ADR Risk - "facet" issues?

[JJames]

While I wait for the day to finally arrive that either the FDA approves bi-level ADR and my medical insurance will pay, or I fight hard enough to get them to, I have been reviewing the posts of those who have actually had ADR surgery.

I am not medically knowledgeable as I likely should be, so much of the terminology, etc is confusing to me. Can anyone tell me in layman's terms what the "facet" is? There seems to be many references to various "facet" issues post-ADR surgery. I realize that only those of us with back issues generally stick around and post on this site, but I am once again beginning to second-guess myself on whether or not I should truly be pushing for this surgery.

Any information would be very appreciated. Thank you - Jeff

[trkdoc714]

Jeff,

Rather than explain it to you and risk not being clear, there is a site called "spine-health". In that site there are videos of conditions, anatomy and surgical procedures.

Good luck on your two level problem. Possibly your doctor could file a humanitarian request to the FDA for you.

Bob

[kimmers]

Jeff,

Facets are the joints between the vertebrae (they are located posteriorly). They are also called Z-joints, if you see that terminology.
My facet joints were with mild hypertrophy before ADR surgery which was fine. As I understand things, you don't want bad facets going into ADR surgery. I cannot speak for surgeons, because each one is going to have their comfort zone, but I understand from reading medical literature about the little "guys" (the joints) that mild and even moderate facet hypertrophy is ok. The hypertrophy is the arthritis the joints take on as we age.

With ADRs, and especially ones that may cause pressure on the facet joints, like ProDisc (the one I have), the disc might "inflame" the facets by putting more pressure on them.
My doctor thought that might be happening in my case, so a couple of weeks ago i had a facet intraartuicular injection into my L4/5 and L5/S1 facets. The injection served two purposes, one it was thereaputic and two, it ruled out the facets as my problem. (so it was diagnostic).
I found out my facets are not causing my sciatica, looks like L5/S1 is.

You can google facets and get all kinds of information about them but they are basically joints that give our vertebrae the ability to bend and rotate. If you look at a picture or diagram of them, you will see what I mean.

Kimmers

[JJames]

Originally Posted by trkdoc714

Jeff,

Rather than explain it to you and risk not being clear, there is a site called "spine-health". In that site there are videos of conditions, anatomy and surgical procedures.

Good luck on your two level problem. Possibly your doctor could file a humanitarian request to the FDA for you.

Bob

Thank you for the information, Bob. I often am on that website as well. I guess I haven't poked around enough there. I will take a closer look now. Thanks again!
Jeff

[JJames]

Originally Posted by kimmers

Jeff,

Facets are the joints between the vertebrae (they are located posteriorly). They are also called Z-joints, if you see that terminology.
My facet joints were with mild hypertrophy before ADR surgery which was fine. As I understand things, you don't want bad facets going into ADR surgery. I cannot speak for surgeons, because each one is going to have their comfort zone, but I understand from reading medical literature about the little "guys" (the joints) that mild and even moderate facet hypertrophy is ok. The hypertrophy is the arthritis the joints take on as we age.

With ADRs, and especially ones that may cause pressure on the facet joints, like ProDisc (the one I have), the disc might "inflame" the facets by putting more pressure on them.
My doctor thought that might be happening in my case, so a couple of weeks ago i had a facet intraartuicular injection into my L4/5 and L5/S1 facets. The injection served two purposes, one it was thereaputic and two, it ruled out the facets as my problem. (so it was diagnostic).
I found out my facets are not causing my sciatica, looks like L5/S1 is.

You can google facets and get all kinds of information about them but they are basically joints that give our vertebrae the ability to bend and rotate. If you look at a picture or diagram of them, you will see what I mean.

Kimmers

Thank you for the explanation. My surgeon plans to use 2 ProDisc implants if I ever have this surgery. Is there some way that a surgeon can tell if you have "bad facets" pre-ADR surgery that you know of? Is this jusy something which he would've already noticed on one of my many MRIs, CT scans, etc?

In your opinion, should the number of posts which I have read stating that facet-issues were a big problem post-ADR surgery be of such concern to me? Am I just overreacting to just another "possible" post-operative complication?

Thanks again - Jeff

[kimmers]

Jeff,

An MRI should show the hypertrophy level of the facets.
In the two lumbar spine MRIs I have had, they state any hypertrophy of the facets.
I may have had some increased hypertrophy in my last MRI but the two MRIs were not compared. My pain doctor just mentioned to me the other day that i could ask one of the x-ray places that did the MRI to compare the two.
One was before surgery in June 2007 and one was after, October 2008.
Of course, the level at L4/5 where the ProDisc is positioned has artifact. It is like a big black blot at L4/5 because of the metal.

I don't know if the MRIs are significantly different; I might have them compared later. I have all my x-ray reports since I have this workers comp exam coming up. Not looking forward to being examined by another doc, esp one I don't know.

That is one thing you should do is get a CD Rom of all your radiological procedures. I have found some people give them free or you pay a small fee, $10-20.

