hybrid surgery? advice needed

[OsteoRach]

hi all,

im new here (have been reading for a while) and would appreciate any information/advice regarding disc replacement/hybrid surgeries and in particular the recovery process.

i see my surgeon next week where i am going to say yes to surgical intervention (i have been trying to rehab conservatively) for chronic discogenic lower back pain at L4/5 and L5/S1 with concordant pain on discography. my surgeon has indicated that i can either use disc replacement (maverick) and/or fusion and he has ultimately left that decision to me.

my concern over disc replacement is the need for anterior revision in the medium to longterm future as i am only 28 so it would have to last a long time.

i have assumed if i opt for adr it will be hybrid (rather than double adr) and would appreciate any advice regarding recovery/return to work. i have read alot of info on adr and fusion however i cant locate much info on hybrid surgeries.

am i kidding myself to think that after two months i will be back at work for atleast 4-8hrs/day?

any help appreciated,

rachel

[Terry]

Rachel:

I firmly believe that it depends on how good of shape you are before surgery and what you do for a living.

I had 4 level ADR November 4, 2006 and was back to work January 4th, 2007 exactly 2 months after my surgery. I am an executive that does not do manual labor and was able to tolerate working full-time right off the bat. Not to imply that I was pain free or anything. I had to buy a brand new chair as the one I sat in for 16 years was no longer supportive. I bought a Herman Miller ergonomic chair that supported my spine much better. I also had to get up and walk a lot.

I have 2 Maverick discs at the same levels they are proposing to you and I have 2 Prestige cervical discs.

I went in to the surgery in fabulous condition.

Terry Newton

[OsteoRach]

hi terry,

thanks for your reply.

i am currently managing two health clubs/gyms. im also an osteopath and a personal trainer although i have not been able to do either of these since i injured my back 14 months ago. i currently see a personal trainer twice a week and my osteopath once a week. we have progressed along way however there is still this lingering moderate low back pain and a complete intolerance for sitting/activities. i have ergonomic chairs at both of my workplaces however i prefer not to sit if i dont need to. i am very fortunate as i have an excellent employer and work colleagues who tell me off if i go to do anything silly (lifting). i currently work 6hrs/day.

i would consider myself in excellent shape considering my limitations/pain tolerance and i have worked incredibly hard to try and avoid surgical intervention.

your return to work sounds promising. at this stage i have yet to speak to my surgeon to ask if he is thinking double adr or hybrid. my concern with adr at L5/S1 is right sided facet hypertrophy. i have good disc height at both levels? has anyone had adr with facet hypertrophy only?

thanks

[annapurna]

OsteoRach, I'm a little lost about your question but I think you asked if anyone had ADR simply due to facet hypertrophy with good disk height. If that is your question, I'd have to say that I can't imagine any reason to do so. ADR is known to alter the loading on the facets to some extent and has been shown for some people to lead to facet damage even if placed correctly, even in the absence of preexisting facet damage. If your disk height is good, I'd avoid ADR now and look at intradiscal repair techniques for now and see if they could head off the need for ADR.

If I've misread and you do show disk height loss, the situation is different and you're dealing with a broken system (your body now) and looking for ways to restore as much functionality as possible (fusion or ADR). In that situation the changed loading on your facets from ADR has to be balanced against the absolute trash you'll have if your disk collapses and you self-fuse vs. the loads you put on adjacents levels and SI joint with fusion.

[OsteoRach]

apologies for not making my question clear. all the literature that i have read says that you should not have adr with preexisting facet problems. does this mean that your facets have to be perfect on imaging?

the reason my surgeon has only spoken of adr and/or fusion is my clinical picture and tests [ct discogram: L4/5 full thickness central tear of with communication through to my spinal canal and L5/s1 annular disruption of over 1/3rd of posterior annulus with contained paracentral protrusion. both l4/5 and l5/s1 hurt insanely during the discogram. mri: moderate disc desiccation, bulge/prolapse, however i have preserved disc height] indicate moderate to severe discogenic lower back pain.

when you refer to intradiscal repair techniques are you referring to IDET? From what i have read the damage on ct following discography suggests i am not indicated for IDET however i have struggled to find a lot of information on this procedure. any assistance here would be appreciated,

i appreciate your response,

[joeytoey]

Hello Osteo,

You're too darn young to have this problem, you know?

