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Thread: Which approach seems better?

  1. #1
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    May 2010
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    Which approach seems better?

    Hi everyone, I am trying to decide between surgeons and have two different opinions so far. I will also see others, and I suppose that in the long run it does not matter - just choose a surgeon and go with their opinion. Any input is appreciated...

    I have two differing opinions from two of the best surgeons in NYC area. I hesitate to mention names as I would like unbiased opinions from you all. Here goes:

    OPINION ONE: Fuse T11 to L4 or L5 -- This surgeon I saw recently. He also said that I would probably need another fusion to sacrum in about 10 years when there is more degeneration in L4/L5 vertebrae. This surgeon would only do posterior - even if to sacrum needed to be done upon further inspection of MRI of L4/L5 vertebrae.

    OPINION TWO: Fuse T5 to sacrum -- This surgeon originally stated T11 to Sacrum (1.5 years ago), but revised a year later (currently) when I progressed 10 degrees. He stated that he believed I would have problems if he did not go higher up to T5. At the time I did not question why to sacrum - my curves are low. This surgeon also wants to do two ops from front and rear to obtain better fusion to sacrum.

    I am wondering which approach seems better. I would rather do everything now (Opinion 2) and not have to go back for more fusion in 10 or so years (Opinion 1). However : Is mobility so impaired when fusing to sacrum (?) that it would be beneficial to keep that bit of mobility for about 10 more years? Also, do you really get a better fusion when going in from A/P rather than only P? I am fine with doing the most up front even if it is more traumatic, so as not to have to redo any surgery - I just want this whole thing to be over.
    Thanks for any opinions!

  2. #2
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    I am fused from T4-L4, and if I had had my way, I would have been fused to the sacrum. My surgeon had originally planned to go all the way to S1, but during the surgery he got amazing correction w/o having to go that far (my curves went from T52 L52 to less than 15 degrees top and bottom), and decided not to do it. I am pleased with my results overall, and trust my surgeon...but I wish I didn't have to think about the potential of another surgery 20-30 years from now.

    My surgeon decided not to fuse to S1 so that I would have that little mobility, and he thinks I may never need it fused completely at all. But if that surgeon who already said you would probably need it in 10 years, he doesn't seem to get the fact that these surgeries are a bear to go through and we'd rather not have another one if we can avoid it. Ten years isn't very long...if it was me, I'd go with the full fusion.

    I don't feel like having it fused entirely would have made me much less flexible. I am so careful not to bend or put extra stress on those last two discs, I might as well be fused to S1 anyway.

    Just my opinion though...I'm sure the people on here who are fused all the way will be able to help you!
    Rebecca
    Age: 28
    Dx w/ scoli @ age 12 S curves T-40* L-42*
    wore night bending brace as teenager
    Curves changed to 50's plus or minus
    herniated disc L2-3, Discectomy October 2007
    fusion L2-3 November 2008
    Revision L2-3 Fusion, Removal of hardware August 2009
    Curves measuring 52 T&L September 2010
    Fused T4-L4, all posterior December 27th 2010
    gained almost two inches in height

    Before and After Exterior
    Before and After X-rays
    My blog: http://herscoliosisjourney.blogspot.com/

  3. #3
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    May 2009
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    hi ripley
    i know it is a blessing IF surgeons agree...a small comfort in the middle of a scary situation!
    how many surgeons did you see? you listed 2 opinions...did you see 2 surgeons...or more than that? have you considered seeing another surgeon just to see whom he agrees with...or is this your decision and you will make it without any further consultation?
    if your curves are low, i am kind of surprised a surgeon suggested not going to sacrum...i thought they only do that for the young teens...i do not remember your age...are you quite young?

    that said, i do not blame you for not wanting to go down to sacrum!

    best of luck
    jess

  4. #4
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    Mar 2005
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    NJ across from NYC
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    Fused to Sacrum

