Spondylolisthesis: Spinal Fusion at L-4-L5

@kremer1 - Good morning. Let me have at your questions.

Yes - all presurgery bowel, bladder issues plus other sensations are 100% gone. As said, I still have some residual (but improving) tingling in my right thigh. I don't recall any other abdominal discomforts pre-surgery.

Yes, I had spondy in the lumbar region with stenosis throughout my spine. After much discussion, the surgeon and I decided on a three-part process: Cervical ACDF followed three months later by a two-part lumbar surgery using new titanium disks and titanium plates to properly secure the repaired spinal sections. We considered a "bigger" lumbar surgery from T10 - S1 but I felt that was too much for me to tolerate. We elected to do L2-5 and I'm rolling the dice on the surrounding spinal areas that show significant degeneration but were not surgically addressed.

There was never a discussion of titanium implants vs grafts. At some point, once I spent enough time with the surgeon gauging both his overall approach and strategy suggestions - I chose to just trust him and accept his surgical recommendations. I think my current condition suggests that was an acceptable strategy on my part.

I understand your dilemma. All spinal patients are faced with a very difficult decision! I saw that fork in the road as a personal risk management decision. What's riskier? Deferring surgery where I might delay to the point of developing permanent and irreversible nerve damage? Or actually having the surgery where there can be no certainty of outcome? You can ask a million questions yet still lack the perfect answer. At some point, you just have to chose and move forward.

You describe "some tingling" and you seem still quite active on exercise equipment. Those are all good signs that your issues are being managed successfully for now.

Sounds like my case. All disks are either herniated, bulging or replaced. For 20 years I had treatments of all kinds, surgery included 8 joint replacements, I'm 77 now, I am not perfect but without treatment I would have been worse; DDD keeps progressing. In 2012,
I became inoperable and was offered a morphine pump. The important point is that not to act you face the loss of nerve function, once that is gone, you don't get it back. Surgeries were a lot easier at 50 than at seventy. I agree about thoracic surgery. I didn't do that either, I think that is the hardest surgery. With each surgery, I had at least 5 disks done at once. My neck front was 12 hours. neck back 12 hours, lumbar spine 12 hours. I wish you good luck, these are not easy decisions to make. Get all the support you can get for yourself.

@upstatephil ,
When did you have the DDD diagnosis made? How long of a time period did it take you to find a surgeon, the one that did your surgeries? It sounded like you waited a period of time prior to getting the full leg numbness, but had you already met and talked with more than one surgeon for your surgery plan? And you had a plan in place so that when you got to the full numbness stage you were ready to proceed, or did you at that time find the surgeon / facility / team that did the surgery?
I'm trying to work through the process, but getting appointments and another opinion is taking way more time than I thought it would. If I were to have your full leg numbness now, it would be difficult to coordinate everything in a timely manner. I don't want to wait and as @morkat says have nerve damage that won't come back. But I don't want to jump in to a L4/5 fusion with the advice from one Dr, knowing that the other Dr I saw says fusion won't help me. The third opinion may take until Aug or even Dec. I'm trying to see a neurologist, but that is also out to Aug. I think the Dr that suggested L4/5 fusion isn't looking at the entire picture of my DDD. I may do another visit with her to try to talk over this, and also get new images.
How was it with you getting appointments, imaging, follow up appointments to discuss things?

@kremer1 - I first had the DDD diagnosis in Sept 2022 from an orthopedic surgeon.I had reported to my PCP that I was beginning to experience frequent, sudden-onset full leg numbness. She immediately sent me for MRI's and a consult with the ortho. When I heard his surgery recommendations, I decided this was getting serious and I wanted a neurosurgeon's opinion and also take advantage of what I think is the best diagnostic equipment at Mayo.

I have been a patient of Mayo for 30+ years so it was pretty simple to get a diagnostic appt. I saw an NP from the neurosurgery dept and a physiatrist. They confirmed the DDD diagnosis and more...They connected me with my ultimate neurosurgeon. He is a specialist in complex spine surgeries and - that's me!

If you have competing diagnoses - you need a tie-breaker. If you are managing on a day-to-day basis, maybe the time delay to get the right diagnosis is a reasonable trade-off?

