The Far Side of Fusion

One of my frustrations while considering this fusion surgery five years ago was the difficulty finding a record of positive experiences online from people who had undergone successful fusion surgery. I might see an initial post or two shortly after surgery, maybe a follow up two to six months in, and then nothing. Well, how are things one year on? Three years on? Sadly, it appears that I have become one such poster.

On the bright side, I’m a single data point confirmation of my hopeful conclusion five years ago as to why I could find so little record of positive fusion surgery experiences: they are too busy leading normal lives to go back and update their original postings.

Five years on, I continue to be virtually pain free. I can pick up my 3-year old daughter as much as I want and even occasionally move my 60-lb nine-year old if need be. I can walk at will and do body-weight exercises. I’ve been careful about heeding the surgeon’s advice to avoid high-impact activities or those involving twisting. This has meant giving up my lifelong love of soccer and consigning myself to screaming at the TV during soccer games, but it’s a small price to pay to be able to be active again and fully functional when it comes to my family (kids, luggage, etc). 

I do continue to experience some adverse symptoms on the right side of my body that are probably related to my condition or the surgery: the muscle mass and tone of my right thigh is lower than on my left leg. I also have nagging knee pain. I’ve tried physical therapy to restore the muscle mass of the right leg, but that has not worked. I suspect there is some nerve impingement in my back near the site of the fusion affecting the function of the muscles in my thigh.

These were the words of my surgeon in response to some symptoms I was experiencing one year after the surgery. This appointment was effectively my exit interview--if everything looked on track medically, this would be the last scheduled appointment with him or the clinic.

Overall, things did look good in terms of my fusion. In the appointment, we examined images from a CAT scan they had taken a week or two earlier, and he pointed out to me on a few images evidence of the bone fusing in the space between L4 and L5. He noted that the definition of bone fusion has changed over the history of the surgery--in the beginning, fusion meant a full fusing of the bone, ie, most of that space filled in with bone; these days, it's considered fused if some part of the space is filled with bone.

It's difficult for me recall my state of my mind and body at the time of the meeting because I'm writing this seven months after it happened. I do know at the time I was able to walk and bike as desired without pain, as well as perform everyday duties like taking in groceries, picking up my kid, etc.

The bigger question for me is why I am writing this one-year update seven months late. I can claim I was busy, but if I'm honest with myself, I can sense some internal resistance for reasons about which I'm not quite clear. I think it was easier to blog about my recovery earlier on because there were clear indications of progress, whereas now, I've entered a time period of "mostly fixed," but without clear evidence of continued progress. I do think there is also the realization that I'm not quite as recovered as I had hoped. I hoped to be in a little better shape--a little less day-to-day pain--than I have.

Hi,

Thank you for your question. I'm sorry it's taken me so long to answer, but I've been traveling a lot of the past month. 

I was also surprised to be having nerve pain almost a year after surgery. The nerve pain is noticeably less now than it was 2-3 months ago. Also, it always subsides, which makes me think that my back is just adjusting to heightening levels of activity/load. Etc.

I have not noticed much difference in mobility/flexibility, but I wasn't very active before surgery, so the comparison may be poor.

By and large, I have been incredibly happy with the results of my surgery, and was amazed with how quickly I recovered various functions within the first several months following surgery. All the time, though, I knew that full fusion would take a good 12 months, so I expected not to be fully mobile or capable of doing all of the everyday living tasks like moving furniture, mowing the lawn, or enjoying a full workout routine at the gym.

In the last several months, though, I've been creeping up on the one-year mark and thus have been excitedly expecting to add to the number and kinds of things I can do. To be sure, I've made a lot of progress: at 4-5 months (last October or so), carrying in groceries from the car still left the occasional ache in my back and leg, and now that task doesn't affect me at all. But there are still some things I thought I'd be able to do by now that still are causing some pain and nerve activity. Just last week, I swung a bat for the first time--not a 90-mph pitch 400 feet away, but a tennis ball tossed by my five-year old! Yet, that motion of twisting and weight shifting left me a dull ache and nerve pain in my leg and back the rest of the day.

