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Thread: How low do you go? (fusing)

  1. #1
    Join Date
    Jan 2009
    Location
    Indianapolis, IN
    Posts
    106

    How low do you go? (fusing)

    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. 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?
    At age 56 my curves measured: 48/60/30 with lots of rotation and getting worse
    Posterior fusion T5-L4 June 30, 2009
    Excellent correction

  2. #2
    Join Date
    Mar 2009
    Location
    Virginia
    Posts
    20
    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 futureand 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.
    _____________________________

    Diagnosed at 9, Boston brace during teenage years
    56* left thoracolumbar curve, slight rib hump
    Deciding on timing for surgery

  3. #3
    Join Date
    Oct 2007
    Location
    Indiana
    Posts
    1,974
    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!
    66 and still heartbroken...
    2007 52 w/ severe lumbar stenosis & L2L3 lateral listhesis (side shift)
    5/4/07 posterior spinal fusion T2-L4 w/ laminectomies and osteotomies @L2L3, L3L4
    Dr. Kim Hammerberg, Rush Univ. Medical Center in Chicago

    Corrected to 15
    2014 DXd w/CMT (type 2)

    Click to view my pics: pics of scoli x-rays digital x-rays, and pics of me

  4. #4
    Join Date
    May 2008
    Location
    long island, ny
    Posts
    233
    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?
    Dolores A
    June 4, 2009 Anterior L3 - S1
    June 8, 2009 Posterior T4 - Pelvis
    Mark Agulnick, MD FAAOS
    NY Spine & Scoliosis Center

  5. #5
    Join Date
    Jan 2006
    Location
    Tasmania
    Posts
    259
    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
    Operation 1966, Fused from T4 to L3, had Harrington rods inserted. Originally had an 85 degree Thoracic curve with lumbar scoliosis as well but had a good correction.
    Perfectly normal life till 1997 but now in a lot of pain daily. Consider myself very fortunate though.

  6. #6
    Join Date
    Sep 2003
    Location
    Northern California
    Posts
    6,797
    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/1...ubmed_RVDocSum
    http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
    http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
    http://www.ncbi.nlm.nih.gov/pubmed/8...ubmed_RVDocSum
    http://www.ncbi.nlm.nih.gov/pubmed/8...ubmed_RVDocSum

    Good luck with whatever you decide.

    Regards,
    Linda

  7. #7
    Join Date
    Sep 2005
    Location
    Sacramento,Calif.
    Posts
    420

    I am to L4

    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*

  8. #8
    Join Date
    Jan 2006
    Location
    near Philadelphia
    Posts
    1,260
    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.
    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

  9. #9
    Join Date
    Nov 2007
    Location
    Houston, TX
    Posts
    1,757
    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
    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

  10. #10
    Join Date
    Nov 2007
    Location
    Big Bear, CA
    Posts
    290
    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.
    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

  11. #11
    Join Date
    May 2008
    Location
    Central NJ
    Posts
    1,956
    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.
    __________________________________________
    Debbe - 50 yrs old

    Milwalkee Brace 1976 - 79
    Told by Dr. my curve would never progress

    Surgery 10/15/08 in NYC by Dr. Michael Neuwirth
    Pre-Surgury Thorasic: 66 degrees
    Pre-Surgery Lumbar: 66 degrees

    Post-Surgery Thorasic: 34 degrees
    Post-Surgery Lumbar: 22 degrees

  12. #12
    Join Date
    Nov 2007
    Location
    Houston, TX
    Posts
    1,757
    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
    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

  13. #13
    Join Date
    May 2008
    Location
    Central NJ
    Posts
    1,956
    Quote Originally Posted by txmarinemom View Post
    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.
    __________________________________________
    Debbe - 50 yrs old

    Milwalkee Brace 1976 - 79
    Told by Dr. my curve would never progress

    Surgery 10/15/08 in NYC by Dr. Michael Neuwirth
    Pre-Surgury Thorasic: 66 degrees
    Pre-Surgery Lumbar: 66 degrees

    Post-Surgery Thorasic: 34 degrees
    Post-Surgery Lumbar: 22 degrees

  14. #14
    Join Date
    Nov 2007
    Location
    Houston, TX
    Posts
    1,757
    Quote Originally Posted by debbei View Post
    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
    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

  15. #15
    Join Date
    May 2008
    Location
    reno,nevada
    Posts
    3,551
    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
    49 yr old male, now 58, the new 53...
    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

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