Which surgery would you have first? UPDATED 3.15

[McGurk]

Here’s my situation -

I have a terrible right knee that requires regular cortisone injections. That surgeon is VERY eager to do a total knee replacement because I am very knock kneed on that leg; he’s afraid if I have an ordinary, non horse related slip and fall, that I will blow out the soft tissue structures of the knee, and then require a much more complicated replacement.

(I had a left total knee 6 years ago, I sailed through surgery and recovery.)

My lower back is frankly more debilitating than my right knee; and THAT surgeon says I need a laminectomy and fusion L4 to S1. Epidurual injections have given me tremendous relief but only last 5 - 6 weeks max. All other conservative therapies have failed. Interestingly, the epidural injections have a great effect on the knee pain.

I have a full time job that I love, and a farmette and horses at home. The back pain has been very limiting, I can do farm work and ride after I’ve been injected or if I’m very seriously medicated. I am very, very leery of taking more than six weeks off of work to recover as I am relatively new in the job.

One part of me wants to do the knee surgery first - barring complications, I know exactly what I’m getting into, and I’m confident that I can be back at work in 6 weeks.

But realistically, the back problem is much more limiting. I am just scared of that surgery AND the potential recovery time.

Any advice or personal anecdotes appreciated.

[AKB]

I wonder if getting the knee fixed will make the back better. Sometimes people are like horses. When one area, like the knee, is causing problems, it aggravate other areas. I would vote for getting the knee fixed first, and waiting on the back.

[KBC]

What are the risks and rewards of the back surgery?

The knee is a relative known for you, you have done one and can hope that it is as easy on the second one, certainly the risk of damaging it further, and turning a routine op into something more complicated should be a factor.

The back is a scarier prospect, when they were talking about doing mine years ago, the loss of mobility that they were talking about worried me, I could have less mobile and maybe less painful back…

I vote for do the knee and see if you get some back relief from a more stable base…

[Where_sMyWhite]

Me? I would do the knee first. Be religious with rehab post surgery. Once you are “sound” on the knee, deal with the back.

L4-S1 is still less than half your lumbar spine so you will still have some lumbar flexibility, or should anyway. IMO, you should still be able to ride, maybe not sitting trot, and do your barn work. Again, follow all post surgical directions. You may need to get someone to help at the barn while your bone heals.

A friend posed back surgery such as you are considering as “elective” surgery (i.e., not trauma related). Only you know if and/or when you may elect to have that back surgery. Yes, the back surgery is more risky than the knee. But, not having it means dealing with some level of “disability” and pain. Only you know when it will be time to elect to have this surgery and move from the known to the unknown.

This is coming from someone with a T10-S1 fusion… my surgery did change my challenges. I had challenges before surgery and I have different challenges after surgery. I also had other health issues which came into play so YMMV.

[Simkie]

Wait, let me sure I have this right:

Your back injections make a big difference for your knee pain?

Sounds like the back pain is referring. Take care of the back first, and you may not need surgery for the knee pain. If you had no knee pain, would you be considering a new knee at all?

[McGurk]

Well, here’s the thing.

Yes, the epidural injections DO improve the knee pain. I tend to drag my whole right leg without the injections.

But the knee radiographs are awful, bone on bone and some spurs, and my whole leg is collapsing toward the medial line.

So I think having the back fusion will help with the knee pain, but the mechanical problems with the knee - no cartilage and bowing inward - will remain.

Appreciate all the responses so far and your continued thoughts.

[beaujolais]

I think knee, as I would not want you to compromise a newly fixed back due to a possibility unstable and bad knee. What does your ortho say?

I’m sure you have certain footwear and orthotics and all but I recently got these sneakers (on Amazon) which are highly recommend for knee patients. I buy 1/2 size larger to put my orthotics in them. I’ve tried all different types of sneakers/shoes, inserts, gel pads, etc., but these are just soooo cushiony and spongy. Love!

ASICS Women’s GEL-Tech Neo 4 Walking Shoe

Well wishes and soft hugs to you.

[JanM]

I agree that the known quantity of the knee surgery should be first. It may prevent a more extensive surgery, and you know that you should be back to work in six weeks.

With the back surgery you absolutely can’t go back before you heal (a friend did go back too soon, and it caused scar tissue, and more issues), and you can’t be sure it won’t heal more slowly. Plus, the knee being damaged could put more strain on the back surgery while you heal.

[Magicboy]

I think you should consider impact of the unfixed part on the recovery from the repair. Bad knee could destabilize the post surgery back…guess I’d do the knee first

[Kyrabee]

I guess as a surgey pro:uhoh:, I would agree with those that say the knee first. Get your lower limbs aligned and I think your back surgery has a much higher chance of success.