About two months ago, I had a session at the gym with a personal trainer meant to transition me back to a normal workout routine. He walked me through about five exercises involving machines and free weights, all of them very doable and causing a minimum of pain. The next several days, however, my right leg was a lightning storm of nerve activity, with impulses crackling all along my leg, including along nerves not usually stimulated by my spondylolisthesis. It greatly discouraged me at the time--I really thought I shouldn't (whatever that means) be feeling these symptoms this long after my surgery. 

Fortunately, none of these symptoms persisted more than a few days. In fact, I've noticed a pattern to the pain produced when I engage in a new activity, or too much sustained activity of a certain kind. I typically feel little or no pain at the time of the activity, but over the next few hours, a dull ache will develop. When I go to bed that night, the pain will oddly increase and disrupt my going to sleep, albeit for perhaps 30-60 minutes at most. If I just dial back my activity a little, I will return to being pain-free within a few days. 

Right after the surgery, I had pictured myself having less and less pain the further I got from my surgery. I realize now that is a mistaken notion. A more realistic expectation is that when I increase my level or kind of activity, I will experience pain as my body gets used to a new kind of motion (say, swinging the baseball bat). I need to proceed cautiously and let my body get used to that new kind or level (more time) of motion. 

Well, it was supposed to be my six-month checkup, but I didn't get around to it till one week shy of eight months. There wasn't much to this one either--just take another set of x-rays to make sure everything looks good and interview me on my current condition.

I continue to have sensation along the nerve running down my right leg, most of the sensation being in the front part of my lower leg. It was along the same nerve that I experienced most of my pre-op pain. I have to make clear, though, that my current level of pain can't be described as any stronger than a "sensation." I literally just feel something there, it doesn't hurt. Also, unlike pre-op, the sensation is independent of my activity--before the surgery, this pain would quickly worsen within a few minutes of walking, forcing me to stop. These days, I can continue to walk and be active pretty much at will.

The PA who visited with me said that we have about another six months before we'll know whether this nerve sensation will be with me permanently or not. Obviously, I would prefer to have no sensation, but I would still be quite happy with my overall surgery experience if that's all I have to end up living with.

Here's a picture of the x-ray taken during this latest visit:

And for comparison, here's another picture of the x-ray taken six weeks after surgery:

I've highlighted the L4-L5 level on both x-rays. One can see that the most recent x-ray shows that level to be more "cloudy"--evidence that bone is slowing growing in that area. It's difficult to discern how much new bone has grown since my left hip crest runs right through that level from the back of the photo. Still, comparing the two photos does show a distinct difference.

Areas of progress since last writing

-I can ride my bike without pain. Four months ago, hunching over the bike brought pain to my back, but now I feel better. I should note that I have yet to get back into a good biking rhythm, so I haven't ridden for more than 30 minutes.

-I can lift "ordinary" things like luggage, trash, etc, without pain or use of the back brace. I still avoid picking up my son, who comes in at just over 40 lbs these days. I've held him a few times, but try not to push it.

-I can twist and go through everyday motions without pain.

Continued trouble areas

-Pain during some exercises while working out. Although Pilates is a great program for me overall, there are still some of exercises that cause pain the next day or two, usually in the form of increased nerve pain down my right leg and perhaps a slight ache in the lower back. I think I've identified which ones they are--if I just avoid those, then the workouts are fine.

-Pushing tables/furniture. For some reason, this movement--even relatively light-weight tables--causes an echo-type dull pain in my lower back.

Well, it was supposed to be my six-month checkup, but I didn't get around to it till one week shy of eight months. There wasn't much to this one either--just take another set of x-rays to make sure everything looks good and interview me on my current condition.

I continue to have sensation along the nerve running down my right leg, most of the sensation being in the front part of my lower leg. It was along the same nerve that I experienced most of my pre-op pain. I have to make clear, though, that my current level of pain can't be described as any stronger than a "sensation." I literally just feel something there, it doesn't hurt. Also, unlike pre-op, the sensation is independent of my activity--before the surgery, this pain would quickly worsen within a few minutes of walking, forcing me to stop. These days, I can continue to walk and be active pretty much at will.