    This was what I was told.... In 2002, when i first saw my surgeon, he said that my L3/4 was degenerative, etc. and that was causing my pain. This was as a result of the Harrington Rod, my initial surgery in 1981. He said he could perform surgery but I would probably have to have another surgery years later as the remaining discs would degenerate. I went back in 2008 as the pain was worse and he recommended surgery to the sacrum but I wasn't mentally ready and went the facet joint injection route with pain management. Two years later I had the surgery (12/7/2010) and am very pleased with my outcome. For me the mobility is different but it's getting better. I don't think I'll ever be able to put my socks and certain shoes on without some difficulty, but you learn to adjust. At times, putting slacks on I have to sit down or I feel like I might lose my balance since I'm so straight. You have to be patient as it takes time and determination to get to a comfortable place. Good luck with your decision. LYNN
    1981 Surgery with Harrington Rod; fused from T2 to L3 - Dr.Keim (at 26 years old)
    2000 Partial Rod Removal
    2001 Right Scapular Resection
    12/07/2010 Surgical stabilization L3 through sacrum with revision harrington rod instrumentation, interbody fusion and pre-sacral fusion L5-S1 - Dr. Boachie (at 56 years old)
    06/11/14 - Posterior cervical fusion C3 - T3 (Mountaineer System) due to severely arthritic joints - Dr. Patrick O'Leary (at age 59)

  5. #5
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    Quote Originally Posted by ripley View Post
    Hi everyone, I am trying to decide between surgeons and have two different opinions so far. I will also see others, and I suppose that in the long run it does not matter - just choose a surgeon and go with their opinion. Any input is appreciated...

    I have two differing opinions from two of the best surgeons in NYC area. I hesitate to mention names as I would like unbiased opinions from you all. Here goes:

    OPINION ONE: Fuse T11 to L4 or L5 -- This surgeon I saw recently. He also said that I would probably need another fusion to sacrum in about 10 years when there is more degeneration in L4/L5 vertebrae. This surgeon would only do posterior - even if to sacrum needed to be done upon further inspection of MRI of L4/L5 vertebrae.

    OPINION TWO: Fuse T5 to sacrum -- This surgeon originally stated T11 to Sacrum (1.5 years ago), but revised a year later (currently) when I progressed 10 degrees. He stated that he believed I would have problems if he did not go higher up to T5. At the time I did not question why to sacrum - my curves are low. This surgeon also wants to do two ops from front and rear to obtain better fusion to sacrum.

    I am wondering which approach seems better. I would rather do everything now (Opinion 2) and not have to go back for more fusion in 10 or so years (Opinion 1). However : Is mobility so impaired when fusing to sacrum (?) that it would be beneficial to keep that bit of mobility for about 10 more years? Also, do you really get a better fusion when going in from A/P rather than only P? I am fine with doing the most up front even if it is more traumatic, so as not to have to redo any surgery - I just want this whole thing to be over.
    Thanks for any opinions!
    This is such a tough decision for a patient to make. I can tell you that we see a lot of patients who are fused T10 or T11 to L4, L5, or S1, who then have to go back for more surgery because they become kyphotic above the fusion. This is probably the single most discussed issue in our weekly surgical conferences. The surgeons do their best to guess which patients need to go up to T4ish, but they're wrong sometimes, and those patients usually have to be brought back for more surgery.

    When I had my first surgeries (20 years ago), I was given the option of only fusing the lumbar curve, or also fusing the thoracic curve. Because my surgeon felt there was a very significant chance that he'd have to go up higher eventually, I chose to get it all over with at one time. In hindsight, I actually wish I had tried having only the lumbar curve fused. Although purely non-scientific, it seems to me that post-operative pain in adults fused from T3 or T4 seems to be greater than in patients whose fusions start at T10 or T11. My post-op pain from my first surgeries was entirely in my upper back. If I was making the decision over again today, I would choose to take the risk of needing additional surgery, and only having my lumbar curve fused. I suspect my recovery would have been very different than what it was. With that said, if I had 100% trust in the surgeon who wants to start at T5, I would let him/her do what they think is best.

    Best of luck with your decision.

