I was diagnosed with spondylolisthesis of L4 nearly 25 years ago and it has now progressed to a level 3. The disk between L4 and L5 is completely gone. Most of my spine above L4 is already fused due to scoliosis surgery over 30 years ago and ankylosing spondylitis. I also have a Harrington rod extending from L1 to the thoracic region. Recently I was diagnosed with osteoporosis. The pain has become intolerable, with tingling and burning in my legs, pain in my buttocks and hips, and aching in my lower back. I also have frequent leg cramps and weakness in my legs, especially upon first standing. I have consulted both an orthopedic surgeon and a neurosurgeon. The orthopedist proposed replacing the missing disk with a wedge that will cause the vertebrae (L4 and L5) to fuse together. The neurosurgeon claims that would be disastrous and wants to link L4 and L5 with the upper lumbar and thoracic vertebrae and then anchor everything with a rod into my pelvic bone. Is that really necessary? Which procedure, if either, would be most practical?
You have sort of a unique problem, not all that common (not unheard of, just uncommon).
Usually, in patients who are ambulatory, it is not advised to fuse the complete lumbar spine to the sacrum. In patients who have neuromuscular disorders or are paralyzed, the fusion to the sacrum is usually necessary to correct pelvic obliquity and allow for sitting in a wheelchair.
Since you already have a long fusion mass, to fuse the rest of your spine would reduce your flexibility and motion significantly. But, on the other hand, due to that fusion, you do place more stress on the remaining open vertebral joints.
There probably is no one correct answer. If you want to have some flexibility and motion to make activities of daily life easier, then the one level fusion is probably the best. However, you run the risk that you MAY have some continued pain and MAY need to have something else done down the road.
If you want to have just one surgery and don't care about the mobility (will put up with the stiffness and problems associated with that), then having the complete spine fused to the pelvis may be the way to go.
As to who is best to fuse the spine, that is really based on the individual surgeons' training. Orthopedic surgeons are usually more versed in the use of instrumentation, but many neurosurgeons do take extra training to learn the use of hardware. So, it really doesn't matter on the specialty, but rather the surgeon.
In any case, you should probably get a third and probably fourth opinion. This is a major life changing event, which cannot be undone. Whatever you decide to do, just to comfortable with your decision. Do not rush into anything.
Thank you for your reply, Gaelic. I definitely think a third opinion, probably from an orthopedic surgeon, is warranted. I had just begun to accept the idea of even having back surgery again after the first consultation when I was presented with the highly invasive procedure at the second consultation. The thought of all of that hardware in my back, in addition to what is already in place from scoliosis surgery, is just overwhelming -- plus, as you said, the prospect of the limitations of having my lumbar spine fused to my sacrum. Yet, I am very limited in movement as it is due to pain. I cannot bend at the waist or lean forward much now, or even tolerate pressure to my stomach/abdomen, as the pain goes right through to my back.
I do understand the physics behind the neurosurgeon's warning against fusion of L4 and L5 alone. He doesn't believe the screws would remain in place before the fusion sets because of the force exerted by my upper spine. However, wouldn't a brace stabilize my spine until the fusion sets (I believe that was part of the orthopedic surgeon's plan)? Also, would the one-level fusion make my spine any more unstable than it was following my scoliosis surgery 30-some years ago? I realize that the surgery performed at that time made the remainder of my spine more vulnerable to injury. However, I believe the only reason my spondy has progressed is the physically demanding jobs I've repeatedly found myself in. So, couldn't the one-level fusion offer a permanent solution as long as I refrain from lifting?
It is very possible that the one level fusion would take care of your problem. But, as you are well aware, there are no guarantees.
The one thing with the lesser surgery, is that, if it works, great. And, you don't burn any bridges, if something else needs to be done down the road, it can be. Once you fuse to the sacrum, that's it. There is no going back.
You really need to get another opinion. Take a list of all your questions written down with you. The surgeon you talk to will be in the best position to offer you advice on your options, as he/she will have your studies, and have examined your back.
Hope you find a solution to your problems. Good luck.