hybrid surgery approved

[OsteoRach]

hi all,

i am looking for some advice,

a couple of weeks ago my surgery was approved and should be happening in may (L4/5 maverick disc replacement; L5/S1 fusion). i have read alot about postop recovery from adr and fusion yet have found little information on recovery from hybrid procedures?

with adr it seems that the advice is get moving (within limits) as soon as possible with PT starting relatively soon after surgery yet with fusion it is no bending, lifting, twisting and delayed PT.

i would appreciate any assistance from those in the know or with personal experience,

[Terry]

Did not have a hybrid but have two Mavericks in the same site as you are having yours.

Best of luck to you and continue to keep us informed.

Terry Newton

[Slackwater]

Originally posted by OsteoRach:
a couple of weeks ago my surgery was approved and should be happening in may (L4/5 maverick disc replacement; L5/S1 fusion). i have read alot about postop recovery from adr and fusion yet have found little information on recovery from hybrid procedures?

with adr it seems that the advice is get moving (within limits) as soon as possible with PT starting relatively soon after surgery yet with fusion it is no bending, lifting, twisting and delayed PT.

i would appreciate any assistance from those in the know or with personal experience,

First, wish you were not in a position to need surgery.
Second, I have not found a magic wand to fix the back yet.

See your surgeon to get a PT person to work with post-op to stay synchronized on the protocol. Seriously, get the PT person lined up now. My recall is the PT todo list looked somewhat similar to my PT routine w/o surgery.

Scratching my head because this was asked before on adrsupport.org and I remember seeing somewhere a PT guide, online, web page with pics, from a doctor based in Europe, ....? May I suggest looking at ADR Surgical outcomes and seeing what other hybrid surgery patients did?

Australian Page is a possible model. Like many other medical items there are variations, ...<UL TYPE=SQUARE>Postoperative Recovery Period

Your surgeon will set out specific recovery steps for you that you will need to strictly follow. This will limit your movement in many respects, especially when lifting objects. The key points being: Bending from the waist is not recommended for 6 weeks. Lifting anything greater than 5 or 6kg is not recommended for 3 months. Twisting is acceptable as long as it is done in a slow and controlled manner at all times. You should wait for 6 weeks before driving a car.

Drive for short periods then gradually extend this. Make sure you take regular standing breaks every 45 minutes on linger journeys. Avoid impact type sports such as heavy jogging, tennis, etc for 3 months. Light walking and swimming are generally good for recovery.[/list]
Above seems "safe".


Third, suggest expect measured progress through a 2-year recovery period. Results vary by individual with the same surgeon at the same level(s). The Oswestry / VAS scores (surgeons' metrics based on what you put down on the forms and their view) continue to improve over the two (2) years of data available from most of the studies. Please don't rush the recovery.

Anyway, "Hybrid" surgery is the operative term in my searches. Results I recall are the following:


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156
Proceedings of the NASS 22nd Annual Meeting / The Spine Journal 7 (2007) 1S–163S
Hybrid Construct Fusion L5S1 and Disc Arthroplasty L4L5 for DDD: 2 Years Follow-Up
Jean Le Huec, MD 1,
John Peloza, MD 2,
Clement Tournier 3,
Stephane Aunoble 4;
1 Institute of Medicine, Bordeaux, France;
2 Dallas, TX, USA;
3 France;
4 CHU Bordeaux, Pellegrin-Tripode, Bordeaux, France

BACKGROUND CONTEXT: Two levels degenerative disc disease (DDD) in the lowest lumbar spine is a very frequent situation to treat. Two levels disc prosthesis is an important surgery with high risk of unbalance of the spine.

PURPOSE: The combination of fusion at level L5S1 and disc prosthesis at L4L5 is an option.

STUDY DESIGN/SETTING: prospective study, clinical and radiographic analyzis

PATIENT SAMPLE: 50 patients were prospectively included in the study.

OUTCOME MEASURES: Clinical examination including oswestry, VAS for back and leg pain, SF 36, X rays with dynamic examination and full standing radiographs , CT scan and MRI were performed pre operatively and at each follow up interval with minimum two years follow up. Complications were noted.

