Fusion to sacrum WITHOUT osteotomie

[Tableone]

I have had three different opinions from different surgeons recently regarding my fusion to the sacrum under my existing T2 to L3 fusion. One said that I needed a two-level osteotomie, another is saying a one-level osteotomie, and yet another is saying that I don't need any osteotomies because my flatback is not that bad. They are saying it is between 15-20%. All of them are major deformity surgeons at medical schools and one private well-known Scoliosis surgeon. Has anyone here had a fusion to the sacrum without an osteotomie? Does it make that much of a difference, either with the lordosis or with the recovery? I know this extension to the sacrum has to be done perfectly; I've read stories here of people feeling off and unbalanced after their revisions because something was not done right. But, I honestly don't know what to think or whom to choose with these different opinions. Also, I have read on here repeatedly that we should ask our surgeons how many Scoliosis revision cases they do each year. This has NOT worked; all of the surgeons have answered with: "I don't know, I don't keep count." They won't even give an approximate number, which I find odd? I've also asked the surgery schedulers and gotten no response. I've also done what has repeatedly been suggested here and asked to be put in touch with their other patients. Again, I have gotten no response. I've also gotten different opinions on Bone Morphogenic Protein: One surgeon said he never uses it because not enough is known about it, he uses cadaver bone instead and the bone gotten from the osteotomie. Another uses it all the time. What to do?
Thank you,
T1

[titaniumed]

Has anyone here had a fusion to the sacrum without an osteotomie? Does it make that much of a difference, either with the lordosis or with the recovery?

That would be me.....Didn’t need osteotomy since my sagittal balance was good. I’m a true scoli, that’s for sure. No kyphotic or lordosis issues other than the standard lack of lordosis in the neck.

Surgeons have to re-construct and get your balance set. This is not an easy thing to do from what I have read. C6 over the sacrum with twists, curves, bent rods, and previously fused sections makes it a quite a challenge. Osteotomy increases lordosis in the lumbar spine. Your lordosis has to balance with your thoracic kyphosis to get that (C6-Sacrum) balance.

If 2 out of 3 surgeons say osteotomy, that does tip the scales in their direction. You can have one larger osteotomy, or 2 smaller osteotomies for the same correction. This is an assumption since I’m not a surgeon. Good question to ask.

I had partial corpectomy done from the front on a 5 level ALIF due to severe DDD. Whenever you grind or cut bone, it has a tendency to hurt in recovery. You have pros and cons to each method.

Allograft bone does not do as well as autograft. I have not seen many posters here talking about cadaver bone.......BMP is ONLY FDA approved in ALIF. (Tibia and some dental procedures)

I’m 7-1/2 years post next week on the BMP.....I hope I count as 1 success on that study. No cancer yet.......

“I don’t know, I don’t keep count” sounds ok.....Its certainly not an answer for one. There are many repetitive things we do as a living that we don’t keep count on. Active surgeons especially in a major spine center are active and operate all the time.

Its better to be operated on in a major spine center......(Per Dr Errico studies.....it only makes sense)

I also like the multiple surgeon concept. In this case. too many cooks don’t spoil the soup. Having a vascular surgeon there for the ALIF is common.

I would have loved coming along for your visits.....Even though you seem very level headed about all of this, these visits for many can become emotionally affected......Its not easy, that’s for sure.

Ed

[jackieg412]

I also do not have any in my long fusion. One surgeon said yes one said no. I wonder if I fractured at t-9 because of not doing it, but will probably never know. Go back and ask more questions.

[Tableone]

Yes, you're right; of course a record/count of what type of surgeries is kept. That is why I found it so strange when two of the surgeons both answered they didn't know and they wouldn't even give a ball-park figure or even say "several" or anything. I asked their surgery schedulers (as that's who the medical assistants told me to ask) and never heard back from either one; maybe they're not allowed to say because of laws or something? Of course it's common in medical offices these days for patients to have to call two and three times to get a response as no one is ever "at their desk," anymore. I can't even get a simple response as to whether they've received my images, for instance. This is the thing that truly adds to my stress - the constant trying to get in touch with the people at the doctor's offices.

