<table><tr><th>From:</th><th>Richard Merkin</th></tr><tr><td>Sent:</td><td>Thursday, October 16, 2014 2:37 PM</td></tr><tr><td>To:</td><td>jeffrey E.</td></tr><tr><td>Subject:</td><td>RE: Re:</td></tr></table>

There may be many approaches to the surgical solution. Is this solution one neurosurgeons plan? I would ask at least two others from reputable institutions[preferably where the neurosurgeon will not be economically incentivized to operate-- I will explain]. If you have a fusion, it puts more stress on the vertebra above and below the fusion. A question to be asked is with screws etc. binding the vertebra together what are some of the sequela of this procedure. The purpose is to stabilize. Does it put more pressure on other areas as flexibility decreases. Commonly, they may say at the lower lumbar areas the flexibility is less important than at higher levels. This may be individual. A second opinionlor third] might be indicated. Is this an orthopedic spine surgeon or a neurosurgical spine surgeon? Ortho in surgery is more interested in the stability of the bone, the neurosurgeon generally tries to be more gentle with nerves.

From: jeffrey E. [mailto:jeevacation@gmail.com]
Sent: Thursday, October 16, 2014 7:10 AM
To: Richard Merkin
Subject: Re:

the claudication when walking after 5 blocks starts. and I have to bend over to relieve. when i sit im perfect but... im concerced that if i wait to long . if the nerves get shot , too late. . they said that that 14 is a bit too forward and to screw it to 15 . neuroligist tests all negative. but when they looked at the stenosis, they said only a matter of time, and no medicince to delay?

On Thu, Oct 16, 2014 at 10:06 AM, Richard Merkin wrote:

Hi,

Sorry for the delay. I spoke to both UCLA and Keck school of medicine. Both, of course would love to see you, but I am sure that is not necessary[l could set up neurosurgical consults in Boston or Johns Hopkins just as well]. There is no extrusion and with bulging discs there certainly is the opportunity with therapy to control the symptoms. For disc issues with, if you can manage the pain, the results six months later do not show any advantage of surgery. For the stenosis that is a different issue. Unfortunately many surgeons[most] operate by the MRI and not by the signs and symptoms of the patient. Have you seen a neurologist? Have you gotten an EMG and a nerve conduction study? These tests will help decide if you would or should have surgery today or can delay as long as possible[maybe forever]. If you do decide to go to the next step and want me to, I will come and accompany you to your physician. Hope you're feeling better!

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