Discussion in 'Injury Recovery Rehabilitation Massage' started by Mama.S, Mar 4, 2012.
Thank you for your tips!
Hi Everyone, newbie here
Why am I here: My wife has just suffered multiple prolapsed discs causing a sciatic infection whilst we were away on holiday in Austria - luckily! As she had a CT scan the day after seeing the local GP over there, then she has received three CT guided epidurals in the last fortnight. (thinngs seem to move a bit quicker over there!)
The surgeons are suggesting she will need surgery to remove the largest disc bulge which seems to be about 2/3 out on the CT image.
So this is why I am here - trawling the internet, doing my research about the procedures and what the future holds...
Why I am on this thread....
We live in Manchester, UK. My wife will be flying back sometime next week. I have been reading a number of threads on here about Microdiscectomy, MISS and Endoscopic laser surgery(are these last 2 the same?).
Is it really worth the £10000 to have the minimally invasive technique? I have found a review paper from 2010 (the study accepted research up until May 2008) from the 'European Spine Journal' which concludes that there is no significant difference in the outcomes of open back versus 'Transoraminal Endoscopic Surgery' (this is MISS, right?)
Thanks for all the help I have already received from reading through previous posts, and any you can offer in the future
Hello and welcome Treebeard!
I am very sorry to read about your wife's problems!
I am busy at the moment with family issues, but will get back to you tomorow with my thoughts regarding your questions and issue about the study, I hope thats OK ?
This article was not published by the surgeons, but by the researchers who do not have personal experience with minimally-invasive spine surgery. They are only researching literature publishes by the others.
I think that in case of your wife price of the surgery would be even higher, because she has multiple herniated discs.
And last, my opinion. If you can afford it, I think it is worth the money.
The researchers may not have any experience of the procedures, but they don't need any - they are simply looking at a lot of research (every study published in English, German, and Dutch over 25years which met specific criterea) by people who do know alot about the procedures, and then extracting the data from that.
Also what does anyone know about Mr Irfan Malik, who seems to be performing MISS on the NHS at kings college, london...?
And another name thats come up in my research... Mr Lester Wilson of the Royal National Orthopaedic Hospital.
However, Lester Wilson does seem interesting. He is member of ISMISS, roof society for minimally-invasive spinal surgery founded by Parviz Kambin. All Members of ISMISS perform true state of the art spinal surgery.
Forgive me, but I don't see how it matters who did the trials as long as they were properly contolled and monitored - the only consideration is the effectiveness of the two different techniques.
And yes, I did think that was a bit odd, how is he allowed to put that on his website? But still, does anyone have any experience with Mr Malik or an opinion on his abilities?
Just a bit more specific info on my wifes problem...
it is apparently a mass prolapse in L5/S1, radiating into the right leg. She has had tests done on a neurological ward and as yet there is no nerve damage.
Sorry, I don't know any patient treated by dr. Malik.
Good luck with your wife
Hi Spinelf, and wow, thanks for your time with the reply!
If I could discuss this a little further with you with regards your points made...
1) Yes, The paper although published in 2010 only looked at research up until March(?) 2008 so there has possibly been much development in the last three and a half years. However, the studies included should be valid as both techniques will have developed over the 25 years the review considered.
3) The paper only makes a conclusion about TES because that is what the paper is about "Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature". In the abstract it states "The objective of the study was to evaluate the effectiveness of transforaminal endoscopic surgery and to compare this with open microdiscectomy in patients with symptomatic lumbar disc herniations" So the only conclusions to be made are whether there are any benefits to TES.
4) Again, the paper is not about L&M procedures, it is reviewing all available suitable literature on those... there may be some interesting stuff in the references though...
