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View Full Version : How low do you go? (fusing)



52skeedoo
04-29-2009, 07:38 PM
On Monday I had my bending xrays to determine what the plan was for surgery.

First the technician took a really good full-length shot while I was standing and then she called Dr. T and he positioned me while I lay on my back. First I bent as far as possible to the right and she took a couple xrays. Then I bent as far as possible to the left. The doctor made sure that I was really stretched as far as possible. I stretched enough that I was a little stiff the next day.

While he was talking to my husband and I, the doctor marked up the full-length xray with his measurements. My husband took a picture of this and I'll try to add that as an attachment.

First Dr. T marked the vertical mid-line and measured that I was leaning 3.5cm to the left of mid-line. Then he marked and measured each of the curves and finally he looked at each of the bending xrays and measured how much correction I was able to get just by bending. The top curve corrected to 25 degrees, the middle curve (the largest) corrected to 22 degrees! He said this was very encouraging and he should be able to get a lot of correction during surgery.

Then he discussed my options and his recommendation. The big question was how low to fuse. He wants to fuse me only to L4. He can't guarantee that it will last but he thinks it will. The two disks below L4 look to be in pretty good condition so we may be able to save them.

By stopping at L4, I will only need one posterior surgery instead of a longer A/P approach (possibly 2 surgeries) and I will retain some lower back flexibility.

The risk is that if my two remaining lumbar disks rupture in the future (ouch !) then he will have to go in and fuse the rest of my low back, but that may not happen and if it does, the surgery won't be very long.

I like this idea. I was so happy after the appointment.:D To me less is best.

What kind of discussions have the rest of you had with your doctors about how much to fuse or not to fuse? What did you choose and why?

mauxi
04-29-2009, 07:59 PM
I am seeing a second specialist in a couple of weeks and will discuss the same issue. My first doctor recomended a fusion to L5 - don't know why. I pretty much worked hard at "holding it" during the appoinment after confirming surgery is in my future:eek:and lost track of the questions (had a list w/ me).

I haven't had an MRI or bending XRays yet. The criteria for fusion lengh is of big concern right now.

This time I'll also focus on questions related to the fusion level..Will keep you posted.:)

Susie*Bee
04-29-2009, 08:04 PM
Hi Sheri! My situation was very similar to yours, except I am fused higher also. We decided to gamble and save those lower vertebrae, knowing that it is quite possible that I may need further surgery. Time will tell. But if it isn't needed, I have that little bit of extra flexibility that I wouldn't have. If you have any questions, please ask. Best wishes!

dolores a
04-29-2009, 08:12 PM
I actually discussed this with my surgeon today, the very same way you described it. My surgeon feels that in my case, that I would definitely have problems due to my curves so it looks like they will fuse me down to my pelvic (so scary). He explained that I do not have mobility in my lower back as it is now, I'm just afraid I'll be walking like one of the wooden soldiers.

Do the surgeons determine after the bending x-ray how far they will go up or down depending on how well you can bend?

macky
04-29-2009, 09:07 PM
Hi, as you can see I was fused to L3, and now have a bit of deterioration and osteoarthritus due to age, so I agree, just go as low as they want and save what you can.
Good luck 52skee, Mauxi and Deloresa with your operations, thinking of you

Mackyxx

LindaRacine
04-29-2009, 11:36 PM
Hi 52skeedoo...

I think you have to determine if you can live with the possibility of additional surgery, or if you want it all done now. Although I'm not a medical professional, it seems to me that your curve goes all the way down. It would be nice to know the probability of degeneration below L3 if the fusion is stopped there. There has been a lot of research on the subject. I'll post some of the references that I know of.

http://www.ncbi.nlm.nih.gov/pubmed/14752356?ordinalpos=61&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/18270753?ordinalpos=20&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/11337635?ordinalpos=93&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/8727728?ordinalpos=128&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/8219548?ordinalpos=140&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Good luck with whatever you decide.

Regards,
Linda

Suzy
04-30-2009, 04:14 PM
Hi 52skeedoo,

I asked my DR. if we should just go ahead and do L5 and S1 and he said NO! He did not want to do that because of the loss of flexibility I would experience. My lower 2 discs are O.K. Leaking a bit (Per my discogram) but still O.K. I was told there is a 50/50 chance I might need to have those lower 2 added later on but he felt it would be at least 20ish years or so, If I needed to have a 2ND surgery, and a shorter operation then the 1st. (I am fused T10 to L4) I decided to listen to him and am SO glad I did. Just adding the last 2 would have changed my recovery tremendously! I think if he wants to stop at L4 or L5 do it. Adding S1 to the mix is a whole different ball game. I am over 3 yrs. post op and I am doing FABIOUSLY!


