How common are self-fusing vertebrae?

[Katie]

This is a spin-off from the 'so far, so bad' thread/saga

Since one surgeon thinks that my worst cervical level is beginning to self-fuse and wants to let it take its own course, my question is this: how many do this naturally? He thinks it is almost bone on bone, so do most in that condition grow together, and is that a good thing?

Once they start to fuse, how difficult is it to separate them and then put in an artificial disc or a man made fusion? And isn't one of the reasons for putting in new discs, etc., to restore height so that the nerves, ligaments etc. are not 'squished' anymore?

He is insinuating that if it completely fuses together on its own, then the pain would disappear also. How? There are also osteophytes involved that are compressing my cord, so how is that relieved? Shouldn't the top priority be to relieve the pressure on my spinal cord?

He said that the damage to the cord was already done and it wasn't likely to get worse. Or better.

I'm just trying to understand his reasoning and don't know the answers to these questions.

Thanks for any help.

[Justin]

This is a spin-off from the 'so far, so bad' thread/saga

Since one surgeon thinks that my worst cervical level is beginning to self-fuse and wants to let it take its own course, my question is this: how many do this naturally? He thinks it is almost bone on bone, so do most in that condition grow together, and is that a good thing?

This depends on the individual patient case. Those patients with severe degeneration can see significant loss of disc height, especially if treatment has been delayed. In many cases, the thought is to let it autofuse. However, I do know patients that were bone-on-bone, had an artificial disc placed and are doing very well. The fear of increasing the intervertebral disc space when a patient presents bone-on-bone is that a substantial increase could lead to other problems (some patients have reported chronic pain after ADR placement). Typically, surgeons like to leave these levels alone.

Once they start to fuse, how difficult is it to separate them and then put in an artificial disc or a man made fusion? And isn't one of the reasons for putting in new discs, etc., to restore height so that the nerves, ligaments etc. are not 'squished' anymore?

Once they start to fuse, it can be very difficult to separate the vertebral bodies. However, I do know that surgeons like Dr. Bertagnoli have been very successful in subsequently placing an artificial disc or performing a fusion at these levels. The disc height is increased with ADR, which allows narrowing around nerve roots to "open up" and help relieve preoperative complaints. However, over-distracting the disc space can lead to situations in which a patient is in more pain after surgery and can even lead to chronic pain post-op.

He is insinuating that if it completely fuses together on its own, then the pain would disappear also. How? There are also osteophytes involved that are compressing my cord, so how is that relieved? Shouldn't the top priority be to relieve the pressure on my spinal cord?

This is a very good question--one that I don't have an answer to. In my opinion, when it completely fuses the degenerative cascade is somewhat stabilized, so theoretically pain would then subside or decrease. However, the autofusing would not address the osteophytes, which are present due to degeneration. There is a possibility that the osteophytes would not increase in size, but there is a possibility that they would continue to "grow;" thus, further compressing your spinal cord (or increasing impingement of the dural sac). In my personal opinion, the osteophytes should at least be addressed (especially if they are causing significant compression) even if the the vertebral bodies are allowed to fuse.

He said that the damage to the cord was already done and it wasn't likely to get worse. Or better.

I'm sorry to hear this. In my opinion, you would best be served with multiple opinions regarding your cervical spine...unfortunately, it sounds like a very difficult situation that would benefit from the recommendation of many qualified and talented surgeons.

Good luck with everything...we are here for you!

[KBear]

What a great question and answer. I never really understood why they might leave it, now I get it. So there definitely are pros to leaving it.... definitely something to think about.

[Katie]

I know Kathy, that crossed my mind for a nano-second, but then I thought about how compressed my cord is, and one did not offset the other, at least to me. But I don't have the education to make that decision.

What chance do we have of understanding all of this if the most educated and experienced in the field cannot agree on most things?

[Cindylou]

Yes, very good questions and answers. Thank-you Justin for your wisdom/training in this arena. We are so fortunate to have you. I hope it helped you Katie.

[KBear]

I know Kathy, that crossed my mind for a nano-second, but then I thought about how compressed my cord is, and one did not offset the other, at least to me. But I don't have the education to make that decision.

What chance do we have of understanding all of this if the most educated and experienced in the field cannot agree on most things?

Katie, I agree, not sure if they could go in and 'clean' out the osteophyte and still let it autofuse. Or, if it would just be better at that point, to do a fusion or adr. I would worry about the added distraction pain. I wonder if there is a such thing as like a 1/2 heigth fusion?? Seems like it would work....

[Justin]

I know Kathy, that crossed my mind for a nano-second, but then I thought about how compressed my cord is, and one did not offset the other, at least to me. But I don't have the education to make that decision.