    Regards,
    Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

  6. #6
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    May 2009
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    3,745
    do i understand correctly that your concern is about how LOW to go..not how high to go...with the fusions...?
    i am just asking that question because i need fusion to sacrum, with pelvic fixation...either starting at T4 or T11...surgeons said they were pleased that i get relief of upper pain with botox shots, so they agreed to start at T11 instead of T4...but what is keeping me from doing the surgery is how LOW they need to go...not how high they want to start....

    best of luck
    jess

  7. #7
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    Dec 2009
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    Bakersfield
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    I am fused T-10 to S1.It is a big surgery so I would choose option 2.
    Aug.17,09 Anterior
    Aug.20,09 Posterior
    Fused T-10 to Sacral Pelvis
    Cedars-Sinai
    Dr.Pashman

    Sheri 47 years young
    Husband married 30 years
    3 kids 29,28,25
    4 grandkids 10,8,5,3

  8. #8
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    May 2010
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    Hi all, thanks so much for the info. I have the two opinions so far, but I'm going to get a couple more. My concern is both going to sacrum and going higher to T5. Right now I'm leaning toward the longer fusion, as I would hate to have problems to go back for. Linda mentioned Kyphosis above the fusion and that is the exact area where I have kyphosis now. Can anyone explain what the difference is of going to sacrum - is it strictly a mobility issue? If so, is it really much different to have only one or two moveable vertebrae above it? I'm having a hard time picturing it. Thanks...

    And I'm 46 - so, not young for avoiding sacrum ...
    Last edited by ripley; 07-28-2011 at 09:22 AM.

  9. #9
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    Jul 2011
    Location
    Australia
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    Dilemmas

    Hi, I am planning being fused L9 to either L3 or L4 in two weeks by Dr Cree in Sydney. He is well respected (Director of Scoliosis surgery at a couple of hospitals and does many scolis incl adults. I asked whether this would set me up for future surgery to lower levels and he replied that he chooses the levels with the aim of avoiding further surgery. I didn't get a second opinion as he is considered the best in Sydney and I didn't want to confuse myself. He said though there is always the possibility if herniation and then further surgery but said surgery now would give me the best quality of life over the next 20 yrs
    Kelly
    49 yrs
    55 deg thorocolumbar

  10. #10
    Join Date
    Jul 2011
    Location
    Australia
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    Hi again!

    I'm writing this in 2 stages because of logging out problem
    I think to myself, should I wait for more degeneration and progression and go to sacrum in 5 to whatever years? Then I look at myself and how I am tilting more now. I don't have a lot of pain but I am uncomfortable with a collapsing torso feeling, and I am noticing I am more laboured when I walk distances. I'm not liking the way I look now either, this will be the first year I won't feel comfortable in a bikini ( 7 deg of progression in two yrs). Dr Cree thinks I am a great candidate for surgery now though he doesn't push it. I guess I am trusting his judgement and hoping by going now will give me the best long term outcome, better correction, avoidance of pain in the future and saving my lower discs. Dr Cree said if I don't have the surgery I likely face greater disc degeneration, pain and deformity.
    It's 4.10 in Aust and I can't sleep!
    Kelly

  11. #11
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    near Philadelphia
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    I feel strongly that with a huge and complex surgery like this, it simply isn't fair to ask the patient to make the decision. The only decision I worried about making was which surgeon I chose, and I made sure that I trusted that surgeon 100 percent.

    I'm fused T10 to L5, and I understood going in that there was a "50-50 chance" that I'd need additional fusion to the sacrum in another 10-20 years. My L5 disc was in great shape (and I hope it still is!), so Boachie felt confident about stopping the fusion there. My thoracic curve was mostly compensatory so I understood his rationale for not fusing higher. I've done well although I did have a large anterior incision, which was very difficult to recover from and I still have some discomfort in that area. I don't think surgeons (including Boachie) are making those kinds of long front incisions anymore.
    Chris
    A/P fusion on June 19, 2007 at age 52; T10-L5
    Pre-op thoracolumbar curve: 70 degrees
    Post-op curve: 12 degrees
    Dr. Boachie-adjei, HSS, New York

  12. #12
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    Quote Originally Posted by ripley View Post
    Linda mentioned Kyphosis above the fusion and that is the exact area where I have kyphosis now.
    You might have to worry about PJK (proximal junctional kyphosis). Its basically where you fall foward above a fusion.