Surgery 2/22/06 @ age 43 Was 49* now 8*

Singer
04-30-2009, 05:03 PM
Ditto what Suzy said: I was told my L5 was in good shape so my surgeon stopped there, telling me I had a 50/50 chance of additional posterior surgery extending the fusion to the sacrum someday....he also mentioned the 20-year mark. (I tried not to think about how much fun it would be to have surgery as a 72-year-old...!!!!!)

I do know I could never face anterior surgery again...no matter what.

When it came right down to it, I decided to trust my surgeon and not sweat the details. Time will tell how it all pans out....after a rough start, it's so far, so good.

txmarinemom
04-30-2009, 06:13 PM
One thing I've noticed is how many people had bending x-rays: I never did, and apparently Hanson either doesn't do them on adults or doesn't normally do them on adults. It seems I remember he had me actually bend side to side, but he just did a visual inspection.

Apparently that was sufficient in my case: The pre-op correction estimate he gave me - 53 down to 20 - was right on target.

The original plan was fusion from T5-L1, but the morning of surgery he asked to take T4, as well. Aside from it being questionable whether T4 was involved in the structural curve, I'd had some pretty severe issues (for several years) with disk protrusions in my cervical compensatory curve. He felt the chances of helping that pain were increased with extended one level higher. I immediately agreed ... T4, T5 ... whatever.

If he'd asked me to take L2, however, I honestly think I would have had to postpone and think about it. That probably sounds silly to those of you fused to L3 and below, but I hadn't had any time to wrap my mind around anything other than retaining 99.9% of my original flexibility - and that's about what I have now. Almost no bending is done through the thoracic area (due to the ribs), so I really don't notice a difference at all.

As far as whether to take L5/S1, I've had more than a few people tell me their doctors believe a fusion to L4 is likely to cause deterioration of the discs below. That said, if the discs are healthy, many of those same doctors allow the patient to decide because it isn't a given. I also know quite a few people who sought 2nd, 3rd and 4th opinions because their 1st consult wanted to fuse them to the sacrum. The majority of them ended up choosing a surgeon who didn't subscribe to prophylactic inclusion of lowel levels.

Even if the odds were 50/50 for an extension later, I personally believe I'd play those and fuse as little as possible. Although I'm sure it's never easy, there's a big difference between giving up that flexibility at 40 years old vs. 60 years old (not that 60 is old - LOL!). There are just a lot of activities I do now that I likely won't be doing 20 years from now ... but who knows? ;)

Regards,
Pam

Geish
04-30-2009, 07:24 PM
I was told by my Surgeon that he was hoping to be able to stop at L4 but he wouldn't really be able to tell until he got in there. Literally the morning of the surgery, just as they were ready to wheel me in, he asked how I felt if he had to go lower. I looked him right in the eye and told him I had complete faith in him and his judgment and that I wanted him to make the decision as if he were operating on his own wife and what he would recommend for her. He ended up going all the way to S1. I wasn't upset at all. I figured this is what he went to school for and had many years of experience. Why should I second guess his opinion? I have no regrets and would do the same thing with the same surgeon in a heartbeat. Sometimes you just have to know when to have faith.

debbei
04-30-2009, 07:27 PM
I am fused T3 to L3. The disks below were in good shape. My surgeon also said that some day I might need more surgery, but we'll worry about it if and when the time comes. Like the others, I trust his opinion and am grateful that I have the mobility that I have right now. I try not to OVER use it though so maybe those disks will last for my lifetime.

txmarinemom
04-30-2009, 07:51 PM
Geish,

I know you trusted Ganocy with that decision, and I hope you realize I wasn't referring to situations like yours. He made an informed decision based on looking at your spine vs. just automatically thinking "Based on her x-ray, and data on low fusions, she might be back at some point. Let's just take it all now.".

Does that clarify what I meant a bit more?

And Debbei, I like your statement about being nice to the discs below the fusion. Even though mine ends higher, I do the same ... and really, even UNfused people should take better care of their backs. Simple changes can matter in the short run and possibly the long run. They certainly can't hurt!

Last time I moved, and unpacked my china, I sat on a chair and sat each box on a chair in front of me. I know from previous experience (pre and post op), I would have seriously paid for the extended stooping to unpack boxes on the ground. When I scrub my tub, I use a bristled mop. I also still rely on things I used immediately after surgery like my rolling, collapsible carts ... and even moved 800 lbs of potting soil (laying each 40 bag across the cart) from my car to where I set up my container garden several weeks ago ;-). BTW, I set all the containers up on cinderblock platforms not only for drainage but to reduce the amount of bending required to reach them. It worked well. I put enough stress on my body doing the things I LIKE to do ... the way I look at it is why not modify the way I accomplish the mundane when I can?