What chance do we have of understanding all of this if the most educated and experienced in the field cannot agree on most things?

Unfortunately, this is where things get tricky IMHO. Surgeons have varied backgrounds and different schools of thought on spine surgery. This is where experience really comes into play. With such a difficult case (from preliminary view of your films), it would behoove you to get multiple opinions. I know this is very difficult with how your care is set up in Canada and the restrictions placed on in province providers. If you have 5 surgical evaluations, you're going to get 5 different opinions--hopefully, some that agree on what the best intervention is. Then, it becomes a "go with your gut" type of situation where you choose what surgeon you feel is most qualified and is offering the surgical intervention that you feel is best. This can be incredibly difficult, especially with varying opinions from surgeons. Money, unfortunately, also factors into this decision so it becomes a complicated situation of pursuing the best care that you can afford. I've been through this type of decision making twice now and it's not easy...do know that if you do your research and you turn over every rock before surgery, you will be that much more confident with your decision. I know it's difficult, but we are here to support you and act as a sounding board through these decisions.

Yes, very good questions and answers. Thank-you Justin for your wisdom/training in this arena. We are so fortunate to have you. I hope it helped you Katie.

No problem, CL. I would caution that what I've written above in this thread is from talking with patients over the last 7 years and my own personal research. Ultimately, the course of action regarding "bone-on-bone" situations is surgeon specific.

Katie, I agree, not sure if they could go in and 'clean' out the osteophyte and still let it autofuse. Or, if it would just be better at that point, to do a fusion or adr. I would worry about the added distraction pain. I wonder if there is a such thing as like a 1/2 heigth fusion?? Seems like it would work....

If the osteophyte(s) is/are on the posterior aspect of the vertebral body, a surgeon could theoretically go in and decompress that area without touching the "fusing" vertebral bodies. However, I think depending on how the vertebral bodies are fusing plays a significant role in surgical "correction." Some surgeons say "leave it alone," while others feel reinforcing with a fusion (complete the fusion), or even placing an artificial disc would benefit the patient. Again, this is widely based on surgical experience and preference.

Just an FYI: I've spoken to many patients that were "bone-on-bone" that subsequently had an artificial disc placed and are doing very well. I know others that have had a difficult go of things after the intervertebral disc height was reestablished. I am not an expert on this subject by any means--I'm just sharing information that the Spine Patient community has shared with me over the years.

Katie--I wish you the very best and please let me know if there is anything I can do for you.

[Fuzzy]

For several years I watched my lumbar vertabraes get closer to one another on the mRI images. My pain got worse and I had events of "mechanically" locking up in my lower back. The vertabrae looked about 2 mm apart on the images. A local surgeon said exactly that, it would eventually fuse and then the pain would get better. I decided to wait some more (2 years!) no dice yet just lots of pain and increasing burning tingling temperature sensation in my feet and legs. It turned out I had already hit bone and sheared of the protruding disks on the back side at 2 levels which meant a messy clean up surgery of at least 5 hours duration. I am lucky I ended up with 1 of the 2 planned ADRs (and it works very well). I am not so sure it would have been a good idea to let it self fuse.

If your new MRI shows a deterioration over the last one 2 years ago that should help prove that things are indeed getting worse. Have your symptoms increased in those last 2 years?

[Katie]

Fuzzy, yes, my symptoms have increased, especially with my balance and clumsiness, including dropping things from my left hand. Bladder and bowel problems are getting worse too, although I haven't lost control much, just problems the other way. Nothing will 'start', and then feels like I'm never empty. Sitting for half an hour in the middle of the night in the bathroom does not make for good sleep

Your story does more to strengthen my resolve about getting the cervical done. Thank you so much for sharing. My ideal situation would be to have the Canadian doctor do the lumbar, either with the pain stopping dye or with the fusion and two Maverick discs, and then winning my appeal and having Dr. Bitan do the cervical levels in NYC. He is limited to only doing one ADR in the States, and I think I would rather have two ADR than two fusions. But I really, really trust him for my neck and all its complications. I'm not so sure I will have that option though.

Justin, if you don't mind, when you have a look at my new MRI, could you trim the personal data off the best image and load it here? I cannot save any of it to my hard drive as I could with the other one, and it would be good to have them side by side for comparison.

If you are not comfortable doing that, I understand. Especially if you are not up to it with the shape you've been in lately.

So many of us have had experience with looking at these pictures, and some feedback would be interesting.

This has been a very interesting thread.

[Katie]

Justin, I may have another chance at yet another opinion. One doctor I contacted a few weeks ago has asked to see my new MRI to compare with the first one.

He probably does the most cervical ADR surgery in our province, so hopefully his comments will make sense, and not muddy the water even more.