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Thread: Is A/P Combo Better?

  1. #1
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    Is A/P Combo Better?

    In a recent thread started by ladare (Considering T-12 to L-5 Fusion), there were several posts relating to "whether anterior/posterior-combination increased surgical success as opposed to posterior approach alone".

    Well, this question greatly concerns me since I'll be having surgery later this year, at age 61, to be fused from T-3 possibly to the sacrum for an 80 degree, rather rigid curve with some stenosis.

    I've seen two surgeons so far. One gave me the option of doing both A/P or posterior alone, saying that adding anterior approach might give 20 extra degrees of correction, but did not say that it might help fusion. Second doctor said that posterior was all that was needed. I'm to see third doctor next week.

    I've been reading everything I can get my hands on concerning whether, in general, the combination of the two approaches is better, particularly when fusion is carried through the lumbar spine. I would like to post some passages I've found........

    (note: "Pseudoarthrosis" is failure of fusion.)

    Dr. Michael Neuwirth in Scoliosis Sourcebook (p.122 & 123) says,
    A patient who has a very large, rigid curve - one measuring more than 75 or 80 degrees on a bending X-ray - will probably achieve the best results by undergoing both anterior and posterior procedures (A/P surgery). --------------- By operating front and back, performing a circumferential (wrap-around) fusion, the surgeon can considerably reduce the pseudoarthrosis rate. --------------I usually recommend stabilizing lumbar curves from the back as well as from the front once a patient passes the age of fifty-five or so. Although the posterior surgery does not provide any additional correction, it further stabilizes the curve, which becomes more important as the risk of pseudoarthrosis increases. -----------A/P surgery is also necessary when fusion to the sacrum or pelvis is required.
    Sounds like he was describing me! ..... over age 55 with large, rigid curve over 75 degrees. Yep, that was me alright!

    Then in Scoliosis Surgery, The Definitive Patient's Reference, David Wolpert says pretty much the same thing on page 36.

    Also, on the HSS site, in an interview called "Adult Scoliosis with Low Lumbar Degenerative Disease and Spinal Stenosis", Dr. Boachie says,
    There are decompensated thoracolumbar lumbar curves for which it is necessary to fuse to the sacrum. If posterior fusion alone is done, there is a very high pseudoarthrosis rate in such cases, reported to be up to 49%. There is also higher loss of correction and incidence of imbalance. In these cases, you should consider a supplemental anterior fusion. -------- Once you talk about fusion to the sacrum in an adult, then you are thinking of anterior and posterior just because of the problems of pseudoarthrosis and loss of fixation.
    Hmmm, I'm wondering why neither surgeon I saw pushed doing A/P when it sounds like I fit all the criteria for using a combination approach. Of course, if all things were equal, I'd much prefer doing just the posterior since it would be easier on me, but, on the other hand, I certainly want the best fusion possible. I would appreciate hearing from others who've had to have long fusions that extended into the lumbar or sacrum on how those procedures were done. I'm going to New York next week for the third opinion (with Boachie), so I want to find out all I can beforehand and have all my questions ready for him.

    Thanks,
    Peachy
    Last edited by Peachy; 06-02-2008 at 02:21 PM. Reason: To add a word definition for clarity

  2. #2
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    In my opinion (mine only...so no slamming me please) I believe some surgeons recommend the approach that they are most comfortable with. If they learn and practice anterior only it's what they recommend, if it's posterior only then that is their recommendation and if they often use both then they recommend both. Again just my opinion. Not sure if that really helps. I know when I was making my decision I asked my surgeon about A/P and he let me know it wasn't necessary. Don't know how many A/P's he does but I must say I am thrilled with my results from a posterior approach only.
    Geish
    47 years old, dx at 13
    +30* to the right, +60* to the left, +30* to the right
    Surgery 12-13-07 - fusion from T4 to sacrum.


    http://www.scoliosis.org/forum/attac...tachmentid=267 Pre surgery
    http://www.scoliosis.org/forum/attac...tachmentid=268 Post surgery
    http://i156.photobucket.com/albums/t...s/DSC01091.jpg Xray from the side
    http://i156.photobucket.com/albums/t...1089-1-1-1.jpg Xray from the back

  3. #3
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    Prior to my consultation with Dr. Boachie and subsequent A/P surgery by him in December, I met with 2 surgeons locally. One said, given my age, both anterior and posterior would be necessary. The other local surgeon said posterior only, which he said would give me a 100% correction and I would need to be hospitalized only 5 days - this all sounded too good to be true.

    So I decided to meet with Dr. B. (who explained that getting a 100% correction, at my age, would place huge stress on the adjoining top & bottom vertebrae and I would likely need surgery down the road to stabilize those 2 vertebrae!), and he proposed A/P with fusion from T2 to L2 (he did not offer a choice of posterior only). Although I had a lot of complications in the 3 months following surgery due to problems unique to me, at this point I can say that I am quite pleased with the results - my back is not perfect but it is vastly improved over what it was pre-surgery.

