had a lumbar fusion? under 40? read me!

[laid up doc]

see my signature... the rest is that i'm 33, a physician, used to be very active until.... ya'll know how this goes. i have done absolutely everything i have been advised to do...

have failed multiple injections, seen 3 different spine pt's who did manip/dry needling/soft tissue work. took baclofen then zanaflex, was on lyrica but stopped it when it didn't help. hate narcs and they don't help. even had a biacuplasty last yr and i was doing really well til the darn mva.

pain doc is out of recommendations - tear i have now is not known to be amenable to biacuplasty, and it didn't take much to "undo" the other, ie cause another annular tear.

the rest of my lumbar spine is completely unremarkable. NO oa, completely concordant discogram (x2 now) w/ a negative control. stupid horse!!!

i have a hx of rashes from all kinds of metals (watches, jewelry) and am a woman of childbearing age (am told this can be a contra-ind to ADR) -- and have been advised that ADR is not a good choice for me. so, i'm left deciding whether to have a L5/S1 ALIF.

i'm hoping that someone who stumbles through here has been through a similar situation - well not REALLY, b/c this majorly sucks, but would love any input.

[MeggieLynn]

Hello,

Have you had testing for the metal allergies? You might already be aware of this but there's a foundation called the MELISA MEDICA Foundation that does a lot of research on metal allergies and does a lot of the testing for dentists and orthopedic surgeons. If you GOOGLE MELISA MEDICA it should pop right up. You might want to do this testing even if you decide to go with a fusion - ? w/regards to metal content of the screws.

Take care,

MeggieLynn

[laid up doc]

thanks for the info - my understanding though is that the fusion pieces are titanium, and adr's are an alloy including chromium and cobalt.

also the first surgeon i saw said that there are significant metal-on-metal problems for women of child bearing age - we have crazy immune systems and he cited some work out of TX (i will post the abstract when i find it) with problems with young women.

knowing that trying to take out a lumbar ADR is a total disaster - that scares me to death! i still have 3 more docs to see (1 here in DC, 2 in Charlotte), will pick their brains as well.

[laid up doc]

here is the abstract:

Spine (Phila Pa 1976). 2011 Apr 1;36(7):E492-7.
Early failure of metal-on-metal artificial disc prostheses associated with lymphocytic reaction: diagnosis and treatment experience in four cases.
Guyer RD, Shellock J, MacLennan B, Hanscom D, Knight RQ, McCombe P, Jacobs JJ, Urban RM, Bradford D, Ohnmeiss DD.
Source
Texas Back Institute, Plano, TX, USA. rguyer@texasback.com
Abstract
STUDY DESIGN:
Report of four collected cases.

OBJECTIVE:
The purpose of this report is to describe the presentation, diagnostic workup, treatment, and pathologic findings in four cases of lymphocytic reaction in patients receiving a metal-on-metal total disc replacement (TDR).

SUMMARY OF BACKGROUND DATA:
Metal-on-metal designs in hip arthroplasty have gained popularity because of decreased volumetric wear rates and theoretically increased implant longevity. Systemic metal ions produced have not been associated with adverse clinical sequelae, although there have been reports of local soft-tissue reactions leading to early prosthetic failure. Histologic evaluation in these cases suggested a cell-mediated delayed-type hypersensitivity reaction. Metal-on-metal bearings have also emerged in lumbar and cervical TDR.

METHODS:
This report is on four patients, from three centers, who underwent TDR, using a metal-on-metal implant, and later presented with symptoms that were determined to be due to lymphocytic reaction. Details of their symptoms, diagnostic work-up, treatment, and outcomes were compiled.

RESULTS:
All four patients initially had a good surgical outcome, followed by the onset and worsening of axial pain, and/or radicular symptoms months later. All patients had imaging findings of a mass lesion with neurologic impingement. All three of the lumbar patients underwent a decompressive posterior procedure before the eventual device removal and fusion. Intraoperatively, in all the lumbar cases, a thick, yellowish, avascular soft-tissue mass was found to be responsible for an epidural-mass effect on the thecal sac. In the cervical case, there was a gray-tinged soft-tissue response around the implant, suggestive of metallosis. Independent laboratory analysis confirmed a lymphocytic reaction to the implant. Three of the patients had a good outcome after the explant and revision surgery. The remaining patient continued to have residual symptoms related to the neural compression caused by the mass.

CONCLUSIONS:
In this group of patients from three centers, a metal-on-metal TDR resulted in a lymphocytic reaction causing subsequent failure of the surgery. This phenomenon has previously been recognized with metal bearings in hip arthroplasty. Surgeons using metal-on-metal TDRs should be aware of this possible occurrence.

[laid up doc]

and another about metals leaching from hips to babies:

March 09, 2010
Elevated Levels of Cobalt and Chromium Found in Offspring of Moms with Metal-on-Metal Hip Implants

Women with metal-on-metal hip implants, where both the ball of the joint and the surface of the socket are made of metal, pass metal ions to their offspring during pregnancy, according to a study by researchers at Rush University Medical Center. The ions are the result of wear and corrosion as the metal parts rub against one another.