The randomized controlled trial included in the paper (Full-endoscopic interlaminar and trans... [Spine (Phila Pa 1976). 2008] - PubMed - NCBI) "Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study." concludes... "The clinical results of the full-endoscopic technique are equal to those of the microsurgical technique. At the same time, there are advantages in the operation technique and reduced traumatization. With the surgical devices and the possibility of selecting an interlaminar or posterolateral to lateral transforaminal procedure, lumbar disc herniations outside and inside the spinal canal can be sufficiently removed using the full-endoscopic technique, when taking the appropriate criteria into account. Full-endoscopic surgery is a sufficient and safe supplementation and alternative to microsurgical procedures."
I must confess I have not read this paper, just the abstract. It looks interesting though as the results blurb states..."After surgery 82% of the patients no longer had leg pain, and 14% had occasional pain. The clinical results were the same in both groups. The recurrence rate was 6.2% with no difference between the groups. The full-endoscopic techniques brought significant advantages in the following areas: back pain, rehabilitation, complications, and traumatization."
5) I undertand that for it to be doubleblinded it is only the care provider/assessor and the patient who do not know the treatment - the surgeon would just perform the procedure (possibly without knowing the identity of the patient). Although yes, it would be quite obvious by the size of the scar! Unless the TES patients received a superficial cut as part of the operation (not sure about that ethically!) but even then the incisions are in different places aren't they?
I have to say, I don't think the paper is a "hatchet job’ which is designed to discredit Transforaminal Endoscopic". It seems quite robust to me. The problem we have is that until any of the MISS procedures can show a clear and definite improvement in results over that of the conventional techniques, there will be little or no new investment by the public authorities... why should they?
I must make myself clear - I don't want to sound like an advocator of Open back techniques! I am just trying to find out the truth about what could be a very hard decision for us. I believe from the little research I have done that MISS is at least as good as microdiscectomy, but also with some benefits (conscious in surgery, less recovery time, less scar tissue etc.). If only MISS was more frequently used then I'm sure the technique would improve further and show real benefits over the conventional techniques.
Thanks again for your time Spinelf (especially considering your current pain), I really appreciate your help.
Thanks for the repIy, I have downloaded the link info and will reveiw it tommorow, as I am getting tired at the moment.
I will get back asap.
This is great article. I have a full version, I must find it on my PC.
...wrote by real MISS spine surgeon, world expert in field of endoscopic spine surgery and innovator in field of interlaminar and extra-foraminal approach to treat spinal pathologies, dr. Ruetten.
If you don’t mind Treebeard, I would like to answer points in your last paragraph first.
Just like you Treebeard, I too am just trying to find a safe, effective and beneficial surgical procedure to remove my remaining ‘multi level’ spinal stenosis. Neither do I have any ‘axes to grind’ for any clinic body or procedure.
However, after 7 years of research, all my findings show, that Minimally Invasive Spinal Surgery (MISS) and Transforaminal Endoscopic approach procedures TESS in particular are ‘by design’ the most safe, effective, reported and studied of all the available spinal decompression surgical options in the UK and abroad.
My last paragraph may seem impossible given how long the NHS have carried out decompression procedures, but I, and other members, have found that the biggest problem during research was the total inability to directly compare MISS and conventional procedures! This was/is due to ‘the very big ELEPHANT in the room’, the elephant that no one wants to take about!!
((The total lack of clinical, scientific, outcome and research information available, regarding all of the NHS’s spinal decompression procedures!))
P.C.T. Clinical Directors
Spinal Unit Heads and
Royal Colleges of Surgeons
Have all failed to supply me with a ‘single scrap’ of peer reviewed studies and published papers that confirms that NHS ‘gold standard’ decompression procedures are safe, effective or appropriate!!
The usual response has been along these lines:
((We do not have information on the various operations with regard to patients))
((We do not make, record or keep any safety and efficacy rates nor any results of trials regarding our decompression procedures))
So when the British Orthopaedic Association, the body responsible with the introduction of and quality control of spinal decompression procedures in the UK, carried out an specialist ‘literature’ assessment of Endoscopic Laser Foraminoplasty (ELF) on behalf of N.I.C.E in 2003,
they, I believe, knew ‘full well’ that ELF actually compared ‘very favourably’ with any of the ‘gold standard’ NHS procedures available at that time! Yet they still decided to limit it’s introduction! WHY?
