Friday 10-12-12, I had my pre-op appointment with my orthopedic surgeon. (go to the “nifty links” tab on the menu to see his bio) The news was not as positive as I had hoped. When the doctor walked in I could tell he didn’t want to tell me, it is hard to explain how he looked but I knew right away that something was wrong. He pulled up my MRI and my discogram results on his computer. He told me that the discogram showed that I actually have 3 levels of damage not just 2 like we previously thought. Apparently L4 “lit up” during that test in addition to L3 and L5. This was a surprise to him and to me. I told him that I didn’t remember that, I only remembered the one that sent that lightning bolt of pain down my R leg. He said that in light of this result, he could not say that my fusion surgery would be 100% effective in relieving my pain. The technology does not exist to repair 3 levels, if they did that, I would end up disabled and with severely impaired mobility.
Multilevel Spinal Fusion for Low Back Pain
By: Jeffrey M. Spivak, MD
While multilevel spinal fusions are a common and necessary procedure to treat many types of spinal pathology, such as scoliosis or other types of deformity, for treatment of low back pain from lumbar degenerative disc pathology this type of procedure remains controversial.
- Two-level fusion. In certain instances, a two level spinal fusion may be an effective treatment for debilitating low back pain from two degenerated lumbar discs.
- Three-level fusion. Lumbar fusion of three or more levels of the low back as a primary treatment for low back pain is rarely recommended, and many surgeons recommend against it in all cases of multilevel degenerative disc disease.
This article examines the potential risks and benefits of multilevel fusion for patients with low back pain from degenerative disc problems.
The lumbar spine (low back) has six mobile spinal levels, also known as motion segments, surrounding and in between the five lumbar vertebrae. A spinal level carries the name of the disc at that level, named by the vertebra above and below the disc. For example, the disc space or motion segment between the L4 and L5 vertebrae is known as the L4-5 disc or the L4-5 level.
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The lowest spinal segment, between the L5 vertebra and the sacrum bone of the pelvis, is known as the L5-S1 level. At each spinal level, motion is controlled by the disc, located between the vertebral bodies, and the paired left and right facet joints, in the back of the spine, which allow flexion and extension motion in the lumbar spine and block rotation motion.
In This Article:
- Multilevel Spinal Fusion for Low Back Pain
Fusion of only one motion segment of the spine (e.g. L5-S1) is referred to as a single level fusion. Multilevel spinal fusion refers to fusion of more than one spinal disc level (e.g. L3-L4 and L4-L5 fusions). When a multilevel spinal fusion is performed, it is almost always on contiguous spinal levels. The most common levels included in a multilevel spinal fusion are L4-5 and L5-S1.
Indications for Multilevel Fusions
Multilevel spinal fusion for treatment of low back pain is a controversial topic. In general, lumbar spine fusion has a relatively poor success rate for treatment of multi-level disc degeneration seen on MRI scans1. A two-level fusion may be considered for patients with severe, disabling pain that occurs at two levels of the spine (e.g. L4-L5 and L5-S1) after extensive non-surgical and pain management approaches have been tried. However, three-level fusions for treatment of low back pain from lumbar degenerated discs are rarely advisable for three main reasons:
- Uncertain outcomes. With fusion at three or more levels of the spine, there is a significant risk that the surgery will not improve the patient’s pain.
- Too much rigidity. Three level fusions limit movement and flexibility in the patient’s back so much that this in and of itself is likely to cause pain.
- Adjacent level degeneration. Extensive fusion of the lumbar spine transfers stress to the next level of the spine and puts that level at risk for degeneration. For example, a fusion from L3 through S1 would put the L2-L3 level of the spine at risk for degeneration and causing future pain.
Because of the above, some physicians believe that lumbar degenerative disc disease at three or more levels of the spine means that fusion surgery is not an option. Instead, patients with severe pain and degeneration at three or more levels of the spine are often advised to enter a comprehensive pain management program.
This Friday, he will fuse L4 and L5S1 , L3 will stay as it is. So, my prognosis has changed. The best I can hope for with this is a 50% reduction in pain instead of a complete recovery and the hope of living pain free. I am extremely disappointed by this news. He did stress to me that even the 50% pain reduction would be hindered by my smoking so I promised him that I will not be a smoker.
Today is day 2 of not smoking. I feel dreadful because I am not using the gum or any nicotine replacement. I am finding that my thinking is cloudy and my reflexes are poor. My hands are very shaky. It’s very hard to type on my keyboard or my phone. After 3 days, the nicotine will be out of my system so by Wed., after that it’s still a psychological addiction that I will have to deal with but the actual physical withdrawal will be over.
Nicotine has a half-life in the human body of 2 hours (although it can range from 1 to 4 hours in different individuals). The average smoker has a blood nicotine concentration of about 40 ng/ml after an evening cigarette. But lets take the example of a very heavy smoker who smokes their last cigarette at the stroke of midnight and has a nicotine level of 80 ng/ml. By 2am it will be 40 ng/ml. by 4am, 20 ng/ml, 6am, 10 ng/ml, 8am 5 ng/ml, 10 am, 2.5 ng/ml, 12 noon, 1.25 ng/ml. So within 12 hours it is almost gone, and so certainly by 24 hrs it is all gone.
The typical half-life of nicotine is 2 hours, and that most assays have a limit of detection of 0.1 to 0.5 ng/ml, following the logic I described above, all the nicotine has gone from the blood stream within 24 hours. i.e. when you take a blood sample from a smoker 24 hours after their last smoke, they will most likely have a blood nicotine level <0.5 ng/ml. (i.e.>95% gone by 24 hrs). Cotinine (the main metabolite) has a half life around 20 hours and so takes days to a week to disappear. But cotinine is an inactive metabolite that is not believed to have a meaningful role in nicotine dependence.”
I keep telling myself that the nicotine will poison my new bone cells so I have to just be done with it. I will also save a lot of money since they have become so expensive so my short term disability checks will go further. Still, I feel pretty bad today. I need the support of my friends! I may be doing a radio interview Wednesday night on Fired Up on kinetic hi fi radio. This will definitely take my mind off of my surgery and my not smoking, mental diversions are exactly what I need right now. I also plan to call my primary care Dr. and update her about all of this. The last time I saw her was before I even met the surgeon so a lot has changed since then. I am planning to call her office later this morning. I am hanging in there! I will keep you all posted, as always, thanks for reading! If anyone has any positive words for me I would really appreciate you sharing them, now more than ever!