ADR-Damaged Facet Syndrome

[sharman]

ADR-Damaged Facet Syndrome (ADFS). If an acronym hasn't been coined yet, this is my suggestion.

Like everyone considering ADR surgery, I'm sobered by the conventional wisdom that ADR is hard on facet joints, and one has only traded the risk of adjacent segment degeneration (ASD) with a fusion, for same level facet degeneration with ADR. To make it worse, facet damage is very painful, and much more difficult to fix than ASD (if the disc at the next level goes, you can always do another ADR or fusion). This has been to me the one most significant respect in which fusion looks better than ADR.

ADFS as a significant ADR risk is seemingly confirmed by studies showing degeneration of operated-level facet joints several years after ADR. This conjures up in my mind an image of a facet-shaped Sword of Damocles hanging over the patient's head: Is it just a matter of time and luck before s/he starts a new era of back pain, after 3 or 5 or 10 or? years of ADR relief?

As I did some reading and thinking this weekend however, a whole new picture of ADFS emerges in my mind. In particular, my ideas were changed by the study presented by Dr Charles Rosen, reporting on 24 ADR patients with ADFS (See thread "Potential Biomechanical Etiology...") (Sorry I'm too stupid to figure out how to copy the URL)

All 24 of the patients in the Rosen study, very much like the ADFS patients on this and similar forums, experienced the onset of their problems fairly quickly after surgery, within the first year. Maybe I'm just missing the data, but is there any significant population of ADFS patients whose symptoms did not manifest until many years after surgery? Can we then conclude that ADFS is a risk factor only for the first year?

Yes, there are studies reporting radiographic signs of facet degeneration in ADR patients. I just read the abstracts on two new ones. One is a 10-patient, all-Charite' sampling. Of those 10, "a startling number" exhibited facet degeneration over pre-surgery levels. But, if I read the abstract correctly, none of these degenerated facets was painful. The other is from a Korean hospital, at the 5-year mark, again apparently showing radiographic, but not symptomatic, facet degeneration.

So these studies, sobering tho they are, do not tell us that a significant number of ADR patients will succumb to facet disease down the road. Indeed, these studies don't even tell us that the patients are experiencing progressive degeneration. All they show us is that operated-level facets show a degree or two of degeneration relative to pre-surgery. For all we know, this may be the result of the surgical trauma, and the damage could be staying level or even improving.

I have read only one study abstract about patients getting revision surgeries many years after ADR (3 to 16 years, with 9 the average, 17 patients in the group). This study reported only on the incidence of wear particles that could be causing inflammation (conclusion: yup, wear particles just like in a hip replacement, certainly something to be concerned about, but a different topic). Since the abstract did not mention any other pathology requiring the revision, presumably this group of post-ADR, new-back-pain patients were suffering painful inflammation from wear particles, not facet degeneration.

[Of course, please note I have not tried to research this at all, just reacting to some studies I read recently. If I'm way off base here, I apologize, and will welcome better information.)

So if I'm reading this information correctly, even if there is a ADFS Sword of Damocles over the ADR patient's head, once you get past the one-year mark, you may be out of the woods.

Now the Rosen study offers even more good stuff.

Rosen claims to see radiographic confirmation of specific pathologies in all 24 patients in his group. All 24 patients showed either compression or distraction of the operated level facets, and in many cases fractures. These pathologies don't sound like slowly-progressing degeneration from hyper-mobile joints, but rather, a dramatic abnormality very quickly resulting in acute symptoms. So first of all, this seems further confirmation of my first theory, that unlike ASD (adjacent segment degeneration) with fusion, ADFS manifests in the first year after surgery, not gradually over several years.

Noteworthy second about the Rosen study is-if he's to be believed--these pathologies are readily visible. Certainly, the pictures included in the study were convincing.

Best of all are Rosen's ideas for revision surgery (posterior, probably minimally invasive? disc left in place). He claims to have acheived excellent results in 5 of the 24 patients whom he revised to fusion. If I had ADFS, I would certainly want to talk to this guy.

These observations suggest to me (i) If you make it past the first year, you're probably in pretty good shape facet-wise. (ii) ADFS should be something you are vigilantly on the lookout for in that first year. (iii) ADFS should not be that difficult to diagnose (both radiographic imaging, if Rosen is correct, and diagnostic injections work well). (iv) If you do get ADFS, maybe you want revise into fusion ASAP. I can't help wondering if a quick response might increase the odds of a successful revision. (v) Maybe the art and science of treating ADFS is finally getting there.

Sure, I'm trying to spin all this into a narrative that will allay my fears about ADR. But tell me your thoughts. Is this not some good news?

[cervie queen]

I do not have ADR, but I do have advanced facet syndrome. Before my 3 level lumbar Dynesys, Dr. Regan called my facets "a 10 out of a 10". The chief of spinal surgery at UCLA says "they were the worst facets" he'd ever seen.

So it stands to reason that sometimes the facets just degenerate even though there is no ADR nor any fusion. Age is probably the most contributing factor.

Now two years post op the three level Dynesys, my lower two facet levels are so bad that they have auto fused.