I strongly believe that the study was fundamentally flawed,
Let me explain using this analogy:
If you walk in to a Vauxhall car dealership and ask the salesperson, which people carrier is the best?
a Vauxhall Zafira
a Renault Scenic
The Salesperson ‘may well’ offer you a balanced opinion, but the obvious potential for ‘bias’ to cloud the opinion, is clear for all to see. The clear ‘conflict of interest’ is also obvious, this is why we tend to use ‘independent comparison web sites’ like WHICH and TOP GEAR.
But because we are talking about our beloved NHS, we disconnect our ‘critical analysing skills’ and simply go with Doctor knows best!
You said you and your wife live in the Manchester area Treebeard, so I was thinking, if you want see, first hand, the NHS’s views of MISS in general and Martin Knight in particular are, just ask your Wife’s Surgeon to referr her to Martin Knight, Then duck!!
I have had Senior Surgeons impugn MK’s name, personality, treatments and his professional international standing. One Spine Surgeon even suggested he had invented a brand new surgical procedure, simply to argue that his treatments were as good as MISS & ELF, he called it (MIOSS) Minimally Invasive ‘OPEN’ Spine Surgery !!!!!!!!!!!!???????? What theeeeeeeeeeeeee!!!!!!!!!!
Sadly Treebeard, it for these reasons, we are going to have to ‘agree to disagree’ about the authors intents. Sorry!!
The link to the abstract of the German study that you supplied on your last post
(Full-endoscopic interlaminar and trans... [Spine (Phila Pa 1976). 2008] - PubMed - NCBI)
was very interesting indeed, it is the clearest indicator yet of an increasing European acceptance of MISS’s parity with conventional procedures. Better still, was it’s conclusion that in some respects, MISS is superior in those areas you pointed out in your last post Treebeard.
Sadly, this is a German study, not British, and as we are some way behind the Germans, let alone the Americans, I feel it will still be a long time before we in the UK will benefit.
I still have some concerns regarding the lack of obvious direct comparison in this study, but it’s methodology appears to be much better than the first one you posted.
So I too think it could be well worth while investing in a copy of full report! Thank you!
In regards to newer development over the last 3 years, the last incarnation of MISS from the USA is Trans-sacral Endoscopic Laser Spine Surgery, I’ll call it TELSS for short.
It involves gaining access to the spinal columns ‘working area’ by entering via ‘naturally existing’ holes (3 I think) in the ’sacral plate’ at the base of the spine, our old tail bone!
If the micro endoscopes, lasers, reamers and other tools can be safely fed through these holes to gain a access to and to be able treat the spinal columns vertebrae and disc issues,
TELSS has the potential to render TESS, ELFD and other MISS procedures ‘obsolete’ within 10 years, as it will not require any dissecting of any vertebrae nor of any the major muscle groups, including the vitally important fascias!!
This how far we are behind the world Treebeard!
With regards to the Randomised Control Trial’s (RCT’s) Surgeons not knowing important information about the patient including their names, just to tick boxes for the assessors, fills me with real fear & dread!!
Another contra-indicative issue is that as the NHS refuse to introduce MISS and TESS procedures, the cost of the bill for the RCT will fall on insurance companies or patients.
There is no way on earth, that I will pay £11-12,000 for possible ‘placebo’ spinal operation!
In addition, the first thing the Theatre Nurse will ask you on arrival, will be your name, age, home address and inside leg measurement! LOL!!
So I still maintain that the preposition of RCT’s for spinal surgery, is preposterous!!
Got to go now Treebeard, I’ll speak to you soon!
All the best
Can I ask you what is the first paper I posted (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899820/pdf/586_2009_Article_1155.pdf) if it was not a direct comparison of the two techniques? Not only is it a direct comparison of the two techniques, it is summary of all the direct comparisons of the two techniques from the last 25 years!
I would say that there is plenty of peer reviewed research on this subject.