I have also found the back to be incredibly complex and everyone reacts differently to surgery. I found the immediate recovery painful but I progressed streadily and had some ups and downs. Muscles would be mad after climbing something as simple as a ramp or stairs. That seems to have gone away.

Eventhough now, I have more sciatica than before surgery as it suddenly appeared around six months post op, my back pain is so much less than before surgery. My gut tells me now that my L5/S1 disc is just a little pissed off. Time will tell. Tuesday, I have an epidural injection to try to calm the nerves down.

IMHO, the most important thing is to select an excellent ADR surgeon.
I also believe in getting a couple of "second opinions" and seeing what they say.

I apparently don't have any facet problems although my surgeon thought I might so, yes, facets might be involved in the future but who knows. Some people on here have gotten some regular facet injections to keep the facets happy.
I do know they (the investigational docs) are working on new technology, including nucleus replacements, fibrin treatment, artificial facets, etc..

I know that severe hypertrophy of facets is contraindicated in ADR surgery. There has been at least one person on here that had surgery and had bad facets and has not had a good outcome. Research the archives here and you should find her.

Besides the facets, I had to have a dexa scan to check for osteoporosis, flexion/extension x-rays to check for slippage of vertebrae and was supposed to have another MRI but my insurance vetoed that, all to be cleared for surgery.

Big surgery, big decisions.
I suggest learn as much as you can but don't get freaked out.

Kimmers

[trucklt]

Facet issues can be tricky and results of MRIs and CT scans are subject to interpretation by whatever radiologist reviews the scans.

The only way to really rule out your facets as a possible source of pain is to have the diagnostic injections as described by Kimmers. The first time I was turned out for lumbar ADR at L4/L5 in 2005, one of the drs. on the final review panel made a big deal out of my not having had "diagnostic facet injections" and cited that fact in his rejection of my ADR. The prospective surgeon didn't seem to think the facet injections necessary due to a strongly positive discogram at L4/L5. I did later have the diagnostic injections, and they ruled out my facets and SI joints as sources of pain. So, don't be surprised if your facets become an issue during your surgical planning and attempting to get insurance coverage for ADR.

Yes, there have been some studies out there positing that current ADRs such as Charite and ProDisc put too much stress on the facets and wear them out prematurely. "Berry" posted a link to a California study which documents post-ADR facet problems complete with some nasty pictures. Some of them could have been surgical errors during implantation, but it's worth knowing as much information as you can. See "KBear's" thread on Arthroplasty Central "Success Rates of ADR" and Berry's posting of 12/19/2008 for the link to the full article. I presented it to my surgeon before I got dropped from the Active-L trial due to osteopenia in my spine. He felt that the authors may have an agenda or a bias against ADR. There's so much conflicting information out there that it's tough to make a decision that will affect your health and well-being for the rest of your life.

Good luck!

[Harrison]

Truck, Kim, nice posts. Surprisingly, some of the big spine sites don’t do a good job describing the facets – I like this description below, taken from a UK chiro site – this is an excerpt:
_____________

The facet joints, also termed zygapophyseal joints, are located at the back of the spine. There are two joints at each level, one on either side of the spine. The facet joints are classified as synovial joints and are enclosed within a joint capsule. There is synovial fluid within the capsule and the joint surfaces are covered with hyaline cartilage, the same type of cartilage that is covering, for example, the ankle joint.

The role of the facet joints is to control excessive movement especially in rotation and extension, and therefore, provide stability for the spine. Injuries to the facet joints can have many causes. But essentially it is a sprain and as such, it is caused by excessive movement, causing damage to the joint capsule, which in turn cause swelling and inflammation and pain. The pain in turn causes a reactive muscle spasm, which is a protective mechanism. The result is a sudden severe pain and inability to move comfortably.
______________

I think we all agree how enormous the responsibility is for the surgeon to properly assess the health of the patient’s facet joints at multiple levels of the spine to properly qualify them for ADR. Historically, they use their clinical assessments, imaging studies and even blocks to make these determinations. There are grading systems for assessing facet degradation, but even doctors don’t agree on any standards for this measure – they’ve even written papers on this issue.

This is not the exact topic I was searching for, but it touches on some of these issues (thanks to Steve for posting this a while back).

Hope this helps!

[kimmers]

FYI Jeff,

I did have facet blocks at L3/4 to L5/S1 prior to having surgery. Actually, it was after two epidurals failed to relieve my pain and next came the facet block as both therapeautic and diagnostic. They didn't do didly squat so on to the discogram and then that was when I was told I would probably need surgery.
I really believe in the discogram because I was blinded to which disc was being injected and I felt nothing at the normal disc and then next disc, was something else. It definitley hurt and then the CT discogram afterwards clearing showed an abnormal disc with a grade IV tear.

Kimmers

[Clarissa]

Harrison- I have a question about the sprain that you brought up in the facet joints. If there is a sprain can it recover, get better or is it sprained forever?