Just Joining-need ALIF

[nursechicrn]

I am so pleased to find this community! It seems that I have had difficulty finding a good base of folks who are knowledgeable on this subject and have been there too!

Here is a little bit of background: I have had low back pain for almost ten years (I am 33). I didn't do anything about it for a long time, but it got to be so bothersome that I saw my PCP in 2005. He referred me to PT, which I didn't find helpful, but I figured it just was what it was. With exercise the back pain improved, until after I had my first baby in 2007. After her birth I noticed it had become more severe and this time went to a chiropractor for help. The manipulations did help, but the effects were short lasting. She obtained an x-ray which showed degenerative disc disease and a 5mm retrolisthesis at L4-S1 as well as an incidental finding of congenital absence of L5. I was referred once again to PT and it once again was not very helpful. Fast forward two years after baby #2, and my back pain had become so severe I was having difficulty with ADL activities such as brushing my teeth and tying my shoes. I again went back to my PCP in September of 2010, who ordered an MRI which was done in October. The MRI showed moderate/severe DDD, retrolisthesis, impingement on the nerve roots and osteophyte complexes on both sides of the disc at the L4-S1 level. I was referred to neurosurgery at this point, and had all of a five minute consultation with the neuro who said "you need an ALIF, talk to my nurse to schedule" and that was it. So I am left with a lot of questions and decisions to make. (I did attempt to get a second opinion, but when I called to schedule they told me that since I had already had a consult with a surgeon of the same specialty, they would not do a second opinion)

The neuro had said that I would be back to work in three weeks, but I am a nurse, we do twleve hour shifts and do a lot of lifting. He was aware of this and still quoted the three week time period. When I called to schedule the surgery, the nurse told me no bending/lifting/twisting and no weight heavier than 10 pounds for 6-12 weeks. I guess what I am looking for here are those who have had single level ALIF, what your in-patient experience was, what the first few weeks of recovery were like, and if three weeks sounds at all reasonable to return to work. Even though I am a nurse, I have NO neuro background, so I am flying blind here!

Any information you could provide would be helpful. Thanks in advance!

[Justin]

Hi Valerie,

Welcome to the Spine Patient Society.

You do have quite a spine history at such a young age. I've been in your shoes with spine issues at a young age (my problems started in my early teens), so I can relate to how hard things can get. However, there are options that can definitely help and get you back to living your life.

With your level of degeneration, a spinal fusion does sound like the best route forward. The osteophytes indicate that you are quite advanced in the "degenerative cascade." There are many different types of fusion; some are more invasive other approaches than others. Also, there is a full spectrum of hardware (plates, screws, cages, etc.) that can be used as well as biologics like BMP (bone morphogenic protein).

The neuro had said that I would be back to work in three weeks, but I am a nurse, we do twleve hour shifts and do a lot of lifting. He was aware of this and still quoted the three week time period. When I called to schedule the surgery, the nurse told me no bending/lifting/twisting and no weight heavier than 10 pounds for 6-12 weeks. I guess what I am looking for here are those who have had single level ALIF, what your in-patient experience was, what the first few weeks of recovery were like, and if three weeks sounds at all reasonable to return to work. Even though I am a nurse, I have NO neuro background, so I am flying blind here!

Any information you could provide would be helpful. Thanks in advance!

In all honesty, you will not be back to working 12 hour days as a nurse after 3 weeks of recovery. Your job is demanding (I work in a clinical setting), to say the least.

Also, I see that you mention a sacralized L5 vertebral body. If your "problem level" is at L4 (which it sounds like it is, if I am understanding things correctly), you might want to look into an XLIF (eXtreme Lateral Interbody Fusion). It is a "less" invasive approach, as the level(s) to fuse are addressed from a lateral approach. The lateral approach is a great option in my opinion--you get to avoid an anterior approach, which inherently causes scarring of the great vessels (descending aorta and inferior vena cava). The scarring down of these vessels can be problematic in the future. However, this is not always the case. Also, in your situation an anterior approach may be the best possible way to address the osteophytes and other degenerative changes you have going on.

Here's a video about the XLIF: Spine Patient Society Videos. Click on Orthopedics and then click on the XLIF video.

Recovery after an anterior spine operation takes time. It honestly took me a good 3 months to recover and about 4.5 months to be completely "pain-free." With recovery, you only get one chance-----and you want to do it right and not rush things due to some artificial deadline. I understand about getting back to work to make money to make ends meet, but sometimes it behooves you to put your health in front of everything else. I do hope you and your employer can come to some sort of agreement regarding returning to work. Maybe you could even start back on lighter hours.

Also, it is always a good thing to get a few surgical opinions before jumping head first into surgery.

Good luck with everything and we are here to answer any questions you may have.

[nursechicrn]

Thank you for your response, Justin. That is the best information I have received to date and gives me a better idea of what I am looking at.