The paper is a dutch one - I don't know the opinion/reputation/vocation of any of the six authors, or what the situation is in holland with regards these procedures. You are talking as if this was a fix up by our NHS...? As far as selection criteria and statistical analysis it seems robust to me.
The methodology is completely different and cannot be compared - this paper is an actual clinical trial - the first one was a review paper looking at lots of clinical trials (including this one!) in order to get a better overall picture!
I suspect you prefer this one because it tells you more what you want to hear... Here is another dutch paper I've just found which apparently shows even better results for MISS than the Ruetten paper - http://www.touchbriefings.com/pdf/3224/godschalx.pdf
(However, not as scientifically robust as the other two papers)
Maybe it is I that am also looking for information that I want to hear... My wife has just been confirmed with needing surgery and has been told that it is not suitable for endoscopic as the herniation is too large (Again, I don't know what the situation is in Austria as to how available/used MISS actually is). She flies back tomorrow.
On a last note I would be interested (via PM instead of clogging up this thread) on anyones experiences and opinions on the Centre for Spinal studies and Surgery at the Queens Medical Centre, Nottingham University Hospital, and in particular a Mr. Bronek Maximilian Boszczyk as this is who was recommended by the specialist in Austria.
Thanks again, and Good night
Don't be misled. Every disc herniation can be treated in minimally-invasive fashion.
Let me see if I can clarify these points.
((Can I ask you what is the first paper I posted))
This one Treebeard.
I am not sure what you were referring to in the next bit, ending in ‘over the last 25 years’ but I would just like to say that I am aware that there are many studies, peer reviewed papers and so on, but when I have ‘dug deeper’ in to the quality and sources of them, what becomes clear, is that potential patients are rarely, if ever offered clear, simple, understandable and direct comparisons between comparable decompression procedures.
This makes it impossible for uninitiated, non medical patients to become fully informed and aware of available choices prior to deciding on a treatment course. Surely you would agree that this cannot be right?
((I would say that there is plenty of peer reviewed research on this subject.))
I respect your belief Treebeard, so all I will say in response to the above statement is to kindly you to ask for the following information from your Wife’s Austrian and/or NHS Spine Surgeons.
Q) Please may I have all available information regarding the safety & efficacy rates, trial results and any other published paper for the proposed procedure))
If you receive enough information for a decision to make, then I offer you & your wife, all the very best of wishes for your prefered procedure!
(The relevance of this Treebeard, is that these are the criteria used to hold back the introduction of MISS into the NHS)
((The paper is a dutch one - I don't know the opinion/ reputation / vocation of any of the six authors, or what the situation is in holland with regards these procedures.))
I understand the first one was a Dutch study and the 2nd one German. I honestly don’t have an axe to grind as to where studies are done or papers produced, I am just insistent about the transparency and scientific quality of them.
((You are talking as if this was a fix up by our NHS...? As far
as selection criteria and statistical analysis it seems robust to me.))
The combined power and influence of medical manufacturers, drug companies and medical personnel cannot and must not be underestimated when understanding how new treatment introductions are allocated and supported. This is in addition to any localized internal politics and shortcomings!
((The methodology is completely different and cannot be compared - this paper is an actual clinical trial - the first one was a review paper looking at lots of clinical trials (including this one!) in order to get a better overall picture! ))
I did not compare these 2 publications Treebeard!
((I suspect you prefer this one because it tells you more what you want to hear... Here is another dutch paper I've just found which apparently shows even better results for MISS than the Ruetten paper - http://www.touchbriefings.com/pdf/3224/godschalx.pdf
(However, not as scientifically robust as the other two papers))
I think this last statement is a little unfair Treebeard!
I made to clear, that I still had reservation about the Reutten paper. This was because, as with the Dutch paper, the source of the conventional procedures stats, were not made clear in this abstract! Also, as you, yourself pointed out, the Dutch abstract was just a paper review and the Reutten was an actual trial, and I believe that this is why Reutten offers a more accurate and up to date picture. I am not a sycophant!
