ADR Doc in San Francisco??

[KBear]

Thanks for the info Deborah. I would prefer to get the Pro-disc, which is what two surgeons have reccommended. I just don't know how to get it paid for. I have searched this forum, looking for anyone who has had Unicare pay for ADR, and found none. I also posted on the Insurance Hell section, asking if anyone had Unicare pay, and as of today had no response. I am trying to figure out how to do an appeal, and am in the process of rounding up my medical record. I did not find a lot of information on the Pro-disc site regarding appeal (it did have a fill in the blank appeal letter). I did see where it listed things to send, half of the stuff, I had no idea what it was. I also do not know where to find study results to include, so I am trying to figure that out as well. All this, while appealing a Social Security denial, being in a lawsuit with the a-hole who caused this and trying to raise a 2 & 5 year old! Anyhow, thanks for all the information, I will check more into it for sure.

[Slackwater]

Originally Posted by Deborah

If you don't mind me asking, how did things go with Hu? Have you been seen, had surgery, etc? Hub's is levels L45 and L5S1.

We got the test results and doctor notes emailed off to UCSF today... supposed to be in Dr. Hu's hands asap, so we wait to hear her recommendation and what they'll do at UCSF. I've heard they've done a fair amount of ACR but remain very conservative with it only doing ADR when all aspects of the reports show excellent candidate. I kind of like that.
D

Dr. Hu met my expectations; she answered my primary question. She said I am 50-50 Fusion or ADR. She answered my other questions with candor: BMP's, nucleus replacement, stem cells, blah blah blah. My appointment was late August 2007, so yes I was seen. It took three (3) or four (4) weeks for an appointment. Dr. Hu noted that I had no record of epidural injections; she prescribed that. I went to Dr. Derby for the Epidural (SNRB) as he did the provocative discogram.

I made a separate visit to get a surgery cost estimate. Dr. Hu's Physician's Assistant (PA) synchronized me to get a cost estimate for two-level ADR, L4/5 & L5-S1, with tests, estimated hospital stay, ... Julius Manuel was the gentleman who was Dr. Hu's PA(?).

Later, 2Q 2008, the UCSF medical school ortho Basic Science curricula linked to the following article:

Pubmed LINK
J Bone Joint Surg Am. 2000 Nov;82-A(11):1589-93

The Effect of Nerve-Root Injections on the Need for Operative Treatment of Lumbar Radicular Pain
A PROSPECTIVE, RANDOMIZED, CONTROLLED, DOUBLE-BLIND STUDY*
BY K. DANIEL RIEW, M.D.†, YUMING YIN, M.D.†, LOUIS GILULA, M.D.†, KEITH H. BRIDWELL, M.D.†, LAWRENCE G. LENKE, M.D.†, CARL LAURYSSEN, M.D.†, AND KARI GOETTE, B.S.N.†

Some text of the JBJS hard-copy follows,

"Discussion:
...
We were surprised that so many of our patients who received bupivacaine with steroids avoided an operation. Normally, all of these patients would have been treated operatively. Unfortunately, our data do not give us a good explanation as to why. We propose several possible theories.

First, it may be that any new treatment modality that is added to the existing treatment regimen may help to decrease the need for operative intervention; a similar study comparing the results of any new interventional treatment may have yielded similar results.

Second, most patients who have sciatica do not have steady, intractable pain but, rather, intermittent, varying degrees of pain. Patients may have intolerable pain for just a few hours during the day or perhaps for just a few days during the week. We found that the patients who proceeded to have an operation had higher baseline scores for back pain and neck pain than did those who avoided an operation, regardless of the treatment group. Treatment with bupivacaine with or without corticosteroids certainly can diminish the pain in the short term. As long as the patient feels that there are alternatives to an operation that can diminish the pain, no matter how transiently, they may feel that they have enough control over the pain to avoid the more aggressive route. This theory is supported by the fact that there was a highly significant improvement in the scores forthe questions on “expectations of improvement” by the time of the final follow-up.

Third, even asymptomatic individuals can have radiographic evidence of stenosis 2,15, and patients who are symptomatic may improve either spontaneously or with anti-inflammatory medications and physical therapy. As stated previously, these are mere conjectures; we do not really know why so many patients were able to avoid an operation."
....


References
1. Berman, A. T.; Garbarino, J. L., Jr.; Fisher, S. M.; and Bosacco, S. J.: The effects of epidural injection of local anesthetics and corticosteroids on patients with lumbosciatic pain. Clin. Orthop., 188: 144-151, 1984.