The PA who visited with me said that we have about another six months before we'll know whether this nerve sensation will be with me permanently or not. Obviously, I would prefer to have no sensation, but I would still be quite happy with my overall surgery experience if that's all I have to end up living with.

Here's a picture of the x-ray taken during this latest visit:

And for comparison, here's another picture of the x-ray taken six weeks after surgery:

I've highlighted the L4-L5 level on both x-rays. One can see that the most recent x-ray shows that level to be more "cloudy"--evidence that bone is slowing growing in that area. It's difficult to discern how much new bone has grown since my left hip crest runs right through that level from the back of the photo. Still, comparing the two photos does show a distinct difference.

Areas of progress since last writing

-I can ride my bike without pain. Four months ago, hunching over the bike brought pain to my back, but now I feel better. I should note that I have yet to get back into a good biking rhythm, so I haven't ridden for more than 30 minutes.

-I can lift "ordinary" things like luggage, trash, etc, without pain or use of the back brace. I still avoid picking up my son, who comes in at just over 40 lbs these days. I've held him a few times, but try not to push it.

-I can twist and go through everyday motions without pain.

Continued trouble areas

-Pain during some exercises while working out. Although Pilates is a great program for me overall, there are still some of exercises that cause pain the next day or two, usually in the form of increased nerve pain down my right leg and perhaps a slight ache in the lower back. I think I've identified which ones they are--if I just avoid those, then the workouts are fine.

-Pushing tables/furniture. For some reason, this movement--even relatively light-weight tables--causes an echo-type dull pain in my lower back.

In early October, I took my son out to a field at a nearby park to play some soccer. We gently kicked the ball around, and I took a 4-5 harder shots on goal as well as kicking the ball high up in the air a few times. We were out there only about 20 minutes or so.

I did not do this carelessly or flippantly--this was a very purposeful slight elevation in activity to see how my body would respond. I did not notice much at first, but about a day later, I began having increased nerve pain. The pain was mostly in my right leg, but sometimes lit up all kinds of areas below my waist like an electrical storm--mostly a tingling or burning unlike I had pre-surgery. The pain was not severe, nor did it seemed to connected to any particular movement I made or position I assumed. It did worsen as the day progressed.

Very uneventful. They took another x-ray of my back and asked a few questions about my current level of back pain. The x-ray looked virtually identical to the one taken at 6 weeks post-op, with perhaps a tiny bit more "white" between the vertebrae to indicated some bone growth in the fused area.

It's early September. I'm three months post-op, done with physical therapy, apparently declared fit--vague descriptions of "take it easy" and "don't overdo it" the only guidance I have. And yet we all know the fusion of the my two vertebrae takes a good 12-18 months, so now what?

This has proven to be the most challenging part of my rehabilitation so far, because there is no continued specific framework for my full recovery. Initially, I had the very concrete constraints of wearing the back brace, not carrying over 10 pounds, doing certain exercises, etc. Now I have nothing. Clearly, I need to fill the void by coming up with a regimen for myself. My plan is to return to my gym and make another appointment with the same trainer who prepared a pre-surgery routine for me.

I started rehab on August 1st, almost six weeks to the day after my surgery. I honestly was quite disappointed in the rehab regimen the first few times I went. I expected exotic equipment and exercises and all kinds of metrics to measure progress. Instead, I got a slew of the standard fare "strengthen the core" exercises, variations on the same ones anyone with back trouble has probably done many times before opting for surgery.

I was able to do all of the exercises they gave me, and in many cases could have done more. I guess they take it more easy than I thought they would. It was all really unexciting and standard. Again, with this big-time surgery, I expected...well, I expected something different! I would expect the exact regimen prescribed to vary slightly from one facility to another (I chose one closer to my work rather than the one at Spine Team TX).

For those who happen to be in or near the Dallas-Forth Worth, Texas area, I thought I'd post my doctor's details in case you are interested:

Spine Team Texas

1545 East Southlake Boulevard #100 Southlake, TX 76092

(817) 442-9300

Dr. David Rothbart (neurosurgeon)

Mark Lutrick, P.A.