I sincerely hope your Wife has a good flight home tomorrow Treebeard, I’m sure it is a worrying time for you both.
Best wishes and kind thoughts
My post is a little late to your original question, its been a while since I last came onto this site.
First I am sorry to read about the problems your wife is experiencing, I can empathise having been a back sufferer for some years. Having read through all the posts I am afraid I am not as scientifically aware as Spinelf or Keano, but I can give you the benefit of my experience.
My back went in October 2007 and despite being in a lot of pain I was told it was muscular and given a raft of pills to take. It was not until January 2008 when I had a scan (I only got that because my husband threatened to knock out the GP) that I found out I had a significant herniation at L4/L5. Despite the word "significant" which generally indiates that it is not going to get better on its own my GP sent me home with more pills, finally signed me off work (I am a police officer!) and told me to have bed rest for three months. A week later I was getting out of bed to use the loo, felt a searing pain and the disc sequestrated.
The piece of disc which left its rightful place took out my L4 and L5 nerve. I was in agony and totally lost the use of my left leg. It was the worst pain I had ever experienced and the total paralysis of my leg was very frightening. Having been fobbed off by the NHS for weeks they decided to rush me into hospital, but again it took my husband to threaten violence to get my GP to see me without an appointment and to send me to hospital. I had no idea what was happening to me and had not had the time to research my condition or the alternatives.
I just wanted the pain to go away and to be able to walk again. I had an emergency discectomy to decompress the nerves. The pain relief was instantanous, however despite only having a sequestrated disc for 24 hours I was left with global weakness of my left leg and a foot drop. Due to nerve damage I now have SI dysfunction as my glutes are no longer strong enough to support my pelvis and on top of this my gait and balance is poor because of the drop foot.
The surgeon who removed the disc particle did such a good job that I was back in hospital the following year having revision surgery! I now have vertually no disc left at L4/L5 and in addition I sprang a leak (full thickness annular tear) at L3/L4 which the NHS said could not be treated unless I had my back fused.
I was wise enought to know that a fusion should always be the last resort and so I embarked on some research. After some searching I found Mr Knight. I checked in with those on this forum who had the treatment and in February last year I had MISS at level L3/L4 to seal up the disc wall, I have fully recovered from that and although the disc is degenerated I have not had any further problems with it. L4/L5 had a further disc protrusion which Mr Knight dealt with at the same time as it was on the same side as the leak above. I also had my nerves liberated from the various structures they had become glued to following open back surgery (scar tissue had stuck them down), as a result I had some improvment in my foot drop, sufficient for me to be able to walk without a splint.
So having had both open back surgery x 2 and MISS I can put my hand on my heart and say YES it was worth the money.
One of the important things to weigh up is the amount of scar tissue which can form following open back surgery, with MISS it is very limited if at all and Mr Knight is a very skilled surgeon. He can do multiple levels if the problem is all on the same side and he can fit it into his surgery time slot.
Of course there is an other alternative to MISS which Mr Knight suggested to me as I have a degenerative disc in my C spine which causes me problems and which he cannot help with - that is disc replacement. I can suggest Mr Shackleford who works at Warrington Hospital or privatly at the Spire in Warrington. He has a very good track record and is in high demand for disc replacment, he also does multiple levels. It gives you something else to consider.
I am sorry that I cannot help you with random studies and data - its all above my head, but I hope my input has helped. Good luck if you havent already decided on a course of treatment.
You have gone through it all ..haven't you!!
Just had a bad situation with my back last week and had my 1st Osteo session ..was due to go in for the 2nd on Monday.. but the therapist had to cancel due to a course..
I was going to wait.. but today was another agonizing waking up session ..was on the floor unable to get up or lay back down without Mark, my husband ..it was pain i have never known before ...so done my research and going to sort it 1st thing on Monday.. without waiting around ..
Reading your painful journey I am appreciating more ...just how important it is to get things dealt with sooner..and also finding the right treatment with the person worthy of our trust !!
Thank you for sharing !
with warm wishes
Separate names with a comma.