    Ed
    49 yr old male, now 60, the new 55...
    Pre surgery curves C12,T70,L70
    ALIF/PLIF T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
    Dr Brett Menmuir St Marys Hospital Reno,Nevada

    Bending and twisting pics after full fusion
    http://www.scoliosis.org/forum/showt...on.&highlight=

    My x-rays
    http://www.scoliosis.org/forum/attac...2&d=1228779214

    http://www.scoliosis.org/forum/attac...3&d=1228779258

  13. #13
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    Quote Originally Posted by ripley View Post
    Can anyone explain what the difference is of going to sacrum - is it strictly a mobility issue? If so, is it really much different to have only one or two moveable vertebrae above it? I'm having a hard time picturing it. Thanks...
    The lowest vertebrae articulate approx 20 degrees each. Not all vertebrae have this figure, just the lowest 2.

    I cannot reach the floor, I can get to about 3-4 inches from the floor. I stood next to a scoli I know who has her lowest untouched, and she can reach the floor.

    Ed
    49 yr old male, now 60, the new 55...
    Pre surgery curves C12,T70,L70
    ALIF/PLIF T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
    Dr Brett Menmuir St Marys Hospital Reno,Nevada

    Bending and twisting pics after full fusion
    http://www.scoliosis.org/forum/showt...on.&highlight=

    My x-rays
    http://www.scoliosis.org/forum/attac...2&d=1228779214

    http://www.scoliosis.org/forum/attac...3&d=1228779258

  14. #14
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    Quote Originally Posted by jrnyc View Post
    do i understand correctly that your concern is about how LOW to go..not how high to go...with the fusions...?
    i am just asking that question because i need fusion to sacrum, with pelvic fixation...either starting at T4 or T11...surgeons said they were pleased that i get relief of upper pain with botox shots, so they agreed to start at T11 instead of T4...but what is keeping me from doing the surgery is how LOW they need to go...not how high they want to start....

    best of luck
    jess
    Yes, IMO. Fusing a patient to L4 or L5 is highly likely to lead to needing additional fusion if the patient lives more than 10-20 years after surgery. And, recovery (in terms of pain from surgery to S1) doesn't appear to be very much different than surgery to L3, L4, or L5. I personally think that going higher (T3-T5) leads to pain very often. So, if it appears that the patient is someone who is unlikely to develop PJK, fusing from T10 or T11 is a better option. Please note, however, that this is purely anecdotal.

    --Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

  15. #15
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    Location
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    Quote Originally Posted by ripley View Post
    Hi all, thanks so much for the info. I have the two opinions so far, but I'm going to get a couple more. My concern is both going to sacrum and going higher to T5. Right now I'm leaning toward the longer fusion, as I would hate to have problems to go back for. Linda mentioned Kyphosis above the fusion and that is the exact area where I have kyphosis now. Can anyone explain what the difference is of going to sacrum - is it strictly a mobility issue? If so, is it really much different to have only one or two moveable vertebrae above it? I'm having a hard time picturing it. Thanks...

    And I'm 46 - so, not young for avoiding sacrum ...
    If you're already hyperkyphotic, I suspect the second surgeon is correct, that you'll have to be fused higher.

    Most of the adults that I talk to who were fused initially to L3, L4, or L5, and are later fused to S1, tell me that there wasn't a lot of difference in terms of flexibility. By the time we're fused to S1, we've usually already had a lot of degenerative changes that inhibit movement at the lower levels anyway. In my case, there was definitely a difference (my fusion was extended from L3-S1 in January), but I have to say it wasn't nearly as bad as I'd feared.

    --Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

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