[jackieg412]

I was given the answer when I asked----one said he did plenty and one said one adult a month. I just went through an unusual surgery to fix a stuck scapula. I discussed it here because the scapula was stuck on a deformed rib from scoliosis. The surgeon straight forward said he had oh did this surgery one other time. It was 3 weeks ago , all is well but too soon to tell. It has been interesting.

[Tableone]

Osteotomy added in later?

Just saw a deformity surgeon and got yet another conflicting opinion about the flatback surgery under my existing fusion. I have seen four surgeons; three at medical schools and one private, George Picetti. Two of them are saying no osteotomies are needed, and the other two say yes I need osteotomies. This is in addition to the three spacers which have to be put in through the front, although one guy said it could also be put in through the side and that this was less painful and better than the front. Does anyone know if this is the case? Also the length of instrumentation is different; some of them want to go up to T12 and some say only up to L3. Since I'm fused to L3, what will they do above that? What exactly do they mean when they say "go up to?" Does this mean they will just place instrumentation there or will they do something else there as well? Remember, we are talking about an area that is already fused.

I realize that I need to find a surgeon that I can trust and let him do his thing. But I don't have any instinctual feelings about any of them. They are all great salesmen; each of them proclaims that the surgery has to be done his way or it will fall apart. Since they are all proposing different ways of accomplishing the same thing, who's right and who's wrong? Or can they all be right?

Also, if I have a more minimal surgery, for instance, with no osteotomies, and if it does "fall apart" can I have osteotomies added in later? One guy said that an osteotomie was a major thing and involved lots of blood loss.

With these different opinions I really don't know what a layperson is supposed to do.

Thank you,

[leahdragonfly]

Hi Tableone,
I feel for you trying to sort things out for this big decision. My only advice would be go back for more visits, ask questions, and find the surgeon who you trust with your gut. If you haven't found that yet you need to go back for more visits and discuss the proposed surgical plans until you can make an informed decision based on all the available information.

I went for 2 other surgical opinions besides Dr Hart. They both suggested a two level fusion to simply address the spinal stenosis and spondylolisthesis, but upon being pressed about longevity of the fix they were recommending, both of them admitted it would only help me for 2 years at best, and both agreed I would definitely be back in pain within two years and need the long fusion that Dr Hart recommended. While this idea was tempting for a couple of seconds, deep down I knew I needed the long fusion, and I thought it a bad idea to have the small surgery only to need a big surgery a few short years later, with all the added scar etc.

The level of instrumentation is determined by many things, including need for stability and strength above. They may need to go up to T12 to find healthy discs, level vertebrae, less risk of fracture, proper balance, etc. You can ask how they determine what level they need to go up to.

Any surgeon who tells you to avoid an osteotomy because it "involves a lot of blood" is not the surgeon you want. If you need an osteotomy, you need one. Blood can be replaced. Proper alignment is SO important…you want to be fused in the correct alignment the first time, not wait and see how it goes because the osteotomy sounds scary, then have to go back in and have a huge revision. To go back later for an osteotomy generally involves removing and replacing at least the rods if not the screws too, not to mention having to work through the existing fusion mass. This is really a surgery you want to look hard for one-stop shopping, get everything done right the first time.

Best of luck as you work through all of this. You will find the right answer in the end if you work at it.

[titaniumed]

Great post by Gail.....

I requested one stop shopping as I didn’t want to come back. There was no discussion about less surgery, or a quick fix, my surgeon just wasn’t going there.....He was going to do whatever it takes to get the job done right. Its hard to accept more surgery, but I accepted the fact that it was the right thing to do. When you lumbar area is completely roasted like mine was, you have to submit. I just couldn’t handle the pain anymore.

