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Spinal Roundtable Discuss Choosing Fusion or ADR in the General Discussion forums; I am considering whether to do ADR or fusion at L5/S1. I probably wouldn't consider fusion at all, but for ...

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  #1  
Old 10-27-2007, 11:05 AM
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I am considering whether to do ADR or fusion at L5/S1. I probably wouldn't consider fusion at all, but for this being a single level, and the level where (I believe I've heard) preserving motion is least critical. Some of the new minimally invasive fusions look to me a lot less traumatic than ADR, tho surgical trauma is only one of many factors to consider.

There are a million points on which to compare the two procedures. I am mostly laying out the questions here, and will really appreciate hearing any thoughts or information you have.

Both procedures should be equally effective at eliminating a discogenic pain generator, as in both the symptomatic disc is completely removed. (Or does ADR leave a piece of the annulus in place?--that always bothered me.) So the questions are,

(A) What are the risks of each procedure/device.

I see five main categories here, the first three being the most common: Damage to (1) adjacent discs (advantage ADR over fusion, which puts increased stress on adjacent segments); (2) facets (a risk for ADR, less so for fusion?); and (3) nerve roots (from the surgery=equal risk in either ADR or fusion? Perhaps the new fusion technique, approach through the sacrum, offers the least neurological trauma. trans1.com.) The choice among these first three risk factors might be dictated by what each patient considers most vulnerable in his/her own body.

Also to be considered is how fixable each of these three problems is. (1) No one wants more discs to fail after major surgery to correct the first failure. But at least we know discs can be fixed (fused or replaced). (2) Pain from damaged facets appears much more difficult to relieve. Nerve ablation is painful, hit-or-miss and must be repeated when nerves grow back. There appears to be one interesting treatment, cryotherapy, but I know little about it. (3) Nerve damage is also difficult to fix, though frequently resolves in time. The treatment, drugs, is not a pleasant one.

(4) The fourth category is damage to structures other than the three listed above. In fusion, there is a risk of hardware loosening or otherwise causing damage, any one know of any others? In ADR, there is the risk of subsidence, poor placement, etc. Osteoporosis is a risk for ADR, is it also for fusion?

Is the trauma done to surrounding tissues and bone worse in ADR (cleats or keel, major abdominal surgery) or fusion (pedicle screws, removal of bone both in the spine and elsewhere). One of the biggest disadvantages of fusion in my mind is the need to harvest bone, with the resultant complication of donor site pain. I do not know what strides may have been taken toward eliminating or diminishing that risk.

With fusion, if the segment does not fuse, where does that leave the patient, and what are the options?

The big question in my mind is an issue I'll call fit, for lack of a better term. Patients come in all sizes, ADRs only come in a few sizes. Do some ADRs turn out badly because the device did not fit well? Is fusion inherently more likely to fit each patient's anatomy? Or do the cages/whatever inserted into the disc space, or the screws, used for fusion also create issues of fit.

Should a patient's body type influence the choice? I have a gut feeling that tall, long-waisted people do better with the ADRs, perhaps as a direct result of the difficulty of fitting or implanting the device in us short, dumpy guys.

(5) The fifth category is long-term and unknown risks. In ADR, there is the risk of the device failing (like artificial hip joints), and the unknown effects of particulate wear. Fusion has a lot of problems, but it's a known commodity.

(B) What are the implications for future surgeries, or revision?

Advantage to fusion here? You burn bridges having that major abdominal surgery for ADR, scarring down the blood vessels so that the approach cannot be used again. Now one thing I do not know, does that mean only that it is now more difficult (or impossible) to access the same level from the abdomen, or would it affect access to adjacent levels too? A not remote issue, as one can foresee needing surgery on L4/L5 some years after an ADR at L5/S1.

(C) What are the relative discomforts of the surgery and recovery?

It should not be a deciding factor, but it's not meaningless, which procedure is more difficult to go through and recover from.

Some of the minimally invasive fusion techniques appear to be easier to go through than ADR. Certainly, it would be nice to avoid abdominal surgery. The incisions are smaller. The new trans-sacral fusion claims to have patients out of the hospital in one day, and back to work in 15.

On the other hand, your new ADR is ready to rock and roll from day one, while a fusion must fuse, over several months' time. At the least, that probably means one's activities are more restricted, and corsets must be worn longer and more faithfully.

One issue on the comfort list is advantage to fusion: The possibility of finding the surgery you want in the US. For ADR, there remain many things not available in the US, like the newer discs and vertebroplasty compounds.

