Any cervical laminoplasty, laminotomy, or foraminotomy folks out there??

[scotto74]

Hello,

Just wondering if anyone out there has had some sort of posterior cervical decompression surgery and how you are doing. I'm facing the prospect of some combination of these surgeries, and would love to connect with anyone who may have some experience in this area.

Also, if anyone has any suggestions on surgeons who might specialize in these types of surgeries (preferably on the east coast) that would be very helpful also. I am trying to get a few opinions from top surgeons before moving forward. The surgeon who performed my two level fusion (c5/6 and 6/7) in January this year was Dr. Fabien Bitan in NYC. I've also been in contact with a couple of docs at Johns Hopkins.

Thanks, and hope everyone is having a good Labor Day weekend!

Scott

[Justin]

Hi Scott,

It's great to see you; although, your post implies that you still have some issues since your fusion with Dr. Bitan. Since you are in Philly, I would see if you can see a physiatrist (a physical medicine and rehabilitation physician) to see if there is something they can do in a minimally invasive manner to help before jumping into posterior decompression. However, if a posterior decompression is warranted, then by all means you should move forward

You should definitely get in touch with "Rob Wilson" here at SPS (do a search for his name in the upper-righthand corner so you can pull up his profile). He has had multiple posterior decompressions after his lumbar artificial disc replacement. He definitely has a lot of insight that should help lead you in the right direction (he's been all over the country looking for a solution to his ongoing issues).

I wish you the very best, Scott. Let me know if you want to talk at some point in the future.

[scotto74]

Hey Justin,

Thanks for the info. I've been under the care of the Penn Spine Center for the past 6 years or so. I just had a diagnostic facet block done there last week, and will likely either be having a real facet injection or possibly a rhizotomy relatively soon, as well as an ESI around the C6 - C8 level on the left side of my neck to try to help with the nerve compression. Hopefully they will help with the pain and arm weakness a bit, as I have had some relief from injections in the past.

My big concern though is the ongoing heaviness in my legs, that initially got better after surgery for maybe a couple of months and since has gotten progressively worse. I have some trouble walking for longer periods of time, and it is especially difficult now for me to walk up inclines or flights of stairs. I'm definitely not eager to undergo a posterior decompression, although I'm getting increasingly worried about what's going on with my legs. I've had my lower back scanned a number of times in the past year, and there's nothing major there that would be causing any symptoms in my legs. I've also had a full neurological work-up which didn't reveal any other potential causes.

I'm off to see my surgeon tomorrow in NYC, so hopefully I'll have a little more insight after then. I'm also trying to get at least a couple of additional second opinions from top-notch surgeons before I move forward with any decisions.

Thanks for the info about Rob Wilson, I'll try to reach out to him soon. It would definitely be great to catch up with you one of these days, considering my proximity to Philly.

Thanks again, and talk to you soon.

Scott

PS... Go Phils!!!

[MDE]

Being in Philly you should absolutely try to get an appointment with Dr. Todd Albert. He's one of the best spine surgeons in the country hands down, and he's at the Rothman Institute and Thomas Jefferson University Hospital.

I'm also very familiar with Laminoplasty and where it is and isn't beneficial.

[scotto74]

MDE,

Thanks for the info and taking the time to respond to my post -- I really genuinely appreciate it. I actually tried to set up a consult with Dr. Albert a month or so ago, but Rothman turned me away for a couple of reasons. First, they said they have a policy not to see a patient until at least one year following their last major surgery (I'm just over 9 months out). Second, I actually consulted with Dr. Vaccarro prior to my surgery and they said it might be "tricky" or "challenging" to try to switch over to Dr. Albert (I didn't really understand why and still don't honestly). Anyway, I think I'm going to call back again tomorrow and try to see if I can plead my case again and get an appointment with him...

A quick update on my situation. I've now gotten several opinions and unfortunately, they are not converging at all in terms of how to address the congenital stenosis in my neck. Here's what has been recommended:

Surgeon #1 (my original surgeon) -- C2 - C7 laminoplasty & foraminotomy, posterior fusion at C5 - C7 (to secure my original fusion better) and an open rhizotomy on my bone-on-bone facet joint at C2/3 left

Surgeon #2 -- C5 - 7 laminectomy & fusion (with some foraminotomy) to address the worst area of compression. No need to go up higher.