If I were you, I'd hold off doing any major surgeries as long as possible. If you have no choice because you're too debilitated, I would do the simplist least invasive procedure available first. I would avoid any anterior spine surgeries for now because, as many of us have found out, it's too dangerous to do a second anterior surgery for a revision or a procedure on a different vertabrael level. Without an anterior surgery you can't do an ADR, of course. But as you've read, many folks are having problems with ADR's, particularly 2 or more lumbar levels. If you can forestall an ADR surgery for now, perhaps you can get lucky later in life when the ADR's become more perfected and less prone to failures. Save any anterior procedures for the "big one" when you're much older.

You got one hand of cards that you need to play right. Looks like you are asking the right questions. Research, research, research.

[LBP]

my understanding of IDET is it cauterizes the inside of the disc and nerve endings????
see: http://www.spine-health.com/dir/idet.html
spine-health has a great animation of IDET procedure.

My pain management dr had suggested this 1st then ADR but my insurance of course denied IDET as too controverial without consistent results. My dr also implied mixed results and you would have to wait some time to see if it worked...maybe 6 mos or so. It's been a long time since I looked into it so my memory is fading on this procedure. At the time I already had been suffering to long and wanted surgery to get it overwith so I never appealed the denial for the IDET.

[OsteoRach]

[i typed out a really nice post however for some reason when i go to post it my messages often error so here goes again]

any decision certainly weighs heavily on my mind as i know anterior revision of a failed adr is more major than it already is and post fusion you are more likely to suffer from adjacent level degeneration.

as much as i would like to avoid surgical intervention my life has been on hold since the incident. i continue to suffer pain on a daily basis and my back dictates every decision i make. to some extent i can deal with the pain, its the loss of function that is really hard.

from what i have read idet is indicated for discogenic pain with limited annular disruption-this is where i fall outside of the indications. ACC which covers all medical costs associated with accidents in new zealand considers idet controversial at best, im pretty sure they do not cover the procedure (albeit they have been fantastic so far). i will follow this up with my surgeon.

lbp, good luck with your insurance and i hope you are able to get what is best for your situation

joeytoey, i wish you well with your decision about possible revision,

[annapurna]

IDET has largely been rejected as a poor technique. There are newer versions of the same basic theme that have been shown to be more successful, like Yue's SED technique. I'm not as up to date on those as I should be but the newer techniques have been shown to work much better than IDET.

As for ADR without perfect facets: it's difficult to draw a line in the sand and say if facets are worse than this ADR isn't possible. We've heard here of people with facet problems improving with ADR and people with perfect facets at the point of surgery winding up with significant damage after a perfect placement. If you're showing hypertrophy already, then you have some real damage in your facets and ADR is less likely to fully resolve your pain in that segment. I can't quantify how much and how likely but the qualitative statements can be proven through review of other surgical outcomes here. There are a number of facet related devices that can take some load off the facets and there are facet replacements in trial that are intended to work with ADR, so you wouldn't be forced to revise to a fusion if things went bad but the other options are still very new and therefore somewhat risky themselves.

[Fuzzy]

Wait as long as you can...I waited a loooong time and that is how I know for sure I did the right thing. I studies ADR and other options for my back for 7 years.

I had a 2 level hybrid surgery (see my post in outcomes) and now at 4 weeks post I am pretty darn mobile and can be on my feet all day with small breaks and no loads and I am sure I can do work along Terry's lines in 2 month as well.Yes, good chairs and auto trans in a soft sprung car with electrically adjustable seats really helps. In my case I don't think it would have mattered wheather it was a fusion or just adr in terms of length of recovery but rather the shape I was in before surgery. Everyone is different, depends on your problems too how well you will do, oh of cause the type of work you do and how physical it is.