Any thoughts most appreciated!
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Old 10-28-2007, 07:38 AM
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Sharman, your thoughts are well organized and clear. I was in a similar mindset three years ago, so I created a document that may help. It's crusty, and worthy of updating, but here it is. I may update this and repost it.
_________________________________

Pros of (endoscopic) ALIF fusion:

 Endoscopic is less invasive, promotes faster recovery (for the incision) but not necessarily lifestyle.
 BMP compounds enable very effective, very high rates of fusion (seem to be 95% or even better for most clinics. But don’t confuse fusion effectiveness with operative success; many patients see 100% fusion but still have problems.)
 Lumbar fusions are proven with good outcomes supported by hard data. Fusion procedures have been performed for more than 50 years; BMP compounds are new but quite effective.

Cons of (endoscopic) ALIF fusion:

 Loss of mobility in fused area after complete fusion takes place (the intended goal!). Short or long term, this can contribute to premature degeneration in adjacent discs and connective tissues, sometimes called Transition Syndrome. Stats vary on the number of patients that require subsequent fusion due to adjacent level degeneration, ranging from 30 to 60% of all patients within five years.
 Procedure with “scopes” is complex, with a comparatively longer operation time (app. 4 hours). Longer operation time may mean higher risk for some people.
 Higher probability of nerve or vessel damage than with open or mini-open techniques. Supporting data for this quite varied.
 Wearing a brace for 3 months (2-4 depending on patient and doctor).
 Limited routine and mobility because of “fusion setting period.” Fusion takes an average 15 months to complete; 3-24 months is the range.
 Medical community’s opinion is decidedly mixed on long-term efficacy. Many doctors seem to be skeptical of endoscopic ALIFs and long-term effects of fusions.
 Some surgical teams do not have a vascular surgeon involved in the procedure, possibly posing a risk in the case of vascular problems.

Pros of Charite’ ADR: (specifically compared to endoscopic ALIF):

 Shorter operation time, app. 1.5 hours.
 Anterior approach makes healing comparatively more “comfortable” than a posterior approach; no muscles are torn either.
 No “walking on eggshells,” and one can resume most normal activities almost immediately.
 Natural range of motion is retained in all critical axis (possible exception of downward potion, as the core is high grade plastic).
 Unconstrained design is more “forgiving” than “semi-constrained” design (as found in ProDisc and others) in terms of providing more device placement margin or error (this point is argued among docs and patients).
 Lots of patient outcome data is available: clinical trials in the U.S.; long-term data from Europe indicate very positive outcomes. Over 7000 procedures have been performed to date.
 Disc core is accessible for replacement or revision (unconstrained design makes it easier to access).
 November 2006 study indicates FAR superior outcomes compared to fusion; especially in terms of adjacent level degeneration.

Cons of Charite’ ADR: (specifically compared to endoscopic ALIF):

 Approved by the FDA, but not by many insurance companies.
 Possible complications post-op; although 48/50 patients from New England Baptist are doing extremely well and had no complications. European results from some studies mirror these outcomes.
 An open anterior procedure and is more invasive than an endoscopic procedure. A longer recovery time for the incision than ALIF.
 ADR is still relatively new in the U.S., and there is still a “learning curve” for doctors, physical therapists, etc. to provide the best possible treatment to patients.
 Clinical data is still being dissected, analyzed and criticized.

Many different sources were used to compile this information.
_______________________________________

BTW: I had a one-level procedure and have done very well. At the time of operation in June 2004, As my S1 vertebral body was "messy," so the doc did a great deal of cleaning -- and removed all of the anulus. I've never had ANY back pain since before surgery in 2004.

My observation is that patients who only have one-level DDD (or dysfunction) are the ones that do best long term; e.g., less or no post-op pain, quicker back to work times, etc.

Hope this helps...
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
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  #3  
Old 10-28-2007, 10:45 AM
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Thanks for your clarity of thought on this issue Sharman.....I wonder too whether bone density is of equal importance with fusion as it is with ADR. Also, I understand that bone is not always harvested from the recipient....ie there are other techniques which make this now unnecessary. You don't mention what the many different types of fusion are......why would one be used as opposed to another ? is that just surgeons preference or do some back issues require certain types of fusion. Do they all require pedicle screws and such hardware ?
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Old 10-29-2007, 06:10 PM
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Harrison, you sweetheart. Thank you so much for that amazing bit of scholarship. I must say, I felt a little guilty throwing all those questions out there, instead of doing my own homework. Much, much appreciated.

