Is it time for surgery for L4-5 disc? s it time for surgery? what kind ? TLIF? where to start?

[RLMIAMI]

hi, I am thrilled to find this forum. it is great as a source of information and support. I am in my 50's,I have, L4-5 central contain disc protrusion and disc bulge of same disc. although only 12mmX5mm in size it causes bilateral leg weakness, buttock pain and lower back pain. i can't stand on one leg on either side without falling immediately. my pain level is 4-5 more or less constantly. i can't stand for more then a few mins and i require a lot of rest on my back to be able to function.this has been going on for 4 years. have i not worked for myself i would have not been able to keep my job. the straggle to conduct my life while in pain and disabled is frustrating and depressing. i have seen 7 physicians between neurologists neurosurgeon and spine surgeons. i have tried; 1 biforaminal epidural injection-ninimal short lived relief. many side effects.
3 perispinal Enbrel injections- 10% improvement for couple of month, side effects. off lable use.
2 perispinal Botox injection, also 10% improvement for 2-3 month.
interestingly Enbrel and botox injections reversed my inability to stand on one leg immediately but did not translate to less weakness.
40 DRX9000 treatments- 20% relief. but requires continues maintenance and have no further relief.
i am not taking any meds now. years of NSAIND drugs caused reduced blood flow to kidneys- a risk i would not take. i would not take muscle relaxants any more, i don't like their side effects. i never took any narcotics. I am trying now a very small dose of Bupropion as a TNF alpha reducer, initially it looked like my back pain was relieved but it did not sustain, i would not take the dose higher then 30mg/day(1/10 of standard dose, because of side effects.
Is it time for surgery? what kind ? TLIF? where to start?.
appreciate your thoughts! thank you. Annette

[Justin]

Hi Annette,

Welcome to the Spine Patient Society! I'm glad you found us. Even though your herniated is contained, it still sounds like it is creating substantial deficits. The lack of postural balance while standing on one leg and the bilateral weakness in your legs jumps out at me to move forward with a surgical evaluation. In terms of what kind of invasive surgical intervention is necessary--my advice is to obtain multiple opinions from surgeons--they can provide you with a much better answer after reviewing all of your films and performing a complete H&P (and, of course, ordering more diagnostics if needed).

is it time for surgery?

This is a hard question to answer. In my opinion, functional compromise and possible nerve damage are definitely reasons to move forward.

Once again, welcome and I do wish you the very best!

[KBear]

I second what Justin said. I would definitely get several surgical opinions, from doctors who are experienced in ADR, fusion and such. I would ask why they suggest what they do and then do lots of research.

to the forum!

[RLMIAMI]

thanks Jastin and KBear, I have taken your advice to heart and contacted Dr Pimenta. sorry for the delay in my response, I had problems logging in. annette

[Justin]

thanks Jastin and KBear, I have taken your advice to heart and contacted Dr Pimenta. sorry for the delay in my response, I had problems logging in. annette

Hi Annette,

I'm glad you are "moving forward." Spine problems are an unfortunate reality for many of us and (I believe) the trickiest part is when to move forward with a surgical evaluation. Dr. Pimenta is a world-class surgeon and he has helped many people on this Forum.

We will be here to support you through everything.

[RLMIAMI]

Justin, thanks so much, i am forever great full to to you for your kindness and starting this forum. i got my biggest gift today when i found the response from Dr Pimenta, he states "Usually indication is when the pain level is in the area of disability ".very well put!, i feel validated !. I can't wait to get it over with. merry Christmas Annette

[Jack-of-all-trades]

If I were you, I would do a lot of research before allowing someone to cut on you. Spine surgeons are just people with a certain expertise, but they do have bias toward one procedure or another. That is were the 'art' of medicine comes into play. You should be made comfortable that whatever your decision is that it is the best for you.

Have you had tests (MRI, discogram, CT, etc.) to make sure L5 is the problem?

Some things to consider:
Disc replacement is the up and coming technology. It is not necessarily the best choice for everyone. A more aggressive surgeon told me he would do disc replacement for my L5-S1 thinking I could get it fused if it didn't work. The odds of it working for isthmic spondylolisthesis is such that it is now contraindicated.
Fusion is 50 year old technology with various approaches and methods. It is kind of like the B52 bomber the Air Force uses. it is constantly being upgraded and still works. Fusion immobilizes that spine level putting more strain on adjacent discs. You have to decide if it is worth it.
There are now surgeries for the facet joints, laminectomy, discectomy and others.

Narcotics are not necessarily a bad thing if used responsibly under the care of an anesthesiologist who specializes in pain management. It is by no means preferred but not the demon thought to be 30 years ago. They are better than a life in misery or suicide.

Any surgery on the spine carries some pretty scary risks even though somewhat uncommon.

[RLMIAMI]

Jack, first, let me wish you good luck with your up coming surgery. you make many good points. I wrote a very long response which described my trials and tribulations with the 8 surgeons i saw. a comical tale! but it was erased accidentally just as i finished typing. I take it as a sign that i should not give the appearance of complaining. one day i would look back and know that the journey is the destination. i learned humility that comes with vulnerability. i have gained the gift of new knowledge. I am fascinated with the field of spine medicine. it took a long time to find the right surgeon. one i can trust. I let Dr pimenta decide what's best MIS PLIF vs XLIF i hope, this time, it will go well from here. as to using narcotic drugs they really don't work for me. i got myself off benzos, after using them for a year as muscle relaxants the beneficial effect run out and only the down side remained. Actually i had less pain after i got off. I guess they contributed to instability. and paradoxically caused more pain. as far as NSAID fheir anti prostaglandin effect reduced the blood flow to the kidneys. i am left with heat pad and rest. I am experimenting with Bupropion in a very small dose for its TNF Alpa properties. a very interesting compound. I allow my body's function to be compromised, i will not compromise the clarity of my mind. I would love to dance all day again soon. Merry Christmas Annette


L4-5 central disc protrusion and bulge 2/2006
epidural steroid injection, 5% short lived relief
40 DRX9000 treatment, 20% improvement
botox 2X, 15% relief for 3 month.
Enbrel perispinal 3x, 15% relief for 3 month.
leg and back pain 4-5/10 95% of time, no meds