Surgeon #3 -- C2 - C7 laminectomy & fusion (with foraminotomy)

I'm really wrestling between the recommendations of Surgeon 1 & 2 -- and unfortunately, both are convinced that the other's approach is absolutely incorrect. So I'm trying to understand the magnitude of my stenosis across each level better -- so I can hopefully decide whether or not it makes sense to be more aggressive now in terms of opening up the entire canal.

I'm also a bit concerned about laminoplasty in general, some of the inherent risks of the procedure, and whether or not it's truly any better than a laminectomy and fusion.

Unfortunately, my symptoms (leg heaviness/weakness, difficulty climbing steps, left arm weakness) are not getting better so I know that I need to move forward sooner than later.

Thanks again for responding MDE, and I would definitely like to catch up more either via PM or offline.

Hope everyone is doing well!

Scott

[MDE]

MDE,

Thanks for the info and taking the time to respond to my post -- I really genuinely appreciate it. I actually tried to set up a consult with Dr. Albert a month or so ago, but Rothman turned me away for a couple of reasons. First, they said they have a policy not to see a patient until at least one year following their last major surgery (I'm just over 9 months out). Second, I actually consulted with Dr. Vaccarro prior to my surgery and they said it might be "tricky" or "challenging" to try to switch over to Dr. Albert (I didn't really understand why and still don't honestly). Anyway, I think I'm going to call back again tomorrow and try to see if I can plead my case again and get an appointment with him...

Vacarro is a good surgeon too, but Todd, especially for cervical, is incredible. Even if you can just convince them to have him give you his opinion based on the medical history, that would give you a good indication of "the right answer". He's very balanced between newer technologies and procedures, and the "tried and true" standards. Vacarro tends to lean more towards doing things the new way even if data isn't out there to completely support it yet.

A quick update on my situation. I've now gotten several opinions and unfortunately, they are not converging at all in terms of how to address the congenital stenosis in my neck. Here's what has been recommended:

Surgeon #1 (my original surgeon) -- C2 - C7 laminoplasty & foraminotomy, posterior fusion at C5 - C7 (to secure my original fusion better) and an open rhizotomy on my bone-on-bone facet joint at C2/3 left

Surgeon #2 -- C5 - 7 laminectomy & fusion (with some foraminotomy) to address the worst area of compression. No need to go up higher.

Surgeon #3 -- C2 - C7 laminectomy & fusion (with foraminotomy)

I'm really wrestling between the recommendations of Surgeon 1 & 2 -- and unfortunately, both are convinced that the other's approach is absolutely incorrect. So I'm trying to understand the magnitude of my stenosis across each level better -- so I can hopefully decide whether or not it makes sense to be more aggressive now in terms of opening up the entire canal.

I'm also a bit concerned about laminoplasty in general, some of the inherent risks of the procedure, and whether or not it's truly any better than a laminectomy and fusion.

Unfortunately, my symptoms (leg heaviness/weakness, difficulty climbing steps, left arm weakness) are not getting better so I know that I need to move forward sooner than later.

Thanks again for responding MDE, and I would definitely like to catch up more either via PM or offline.

Hope everyone is doing well!

Scott

Well, I can understand how you feel like they are not converging, but I think you have to look at what they're saying in a different way.

Surgeon #1 is saying we'll support the previous fusion (just in case) and that the myelopathy caused by stenosis exists C2-C7. I'll tell you that the typical laminoplasty case is C3-C7, and I haven't any done at C2 personally, but I can't see why you couldn't.

Surgeon #2 questions how effective your first surgery was by saying we just need to stabilize C5-C7 more, and do the laminectomy to fix the stenosis. Because those level's are already fused, there is very little difference in benefit or risk when looking at laminoplasty versus laminectomy (In this specific case)

Surgeon #3 agrees with surgeon #1 in that the stenosis exists all the way up to C2, but he thinks lami/fusion is the way to go. If I were to guess by the diagnosis, surgeon 3 is the oldest.

