How does discectomy (ADR or fusion) help severe foraminal stenosis?

[scotto74]

Just something that I'm wrestling with right now, that I'm not quite sure I understand. I have moderate central stenosis and severe foraminal stenosis at the two levels (5/6 and 6/7) in my neck that are going to be operated on very soon. I understand how removing the disc and cleaning out the disc space would help the central stenosis, but how would that address the severe foraminal stenosis?? (which I also have at 3/4 and 4/5) I also don't understand how the anterior discectomy would address any of the bone spurs that are impinging on the cord from the back of my neck. When I posed this question to my surgeon, he just said that the discectomy will address the stenosis. I may follow up today with him to try to understand the process more, but intuitively I just don't really get it right now.

I'm also still wrestling with the whole ADR versus fusion idea, though I'm scheduled to have surgery in a week. It seems that a double fusion would make sense given my arthritic neck (and facet hypertrophy), however pretty much all of my discs are degenerated, so a double fusion would likely lead to more surgery in the very near future. I know I can't deliberate forever on this, but I really want to try to get this first surgery as "right" as possible... although I realize that is probably an impossible thing to try to do.

Sorry for the long, rambling post everyone, just trying to get my arms around everything and make a decision soon.

Thanks,
Scott

[New-disc]

Hello,

I've had both... my fusion has left me with some long term range of motion problems, but has also taken most of the pain away ... I due have flare ups..

Before surgery I was unable to use my right arm/hand.

Best of luck with your surgery

Todd

[KBear]

You are right that there isn't a one size fits all answer. I know they say fusion can cause more degeneration; but there are a lot of people with ADR that have more discs go bad too. No guarantees either way.

[Justin]

Hey Scott,

You bring up a good point. In theory, an artificial disc replacement (ADR) device or a fusion will help increase the intervertebral height and thus would help with central stenosis somewhat. However, foraminal stenosis is another animal and usually requires specific surgical correction. A great Spine Patient Society Member to contact regarding this would be Rob Wilson, as he had ADR and subsequently needed his foraminal stenosis addressed through another operation.

To be honest, the anterior decompression is not going to help with posterior bone spurs. Sometimes posterior bone spurs can be addressed through an anterior approach, but this is typically not the case. Also, if you have bone spurs impinging on your spinal cord, it would be wise to have those addressed as they are probably contributing to your pain (not to mention possible functional deficits in the future).

If I were in your shoes with your level of degeneration and facet hypertrophy, I would pursue spinal fusion. However, the kinematics in the cervical spine are much different as compared to the lumbar spine, so ADR might be an option despite your level of degeneration.

Just throwing my two cents our here: don't feel rushed into having surgery until you are 100% comfortable with moving forward. You really want to have all of your bases covered and you want to make sure that all of your spine issues will be addressed by the surgery proposed. Good luck!

[scotto74]

Hey Justin,

Thanks for the insight and feedback, I really appreciate it. I actually cancelled or postponed my surgery today (was scheduled for next Wednesday) because I just didn't feel 100% sure about what direction I want to go in. I am starting to think that as much as I really would like to have ADR surgery, that perhaps (unfortunately) I may not be a good candidate given my moderate/severe stenosis and moderate facet joint hypertrophy. I even reached out again to Texas Back Institute today (they initially said I was "not surgically remediable") to see if they would be willing to provide me with any additional insight that might help guide my course of direction (fusion or ADR). I also reached out to Dr. Lauryssen and will be overnighting my films to him tomorrow to see if I can get his opinion on whether or not he would suggest ADR for my neck.

Any other top spinal surgeons that you think might be worth reaching out to? Thanks for letting me know about Rob, I'll definitely try to reach out to him.

Todd and KBear -- thanks for the feedback and support, much appreciated!

I've also attached a snapshot of my MRI and a copy of the last two radiology reports in case you want to check them out. The reports are from two different facilities (UPenn and a local South Jersey imaging center) so they differ a bit in their wording and analysis.

Scott

[Justin]

Scott,

I've got to run out the door, but have you thought about seeing anyone at the Rothman Institute or Dr. Balderston in Philly? There's a lot of great location surgeons right in your back yard. Let me know if you need any more names in Philly.

[Gilbert P]

HI Scott

I think you are making the correct choices by sending your information to several Doctors.

I have been doing the same and is overwhelming but must be 100% comfortable with the Surgeon I choose.

Also the TBI would not do Surgery on my Four Level Lumber Issues????