I was especially interested in the significance of the Osteophytes. My PCP did not know much about spine MRI and the neurosurgeon did not review the results in detail with me. Can you direct me toward a resource that explains the physiology associated with DDD and the other findings on my MRI? I confess I am not very educated in what it all means, or where I sit on the spectrum of back issues.

I am in full agreement with you that there is only one shot at a good recovery, however, the financial aspect is also very real. My husband is unemployed right now and if I am not working we sink! That is why I need the recovery period time frame to be more firmly established. I understand there needs to be flexibility, but the difference between three weeks and 12 is significant. I feel so pulled between being in pain constantly and having difficulty coping with ADL's, and wanting to put it all on the back burner because my life is so busy and the potential financial implications are unsettling.

I looked into XLIF, but was told that it was not an option when the level involves the last lumbar vertebrae and the first sacral vertebrae. I was told that higher levels are ok, though. I also looked into disc replacement but was told insurance will not cover it, and I don't even know if I would be a candidate. I am actually not sure which level is actually in question... the MRI reads "The pt has four non-rib bearing lumbar verebrae and transitional lumbosacral vertebra that I will refer to as L5 for the purposes of this exam." then in the L4-5 section of the findings, it talks about the osteophyte complexes, end plate spurring of L4 and superior endplate of L5, but the neurosurgeon said that he thought it was actually L4 on S1, so I guess what I am saying is I have no idea of the level

Anyway, thank you again for the information. I am learning a lot here and hopefully I can wade through with a better understanding of what I am looking at and what my options are.

[KBear]

Welcome Valerie and so sorry you are dealing with spine issues at a young age and with young children at home. I had ADR almost 2 years ago and it took me 18 months to become completely pain free, though I did see major improvement at 12 months post op. You will need major help for at least 6 weeks after surgery, no lifting of the kids, bending, twisting, no chores, just taking care of you. When I had my first surgery, an Idet my youngest was 9 months and my other was 3 years. With my ADR they were 5.5 and 3 years old and that was much easier, because they could understand mommy had a 'boo boo' and couldn't hold them. I was able to have family and friends keep the kids during the week when my husband wasn't home, which was also nice because I was so tired and napped all the time, which is hard to do with little kids running about. I guess depending on your job and how flexible they are on letting you have light duty, would depend on going back to work. I can't imagine having to have had go to work until at least 6 months post op. People do do it though and it all depends on their work situation. With you being a nurse I would be concerned about the lifting that is required. I would also suggest consulting a surgeon outside of that office and seeing what they say, because to me 3 weeks is not at all realistic. Anyhow, best of luck, Kathy

[ajj1001]

hiya, I have had both anterior and posterior ops and can tell you how much harder the anterior is to get over. the no bending, twisting and lifting is also very restricting. you will not be well enough for work in 3 weeks.

alison x

[Justin]

Thank you for your response, Justin. That is the best information I have received to date and gives me a better idea of what I am looking at.

Sure thing!

I was especially interested in the significance of the Osteophytes. My PCP did not know much about spine MRI and the neurosurgeon did not review the results in detail with me. Can you direct me toward a resource that explains the physiology associated with DDD and the other findings on my MRI? I confess I am not very educated in what it all means, or where I sit on the spectrum of back issues.

Here's some information on osteophytes and the degenerative cascade of the spine that I typed up for another Spine Patient Society Member:

Kirkaldy-Willis provided a classification of degeneration of the spine based on 3 phases that inherently included spine instability:

The first phase, Phase I, is known as the Dysfunctional Phase. This phase is characterized by circumferential tears or fissures in the outer annulus. In addition, endplate separation or failure can disrupt the blood supply, resulting in the loss of nutrition to the disc. These changes are thought to result from repetitive microtrauma. One hypothesis is that the discs' nuclear proteoglycans lose the capacity to absorb water and maintain their protective function. Low back pain, low grade disc degeneration and laxity of the facet capsule is included in this phase.

Phase II, or the Unstable / Instability Phase, is characterized by multiple annular tears (both radial and circumferential), internal disc disruption, and resorption or loss of disc space height. This phase is thought to result from the progressive loss of the mechanical integrity of the 3-joint complex. Increased facet joint laxity and moderate disc degeneration is present.

Phase III is also known as the Stabilization / Restabilization Phase. Further disc resorption, disc space narrowing, endplate destruction, disc fibrosis, and osteophyte formation are present leading to decreased overall motion. Disc injuries are more likely to occur in phase I or II of the degenerative process. Disc degeneration has reached final stage (grades 3 to 4).

Source: Kirkaldy-Willis WH, ed. The pathology and pathogenesis of low back pain. Managing Low Back Pain. New York, NY: Churchill Livingstone; 1988:49.