In the cervical spine, the posterior elements serve as stabilizing structures. When you completely remove them (AKA laminectomy), you have to fuse those levels to eliminate the instability and eventual kyphosis that would be caused if you didn't "support" them somehow.

Critical notes:
Laminectomy and Laminoplasty require that the neck still have some natural lordosis. This is the front to back curve that your neck has. Basically, by removing or displacing the lamina, you're allowing the spinal chord to move "backwards" slightly, but it will only move backwards if gravity can pull it that way.

A study published in Spine journal in 2001 by Heller et al, noted significantly fewer complications (none) with laminoplasty when compared to many more with laminectomy&fusion. (including hardware failure, myelopathy at additional levels, non union, adjacent level degen, infection, etc)

Risks: C5 root palsy is the biggest risk of Laminoplasty. 5-12% depending on the study, and can cause some serious issues in your arms/hands Because you're already fused at this level, this risk is not really an issue. It's also inherent to both procedures so no benefit either way.

The benefit of laminoplasty over fusion is that you retain motion. Motion is reduced by 30% on average, but you keep 70% versus losing all with fusion. This doesn't play into Surgeon 1 vs surgeon 2, but would be a good reason not to go with surgeon 3.

So really, they're all looking at the same picture, but the question arises, are symptoms coming from c2-C5 or only C5-C7? It's a judgement call by the surgeon and unfortunately there is no way to prove one way or another through testing.

If you summarize the three opinions, 2 out of 3 say you need provide some stenosis relief at C2-C5, 3 out of 3 say you need to provide some stenosis relief at C5-C7. 2 out of 3 think laminectomy is the correct choice for stenosis relief, 1 out of 3 says laminoplasty.

If it was me, aside from getting a couple more opinions, I'd look at the MRI myself and see how compressed the spinal cord looks at those upper levels. Then it's a risk/benefit ratio. If you go through the surgery and don't "fix" it all, you'll looking at another surgery. If you go more aggressive and you didn't need to (surgeon 1) you lose 30% of motion at C2-C5 and potentially have more complications (VERY rare) versus not doing anything at those levels.

Let me know if you have any other questions.

[scotto74]

Hey Greg,

Thanks for the additional info. The way you broke down the surgical info thus far definitely helped frame the information and got me thinking about things a little differently. I guess I've basically broken it down to a 2 - 2 split with two of the surgeons recommending that I only address the worst levels of compression and possible pseudo-arthrosis (c5-7), and the other two saying that I have congenital stenosis throughout my cervical spine and therefore need to decompress c2 - c7 (one laminoplasty and the other laminectomy). The way I've gotten to 2 - 2 is that there is another surgeon I saw at Hopkins who basically agreed with the more minimalist approach of c5-7 laminectomy/fusion for now. Oh, and the other wrinkle in my situation is that I have a c2-3 left facet joint that is basically bone-on-bone and really painful. Not sure how the laminoplasty would affect that...

One question I have for you... It seems like, all else being equal and assuming that I'm properly indicated for it, you feel that laminoplasty is a solid alternative? Just seems like a complex procedure to me, but I guess it has advantages in terms of protecting the cord and retaining some stability. My original surgeon (Dr. Fabien Bitan) is a strong proponent of laminoplasty in my specific situation.

Another question I have for you or anyone else out there is this idea of the cord "drifting back" once decompressed. My surgeon argued that if I only decompress c5-7, the cord will drift back into that space and cause additional cord compression above and below those levels. This is one of the key reasons why he and the other doc who recommended c2-7 lami/fusion were opposed to only addressing the c5-7 levels.

I lobbed a call into Dr. Albert's office as well as an email to him directly. Sounds like there's still some politics involved since I was seen once by Vaccarro, and additionally I'm not sure that they will be willing to bend their rules in terms of one-year post previous op. But I'm keeping my fingers crossed and plan to keep following up...

Thanks again for all the info and support, it definitely helps. I've also attached a snapshot from my latest MRI a couple of months ago.

Best regards,
Scott

[scotto74]

Wow... Just looked back at my last MRI pre-op (see attached) and it looks like I've lost of good bit of lordosis in my cervical spine as my neck now has more of of forward slant to it. I know this factors into the whole laminectomy thing, but I'm not really sure what it means at this point. The lordosis in my neck is also one reason why the surgeon at NYU Langhone recommended a C2-7 laminectomy and fusion -- to try to bring my spinal alignment into better structure.

