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Fake or Fusion

Last week, I went to see if I was a candidate for an artificial disc in my back at L5S1. I had a second discectomy six weeks ago to remove a bulge that was pressing on my spinal nerves. At my three week follow up with my neurosurgeon, he told me I probably had one more surgery in my future – a spinal fusion.

"If your disc bulges a third time,” he told me and The Hubby. “I have no choice. I will have to do a spinal fusion and put in hardware.” (Right: See the rods and screws used in a spinal fusion. Sometimes, there is a metal plate used as well.)

The Hubby and I were sad and disappointed to hear that. Another surgery! I’ve had so many over the last 10 years. It seems never ending. My body decides to do things that I have no control over. The Hubby gets upset about it sometimes, but there is nothing that I can do. I’m not over using my body and causing this to happen. All of this was done to me by one self-righteous doctor trying to play God.

I spoke with my pain management doctor and my physical therapist about the possibility of a fusion. They both immediately said I was too young for a fusion and should look in to a fake disc instead. My neurosurgeon understood that I needed to explore all my options and referred me to a colleague who placed artificial discs. I needed to gather information to make the best decision should my back pain return.

Dr. Tip (not his real name) smiled in to the exam room, clad in brown loafers, jeans and a salmon colored polo, proffering his hand. I got up from my laying position on the exam table and shook his large hand. We viewed my latest MRI and the x-rays, taken minutes before, on the computer screen in the room. He pointed out my lack of disc space right above my pelvis at L5S1. The space was very small compared to the healthy disc spaces in my spine above it.

“I see you are five weeks out from your second discectomy,” Dr. Tip started. “Do you have pain in your back?”

“No, not right now,” I replied. “I still have pain and numbness in my foot and sometimes I feel like there is something in my shoe that is not there.”

“I don’t deal with nerve issues down the leg. Just pain in the low back. What are your concerns today?”

I explained my worries of a spinal fusion and my preference for an fake disc instead, filling him in on what my neurosurgeon told me about my disc bulging a third time. “I’m here to learn about my options. I want to be prepared and know what I can do if my back pain comes back. Because when it comes back, I don’t want to be searching for options then. The pain comes back with a vengeance and I want to take care of it quickly.”

Dr. Tip nodded. “Let’s discuss your options for an artificial disc. But if your disc bulges again, you will not be a candidate for an artificial disc.”

“Oh,” I blinked at him with wide eyes. This was not what I wanted to hear. I leaned against the exam table in stunned silence for a moment. “So, the artificial disc can’t be used in place of a fusion?”

“No, these discs are made for people with degenerative disc disease. A very specific group. When the artificial disc first came out, it was very difficult to get insurance to pay for them. Which in hindsight, was a good thing so not every random doctor was putting them in. Once these are in, you can’t take them out.”

“What do you mean, you can’t take them out?” I inquired. “Do you have the actual discs here that I can take a look at?”

“Let me go grab them. If I can find them,” Dr. Tip muttered the last part as he left my exam room.

He breezed back in with two types of artificial discs. “This is the one I put in now. The Active L, Fourth Generation.”

I looked closely at the two gray, titanium sets of discs placed in clear spinal bone shaped pieces of plastic.

“This is the old one,” Dr. Tip held up one that was in two pieces. “I don’t like it because it has this keel that I have to put up in to the healthy spinal column. I have to take out a large chunk of bone to put this one in.”

I grimaced. The keel was easily a half inch high. That was a lot of healthy bone to remove. And in two places – the bones above the disc and below it.

“Once you put the disc in,” he said still talking about the first artificial disc. “The sandpaper-like surface grips on to the spinal bone and helps secure it while the bone grows around the new artificial disc. The two pieces of the artificial disc attached together by sliding in these little grooves.”

I thought the grooves looked pretty thin and flimsy. If the recipient bent too much it might just pop apart, I thought. Even though the likelihood of that happening was nil.

Dr. Tip continued picking up the newer looking disc. “This is the one I use. See the three teeth here?” He pointed down through the clear plastic ‘bone’. “Those are what grip the bone instead of the keel. I don’t have to take out healthy bone with this one. It has a sandpaper like surface which help it to adhere to the bone as well. This one has a ball joint that it moves on so you can twist and bend.”

I pulled the two pieces of the joint a part to see a large round dome sitting on the lower piece. The top section of the disc floated on top of it. (See the dome to the right.)

“How do you put these in?” I inquired.

“I go in from the front on the left side of your abdomen. On you, I could possibly get the incision below your bikini line. Move all your insides over, remove any remaining disc and insert the two pieces in your spinal column above and below the old disc. Once these are in, they don’t come out. The teeth hook in to the bone and can’t be pulled back out. To take them out, I would have to remove a good chunk of bone that the implant attached to.” (Below, see the Active L in a spinal column one vertebra above were I would need it. Look closely at the right of the artificial disc and see the small teeth that hook in to the bone above and below the disc space. )

“I see,” I said still looking over the Active L artificial disc. “How many of these have you put in?” (Always ask your doctor how many surgeries he has done like the one you are about to have. You want the most experienced! They may lie, but you at least did your homework.)

“I’ve been putting artificial discs in for about 15 years and done just under a hundred. I did a neck this week and a back last week.”

“That’s it?!” I exclaimed. “Less than a hundred? I figured you would have done a thousand or more in 15 years.”

“No, insurance won’t pay for them. Plus, you have to be the perfect candidate.”

To me, this stat was worrisome. I was still of the understanding that this was a simple substitution for a fusion. But I was beginning to see I was wrong.

“What happens if the artificial disc fails?” I asked.

“A fusion,” Dr. Tip stated flatly. “You can only go in from the front once for these.”

“So, you would put the rods in around the artificial disc?”

“Yes, one either side, just like normal. Maybe one on either side of the spinal process too.”

“I’m not really a good candidate for this am I?” I said slowly as I came to the realization of my future.

“You are a good candidate now. Not a great one. But if the disc bulges again, you’re out. If you have low back pain because your spine is rubbing where the disc was removed, then we could do an artificial disc.”

I nodded. This was the information I needed. The artificial disc hadn’t come as far as my other health care professionals had thought.

“When I put the new disc in,” Dr Tip interrupted my thoughts. “I will pull your muscles and spinal nerves to fit the disc in. They will be tightened because they are used to the small space you have now with the loss of your disc. The pulling of the nerve may cause more issues for you, so I would try not to make them as tight as I do in other patients. This pulling could cause even more problems with your nerve. You already have problems that cause the pain, numbness and weird feelings in your foot.”

I looked up from the fake disc in my hand to him with raised eye brows. I hadn’t thought about all that. “You have given me a lot to think about,” I nodded pondering what he just said.

“Well, you are good for now, so let’s hope it stays that way,” Dr. Tip said smiling.

But I know my body. It won’t be good. I got the answers I was looking for. I know my options. I doubt an artificial disc is in my future. I believe it is only a matter of time before more disc comes out at L5S1. It only took four months the last time. But I will hope and pray my body cooperates with what I want it to do. Hear that body?!

This little bit of encouragement was in the bathroom at the doctor's office. I gave me a bit of hope.

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