Degree of Facet disease before turned down for TDR

[Jack]

From the research on this site that I have done for lumbar Disc replacement, it seems the Charite puts the least strain on the facet joints. I talked to an office person and have an appointment (I think), with Charles Branch, M.D. a recommended neurosurgeon who does disc replacements. I'm trying to get educated with real world results as much as possible prior to the visit. For someone like me with spondylolisthesis, there is automatically some facet involvement.

Anyone out there with a small or large amount of facet disease with a disc replacement?

[rhatzy]

I have the maverick disc which is designed reduce the load on the facets. Mine were diagnosed as mild to moderate and that was my main concern. I am now 17 months out from ADR surgery and I am totally pain free. Charite is the last disc I would think about putting in my back.

Mark

[Harrison]

I personally don't like a metal on metal design, or a keel -- and the lumbar Maverick has both. This is just my opinion based on my personal observations.

Since 2004, we've seen good outcomes and poor outcomes with all disc types. An experienced surgeon, precise device placement and the right patient selection are of paramount importance in determining the outcome! Carefully read the first topic in the forum if you've not seen it: ADR Risks, Complications, Disqualifications

I am now five years+ post-op and doing great.

[rhatzy]

Harrison,

How many personal stories of failed mavericks do you have. I don't like the ones with the plastic cores. This is just my opinion based on my personal observations. I LOVE my Maverick and I personally know a lot of other people that like theirs too.

Let's get real. I think, except for Charite, that they are all good, prodisc, maverick, etc.

Mark

[annapurna]

If you look at the pile of patient reports, there isn't an ADR out there that you could arbitrarily dismiss or endorse. None of the claims for facet sparing, constrained, unconstrained, metal vs. plastic, you pick the division, have been proven in anything other than marketing literature.

Facet degeneration has been poorly graded and still suffers from some difficulty in detection and quantifying. With spondy, though, I'd wonder about selection of a constrained design over unconstrained. Not because of its purported effect on facets, but because the constrained design might, in my pea-brained view of the design, resist the spondy better.

[Harrison]

Annapurna, well said, as usual. Thanks for the good points all around.

Mark,

Like I said, we’ve seen good and bad results across the range of devices and procedures. I am happy to see that different people, with different spine pathologies, different doctors and even different clinics (etc.) find a solution to their chronic back problem. It sometimes seems like a miracle indeed.

It is quite naïve to think that any disc design is impervious to complications that result from any one of the factors mentioned here or a zillion places on this forum. E.g, take a looskey at the image of this “failed” Maverick procedure (figure 2; failure attibuted to "facet degeneration to hyperlordosation "):

http://www.pssjournal.com/content/3/1/15

Let’s be more sensitive here: this XRay was from a human being. The suffering that these people go through to eventaully be published in a case study is terrible! I hope that that we all appreciate their suffering and hopefully that it is not in vain. We have much to learn from their tribulations.

Shame on ALL of us to DARE make any hard conclusions with the SCARCITY of clinical data about the long-term efficacy of these devices. There continues to be conflicting data within medical societies, published literature, and as we see here, in patient communities. That said, as you may know, many first generation discs have been out for 25 years (Charite), and a bit less (ProDisc), so they are more likely to see more complications because of the learning curve with surgeons and the other people involved in the R & D process. It's easy to pick on the first-movers, and Rosen's piece (coming out soon) is proof-positive of that point. The article may be helpful to some folks, so I'll post in the new "complications" FAQ I posted in the days ahead.

Don't get me wrong, it seems like you want to peg me as a Charite' defender of sorts. I am, insofar as I have NO pain in my spine. But I happily support other, newer discs as well, with refinements that I feel are superior to that of the Charite'; e.g., the Mobi series as well as the ActiveL. I noted their progress in design and surgical approaches. Again, I believe many of these "next generation" discs are good; better for MOST patients with the RIGHT indications.