    Let us know how the appointment with Dr. B goes. Be sure to bring food and reading material - he is always running late, but he will spend the time to answer all your questions.
    As of 12/25/07, age 62, 100* thoracic kyphosis, 73* L1-S1 lordosis, 37*/25* compensatory S-curve scoliosis. On 12/26/07, Dr. Boachie @ HSS NYC did 11 hours ant. & post. procedures, fused T2-L2, kyphosis now 57*, scoli 10*. Regained 2 1/4 inches in height!! Improving every day.

  4. #4
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    Ugh, Janet ... I'd never noticed the "7 weeks of almost non-stop vomiting" in your signature - you poor thing!

    And starting at 2 weeks post-op ... wow. I can't even imagine.

    So glad to hear your recovery has become less "eventful" ...

    Regards,
    Pam
    Fusion is NOT the end of the world.
    AIDS Walk Houston 2008 5K @ 33 days post op!


    41, dx'd JIS & Boston braced @ 10
    Pre-op 53, Post-op < 20
    Fused 2/5/08, T4-L1 ... Darrell S. Hanson, Houston


    VIEW MY X-RAYS
    EMAIL ME

  5. #5
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    Quote Originally Posted by Geish
    In my opinion (mine only...so no slamming me please) I believe some surgeons recommend the approach that they are most comfortable with. If they learn and practice anterior only it's what they recommend, if it's posterior only then that is their recommendation and if they often use both then they recommend both. Again just my opinion. Not sure if that really helps. I know when I was making my decision I asked my surgeon about A/P and he let me know it wasn't necessary. Don't know how many A/P's he does but I must say I am thrilled with my results from a posterior approach only.
    Janet... I totally agree with this. If you feel that the surgeons you've seen may not be up to the challenge, you might want to try getting in to see one of the better known specialists (e.g. Boachie). You've done a great deal of research, and it would be a shame if you had a bad outcome because your surgeon has less than optimal experience/training. Good luck with your journey.

    Regards,
    Linda

  6. #6
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    Thanks

    Geish, thanks for your note. My fusion will be very similar to yours. I'm sending you a pm.

    Linda, right, that's why I have the appointment with Boachie next week.

    Peachy

  7. #7
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    Janet,

    I'm very excited about getting to see Dr. Boachie next week, and I'm so glad that you're pleased with the results of his surgery on you, despite the complications. I remember reading your posts at that time and know you really went through a lot! I also have a hiatal hernia, so I'm hoping it doesn't give me problems with the surgery.

    I feel almost positive that Boachie is going to tell me that A/P is necessary, considering my age and the long length of spine to be fused. I just want to know as much as possible from other's experiences, so I can have my questions ready for him.

    One other question, did you have a rib hump? If so, was it corrected by the surgery, and did he do a thorocoplasty?

    Peachy

  8. #8
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    Um I'm confused

    My understanding of using an "approach" has all to do with the condition of the spine.

    For example, I have some really bad discs in my lower lumbar. Every surgeon I saw said I needed an anterior approach for one purpose - to replace those bad discs, not for fusion.

    Please correct me if I'm wrong but there would be no need for an anterior approach if all that was required was to fuse and correct the scoliosis. If that was all that was needed, the posterior approach was adequate.

    Help please, as now I'm questioning my surgery.
    Susan
    XLIF/Posterior Surgery 6/16/08. Fused T10-L5 in CA by Dr. Michael Kropf (don't go there unless it's simple, I hear he's at Cedar's now). Very deformed, had revision w/5 PSO's, rods from T-3 to sacrum including iliac screws, all posterior, 5/23/16 with Dr. Purnendu Gupta of Chicago.


    Owner of Chachi the Chihuahua, So Cal born and bred, now a resident of 'Chicagoland' Illinois. Uh, dislike it here....thank God there was ONE excellent spine surgeon in this area.

  9. #9
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    Susan, when it's all said and done, your surgeon knows best what approach to take, how many levels to fuse, etc. When I was researching my own surgery I had to keep reminding myself that even though I THINK I deserve an honorary M.D. because of all the research I've done, the surgeons, after all, are the ones that went through medical school.

    It will all be okay.
    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

  10. #10
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    Thanks Chris

    What I meant though when I said I was questioning my own surgery wasn't so much that I shouldn't have it, just that the anterior portion was to remove discs and replace with an interbody fusion device...normally a titantium cage.

    If all my discs were good, there would be no need for the anterior, correct?

    I think my surgeon wants to do three levels in the anterior portion, but he'll know which ones once he gets in there.

    Does anybody know if they do flouroscopy (I'm sure that's not spelled right) during the anterior surgery? When had injections in my lower lumbar, they used it to make sure the injections went into the right place...I could see the picture of my spine - it was pretty interesting to watch! Then the Versed kicked in...

    I think you should have an honorary MD...from now on, you are Dr. Singer
    Susan
    XLIF/Posterior Surgery 6/16/08. Fused T10-L5 in CA by Dr. Michael Kropf (don't go there unless it's simple, I hear he's at Cedar's now). Very deformed, had revision w/5 PSO's, rods from T-3 to sacrum including iliac screws, all posterior, 5/23/16 with Dr. Purnendu Gupta of Chicago.