I had a 5 level ALIF with 5 spacers, L1-Pelvis, so you know it can be done. It really worked like a charm in my case. Long painful recovery, but was worth it. ALIF surgeries are deep surgeries......but the benefits of this access are noted from various sources. The main thing is that it helps guarantee that you fuse.

“Going up to” would mean how high they would run your hardware into your previously fused spine. The higher they go, the more attachment points there would be, and thus a stronger construct.

I would think that any surgeon that would do a multi level ALIF on a revision scoli would not hesitate on an osteotomy.....Maybe Linda can chime in on this thought?

Ed

[Tableone]

Hi and thanks for the responses. To clarify: no surgeon said they didn't want to do an osteotomy because of blood loss; it's just that two of the four said that they didn't feel I needed osteotomies. The medical opinions are split cleanly in half. Regarding going back to see the surgeons - it takes an average of 3 plus months to get an appointment with any of these guys and I have already seen some of them three times. Unless I find a way to record my visits with my phone or something (if the docs would even allow that) it's just impossible to nail them down on every detail, plus if you ask too many questions they don't like it. Plus it's just hard for me to remember and understand everything they say. And yes, I take notes!

I just don't know which person to choose. Can lordosis be corrected just by spacers? Two of the surgeons are saying my flatback is not that bad, the two others are saying it is bad. How can I as a layperson judge whether I need an osteotomy or not? And these are all major players in the field of adult Scoliosis revision surgery.

Thank you,

[susancook]

Tableone: Wow....what a journey! I can see how you are confused as you are getting different messages. How does a lay person judge, you ask? Not well, really. My husband was a submarine nuclear engineer and when I heard him talking with some of his friends....I was lost!

I had 2 opinions and they both recommended the same levels and both said that I should have surgery, one said, "Yes" and the other said, "I don't know why someone in your situation wouldn't want to have surgery". So, I was not confused.

Gayle made some great points. She has done a lot of research and has had personal experience.

The anchor point at the top and bottom are generally the first "good" or "stable" vertebrae.

Your revision sounds very complicated and I so hope that you can find much less pain and increased mobility. My suggestion? Which surgeon gave you a feeling of confidence in his/her competence? Who can you TRUST? Who communicates best? Who has a good history of doing revisions?

I always take another person to also take notes. Ask whether you can record the conversation. That sounds very reasonable, but with the medical-legal climate such as it is, a surgeon may refuse.

Best of luck in making your decision. Wishing you a better life.

Susan

[Jamie1955]

Hi Tableone, I was told prior to my posterior lumbar surgery, he would pick up one level above the current fusion. They also open your complete scar and inspect the entire fusion. If they find anything that is not fused then they would have to go higher with hardware and fuse any area that is not fused. I had flat back. I just knew at 31 years old I could not live with the symptoms for the rest of my life. My surgeon did not fuse to the sacrum at that time but did inform me I would need the fusion to the sacrum later in life. He felt I was too young to take that kind of flexibility away from me. I am happy he handled it that way. During the flatback surgery he did the osteotomies and thoracoplasty. I was very happy with that surgery. I am in my mid 50s now. He was right, my lumbar spine deteriorated and I required to be fused to the sacrum. I have never researched any of the details of surgery when I was young. I was always frightened I would talk myself out of doing it, remembering childhood surgery without adequate pain management. You are very smart to get many opinions and to do your homework. I'm not sure of your age, but before my fusion to the sacrum my pain as unbearable!!! I could not sleep, painful walking and sitting was a task. I don't know if everyone comes out perfect, but I am far from it. But I am not in the same kind of pain I was in prior to surgery. I did not have as many options regarding surgeons in my area. You are very lucky. You will know when you meet the right person, you will also know when the time is right. They did tell me putting the cages in from the side was not an option for a scoliosis patient when I asked about that. Who knows though, they all tell us a different story.