2. Boden, S. D.; Davis, D. O.; Dina, T. S.; Patronas, N. J.; and Wiesel, S. W.: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J. Bone and Joint Surg., 72-A: 403-408, March 1990.

3. Bogduk, N.: Epidural steroids. Spine, 20: 845-848, 1995.

4. Bush, K., and Hillier, S.: A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine, 16: 572-575, 1991.

5. Cuckler, J. M.; Bernini, P. A.; Wiesel, S. W.; Booth, R. E., Jr.; Rothman, R. H.; and Pickens, G. T.: The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. J. Bone and Joint Surg., 67-A: 63-66, Jan. 1985.

6. Daltroy, L. H.; Cats-Baril, W. L.; Katz, J. N.; Fossel, A. H.; and Liang, M. H.: The North American Spine Society lumbar spine outcome assessment instrument: reliability and validity tests. Spine, 21: 741-749, 1996.

7. Derby, R.; Kine, G.; Saal, J. A.; Reynolds, J.; Goldthwaite, N.; White, A. H.; Hsu, K.; and Zucherman, J.: Response to steroid and duration of radicular pain as predictors of surgical outcome. Spine, 17 (Supplement 6): S176-S183, 1992.

8. Koes, B. W.; Scholten, R. J.; Mens, J. M.; and Bouter, L. M.: Efficacy of epidural steroid injections for low-back pain and sciatica: a systemic review of randomized clinical trials. Pain, 63: 279-288, 1995.

9. Krempen, J. F., and Smith, B. S.: Nerve-root injection. A method for evaluating the etiology of sciatica. J. Bone and Joint Surg., 56-A: 1435-1444, Oct. 1974.

10. Macnab, I.: Negative disc exploration. An analysis of the causes of nerve root involvement in sixty-eight patients. J. Bone and Joint Surg., 53-A: 891-903, July 1971.

11. Mathews, J. A.; Mills, S. B.; Jenkins, V. M.; Grimes, S. M.; Morkel, M. J.; Mathews, W.; Scott, C. M.; and Sittampalam, Y.: Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections. British J. Rheumatol., 26: 416-423, 1987.

12. Stanley, D.; McLaren, M. I.; Euinton, H. A.; and Getty, C. J.: A prospective study of nerve root infiltration in the diagnosis of sciatica. A comparison with radiculography, computed tomography, and operative findings. Spine, 15: 540-543, 1990.

13. Tajima, T.; Furukawa, K.; and Kuramochi, E.: Selective lumbosacral radiculography and block. Spine, 5: 68-77, 1980.

14. van Tulder, M. W.; Koes, B. W.; and Bouter, L. M.: Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine, 22: 2128-2156, 1997.

15. Wiesel, S. W.; Tsourmas, N.; Fetter, H. L.; Citrin, C. M.; and Patronas, N.: A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine, 9: 549-551, 1984.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
My legs still twitch, get tight, pressure, hurt, spasm, blah blah. Surgery is still in the cards, ..., yes I have a new passport.

Otherwise, I cleared the air with Dr. Serena Hu, in lieu of the MVA that led me to seek surgical advice and counsel, by saying I would not get surgery because a lawyer recommended it.

[graphicsliz]

I've been to Dr. Berven at UCSF. I really liked him after seeing many doctors and other doctors as UCSF. Dr. Derby did my discogram and was the first person to diagnose my unusual case. They are good friends. There is a trial underway for ADR as UCSF currently. I was unable to participate as I had cancer 3yrs ago. If I could afford it, I'd have Dr. Berven do my surg. But remember it's a teaching school and one must ask for the Dr. to do the surgery. Otherwise ANYone could be doing it. I think in the end I'll be going to Germany. Best of luck. Also spoke with Delamarter who I felt wasn't right for me.

[Deborah]

We saw Dr. Hu for consult in mid Nov and were very impressed. We've consulted with a lot of docs on my hub's case and this is the first one that answered all questions before they were asked, had conclusive data for all reasoning, had an incredibly professional staff and was personable to boot!

It's taken since then until about 2 weeks ago to finally have a comfort level the proposed procedure will be a covered expense. Thank God! My hub is having a 2 level hybrid surgery. L4/L5 ADR (prodisc) and L5/S1 fusion.