When I can’t walk mechanically correct, it mucks with my back…a lot. It is tough when you have multiple areas that need attention.

Jingles you can get some relief soon.

Susan

[DMK]

I don’t know about back first. If the knee is known to be problematic - meaning you have torn the meniscus/there’s severe degradation of the cartilage, fixing the back is not going to fix that. The knee is shot. It might be shot because of referred pain in the back/altering gait, but there’s no getting around the fact that the damage is already done.

But if you can walk pain free that will make rehabbing the back much easier and probably more successful. At least you can do some of the knee rehab (motion/full movement) without walking, but I think most of back rehab involves movement…

[sdlbredfan]

[QUOTE=AKB;8850687]
I wonder if getting the knee fixed will make the back better. Sometimes people are like horses. When one area, like the knee, is causing problems, it aggravate other areas. I would vote for getting the knee fixed first, and waiting on the back.[/QUOTE]

I agree, for same reason. The back is quite possibly at least in part due to compensating for knee(s) over the years.

[McGurk]

Thanks to everyone for the thoughtful and insightful replies.

Knee it is then!

[Cuttergal]

Do you mean the back is debilitating due to pain or limited mobility? Likely you’ll still have back pain, fusions don’t have the best record for alleviating pain, the laminectomy could bring some relief though.

I think I’d go with the knee first, since you’re fairly familiar with the rehab, in a few months you’ll be stable enough to do the back, and when you’re released to return to normal activities from the back surgery, you won’t be still battling the knee instability.

Good luck, be diligent with your rehab.

[McGurk]

The back is mostly debilitating because of pain. I can’t stand or walk for very long at all without the epidural injections. I tend not to be riding much lately not because riding hurts, but that catching, bringing in, grooming and tacking is more than I can bear.

In regards to farmwork; anything that involves sitting on the tractor is fine - bushhogging, harrowing, using the front end loader. Anything that involves standing - mucking, holding for the farrier, etc., is miserable and an endurance test.

I do think the knee factors into that equation, though - I can’t put all my weight on my right knee or it gives out. So if I want to rest my back I tend to lean forward onto something.

With my previous TKR, I was so diligent with the rehab that I gave myself bursitis in the new knee! I tend to overdo things.

So - I can a lot of the knee rehab without standing/walking for long periods, and I’m pretty sure all the back rehab involves standing or walking. I think that’s the answer.

[Where_sMyWhite]

Please keep us posted.

Backs are the bigger unknown but if your quality of life is kinda sucky now, at some point, maybe worth the risk…

[DoodlesMom]

So I was in a similar situation, but it was my ankle, not my knee. Bad car accident 7 years ago left me with a seriously messed up ankle. My job requires me to sit for 12+ hour shifts, which has caused and exacerbated disk herniations between L4-L5 and L5-S1. The limp when my ankle hurts has done nothing but make the back worse.

I’ve gone through several cycles of ankle surgery and/or PT, then back PT and injection, then back to the ankle. The back ALWAYS feels better when my ankle isn’t causing me to limp. Right now is the first time my back has been bothering me since my ankle has been mostly ok. I had injections last year, before I had ankle surgery in October. In fact, my PT, who I was going to for my back, encouraged me to get my ankle looked at again (she’s been my PT since the accident).

So yeah, I’d say go for the knee. You’ll be SHOCKED at how much better your back feels when your knee isn’t bothering you!

[Cuttergal]

Found this today while browsing Facebook

http://www.regenexx.com/nejm-back-neck-fusion-surgeries-not-needed/

[invinoveritas]

Whatever you choose, I hope it all works out great for you.
Consult all the doctors, then check everything out on the internet, and make a rational decision as to which surgery to have done first.
Good luck!

[McGurk]

Wow, Cuttergal, thanks for that link!

Most of the people I know who have had fusion have ASD 5 - 10 years out, that’s one of the things that scares me about the surgery.

What the spine guy said at my last appointment is that he will not do a traditional laminectomy without fusion because he believe the laminectomy weakens the structural integrity or the vertebra.

And the fusion would also require a graft, I’m assuming from me rather than donor/cadaver bone. I’ve had bone grafts taken from my hips twice for an unrelated injury, and recovery from the graft was as bad or worse that recovery from the surgery/repair that required the graft. Another thing that puts me off this surgery.

So perhaps I should get the knee done, and when I feel I have to do something about the back, find a surgeon who will do traditional laminectomy.

Since you all have been so helpful and wonderful, does anyone have any experience with nerve ablation for low back pain?