    Owner of Chachi the Chihuahua, So Cal born and bred, now a resident of 'Chicagoland' Illinois. Uh, dislike it here....thank God there was ONE excellent spine surgeon in this area.

  11. #11
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    Peachy,

    When you see Dr. B, be sure to mention the hiatal hernia - my situation should be fresh in his mind. But, as Singer mentioned previously, he is a spine surgeon and he thinks about spines. I strongly recommed you consult with a stomach surgeon to get an opinion and whether you should have the hernia fixed before back surgery. I think a lot depends on the degree of the hernia - my stomach surgeon told me I was a "category" (or maybe it was "class") 4, which apparantly is the most severe, plus the bottom of my esophaegus had moved up to accomodate entering the herniated stomach.

    In my case, I had a big kyphotic hump that pushed out the right shoulder blade - that is mostly corrected now. I expected my internal organs to move around as a result of spine surgery, but didn't expect the hernia problem to get worse.

    I do not want you, or anyone, to have a second surgery while trying to recover from the spine surgery. Although I am feeling much better now, my spine rehab & recovery was delayed by 2 1/2 months.
    As of 12/25/07, age 62, 100* thoracic kyphosis, 73* L1-S1 lordosis, 37*/25* compensatory S-curve scoliosis. On 12/26/07, Dr. Boachie @ HSS NYC did 11 hours ant. & post. procedures, fused T2-L2, kyphosis now 57*, scoli 10*. Regained 2 1/4 inches in height!! Improving every day.

  12. #12
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    Quote Originally Posted by Chihuahua Mama
    If all my discs were good, there would be no need for the anterior, correct?
    Sometimes, discs are removed anteriorally so that a better correction can be achieved posteriorally, in people with stiffer spines.

    Does anybody know if they do flouroscopy (I'm sure that's not spelled right) during the anterior surgery?
    Yes, flouroscopy is usually used during both anterior and posterior surgeries.

  13. #13
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    loves to skate

    Hi Peachy and Susan,
    I also had DDD and my Dr. used titanium cages at L3-L4 and L4-L5. At L5-S1, he used a ring of some sort. In my case, he said he could get a more stable fusion by doing that in addition to the posterior approach. He also said that his goal was not to get a correction, but to stabalize the spine since my head did not line up with my pelvis (I guess they call that decompensated). During the posterior approach, He had to decompress the vertebrae and release the nerve roots from being trapped and pinched, so that part of the surgery had to take place first before the anterior surgery. So it seems that you are correct Susan, that if there are no problems with the discs, than an anterior approach might not be necessary, since correction of the lumbar curve is not the major concern when performing the surgery in us older folks. Susan, it sounds like your surgery will be similiar to mine except for one level higher at the top and the bottom. Sally
    Diagnosed with severe lumbar scoliosis at age 65.
    Posterior Fusion L2-S1 on 12/4/2007. age 67
    Anterior Fusion L3-L4,L4-L5,L5-S1 on 12/19/2007
    Additional bone removed to decompress right side of L3-L4 & L4-L5 on 4/19/2010
    New England Baptist Hospital, Boston, MA
    Dr. Frank F. Rands735.photobucket.com/albums/ww360/butterflyfive/

    "In God We Trust" Happy moments, praise God. Difficult moments, seek God. Quiet moments, worship God. Painful moments, trust God. Every moment, thank God.

  14. #14
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    Peachy,

    I share your concern. We are close in age and have the same degree curvature. Two surgeons, within 10 seconds after reviewing my x-rays, recommended A/P from T2 to the sacrum. One of these surgeons also said he may require doing additional anterior lumbar interbody fusion if that was performed at the L5-S1 level. He stated that this is his opinion based on the AP view and the sagittals on the MRI. My surgeon initially recommended A/P but has now decided on posterior alone. While I was initially relieved to hear this, Im wondering now if this is the best approach to take, based on much reading that I too have done. I also noted the comments by Dr. Neuwirth and Dr. Boachie and I recently pointed out Dr. Pashmans opinion. These are some of the top surgeons in the country who treat many older adults with severe curves and Im most inclined to trust their judgment. You are fortunate to have the opportunity to get an opinion from Dr. Boachie. I will be meeting with my surgeon tomorrow at which time I will discuss my concern with him. The last thing I want is hearing that I need a revision when Im 70.

  15. #15
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    Smile Grateful

    Once I got through the long recovery process I became so grateful the I can still work, am pain free and plan a trip abroad in the fall. I live a totally normal life.
    50% correction and in good balance. I do hike and do Pilates with a personal trainer whp started with me before my revision. I don't do anything stupid like trying moves not recommended by Dr. B.
    Original scoliosis surgery 1956 T-4 to L-2 ~100 degree thoracic (triple)curves at age 14. NO hardware-lost correction.
    Anterior/posterior revision T-4 to Sacrum in 2002, age 60, by Dr. Boachie-Adjei @Hospital for Special Surgery, NY = 50% correction

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