Which Type of Fusion Surgery?
• As I mentioned earlier, I was able to complete six appointments in 18 days with Spine Team Texas:
1) Initial appointment with PA
3) Initial meeting with neurosurgeon (Dr. Rothbart), who, after reading over my file and studying the MRI results, offered my treatment alternatives. I could opt for fusion surgery or a six-week program of pain management. which ultimately would offer only temporary relief to my symptoms. He said my fusion surgery was not a matter of "if, but when." As I had begun this latest round of doctor visits with intention of consenting to surgery, I told him I wanted to go ahead with fusion. After 13 years of seeking alternatives and fervently hoping to avoid surgery, I had satisfied my conscience that I was not rushing into anything.
4) More imagery: x-rays of me in the standing position, but leaning right, left, forward, and backward, as well as CT scan (basically a 360 degree x-ray).
5) EMG (Electromyelogram). This procedure tests the responsiveness of nerves. In my case, the doctor sent electrical pulses down my right leg and measured how quickly the signal traveled as well as its amplitude lower down in the leg. For chronic sufferers, permanent nerve damage can set it, adversely affecting the chances for a full recovery from fusion surgery (slow speed of low amplitude could indicate lasting nerve damage). Fortunately, they found my nerves to be responding well and showing no permanent damage.
6) Follow up appointment with neurosurgeon and his recommendation.
I was shocked when the surgeon recommended an ALIF/PLIF combo. I was frightened of the anterior approach because of the vitals to be navigated there, plus what I expected would be extra healing time due to extra incisions. He went into a lot of detail with me on the different approaches he considered:
• XLIF--he considered this approach as well, but judged my iliac crest to be too high, thus obscuring his approach to L4-L5. XLIF is sometimes possible at L4-L5, it just depends on the positioning of the hip. He had taken x-rays to determine the position of the top of my hip in relation to L4-L5. It was borderline too high. He did say he was expecting some new instrumentation in a few weeks that would allow him to navigate this better and if I wanted to try it, I could. He did warn me, though, that another risk of the XLIF is the placement of the nerve root as it exit the spine--10-20% of the time, he has to abort a XLIF because the nerve can't be circumnavigated to get to the disc. I thought about the XLIF approach briefly, but ultimately consented to the surgeon's recommendation.
• TLIF/PLIF--not really options here, don't remember why.
• ALIF--advantage here is that an anterior approach offers the best view to the surgeon of the inter-vertebral space. Two key components of a successful fusion are 1) cleaning out the space between the vertebrae very well; 2) stuffing as much BMP and bone into that space. The better the surgeon can see into this space, the better s/he he can accomplish these two goals. The risk of ALIF is of course having to navigate through the vital organs and blood vessels. The aorta and vena cave lie right on the spine, so the vascular surgeon has to stretch them out of the way to open up access to the spine. It turns out that the aorta branches right at L4/L5 to go to each of the legs, so moving the blood vessels is a little bit trickier for L4/L5 but still very doable. My vascular surgeon told me right before surgery that he does these at about 20 different hospitals/week and has done over 4000 of them.
• Surgeon informed me that his surgeries are successful 85% of the time. Successful is defined as my answering "yes" to both of these questions: 1) Is my quality of life significantly improved from before the surgery? 2) If I had a choice, would I do this again?
• Combination ALIF and PLIF
⁃ ALIF: Vascular surgeon makes 3" incision vertically right below the belly button and secures the approach to the spine. Then neurosurgeon extracts disc, cleans out space, inserts spacer and injects with Bone Morphogenic Protein (BMP). Vascular surgeon patches up front with internal stitches and butterfly closure bandage.
⁃ PLIF: Neurosurgeon makes two 2" inch incisions on both sides of spine to insert pedicle screws at L4 and L5 (4 screws total). He then threads two rods between the two sets of screws and staples up the incisions.
