Should I wait to have surgery and do physical therapy?

[Pooka1]

I read an abstract recently wherein they were claiming that degeneration in the lumbar below either a fusion or an unfused curve was not distinguishable against the huge propensity for degeneration in the general public. That is not the paradigm as far as I can tell. Plus, as a reseach report, it is most likely false.

Here's that abstract...

http://www.biowizard.com/pmabstract.php?pmid=20959776

Adjacent segment degeneration after lumbar spinal fusion: the impact of anterior column support: a randomized clinical trial with an eight- to thirteen-year magnetic resonance imaging follow-up.

Videbaek TS, Egund N, Christensen FB, Grethe Jurik A, Bünger CE
Spine Unit, Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark. tina.s.videbaek@ki.au.dk

STUDY DESIGN: Randomized controlled trial. OBJECTIVE: To analyze long-term adjacent segment degeneration (ASD) after lumbar fusion on magnetic resonance imaging and compare randomization groups with and without anterior column support. SUMMARY OF BACKGROUND DATA: ASD can be a long-term complication after fusion. The prevalence and the cause of ASD are not well documented, but ASD are one of the main arguments for introducing the use of motion-preserving techniques as an alternative to fusion. Anterior lumbar interbody fusion combined with posterolateral lumbar fusion (ALIF+PLF) has been proved superior to posterolateral fusion alone regarding outcome and cost-effectiveness. METHODS: Between 1996 and 1999, 148 patients with severe chronic low back pain were randomly selected for ALIF+PLF or for PLF alone. Ninety-five patients participated. ASD was examined on magnetic resonance imaging with regard to disc degeneration, disc herniation, stenosis, and endplate changes. Disc heights on radiographs taken at index surgery and at long-term follow-up were compared. Outcome was assessed by validated questionnaires. RESULTS: The follow-up rate was 76%. ASD was similar between randomization groups. In the total cohort, endplate changes were seen in 26% of the participants and correlated significantly with the presence of disc degeneration and disc herniation. Disc degeneration and dorsal disc herniation were the parameters registered most frequently and were significantly more pronounced at the first adjacent level than at the second and the third adjacent levels. Patients without disc height reduction over time were significantly younger than patients with disc height reduction. Disc degeneration and stenosis correlated significantly with outcome at the first adjacent level. CONCLUSION: The cause of the superior outcome in the group with anterior support is still unclear. Compared with the findings reported in the literature, the prevalence of ASD is likely to be in concordance with the expected changes in a nonoperated symptomatic population and therefore not accelerated by fusion.

[Pooka1]

In re the posted abstract, I don't think those are scoliosis patients. That may matter in trying to figure out the deal with fusion for scoliosis. I have no idea.

[hdugger]

In re the posted abstract, I don't think those are scoliosis patients. That may matter in trying to figure out the deal with fusion for scoliosis. I have no idea.

I would think that would make some difference. I realize we don't necessarily have a good cross population of all scoliosis patients here, but there are *alot* more discussions about serious back pain here then I normally have with people in this age range.

[ctown]

Is there a possibility of C) One long fusion now, to get the best possible correction while you're young, and avoid the possibility of another surgery later in life.

I don't know enough about it, but have you thought about C)?

I am not considering one long fusion now because mobility is very important to me. But I am thinking I should talk to Dr. Gupta, and perhaps another surgeon in Chicago, about the possibility of only fusing to L1, instead of to L3. I'm very flexible in my lumbar spine. Do you think this might up the chances of only having to fuse to L1?

[Karen Ocker]

My experience

One thing to consider: the curved spine wears down the discs unevenly and damages them. This requires a longer fusion if left too long. In my case a MRI was done to see the condition of the discs below my 1956 fusion to L-2. Not only did the curve below that fusion double in 20 years those discs were shot and I needed a fusion to the sacrum. That was 8 years ago. I live a perfectly normal, pain free life.

[Pooka1]

One thing to consider: the curved spine wears down the discs unevenly and damages them. This requires a longer fusion if left too long. In my case a MRI was done to see the condition of the discs below my 1956 fusion to L-2. Not only did the curve below that fusion double in 20 years those discs were shot and I needed a fusion to the sacrum. That was 8 years ago. I live a perfectly normal, pain free life.

Wow so you got 36 years on a fusion to L2. Maybe that is pretty good and a decent trade-off for the flexibility during those years.

There are people here with older fusions down to L3, L4 and L5. Maybe we should start keeping track of this to see if there is a pattern.

I'm thinking with the third generation hardware, it might be a different story. I recall one parent whose son was fused to L4 saying the surgeon (Betz IIRC) said he only had about a 15% of needing a distal extension in his life. Those are pretty good odds that don't agree at all with what our surgeon said. This is why I am skeptical of what surgeons say unless they can point to data. And maybe not even then if the sample size is too small.

[Karen Ocker]

Long ago fusion.

[QUOTE=Pooka1;110506]Wow so you got 36 years on a fusion to L2. Maybe that is pretty good and a decent trade-off for the flexibility during those years.

Sharon, First surgery-(1956)-2002(revision) lasted 46 years----but my spine was recurving the whole time because it was uninstrumented. The discs in the fused area degenerated. With revision the discs are removed and bone braft is placed in that space.

[Pooka1]

[QUOTE=Karen Ocker;110546]

Wow so you got 36 years on a fusion to L2. Maybe that is pretty good and a decent trade-off for the flexibility during those years.

Sharon, First surgery-(1956)-2002(revision) lasted 46 years----but my spine was recurving the whole time because it was uninstrumented. The discs in the fused area degenerated. With revision the discs are removed and bone braft is placed in that space.

Ah thanks for catching that math error!

Forty-six years is quite a long time but maybe with an instrumented curve above, do you think you might not have needed an extension? I guess it's hard to say.

And if someone can get 46 years with the old hardware, I am tending to believe they can get a lifetime with the new hardware if stopping at L2. That would comport with what our surgeon said.

Cool data point.

[Karen Ocker]

[Forty-six years is quite a long time but maybe with an instrumented curve above, do you think you might not have needed an extension? I guess it's hard to say.

And if someone can get 46 years with the old hardware, I am tending to believe they can get a lifetime with the new hardware if stopping at L2. That would comport with what our surgeon said.

Cool data point.[/QUOTE]

There was no hardware until the 1970s. In my case the thinking was, at the time, to fuse the major curve and that the upper and lower curves---remember I had triple curves, wouldn't change but they did! Not sure I could have avoided an extension with my particular curve history. I was such an extreme case, even at the time.

But I am now absolutely pain free! I never had excessive pain but I believe progressing curves, without pain, can also become deadly over time. A severly curved spine affects everything in the chest cavity.

[Pooka1]

Right. I misspoke again when I said,

"And if someone can get 46 years with the old hardware,[...]"

You had no hardware before 2002 and you had a triple curve. That would not be a data point about the general longevity of lumbar curves under instrumented thoracic curves fused to L2.

But it is still a cool data point.