his website that they use it at his facility.

Lisa

[SpineTime]

My son had xrays, an MRI as well as a thorough examination by Dr. K before his surgeries/traction. I asked him what he thought the length of the fusion would be and he indicated it would 'probably' be from T2-L2 but at the time of his second surgery/fusion he had decided to go from T4-L2. I think the surgeon makes his final decision once he sees for himself what is going on with the spine.

I think you're right about that. I'm sure the imaging studies are very helpful, but it can't tell them everything they need to know. That's true for all kinds of surgeries. There is no substitute for actually "going in" and seeing what's there.

I'm so amazed by your son's story, BTW. He looks fantastic!

Lisa

[mabeckoff]

Hi Melissa,

The appt. will be this coming Monday, November 7, the same day as your surgery. I hope all goes well for you! I'll be thinking of you as I'm (probably) sitting in traffic, inching my way into L.A.

BTW, do you know if Dr. Bederman used the SpineAssist robot on your surgery? If so, what did you think of it? I saw on his website that they use it at his facility.

Lisa

OK Please let us know how it goes. No he was not able to use the robot on me because most of my surgery was the neck area and he does not use it there.

Thanks for your good wishes

[SpineTime]

On a side note...

Well, I had my appt. last Monday. The appointment itself went well, but I had an issue with getting a copy of my x-rays on disk. After crossing the street and walking a fair distance down to a different building, then wasting 30 minutes waiting (they said it would only take 10-15 minutes - grrrrr), I settled for them mailing the disk to me later, which they did. I'll try to attach the x-rays in my signature later.

For some bizarre reason, I made the decision that morning not to wear my (self-prescribed) corset/lumbar back brace, which I normally would wear for a long car ride like this was (this trip was 5 hours, round trip). In addition, I forgot to take a muscle relaxer, and forgot to bring them with me. I don't know what I was thinking! Honestly. Not a morning person. *sigh* I did have my pain reliever, Norco, with me, but it didn't make a dent in the pain I felt. The pain started with walking down to get the copy of my x-rays and waiting there, and it continued for the whole car ride home. I couldn't get comfortable, and the burning pain just wouldn't stop, so I was pretty miserable for a good 3 hours.

I'm actually worried about this burning pain. I've been getting it off and off for a few months now. I'm used to my usual low back pain with standing and walking that resolves with sitting or lying down, so it doesn't interfere with me being able to work, since I work at a computer. But this new burning pain is higher up, more across the middle of my back. It doesn't seem to be related to activity, and has happened several times now when I'm just sitting at my computer working. It hurts so much sometimes I feel like I can barely keep sitting there working, and almost can't think straight. It's awful.

I decided to go back to my pain mgmt dr. sooner than expected, to talk about this and see what he can do. Interestingly though, when I called to make an appt. with him, they said he's no longer there, left a few weeks ago, and they don't have a forwarding address for him! Whaaaat? So my pain mgmt guy flew the coop? I saw him for almost 3 years. I wonder what happened. Very strange. They said I could make an appt. with "Maryanne." I specifically asked if "Maryanne" is a pain management doctor, since most drs. don't go by just their first name, and they said yes. But I looked on their website, and she's listed as a PA-C - a physician's assistant. Hmm. This is not looking good!

Okay, enough scandal. LOL. I'll write more about my 2nd opinion appt. later.

Lisa

[SpineTime]

Where was I?

Oh yeah, second opinion appt. Sorry to take so long! Things have been hectic lately.

Traffic (my big fear) wasn't bad at all. We were able to use the carpool lane a lot, so we got to the appt very early. I checked in and they had me fill out a couple forms, then go for x-rays. I wasn't sure he'd take new x-rays since I just had x-rays 6 months earlier with the 1st surgeon, and they were in Kaiser's system for him to see, but he did.

Dr. Ganocy was nice, knowledgeable, straightforward. He seemed less enthusiastic about doing surgery right away though, than the 1st surgeon was. He referred to the size of my curve as "borderline" for surgery, and he said curves tend not to progress as rapidly in adults as in teenagers, which I knew, but you see so many people adults here on the forum who have had rapid progression. He also said he'll do this surgery on someone up to the age of 70, but he doesn't like to do it after that age (I didn't ask why). So I certainly have plenty of time to decide.