Ah, finances, not talked about so much--perhaps considered tacky to do so. To quote Seal, "whateva whateva!" If you are considering surgery, I'm sure you've thought about this so I thought I'd give you some numbers.

My doctor's office is attached to a hospital where I had my surgery. I ended up having two sets of bills, one from the hospital (Harris Methodist Hospital in Southlake, TX) and one from the doctor's office (Spine Team Texas in Southlake, TX). I'll list the total cost first, with the details after it.

TOTAL COST (approximate): $123,000 (see caveats below)

Here are the numbers:

Hospital bill (I'm rounding a bit for readability):

1-day stay in hospital $1200

OR services: $11,100

Surgical supplies: $4100

Lab services:  $1800

Anesthesia: $1800

Recovery room: $1100

Pharmacy & drugs: $900

Radiology & EKG: $650

Supply/Implants (??): $80,500

Total Hospital Costs (rounded): $104,000

$1 million question: what is "supply/implants?" (ok, the $80,500 question...)

Here is the doctor's office bill (kind of cool to see what they charged for each part of the operation; again, numbers are approximate for readability):

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; lumbar: $7350

Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, face screw fixation) $4500

Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace: $2400

Allograft for spine surgery only; morselized: $450

Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, face screw fixation): $2700

Office visit, x-rays: $1030

EMG, neural monitoring: $870

Total Hospital costs: $19,300

TOTAL COST: $123,000

I suspect there is some overlap between the two, as one of the items on the hospital bill reads "Supply/Implants," which sounds like it's covered by some of the line items on the hospital bill. I really am doubtful I have a full handle on this bill, since the "supply/implants" is so vague, yet represents 2/3 of the total bill...

It became apparent to me during this process how focused my surgeon and PA were on the "surgery event" itself. They really did a great job and I couldn't be happier with their work or the results so far. But they had nothing to say to me about preparing for surgery and little about my recovery and rehab. I was sent from specialist to specialist, each with his or her narrow focus.

It occurred to me that it would have been helpful to have someone in my provided care who had the "big picture" of my health in my mind. For example, why was I not advised to get into better physical shape before the surgery? (I knew to do so by having heard from others who had gone through the surgery). What if I had been overweight--would I have been advised to lose weight? And what qualifies as "good shape"--what should I focus on in terms of strengthening my body? And what about during the recovery--is there really nothing I can do but walk (I started adding in some stretches after about four weeks)?

Perhaps this is where the role a primary care doctor would fulfill. I don't happen to have one, but I'm not sure that even if I did, he/she would fulfill this role. I'm envisioning something like a wellness coach or something, but with enough knowledge and expertise to know the effects of specific types of surgeries, how to prepare, what I can expect post-op, and so on.

I had this appointment just over six weeks after my surgery on July 29th. The P.A. took X-rays of my back to confirm that everything looked good.

He then wrote me a referral to begin physical therapy and encouraged me to starting weaning myself from wearing the back brace, although the physical therapist would give me more exact guidance in this regard.

I was surprised to be "released" from the back brace so soon, as I had been given the impression that I would be wearing it closer to three months. The first adjustment I made was to switch out the bigger back plate for the smaller one. I still wore it for most of the days for a few more days until I had my first appointment with my physical therapist.

She told me that I should wear the brace when I feel like I need it. Really? Because I don't feel like I need to wear it at all! This changed my perspective on the discomfort I felt from my back. Before, I interpreted any pain or discomfort from my back as bad and to be avoided. Now I began to look at it more as a soreness that needs to be worked out. I do still wear the brace if I go shopping or am working around the house, but otherwise, I am taking it off and doing without.

My condition did not change significantly during this time. I think that by three weeks, I had healed pretty well from the surgery. The steroids were effective in decreasing the nerve pain I felt down my right leg. I tried to walk once a day for 1-2 miles but it ended up being probably more like 4-5 times a week.

The only thing the doc told me to do was to walk, but I started adding in some stretching during the 5th week, focusing on the hamstrings. I would lie on the floor and prop my leg on the corner of a wall, so that one leg was bent next the end of the wall, the other propped straight up  on the wall. This was a good stretch for the hamstrings without putting the back in a compromising position.