Thanks for your timely reply @upstatephil. My case / back discomfort and pain has been going on for quite a while, probably 15+ years ago. But the DDD was indicated from a lumbar MRI done in 2019. Neurosurgeon then suggested the typical non-invasive approach with PT and OTC pain med. I've been doing that since, and added pain management DR in 2021 for facet and epi both cervical and lumbar. The first ones helped some, but the more recent ones last year didn't do much. I tried MBB pre ablation, it didn't help enough to consider the ablation. Had more MRI done last fall, stenosis and some osteophytes are progressing, but the initial neurosurgeon is saying my symptoms are not warranting fusion. The second opinion neurosurgeon said fusion L4/5. So yes, I need a tie-breaker opinion.
I'm able to manage the discomfort and pain for now, the tingling / numbness varies as well as the localized pain at the lower lumbar. I don't have much choice with ease of appointments. I don't know that it is more or less difficult for people in other parts of the country for getting in to see your PCP or specialist, but it is typically a long wait time here, I guess unless it is a life threatening situation.
I was just wondering what your overall time frame has been. How long you have had back issues, to when you had DDD diagnosis to when you were able to decide on the surgery and surgeon team. And I think you answered that pretty much.

DDD was diagnosed in 2001, after complaining for years, I was finally referred to a neurosurgeon. At that time, I could only raise my arms about 4 inches. The advice I received was there was a window of 4 months to make a decision, if not I would lose nerve function. Also, I was in pain day and night, a friend of mine said the pain makes the decision. You have to face the fact that this is not the kind of discomfort felt by many due to overexertion. You are way past that. Over a 20 year period I learned to trust my doctor. I felt he showed an accurate picture of my condition. He told me the truth, answered questions and thoroughly explained the procedure and outcome.

Here is an update on my situation. I've saw another neurosurgeon in June for a second opinion. He did a flexion and extension xray as well as straight on for scoliosis. His interpretation of the xrays and previous MRI's was instability of L2/3 mainly, possibly some in L3/4. He is suggesting L2/3 LIF.
I saw him again yesterday, went over the xray's & MRI's and where my pain is. I have pain in the L2/3 but also below. We talked about other imaging, and he is ordering a Spect CT, lumbar MRI, and bone density. Has anyone had the Spect CT done? It apparently shows areas of bone inflammation / pain on the scan and can help to determine areas needing treatment / surgery.
Not sure how fast those will get done, but hopefully soon. I'm keeping as active as possible with walking (1.5-2.5 miles daily), some core exercises as much as I can tolerate. But things are progressing with feet, calve, thigh, lower groin tingling as well as the pain/discomfort in the lumbar region for L2-5. I'm to the point of needing at least the L2/3 surgery, but am concerned about the ones below too. The imaging should help decide that? I'm comfortable with the neurosurgeon, his knowledge, experience, and concern. That's something that I didn't feel with the first two.
So the main thing for this posting is asking about Spect CT, who has had it and did it help with your situation and deciding surgery?

@kremer1
I have cervical/lumbar congenital stenosis/DDD and neurogenic clarification. My pain in lumbar region started when I was 41 after my only pregnancy. I had ACDF surgery C5-C6 for myelopathy (spinal cord compression injury) and just saw my surgeon yesterday to plan for lumbar surgery. It has been about 13 years of progression/worsening of pain/numbness/weakness which has really impacted my quality of life (I am currently 55 and a single parent of a teenage son with no family/support system except for my ex-husband which luckily we are amicable in raising our son).

My surgeon is considering minimally invasive surgery to decompress/fuse L4-L5 at a minimum due to severe stenosis and L4 slipping over L5. He will need to use hardware to stabilize my spine. I am getting an updated MRI of lumbar spine to determine if L3-L4 and L5-S1 would need to be included.

The CT spect scan may help your surgeon narrow down the source of your pain to help plan targeted surgery. I have not had that done but believe I will need to have a CT scan done before my lumbar surgery to help my surgeon plan and focus surgery. I had a CT scan right before my cervical ACDF surgery to supplement my MRI.

Here is a link for CT spect scan from Mayo.
https://www.mayoclinic.org/tests-procedures/spect-scan/about/pac-20384925

@kremer1
*Correction…neurogenic claudication, not clarification. Just love autocorrect. 😉