William, I'm only just starting to learn about the different fusions, with my eyeballs rolling well and truly back in their sockets. I keep trying to tell myself, "'Sall good. I bet they're just getting better and better."

Fusion can be done from the front or the back, and with some very small incisions. I'm still sorting through the maze. Fortunately, it does indeed appear that you can graft from cadavers and magic sauce, so I can scratch donor site pain off the list of things to fret about.

Right now, I'm most focused on the risks of adjacent level degeneration and nerve damage. Certainly, fusion has the rap for adjacent segment syndrome. The statistics are grim, but I would like to see the stats for single level L5/S1. Sure enough, without much google effort, I found a pro-fusion guy confidently asserting that, at L5/S1, "there is minimal motion, so fusing does not significantly change the biomechanics of the segment."

Nerve damage I have a lot of questions about. Both procedures involve distracting the disc space, during the surgery. And--this I've never understood--both also proudly claim to permanently "jack up" the disc, "restore disc height." Now, from the pictures it appears to me that both fusion cages and ADRs stretch the space, not just more than pre-surgery, but more than normal. This is a good thing? Why do I want to grow an inch after surgery? That just seems awfully brutal on the nerve roots. I could understand if a patient has radicular pain due to a disc space so flat, there was impingement on the nerve roots. But that's not my case. I don't have any leg pain. I really hate the thought of ending up with leg pain.

So which is worse for nerve damage, fusion or ADR? It seems to me I never heard of "distraction pain" before ADR. But nerve damage is considered a not uncommon complication of fusion. And there are so many variations on the fusion theme, who knows what outcomes correlate to what flavor? Perhaps some of the new procedures succeed in minimizing the trauma.

Finally, this is a weird factor to ponder. I've somewhat suspected that fusion is for patients with great loss of disc height, and ADR for patients who still have good height. And that's not just because the other option is ruled out, but because those respective symptoms work best with the two respective procedures. Now, in the same article from the pro-fusion guy I quoted above, very strong confirmation: "The two findings on the MRI that correlate best with a successful postoperative outcome is the presence of disc space collapse and cartiliginous endplate erosion. Findings such as disc bulge, disc dessication or an annular tear do not correlate well with a successful outcome." Isn't that weird?
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Old 10-30-2007, 07:38 AM
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Hi Sharman. I am glad you put this post up because I am going through the same decision as you. I just recently visited a spine specialist in NYC and he recommended a fusion. The type of fusion recommended was open ended and he stated that it is better than the endoscopic one. I read that their is still not enough empirical evidence to say which method of fusion is best for patients. Personally, I would prefer the endoscopic fusion because of the quicker recovery and the doctor would have to make fewer incisions into my body. I also asked the doctor about the long term prognosis. He stated it is possible that you could have 10 good years from the date of the fusion and then the adjacent segments could be effected. However, at the l5-s1 it is less minimal where I also have my problem.

The doctor is still skeptical about ADR since it has not been around as long as fusion. I personally would rather have the ADR surgery done because certain disks like the charite can be replaced or revised. However, after a fusion, that's it.
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1999- Diagnosed with a bulging disc after a work related accident at l5-s1.
1999-2003- Epidural/Facet/Nerve Root Blocks, pt, acupuncutre, chiropractic
2003-Lumbar Disectomy at l5-s1
2003-2009 Epidural/Nerve Root Blocks, pt, chiropractic
2009- Diagnosed with Degenerative Disease at l5-s1
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Old 11-01-2007, 01:35 PM
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This is my first time, I also am not sure weather to have surgery or not. my mri shows mult-level broad based disc disease of the c-spine, most notiable at c5-6 with left paracentral and foraminal disc osteophyte complex with focal disc protrusion resulting in sever left neural foraminal stenosis, moderate right neural foraminal stenosis, and moderate central canal stenosis.....tried the shots...had muscle spasms for 3 day...they said no more shots....tried physical therapy(heat,traction and easy exercise) was in the bed for 2 days sever pain, second therapy today...(heat,eletrodes stimulation, and message) hurting pretty bad right now....What should I do?
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Old 11-01-2007, 02:40 PM
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Sheri:

Don't know how many levels are involved but the neck is more tolerant of ADR surgery than lumbar. I believe this is due to the weight of your head being less than the lumbar area supporting your body's weight.