The data showed a correlation between levels of cobalt and chromium – components of metal implants – in mothers and their babies at the time of delivery.

The study will be presented March 9 at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans.

“We don't know whether metal ions pose any health risks for pregnant women and their babies," said Dr. Joshua Jacobs, professor and chairman of orthopedic surgery at Rush, "but as metal-on-metal implants increase in popularity and use, especially among young, active patients, women of child-bearing age and their doctors need to be aware of these findings when considering options for hip replacements.”

Jacobs and his colleagues evaluated three women who had metal-on-metal hip implants and gave birth two to six years after their surgeries.

Maternal and umbilical cord blood was obtained at the time of delivery and tested for blood serum concentrations of titanium, nickel, cobalt and chromium using inductively coupled plasma mass spectrometry, a highly sensitive technique that can detect trace amounts of metals in biological samples.

The researchers found that mothers with metal-on-metal implants and their offspring had significantly higher levels of chromium and cobalt compared with a control group of seven women and their offspring who were also tested at the time of delivery. Moreover, the levels of these metals in the blood of mothers with implants correlated with the levels found in the umbilical cords. Cobalt levels in newborns were about half that in the mothers' blood, while chromium levels were about 15 percent of the mothers' chromium levels. In the control group, no correlation existed.

The lower levels in the umbilical cords indicated that the placenta provided at least some barrier to the transfer of metal ions from mother to fetus, but not a complete barrier, Jacobs said.

Levels of titanium or nickel showed no significant difference between the two groups.

It is unknown whether metal ions in the bloodstream – for pregnant mothers, developing fetuses or newborns – pose any significant health risk. According to Jacobs, medical device companies are working to improve the wear and corrosion properties of metal implants to reduce the release of metal ions.

“Any advancements in this area will directly benefit patients,” Jacobs said. Rush University Medical Center has an active research program testing different materials for components in joint replacement devices.

[MeggieLynn]

Hi again,

I don't wish to add any further stress to your decision-making process but it appears I might be. I only want to mention it because from your initial post it seemed that you really were quite sensitive to various metals.

On the MELISA website they state, "Titanium allergy is barely recognized in mainstream medicine - yet laboratories using the MELISA technology have reported that about 4% of all patients tested to titanium will be allergic to it (Valentine - Thon E., et al) They also state that some of the titanium alloys can also contain traces of nickel and that even some surgical stainless steel compounds can contain up to 40% nickel.

The titanium may not be an issue as it is in many items that we use everyday like candy, paint, & toothpaste, but I might be concerned about if there are any alloys in it. Just something else to consider.

ML

[laid up doc]

no extra stress, but i probably will ask for some testing. wasn't aware there was such a thing.

it's a blessing and a curse to be a doctor - you want to know everything and can understand the literature, but sometimes it's information overload! it is most definitely helpful in getting in to appointments, and being in close touch w/ the office, etc. that and i'm sort of a generalist (ER doc), so i keep abrest off all kinds of medical advancements - i see the emergent complications and whatnot in the ED.

[Hooch]

I have an l5s1 fusion, using a stalif cage and bmp. The cage is PEEK, I'd imagine the screws are titanium. It was pretty well fused up in the cage and around the back as well at 6-7 months.

I just came back from a run, went canoe outrigging yesterday. I still have pain, but its not anything like that discogenic smash you sideways pain. I'm still working on muscle control (getting deep stabilisers working without having the lumbar extensors kicking in and take over.. then pain and spasms start..), but you can see by my level of activity, well thats a very high level of activity. No meds.

It's a bitch of a recovery and you've got to relearn all your motor patterns and get all that sweet, but they can work and work very well. At 4 months I was in trouble and being kept up at night but I could feel stability I had in there that I didn't before (could sit without a back support without feeling like caving in two, ran a few steps and didnt feel like my back exploded) and started working with that and fixing the mess and it all started to improve. but being a pro in the field you know that sometimes they dont work so well... but you're disabled by pain now and you know it, it's degenerative... so what do we do...

[annapurna]

If it makes a difference, some ADRs are the cobalt alloy some are titanium. It's almost shaping up to be all the new devices are titanium and all the old ones are the cobalt alloy.

Of the two, I'd be much more worried about titanium than cobalt alloys. Titanium is far more active, in the sense of corrodable or participating in reactions. It has a stable oxide that protects it but once that's scratched, it tends to react readily. Cobalt or chrome cobalt is less active but also has the problem of being an active metal protected by a oxide film. Break the oxide film by scratches or wear particles, and you have an active metal inside your body. It's also quite a bit different from ingesting those metals. Ingesting them passes the metal through a severely acid environment in your stomach, which will tend to repair that oxide film and encourage what your body can't deal with to pass through your body and into the toilet.

[laid up doc]

will see what the NC docs say next week. i'm not looking for any particular answer, just the best answer. and, it is L5/S1 so i'm not as horrified of an ALIF as i would be were it higher up. still, fairly horrified in general!... but also horrified of continuing my life as it is.