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What helps spinal stenosis besides surgery?
Spine Health | Last Active: Dec 15, 2024 | Replies (193)Comment receiving replies
@jenniferhunter
Thank you very much for taking the time to converse with me on this.
Sorry, for the late reply due to a lot of holiday activities and visiting families.
Re. "So your choice with the orthopedic spine surgeon is they would add 2 extra levels of fusion at the upper end and is that going down to the sacrum at L5 / S1?"
-> Yes, pretty much, at least that is my understanding. Below is the exact wording from the doctors, I would like to know if my understanding is incorrect, therefore the direct quote. Thanks!
Ortho's plan: "3-stage surgery over 3 days. Stage 1 would be a posterior lumbar decompression at L2-3, 3-4 and 4-5 with screw placement from low thoracic T11 down to the sacrum and a TLIF at L2-3 and L3-4. Stage 2 would be an anterior lumbar decompression instrumented fusion at L4-5 and L5-S1 with the assistance of our vascular surgery colleagues. He would use NuVasive base cages as instrumentation for the anterior surgery. Then, stage 3 would be the remainder of the procedure with any additional decompression that was needed and then instrumentation from T11 down to the pelvis. We would request BMP and allograft for all 3 stages."
Neuro's plan: 2 stages. "Based on the numbering of L6 as the transitional segment I think she would require at least an L5-6 and possibly L6-S1 ALIF if we are able to mobilize that segment and break up the autofusion followed by multilevel posterior column osteotomies and fixation from L2 down to the sacrum and pelvis."
Re. "What are the symptoms that you have right now that concerns your surgeons?" Currently, I am unable to walk or stand without pain. I have had a lot of conservative treatments, PTs, Chiro, injections and so on. I came to Mayo June of 2021 looking for help. After initial assessments, I saw an Ortho surgeon in Aug. of 2021, then a neurosurgeon Oct. of 2022. Both surgeons said my deformity could only be corrected by surgeries. The Ortho surgeon mentioned, scoliosis is in the future, developing. The Neurosurgeon, said I have a lot of curvatures which are off.
Re. Dr. Fogelson, I did not get to see him even though I requested him after reading people's comments about him. I was told that his schedule was full and was unable to see me.
In terms of doctor, I like both of my doctors. The ortho surgeon seemed very good. He spent quite a bit of time with me during our consultation. His office has also been very responsive to all my questions since last fall. I am currently on the 8th dose of the bone density building medicine, Evenity. The neurosurgeon also was personable and also spent a lot of time with me during consultation. The ortho surgeon is listed as working in the spine area about 20 years and the neurosurgeon is listed as in the spine area about 5 years.
Thank you so much for your assistance. I know I am the one that need to make the decision eventually, but conversing with someone who has been through similar surgery really helps. I appreciate all of your inquires, as they help me to think through my issues.
Replies to "@jenniferhunter Thank you very much for taking the time to converse with me on this. Sorry,..."
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@rita9876 There are some differences between the 2 surgical plans other than the number of levels involved. The ortho surgeon describes fusions from both an anterior and posterior approach. He isn't real specific about exactly what his stage 3 plan is or how many more levels could be involved.
The neuro surgeon recommends ALIF which is anterior approach, and he would achieve deformity correction using osteotomies. This is an over simplification, but basically, they figure out all the geometric angles to correct the curve by taking pie shaped slices of bone from the spine and fusing the spine without those pieces. That can make the foraminae closer together which can compromise the nerve roots unless the surgeon takes that into consideration and may enlarge the foramin if necessary. That would be a question to ask if the nerve roots will have sufficient space and is that likely to change in the years after your spine surgery.
The ortho proposes more hardware and more screws into the spine with rods to support the spine. Both would use rods and screws as instrumentation. The screws needs to be paced at very specific angles so they don't pull out because there is a lot of pressure with body weight at the lower end of the spine. With your osteoporosis and Evenity injections, does that significantly improve your bone density of the spine? Severe osteoporosis can cause a spontaneous compression fracture of the spine and that happened to my elderly mom. It may be worth asking which approach would be a better choice for someone with osteoporosis. Would the extras screws from the orthos procedure be better or worse or cause pressure that could lead to fractures?
The surgeon needs to address what they call sagital balance. Essentially that means that if you drew a center line from your head down your body, your spine should be symmetrical in that sagital plane and not tilted to either side. They also address if the spine is tipped forward or backward in places where it should not be. It is supposed to have a nice S curve. All of this requires correct angles between vertebrae. When you have uneven pressure on the vertebrae, it causes bone growth and remodeling. The neuro mentioned that there is an "autofusion" that needs to be mobilized before it can be fused properly. That is a spontaneous fusion and it might not be lined up in a good way.
The ortho mentions using BMP which is Bone Morphogenic Protein. The neuro may use it too, but doesn't mention it.
Bone Morphogenetic Protein‐2 (rhBMP‐2) has been FDA approved as a bone graft substance in order to increase fusion rates and avoid autograft (taking bone from patient's hip during surgery) harvest. There is some literature that BMP may increase the rate of swelling complications.
Allograft is donor bone that has been cleaned of all the cells, so you have the mineral matrix left that is milled into a shape like a disc for a spine fusion. That is what I have for my fusion at C5/C6.
Both surgeons would include an ALIF (Anterior lumbar Interbody Fusion) which requires a vascular surgeon to be able to move the major blood vessels in front of the spine out of the way, and then move them back after the spine surgeon has finished his work.
The comparison of 20 years experience vs 5 years isn't indicative of the surgeons' capabilities. The question to ask is how many of this particular surgery have they done and what is their personal success rate with it. This is a big surgery that needs a spine deformity expert. Is a surgery with osteotomies preferable to surgery with more hardware with pedicle screws with a history of osteoporosis? Which surgery carries greater risks between the 2 choices? Do you want to get a third opinion? I also look at the surgeons credentials of where they trained, their publications, their areas of interest which needs to match what you need, and if they have won awards or are recognized in their field. Do they also teach their surgical procedures at spine conferences? Does this raise more questions for you?