We know there is a 10% chance of no improvement (or worse) and any improvement could be as little as 15% to a whole bunch, but those sound like great odds given his current condition. I do think that for those who can wait, the next years will bring out many more options and improved methods to help, but then again, that logic holds true forever. I guess it's when you reach that point you have to do something, you just search for the very best potential solution available.

We've *very* happy with both doctor and hospital. That alone is priceless; we do feel he's in the most capable hands possible (others may match it, but I doubt any surpasses it). I'll try to post results as they happen... and after all is done I'll be glad to share any and all info I've gotten about any aspect of the whole process.

I'm sorry I haven't posted more often... life has been both unusual and hectic for us during these last couple months. Thank you all for the input we've gotten!

Debi

[Slackwater]

Originally Posted by Deborah

We saw Dr. Hu for consult in mid Nov and were very impressed. We've consulted with a lot of docs on my hub's case and this is the first one that answered all questions before they were asked, had conclusive data for all reasoning, had an incredibly professional staff and was personable to boot!

We know there is a 10% chance of no improvement (or worse) and any improvement could be as little as 15% to a whole bunch, but those sound like great odds given his current condition. I do think that for those who can wait, the next years will bring out many more options and improved methods to help, but then again, that logic holds true forever. I guess it's when you reach that point you have to do something, you just search for the very best potential solution available.

We've *very* happy with both doctor and hospital. That alone is priceless; we do feel he's in the most capable hands possible (others may match it, but I doubt any surpasses it). I'll try to post results as they happen... and after all is done I'll be glad to share any and all info I've gotten about any aspect of the whole process. (del.text)

Debi

Valid answers from a respected surgeon, better understanding all around.


Understand agree, chance of

• worse condition
• slight improvement (10%-15%? = Minimally Clinical Important Difference [MCID in the literature, ref: Berven Journal Articles])
• much improvement ( I know a pt w/2-level Lumbar ADR and no symptoms )

Dr. Berven is mentioned above & in other posts; nice gentleman that I met at a UCSF spine conference.


Glad you got the numbers. Conclusive data is important. Please assume like all else, the numbers are the best available to date. Glad you have the hybrid option,

• Fusion: L5/S1
• ADR : L4/L5

Trust I got it right on hybrid. Best wishes, S-->

[ZorroSF]

I wouldn't trust zucherman. He's very skilled at surgery and has performed many disc replacements, but he doesn't do anything to determine the pain generator.


never assume from MRI's or x-rays. it's just not enough info to go on.


btw $140,000 is a lot. sounds like way too much. my prodisc was only $10,000 and that includes the doctor bill, but not the $60,000 hostpital bill for a 6-day stay at st. mary's.

[ZorroSF]

Originally Posted by Deborah

I do think that for those who can wait, the next years will bring out many more options and improved methods to help, but then again, that logic holds true forever.
Debi

to be frank, I doubt the next year will be better than the last year. with this economy many new tools or devices will be shelved. And do your reference checks with bervin. he's very nice, but had very little experience with disc replacements in 2006/2007, however he was the only spine surgeon that recommended a discography.

[Deborah]

I'm not really surprised you find the amount high... it was quoted by Texas Back who is an all private group and they have to be sure they're covering all expenses.

Hub is scheduled for surgery 3/3, so we're moving forward and very happy after 8 years of trying everything else. I'm convinced there isn't a doctor that's better than Dr. Hu, although there may well be many that are just as good. As far as I know, at UCSF they've done a lot of disc replacements in the last couple years, and I know Dr. Berven is highly recommended, so I'm guessing he's had a lot more experience since 2006.

I'm honestly not sure of the details, since we are past the options phase with hub's upcoming surgery. But I do hear there are several new clinical trials coming along now, so I wouldn't discount the chances of new technologies in the future. We're satisfied with Prodisc results for now, but I don't know what might be possible when we are ready to readdress cervical spine issues (we both have had C fusions).

I'm sorry you have had such problems since your ADR surgery as it appears in your sig. What level did you have the ADR on? It does look odd that it would be recommended with so many levels involved and not correcting the rest (it appears you have several levels involved; both cervical and lumbar). The misdiagnosis was from all doctors you saw prior to surgery?

Thanks for commenting. All input is appreciated!

D

[Tatonka_usn]

Deborah,

It's been a number of months and I'm curious how the surgery went earlier this year. I'm in the process of looking at ADR-capable surgeons in the Bay area and would be curious as to your experience (pre/post surgery). Thanks!!

Alan