Regards,
Pam

debbei
04-30-2009, 08:13 PM
Geish,

I know you trusted Ganocy with that decision, and I hope you realize I wasn't referring to situations like yours. He made an informed decision based on looking at your spine vs. just automatically thinking "Based on her x-ray, and data on low fusions, she might be back at some point. Let's just take it all now.".

Does that clarify what I meant a bit more?

And Debbei, I like your statement about being nice to the discs below the fusion. Even though mine ends higher, I do the same ... and really, even UNfused people should take better care of their backs. Simple changes can matter in the short run and possibly the long run. They certainly can't hurt!

Last time I moved, and unpacked my china, I sat on a chair and sat each box on a chair in front of me. I know from previous experience (pre and post op), I would have seriously paid for the extended stooping to unpack boxes on the ground. When I scrub my tub, I use a bristled mop. I also still rely on things I used immediately after surgery like my rolling, collapsible carts ... and even moved 800 lbs of potting soil (laying each 40 bag across the cart) from my car to where I set up my container garden several weeks ago ;-). BTW, I set all the containers up on cinderblock platforms not only for drainage but to reduce the amount of bending required to reach them. It worked well. I put enough stress on my body doing the things I LIKE to do ... the way I look at it is why not modify the way I accomplish the mundane when I can?

Regards,
Pam


As far as my tub goes, BLAHHHHHH!!! I make my hubby clean it!! As far as I'm concerned I will never scrub a tub again!! (One of the 'perks' of a fusion as far as I'm concerned!) :)

Seriously though, good for you Pam on doing things in a way that treats your disks gently.

txmarinemom
04-30-2009, 08:34 PM
As far as my tub goes, BLAHHHHHH!!! I make my hubby clean it!!

Oh, trust me ... were anyone crazy enough to marry me (and vice versa), he'd have "Tub Scrubber" tattoed on his forehead - LMAO!

It's a more practical plan for me to hope my dog miraculously sprouts opposable thumbs ... ;-)

Pam

titaniumed
04-30-2009, 09:36 PM
Oh, it hurts when I laugh.
Right in the gall bladder area.

Pam
You know, I never thought that comedy can induce pain.........
I need to apoligize to everyone.
Ed

LynnMarie74
04-30-2009, 09:50 PM
I guess I had a similar experience.....I had a few other opinions that ended me at Dr Tribus. My 1st (original) back doctor advised that I would def. need surgery & it would most likely need to end at L5 possibly into the sacrum. This level of fusion was out of his "league"....that is not what he said but it just seems fitting...so he referred me to a Doc in MN who I did not like one bit.(bad bed side, taked down to me,etc) He said I would need to be fused into the sacrum no questions asked & basically was trying to talk me out of the surgery. I left confused obviously. I went back to doc #1 and said do you have another referal.....which left me w/Doc Tribus. He took xrays which included the bending ones & also a MRI. After reviewing them he said he felt very confident that he could achieve good results going the a/p approach & would fuse me from T5 to L4, as this would allow me more flexability, etc. He did tell me however, that in the future....15-20 yrs donw the road, he may need to finish the fusion but it was choice. It ended up only being a posterior fusion, thank goodness & I obviously decided to end at L4 & personally Im glad I did. I actually notice more of the fusion/hardware in my thorasic area than I do in my lower. I easily bend at the waist when I need to or use a combo of squating and waist bending. I dont regret where it ended & if I do take it easy, perhaps I can hold off even longer on the last 2. :)

Oh...and I never did the tub scrubbing to begin with, so my back wont know the difference! :D

Geish
04-30-2009, 09:54 PM
Hey Pam...Glad to see you still here! Yea!
No offense taken at all. Hadn't even thought of it that way. And yes, Ganocy did take me by my case alone. He really was hoping to stop at L4 and I was too, but knew in my heart that I was really messed up down low. Just thought some might like to know that the decision sometimes has to be made on the table and I trusted Dr Ganocy to make the right decision.

Ed, Hope you are healing well. Now quit laughing! I remember my wrestlers thought it was great fun to make me laugh 2 days after hernia surgery. Of course they paid for it in push ups!

sccrm08
04-30-2009, 10:51 PM
I had this same conversation with my surgeon at the pre op appointment. He told me he was planning on going to L4 but what did I feel if once he was in he had to go lower. I told him I totally trusted him and what ever he felt needed done I would be OK with. When writing up the surgery consent he covered all this in the paperwork which I signed. He only went to L4 but told me he would love to see me get 20 years out of L5 & S1 but he would not be surprised if I was back in 5 years for the extension. At the time 5 years seemed a long way off but I am already 2 years in and I do get strains and pains below the fusion. The PT is always telling me I need to treat the last disks better.

debbei
05-01-2009, 01:28 AM
Oh, it hurts when I laugh.
Right in the gall bladder area.