I am in full agreement with you that there is only one shot at a good recovery, however, the financial aspect is also very real. My husband is unemployed right now and if I am not working we sink! That is why I need the recovery period time frame to be more firmly established. I understand there needs to be flexibility, but the difference between three weeks and 12 is significant. I feel so pulled between being in pain constantly and having difficulty coping with ADL's, and wanting to put it all on the back burner because my life is so busy and the potential financial implications are unsettling.

I completely understand. I will send you a PM with some ideas that you might find helpful.

I looked into XLIF, but was told that it was not an option when the level involves the last lumbar vertebrae and the first sacral vertebrae.

This is true; XLIF cannot address L5/S1.

I am actually not sure which level is actually in question... the MRI reads "The pt has four non-rib bearing lumbar verebrae and transitional lumbosacral vertebra that I will refer to as L5 for the purposes of this exam." then in the L4-5 section of the findings, it talks about the osteophyte complexes, end plate spurring of L4 and superior endplate of L5, but the neurosurgeon said that he thought it was actually L4 on S1, so I guess what I am saying is I have no idea of the level

The "normal" lumbar spine has 5 non-rib bearing vertebrae above the sacrum. Since your report states that you have four non-rib bearing vertebrae, it means that your L5 is "sacralized" -- meaning that it actually became part of your sacrum during development. Thus, in theory, you could still have an XLIF at your affected level(s); the sacralization of your lowest vertebral body will "place" your affected levels above the brim of the pelvis--meaning that your level(s) can be addressed from a lateral approach (XLIF). Of course, this is not medical advice and this would warrant a discussion with your surgeon to get a better understanding of your anatomy and the feasibility of such a procedure.

Let me know if you have any other questions.

[Cindylou]

Welcome Valerie, I am sorry too for all you are dealing with spine wise, at such a young age, and with little children to boot. I have also had anterior and posterior operations and the anterior is a difficult, tedious recovery. It also sounds like you are getting the picture from all the responses that 3 weeks out for recovery is rubbish. But at least you are getting the straight scoop beforehand. You'll be more equipped with your decision making. Good luck! Cindylou

[nursechicrn]

Wow thanks guys! I really appreciate all the support and information. I am glad I followed my instincts and got more information otherwise I think I would have made a poor choice. What is interesting is that my neurosurgeon made PLIF sound like a long hard slog, and ALIF a blissfully easy alternative. I have really taken to heart all the information and comments about ALIF not being the cake walk it was painted out to be.

I think I will look into alternatives (possibly XLIF or disc replacement) and see if I can get any solid information on a shorter recovery period. Even if I don't I will know I am moving ahead on solid information and will have a realistic expectation.

Thanks again!

[Victoria]

Wow thanks guys! I really appreciate all the support and information. I am glad I followed my instincts and got more information otherwise I think I would have made a poor choice. What is interesting is that my neurosurgeon made PLIF sound like a long hard slog, and ALIF a blissfully easy alternative. I have really taken to heart all the information and comments about ALIF not being the cake walk it was painted out to be.I think I will look into alternatives (possibly XLIF or disc replacement) and see if I can get any solid information on a shorter recovery period. Even if I don't I will know I am moving ahead on solid information and will have a realistic expectation.Thanks again!

Hi, I just had the Nuvasive XL TDR. I stayed in the hospital 1 night and am at home resting. 3 days post op am able to get in and outta bed by my self. There is a clinical trial going on right now. You may wanna see if there is someone in your area as there are 18 sites. Best of luck, victoria

[laid up doc]

sorry to hear of another young health professional needing surgery i'm a doc but not a surgeon or pain dr... but i have learned a lot leading up to my own ADR surgery last week.

agree w/ those above that fusion is really your only option - and i'd say if you have unusual anatomy, a surgeon would be verrry reticent to do an XLIF.

if i were you, i would look into finding a surgeon who does the TLIF (transforaminal lumbar interbody fusion) procedure, and see if you are a candidate. they go in through your back but to the sides (say, where they go in to do epidural injections) - a lot less damage to adjacent structures and muscles than a PLIF, and no abdominal recover for ALIF. I know of docs in DC and NC who do them, but those are the only places i know well enough to say.

ALIF takes longer to get over for sure - but for a fusion to take i would say you wouldn't be able to work for AT LEAST 2 months, maybe 3-4. you didn't mention what kind of nurse you are - obviously for a doctor's office or triage would be different than med/surg, icu, or ED nursing, even OR where you have to move the pts. i am 5 days s/p a lumbar ADR, and it will be some weeks til I would be able to work - and you REALLY want to do it right the first time, ie not rush things.

Justin may have told you about this, but depending on your employment status, you may be eligible for Family Medical Leave Act (FMLA), or short term disability. the way you describe your situation, though - sounds like you need to act before you get any worse. staying in decent shape going into surgery helps a lot - i wasn't bedbound or on narcs, and my recovery is going extremely well. i couldn't do much at all though, and did every reasonable nonsurgical treatment for nearly 3 years.

good luck to you, feel free to PM me.