I guess these are good questions to ask my surgeons, although I feel like at this point my surgeon and #2 (the c5-7 lami/fusion guy) are getting a bit annoyed with all of the follow up questions!

I just feel like there's a lot more riding on this surgery, and I really want to get it as "right" as possible... alleviating the cord compression symptoms in my legs, hopefully some of the pain in my neck and weakness in my arms, and most importantly, setting myself up as well as possible for the future.

Thanks again for all the help.

Scott

[Katie]

Scott, may I ask why Dr. Bitan isn't addressing this directly? If you don't want to answer, or would rather do it privately in a PM, just let me know. I'm not sure if I'm the one who recommended him to you, and am curious about what has transpired. While I didn't have surgery with him, he certainly spent a lot of time with me and was the first to point out how serious my cervical issues were. Without him, I would have still been focused on my lumbar levels...major pain contributors, and may not have sent my full spinal images to my eventual surgeon.

My symptoms from Cervical compression were varied, but the worst was the lack of balance and inability to walk with one foot in front of the other...I could not have passed a sobriety test There were other things...bowel & bladder issues, numbness in my arms & hands, etc. All of those disappeared after my C5/6 ADR surgery, although Dr. Bitan would have done a hybrid with that and C4/5.

A surgeon I found here in Quebec wanted to do a laminectomy on me in my cervical level, but I'm glad I went for the ADR instead.

Hope everything gets resolved sooner than later.

[scotto74]

Scott, may I ask why Dr. Bitan isn't addressing this directly? If you don't want to answer, or would rather do it privately in a PM, just let me know. I'm not sure if I'm the one who recommended him to you, and am curious about what has transpired..

Hey Katie,

I actually just looked back at my MRI's for comparison (pre-op and most recent) and prior to now, haven't really brought the whole lordosis topic up with Dr. Bitan. He is just standing really firm in what he thinks is the right procedure to correct my stenosis -- a laminoplasty from c2-c7 with a posterior revision fusion from c5-c7, as I still have an incomplete fusion. He also would do some foraminotomy work (mostly on the left side, where I have nerve damage and have lost a lot of strength) and an open rhizotomy to address my bone-on-bone facet joint at 2-3.

One thing I just remembered after posting this last night was that I'm pretty sure the radiology tech for my last MRI propped up my head ever so slightly with some sheets so that I would be more comfortable. That could very well explain the big difference in the two images!!

Right now the one thing all of the surgeons I've talked to, including Bitan, agree upon is: (1) I have an incomplete fusion that needs to be stabilized posteriorly and (2) I still have some cord compression around the 6/7 level coming from the back of my neck. The also all acknowledge that my facet joint at c2/3 on the left is completely gone.

In terms of recommendations, the big differences arise around whether to just address the levels where the most compression lies (c5-7) or to decompress the entire canal c2-c7 with either laminoplasty (Bitan) or laminectomy and fusion (still seems too aggressive to me).

So I'm hoping to break the tie soon and move forward with the surgery soon as my symptoms remain constant --severe, stabbing pain in the neck, weakness in my arms (mostly left) and dropping things more often, constant nerve pain in the groin area, and heaviness/cramping in my legs that makes it really difficult at times to climb even one flight of stairs. I'm going for another follow-up neurological evaluation (my fourth this year) just to make sure there's not some other neuro-muscular disease or something else causing my symptoms. Lumbar spine checks out ok, just some minor degeneration at L5-S1 but nothing that would cause any symptoms.

Enough about me though... I'm so glad you are continuing to do well! Dr. Pimenta sounds like he did a brilliant job in addressing the root cause of your problems, and I'm so happy that you're recovery continues to be a successful one! I also think the disc you have in your neck is really, really cool

By the way, I don't have a bad word to say about Dr. Bitan. I think he did a great job on my surgery is a wonderful, thoughtful surgeon. I'm just trying to figure out the right way forward, and I think he's starting to get a little frustrated with all the questions....

Scott