I had two-level ADR cervical and two-level ADR lumbar surgeries last November 4th, three days shy of one year. The neck is doing incredible and has a range of motion that I did not have for years.

I encourage you to read through here and make your decision accordingly. Many have been there before and there is a wealth of knowledge here.

Good-luck.

Terry Newton
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1980 ruptured L4-L5
1988 ruptured SI-L5
1990 ruptured C5-C6
1994 ruptured C6-C7
1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic
Bicycle Accident 2004
MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram.
Stenum Hospital Surgery November 4, 2006
Prestige Disc C5-C6, C6-C7
Maverick Disc S1-L5, L4-L5
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Old 11-01-2007, 05:18 PM
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We'd be irresponsible and domineering to tell anyone to have or not have surgery, but questions to ask yourself are things like: how old am I? If I'm looking at ADR to avoid adjacent level problems, am I young enough for that to be a problem? How active am I? How active do I wish to be?

Foraminal stenosis suggests pretty serious facet joint involvement; is ADR even possible for the severity you're suggesting? You may get further into this and discover that your choice is fusion with some work to remove the osteophytes or nothing.
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Laura - L5S1 Charitee
C5/6 and 6/7 Prodisc C
Facet problems L4-S1
Knee, Shoulder, Toe, Finger, Elbow Problems

Jim - no spine problem but lots of other fun medical challenges

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Old 11-02-2007, 09:45 PM
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I see that few people are suggesting that it is easy to remove or revise Charite. Who told you that?!?!
H: "Disc core is accessible for replacement or revision". Really?! Maybe, if you are L5/S1 level. What if you are L4/5?
For the first, you'll have tons of scar tissue surrounding everything around and it is sometimes impossible to see what is what. Even the most experienced vascular surgeons fear the second access and avoid it at all costs. Secondly, my vascular surgeon (and he is the top in ADR revisions) told us that in many cases it is even unthinkable as veins and lymphatics are "glued' to the spine and you dont even need to cut it-it is enough just slightly move it and they can disrupt. He said "One CAN NOT force it. If it is scarred-it is scarred."
Ask Blair who had Charite revision how "easy" it is revised and how "fun" the recovery is.
If one cant take it out frome the front, then the lateral access a must. And here, I will tell you guys, how accessible it is. It is basically guaranteed after the lateral explanation to have your leg function 90% gone. No feeling in the hip, groin, adjoint part of the low abdomen with the groin, upper leg, low leg. When some feeling start to return, it is unbearable pain that you want to crawl walls. Why? Because during the lateral explantation, they psoas muscle must be split and there is a geneto-femoral nerve is going through this muscle. If your surgeon knows all well about it-the function of your leg will return and numbness will go away. If he is not an expert-well, you are basically, screwed.
I see people are speculating about the adjacent level disease in fusions. Where did you get these facts? What about facet degeneration in ADRs? Sure, ADR just started to roll (big bucks here) but as time goes by, more and more people are having peoblems with facets. Many of them, will be "complaining" about returning pain and NO ONE will want to tell them why they have pain. It is much easier to sign you into the "chronic back pain syndrom" patient. Nice cop out. Why do people have pain (mostly)? Because they have a problem. Pain doesnt just come for no reason.

Here is an article from a surgeon who has done many revisions of Charite's.
http://www.geocities.com/javanoginn/sitebuilder/preview...Disc_Replacement.pdf

Zeegers at al25 reported on the first 50 of 350 patients,with follow-up evaluation of all patients after 2 years. In
70%, a satisfactory clinical result was achieved. Four patients were lost to follow-up, and it is not clear from the
text if these patients were regarded as failures. Permanent sequelae and complications were seen in 13%, and 12 patients (24%) needed a reoperation, which benefited only 3 of them. One patient had to undergo three reoperations because of a lesion of the aorta. The end result of this patient is not mentioned. There was an asymmetric position of the prosthesis in 18%.

Regarding European studies: "In both these series, a nonbiased observer was not involved in the investigation."

"In this relatively small group of patients operated on with a Charite´ disc prosthesis, most problems arose from degeneration of other lumbar discs, facet joint arthrosis at the same or other levels, and subsidence of the
prosthesis."
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  #10  
Old 11-03-2007, 11:11 AM
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Job13, quick question since someone else asked: are you Matt or Anastasia?

In general, it's easier for all involved to have their own, unique log-ins.

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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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