Pam
You know, I never thought that comedy can induce pain.........
I need to apoligize to everyone.
Ed

Ed,
I guess the surgery went well? Here's hoping you have a quick easy recovery and are off to skiing in no time.

titaniumed
05-01-2009, 04:16 AM
Sheri
How low do you go?

Some of us have no choice. Mine was a case where I used up my timeframe window. It just goes to show that you are wise in addressing this now, and not waiting. Curves can increase rapidly with age...... and with no warnings. Having large curves is like watching a 2 yr old. Don't take your eyes off them!

With all the advancements with artificial discs, and I believe they might be using 2 now in scoli ???, in the future, the technology in that area will improve dramatically. Just in case there was a problem down the road, you will have that option. That does tip the scales away from fusing to the pelvis and the "git r done right" thought.
Ask your Doc about this and his thoughts. Also, if he changes his mind and wants to "go to the big toe" have the proper mindset.

Being fused all the way for me is way better than I thought. People cannot tell I'm fused as long as I am. In fact, when I go to my next scoli meeting, I think what I will do is say that I'm "thinking about surgery" jump around a little, and at the end, I will surprise everyone, including the Docs! It will be fun! I will have to tilt my shoulders on purpose. Left for 5 minutes, right for 5 minutes.

I may not paint my toenails, but I could. Gee? What color should I go with today? Black would hide the dirt.LOL
Thx for posting your x-ray.

Mauxi

Its hard to concentrate when interviewing your surgeon.(after all, your the boss now) I asked all sorts of questions that had nothing to do with scoliosis, It was a "feeling out" that I will do with people, and it took 5 visits over 2 years. You need to be comfortable with your surgeon. He also needs to be comfortable with his "team" and the hospital. He needs to be confident, almost cocky, but not arrogant. He needs to be busy, but not too busy to spend just a little time with you. My God daughter is in Medical school, she is 25, and I need an appointment with her............

Ask your Doc if you can have questions answered by e-mail. If so, this is a good sign.
Its also good that you are here posting and reading about scoliosis.

Dolores

The "wooden soldier" walk is usually due to hip, knee, and leg issues. I have friends with wooden legs. Back in college at a party, we drank champagne from a wooden leg. Its a male bonding thing. We sterilized it with grain alcohol. I know, it was lunacy.

Geish and other future Hawaiian travelers, divers, touriste types, hula dancers and the scoliotic surfer society members:
RT planefare to Hawaii is cheap now. RNO-KOA $331. farecompare.com

Scolialoha
Ed

JenniferG
05-01-2009, 08:48 PM
Good to see you haven't lost your sense of humour since your most recent surgery, Ed.

When I was told last year that I would need to be fused to the Sacrum, I didn't really know what it meant. As it happens, he went right down to my pelvis, and up a notch from T5 to T4.

I already have some flexibility back and am getting around better than I had expected. I feel slightly wooden when I walk, but feel confident I can modify that enough to be unnoticeable as time goes by.

I guess my age was the reason he went lower. He said my bones were good. Perhaps he sensed I wouldn't have it in me to go back for further surgery later on, that it was now or never. ;)

Geish
05-01-2009, 11:13 PM
Geish and other future Hawaiian travelers, divers, touriste types, hula dancers and the scoliotic surfer society members:
RT planefare to Hawaii is cheap now. RNO-KOA $331. farecompare.com

Scolialoha
Ed

My airfare is already booked! Just waiting until my departure date!

Nancy Joy
05-11-2009, 10:19 PM
I am fused T10 to my pelvis and even have metal embedded in both sides of my pelvis bones. My curve was pretty much in the lumbar area which effected the top. I knew in advance that I would never bend at the waist again and thought I was prepared for that but was not. All I can say is my legs get a great stretch every day. I do not use any aids and STRETCH to put on socks, STRETCH to cut my toenails, and have to pick things up the "correct" way, etc. After a while, I figured out that I was in a different ballgame than most on this site. Ed, you have no idea how encouraging your ski pictures were to me!!!!! Probably, the most frustrating part for me right now is I can't just sit down and give myself a good pedicure and I am too cheap to want to pay for one! But, a positive is, I shouldn't have to have surgery ever again (and that is a REAL positive!) and all of my previous pain is gone. Also, I have TERRIFIC posture! All I can say is trust your doctor and do what you think is right for you. I gain a little more flexibility everyday and am still grateful something could be done for me and that I went thru with it.