All The Best

Gil

[Cindylou]

Scott, good for you for stopping to be sure about which surgical approach you take. Not an easy decision, but you want to be sure you are going into this with as much ammunition as possible to address your current pain issues. And it sounds like you know that. I hope you get some good feedback from TBI. You've been given some great advice from Justin and others. Good luck as you narrow in again on the most appropriate treatment for your spinal needs. Cindylou

[scotto74]

Justin -- I actually reached out to Dr. Balderston on your recommendation (and the fact that my mom has had her knees replaced there), however his assistant told me that he only deals with lumbar cases. They had one guy in the office who handled cervical cases, but I decided not to reach out to him. Also, I have been to Rothman. I met with Dr. Vaccaro, who I was referred to by TBI when they turned me away, and honestly I did not have a really great experience with him. I know he is a highly respected surgeon (was listed in the Becker's 50 best spine specialists) but the whole thing felt very rushed and "chop shop" like to me. His recommendation was a two level fusion using cadaver bone. In philly, I've also seen Dr. Marcotte at Penn (who did both of my dad's surgeries and my brother's 3rd cervical surgery) -- he recommended a laminoplasty (or laminectomy, not sure) and thought a two-level fusion was "too risky" for me. If you have any other names you think might be worth talking to, I'm definitely open for suggestions! Have you ever heard of Dr. Joan O'Shea in South Jersey?


Gil -- Thanks alot for the support. I definitely feel like postponing the surgery was the right decision. Even if I ultimately end up going with a two-level fusion with Dr. Bitan, I want to be absolutely sure that I've fully fleshed things out. So TBI turned you away also, huh? I'm sorry to hear about your lumbar problems, and hopefully you will find the right solution also!

Thanks Cindylou. Honestly, Justin and everyone else on this board have been such a great resource and sounding board for me. I'm so thankful for finding you guys! As for TBI, I didn't hear anything back today unfortunately. I'll follow up tomorrow, although I'm really doubtful that they will be able to share any more info than they did before. I also overnighted my films to Dr. Lauryssen today, and am contemplating going up to see Dr. Yue at Yale next week. It's a bit of a hike (3 hour train ride) but may be worthwhile to get another informed opinion on whether or not I truly am a good candidate for ADR.

Thanks again everyone!

Scott

[Justin]

Justin -- I actually reached out to Dr. Balderston on your recommendation (and the fact that my mom has had her knees replaced there), however his assistant told me that he only deals with lumbar cases. They had one guy in the office who handled cervical cases, but I decided not to reach out to him. Also, I have been to Rothman. I met with Dr. Vaccaro, who I referred to by TBI when they turned me away, and honestly I did not have a really great experience with him. I know he is a highly respected surgeon (was in the Becker's 50 best spine specialists) but the whole thing felt very rushed and "chop shop" like to me. His recommendation was a two level fusion using cadaver bone. In philly, I've also seen Dr. Marcotte at Penn (who did both of my dad's surgeries and my brother's 3rd cervical surgery) -- he recommended a laminoplasty (or laminectomy, not sure) and thought a two-level fusion was "too risky" for me. If you have any other names you think might be worth talking to, I'm definitely open for suggestions! Have you ever hear of Dr. Joan O'Shea in South Jersey?

Hey Scott. Now that you mention it, I do remember you posting about your experience with Rothman and other local surgeons. I forgot that Dr. Balderston only does lumbar cases.

I have heard of Dr. Joan O'Shea; however, I have not spoken with any Spine Patients that have seen her.

Thanks Cindylou. Honestly, Justin and everyone else on this board have been such a great resource and sounding board for me. I'm so thankful for finding you guys! As for TBI, I didn't hear anything back today unfortunately. I'll follow up tomorrow, although I'm really doubtful that they will be able to share any more info than they did before. I also overnighted my films to Dr. Lauryssen today, and am contemplating going up to see Dr. Yue at Yale next week. It's a bit of a hike (3 hour train ride) but may be worthwhile to get another informed opinion on whether or not I truly am a good candidate for ADR.

I'm glad that you have found the Spine Patient Society (SPS) helpful! I remember not knowing where to to turn in 2002-2003 while researching artificial disc replacement surgery. I felt in the dark, alone and without a place to turn for support. After helping hundreds of Spine Patients over the last 10 years, I decided to "make it official" and start SPS before my 3rd spine in May 2009.

We are here to support you and I do hope Dr. Lauryssen will help shed light on your situation.