As far as pain goes, it's not as bad as my leg and other back pain. I certainly wouldn't sign up for surgery to correct any pain that I have.

[Clairem]

Hi Sharman,
Where do I find the study you quote by Dr Rosen? I am currently suffering facet problems, and you post was of great interest to me.
Thanks,
Clare

[spineally challenged]

Hi Clare
I think this is what you're looking for..
http://www.ispub.com/ostia/index.php?xmlFilePath=journa.../vol1n2/failures.xml

This came from the earlier post 'The Potential Biomechanical Etiology for Lumbar Disc Replacement Failures', which has some good discussion.
All the best
Tim

[Linda]

Sharman,
I am over 5 years out with my lumbar disks and have been having severe pain for about a year and a half now. My facet joints were shot before my surgery but I wasn't told that. I did rather well for the first 3 years but now my spine is a mess and I am looking at a life-threatening revision surgery. I have been told there is a good chance I could die from having both of my ProDiscs removed, if even possible, but I have told the doctor that I would rather die than continue to live in bed. I also am about 3 years out from my 2 cervical ProDiscs that seem to be doing fine although I am on a pain patch constantly. I am in the process of weaning off the pain patch to see how bad the pain really is in my spine. It has been bad enough to keep me in bed most of the time even with the pain patch. I am wondering if my cervical disks will cause facet issues as time passes too? I am obviously not as Pro ADR as I once was. My lumbar disks were placed incorrectly which has further complicated my spine issues. You are doing the right thing by thoroughly researching. I wish I had been as thorough and maybe I would have a life today.

Linda

[spacemusic]

How were your facet joint problems diagnosed? Would it show up on an MRI or are other tests required?

[sharman]

Linda, I can't tell you how much I appreciate people like you, posting their difficult experiences. It is so helpful to people in my situation, and I so hope you find the help you need soon.

There are so many ADR revision questions I want to ask. You mentioning that revision surgery is "life-threatening" reminds me of one in particular.

Presumably, you've been warned that your ADR revision is life-threatening, because of the anterior approach to an area where the great vessels are scarred down. Just this year I've seen reports of new technologies for posterior ADR surgery. Wouldn't you think, if you can implant an ADR with a posterior approach, you could even more easily remove one posteriorly?

[Linda]

Sharman,
I don't know, but it is definitely a question worth asking my doctor. I hope to hear something from him tomorrow as to what the plan is. Thanks!

Linda

[annapurna]

Hello everyone,

This is Laura. My husband Jim and I both post as Annapurna. The past few months Jim has been doing all the posting since I've been lazy and self-absorbed with my health issues. Time to get with the program and become a better forum-member.

I've read some very informative articles about the effect of fusion and disc degeneration on facet kinematics and loading. These articles were written by engineers at Archus Orthopedics and are available on the Archus website as well as several refereed journals. Archus is in the business of designing facet replacements for both stand-alone facet arthritis and for use with ADR's. As such, I believe that they have quite a vested interest in understanding facet loading in a variety of spinal conditions.

From what I could gather, ANY change in the disc condition will change both kinematics and loading of the facets at and adjacent to the affected disc level. This includes both adjacent-level fusion AND same-level disc degeneration. Speaking with one of the Archus engineers, the work they have done developing an ADR-compatible facet replacement has shown that ALL the total disc replacements alter facet loading to some extent.

So, as patients I suppose we have no perfect options as far as facet joints are concerned. We can do nothing and they will degenerate - like Cervie Queen described. We can get a fusion and increase the risk that the adjacent set will degenerate. We can get an ADR and have the same risk.

As far as pain is concerned, fusion has a definite advantage in that it doesn't force or even permit damaged facets at the affected level to move the way ADR does.

Of course, not everyone who gets an ADR ends up with facet damage at the operated level. This would lead one to believe that the ADR ALONE doesn't change the biomechanics enought to guarrantee rapid facet degeneration. Perhaps other factors such as disc placement, ligament laxity, and pre-ADR facet condition all play an important role in whether we end up needing a revision a few years later or not.

Personally, I'm almost five years post-op from an L5/S1 Charite and have developed facet arthritis at both L5/S1 and L4/l5. I now have lumbar muscle spasms on my right side that cause nearly as much pain as my replaced, degenerated disc. Diagnostic injections have shown the spasm pain to be related to the L4/L5 facets, but not a very clear indiction. Has the non-physiologic motion of my ADR combined with progressive facet damage resulted in some sort of instability for which my muscles are attempting to compensate? I have no idea, but, I'm certainly a LOT more interested in dynamic stabilization and facet replacement than I was a year ago.

Best to all,
Laura

[Fortitudine]

This is a tough question. Particularly as there is such a difference in loading between c-spine and lumbar - can we even compare facet issues? If there is indeed an issue with lumbar ADR and future facet problems, can it be in any way correlated to future issues in the neck? Does age matter? i.e if we get our ADR long before the facets are programmed to deteriorate, perhaps they can adjust.

As for Dr. Rosen, I believe he is not a proponent of ADR so I would take his findings with a grain of salt and check his variables carefully, and keep on looking for more studies that have been puiblished in reliable journals.