Mark, your comment is a bit confrontational, so please note (again) this guideline found at:

http://www.adrsupport.org/forums/guidelines.php

Disruption and instigation. Do not engage in any disruptive activities on any forum, such as off-topic postings or comments, or statements that might incite other members to violate these guidelines or participate in questionable activities. Refrain from "trolling", i.e. posting topics or opinions that are designed to provoke a negative response from members. Refrain from using offensive language. If you have any doubts about whether a particular statement might be considered offensive by other members, do not post it. Do not use profanity. Treat others as you would expect them to treat you. Personal attacks or any type of "flaming" of other community members will not be tolerated. Refrain from personal attacks and use constructive criticism not destructive criticism. Members must comply with generally generally accepted business e-mail etiquette.

And:

7. High Maintenance Members. Any member who requires an extraordinary amount of administrative time or resources from the moderators may lose some or all forum privileges. High maintenance can be defined as causing, creating, or adding excessive difficulties to members or moderators.

[Jack]

Yes, I have read all the Risk, complications, etc. and it was very helpful. I saw nothing there that would outright disqualify me. My problem is that we are dealing with medical practice. Some doctors can come up with a logical reason on both sides of the fence to support their views. I don't want to have a fusion just because the doc is more comfortable doing them or he/she feels they get less post-op grief. They may not wish to feel the wrath of the insurance company if the disc doesn't work out and they then have to fuse on their nickel or worse get sued.

As much as possible, I want to be able to ask them to justify their position.

annapura,

What means constrained and unconstrained?

[Harrison]

Jack, I just finished my post and saw your question. I found your post helpful to me, and others, because it was:

- honest;
- interesting, in terms of what you are asking from spine doctors.

That said, I hope we can help you with your next steps. These are tricky and very important questions. I have more comments and questions, but I have to do laundry, clean the kitchen and get ready for tomorrow...

[2cool4U]

Jack,

Lost in the above...debate (ahem) is the comment that you made regarding spondylolisthesis. Depending on the degree of misalignment, this can disqualify you as a candidate for ADR. How much spondylolisthesis is demonstrated on your studies?

Also, note my sig. I am a physician and chose to allow placement of the Charite. All of the design debate aside, long-term results are not available for newer disks. They may turn out to be much better, the same or worse than older designs for which we know 10-15 yr. results. Don't let anecdotal reports of some people having a bad outcome from any of the different devices influence your opinion. Research the actual statistics on success and failure rates reported in the literature. Every surgery has its share of unsuccessful results, but what matters are the population data. Is the device 90% effective at 10 yrs or only 60%? Does the device in question even have 10 yr. clinical in vivo (not lab stress testing) published results?

Newer doesn't always mean better, and we can't know for certain what the success rate of any device will be at 10 yrs. until we wait 10 yrs. I opted for a proven design placed by an experienced surgeon, but there are certainly many other directions to take when seeking surgical treatment for your pain.

Remember, check the degree or grade of spondylolisthesis.

[annapurna]

Originally Posted by Jack

annapura,

What means constrained and unconstrained?

There's probably a better definition of it but essentially a constrained design is intended to constrain how far the ADR is free to move, tilt, slide, etc. Unconstrained designs, like the Charite, pretty much let the ADR move however it needs to match the spine's movement. Constrained designs place limits on that movement and might help you deal with minor spondy. You can see Tconnor's comments about spondy. I'm not disagreeing with his recommendation for Charite, just wondering if this might be a nitch where constrained designs might actually prove better. The problem with the question is that it would be difficult to prove even in a computer model because the answer would depend upon the degree of spondy assumed in the model: assume too much and any ADR becomes a bad idea.

I suspect the debate about ADR types is misleading you. There hasn't been a single ADR type that's proven to be THE ADR for facet problems. The best advice is to find the best surgeon you can get to and get the ADR he or she is most experienced with. If you have equally good solutions for a couple of ADR types, that's when questions about which ADR is better should be asked. While superiority of one ADR over another is still speculation, a bad or inexperienced surgeon can screw you up beyond belief.