He also asked if I'd tried acupuncture for the pain. I haven't, but I'm willing to give it a shot. Several people have suggested it, and I have said I wanted to try everything before resorting to surgery. Anyone here have experience with it for back pain? I guess I just don't have much hope of acupuncture providing long-term relief. I figured it either wouldn't work, or would only help for a short time, like p/t did.

I explained the main problem for me is the pain, and that I've already tried so many things with pain mgmt that didn't help (facet injections, lumbar epidural injection, nerve ablation) and I'm now on daily narcotic pain medicine & muscle relaxers just to function normally, and still in pain. I've long ago tried exercise, over-the-counter pain medicine, p/t, TENs unit, chiropractor. He said my pain is typical of someone with scoliosis.

So we talked about some of the specific questions I had about surgery: How long would I be in the hospital? About 4 nights. Would I go to rehab after that? Probably not. Would I have p/t? Probably not. He said (like others here have said) sometimes physical therapists have you do more things than he would want me doing right after surgery. Surgery would take about 6 to 8 hours and would be posterior only (yay!). He uses BMP. My rib hump isn't that bad, and he wouldn't suggest costoplasty.

Oh, I asked if he uses the SpineAssist robot and he said not yet, but they will get it in about a year or so. Cool! He said there is a 2-month wait to schedule surgery, so that's not bad. I asked what pain and pain control is like after surgery. He said pain varies so much with each patient, he tries to predict it and can't, but they (meaning his dept/team) can usually handle pain control. If not, they bring in Pain Management.

He said he'd probably fuse T10 to sacrum. I asked if I needed to worry about PJK. He looked closely at my x-rays again and said... possibly. There is a chance. If so, I'd have to be fused probably T4 to sacrum. OMG. But he didn't think so... so I'm going to try not to obsess and worry about it. As I mentioned on another thread, I said I was worried about loss of flexibility, and having a hard time picturing what it's like after surgery. He said I'd be stiffer, but probably not as bad as I think. (Any and all comments on that are appreciated, guys!)

He said if I'm not ready for surgery yet, he suggests coming back in about a year and getting new x-rays. He seemed very neutral about me having surgery, which is good that he didn't pressure me one way or another, but it doesn't make it any easier for me to make a decision. I was kind of hoping he'd put some kind of time frame on it like, "You might want to think about having the surgery within the next few years" or something like that.

Oh, Pooka, I did ask how he achieves balance in all the planes to avoid flatback, etc. We didn't get into all the details because we had so many other things to talk about, but it sounds like he relies heavily on CT scans, and has the CT scan images up during surgery to help guide things. I also thought it was interesting how he said they start with making a very small hole where they're going to put the pedicle screw, and if there's any problem, they will just skip that side at that level and not put a pedicle screw there. Explains why sometimes on a postop x-ray you might see screws everywhere except 1 side at 1 level.

I also asked if he does any minimally invasive procedures, and he said no. He mentioned Dr. Neel Anand, at Cedars Sinai in L.A., does a lot of min. invasive, but what Dr. Ganocy doesn't like about it is the amount of intraoperative radiation the patient is exposed to, because the surgeon has to use fluoroscopy to "see," and these are very long procedures. Hmm. good point. I hadn't even thought about that.

Lisa

[Pooka1]

Oh, Pooka, I did ask how he achieves balance in all the planes to avoid flatback, etc. We didn't get into all the details because we had so many other things to talk about, but it sounds like he relies heavily on CT scans, and has the CT scan images up during surgery to help guide things.

Hey Lisa,

Thank you for asking that question and posting the answer! That's pretty interesting. It stood to reason they had something to work from, if only standing and bending radiographs. It would seem hard to eyeball it although I think a very experienced person might be able to nail the balance. Both my girls are very balanced yet they never had CT scans for the surgeon to use.

Good luck with your decision.

Sharon

[mabeckoff]

Good luck making your decision. Are you going to other doctors?

[jrnyc]

hi Lisa
i have been putting off needed surgery..either T4-sacrum or T11-sacrum....for years...
there is no guarantee of pain relief after surgery...
i wojld only consider minimally invasive surgery if/when i do decide...

the surgeons i consulted with all said they thought i would get pain relief....but they could not guarantee it...
the only shots that have helped me are botox in thoracic area and sacroiliac joint injections in lumbar area....
i tried all kinds of things before we hit on the SI joint injections by a fluke!
what a blessing that was!

best of luck finding a new pain doctor....
but in southern CA, it shouldnt be any problem finding someone good...


jess