METHODS: Fusion at L5S1 was performed with anterior impacted cage(Union cage or Perimeter cage, Medtronic, Memphis, USA) filled with autologous bone harvest from the left iliac crest for 40 and 10 received Inductos (Whyeth, USA), and with an anterior plating with the Pyramid titanium plate (Medtronic, Memphis, USA). The disc arthroplasty at the level L4L5 was performed with a maverick implant (Medtronic, Memphis, USA), metal and metal ball and socket prosthesis using the A Mav design in 28 cases and the O Mav design in 22 cases. All patient were operated with a retroperitoneal video assisted anterior approach from the left side.

RESULTS: 45 patients have completed the 2 years follow up. Mean follow up is 34 months (23 to 46 months). No evidence of non union was noted at the level L5S1 at the last follow up. One patient has periphereal calcification at level L4L5 but is still mobile on dynamic X Rays. One patient has a subsidence of the prosthesis in the L5 vertebral plateau but is mobile with 9 degrees of total range of motion. Two females complain of sacro iliac pain on one side and were improved by steroid injection. Their global lordosis, the sacral slope and pelvis tilt were not significantly modified between pre op and post op analyzis. Local lordosis increased at level L5S1 and L4L5 (discale (L4L5 : 5,9 ° pre op vs 11,1 °; L5S1 : 10,3 ° pre op vs 15,2 °) (p< 0,04)) and significantly decreased at level L3L4 (7,8 °
pre op vs 5,7 ° post op). Oswestry score improved by 29,6 % (p<0,05), VAS for back pain improved significantly (39,1%) and SF 36 showed significant improvement for mental (3 pts) and physical scores (6,4pts). Mobility at level L4L5 was 8,4 degrees (4 to 15 degrees) with an average L3L4 range of motion of 10,2 °.

CONCLUSIONS: The hybrid construct doesn’t modified the clinical outcomes when results are compared with single level disc arthroplasty. Two levels disc arthroplasty previously published demonstrated similar results. This hybrid construct provides a good basement for the disc arthroplasty
and decreases the risk of misplacement of the implant which is highly correlated with bad results in case of important offset in the charite´ experience. The use of BMP2 erases the pain from iliac crest harvest. This hybrid construct is an effective and safe compromise for patient with two levels DDD.

FDA DEVICE/DRUG STATUS: O MAV: Investigational/ Not approved.
doi: 10.1016/j.spinee.2007.07.366


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PMID: 17906573

Spine. 2007 Oct 1;
ProDisc-L Total Disc Replacement: a comparison of 1-level versus 2-level arthroplasty patients with a minimum 2-year follow-up
[i]PMID: 17906573

Hannibal M, Thomas DJ, Low J, Hsu KY, Zucherman J. Greater Pittsburgh Orthopaedic Associates, Pittsburgh, PA, USA.

STUDY DESIGN: This is a retrospective analysis of data that was collected prospectively from 2 concurrent FDA IDE lumbar arthroplasty clinical trials performed at a single center.

OBJECTIVE: To determine if there is a clinical difference between the 1-level ProDisc patients versus the 2-level ProDisc patients at a minimum of 2 years of follow-up.

SUMMARY OF BACKGROUND DATA: Marnay's work with ProDisc I prompted the U.S. Clinical Trials of the ProDisc II under the direction of the FDA. Disc replacement surgery in the United States has shown promising results for all types of prostheses up to 6 months. Marnay and colleagues showed that their results at 10 years were still promising, and they saw no significant difference between 1-level and multilevel disc replacements. The findings of Ipsen and colleagues suggest that multilevel arthroplasty cases may be less successful than disc replacement at a single level.

METHODS: Patients were part of the FDA clinical trial for the Prodisc II versus circumferential fusion study at a single institution. We identified 27 patients who received ProDisc at 1 level and 32 who received it at 2 levels with at least a 2-year follow-up, for a total of 59 patients. Unpaired t tests were performed on the mean results of Visual Analog Scale, Oswestry Disability Index, SF-36 Healthy Survey Physical Component Summary, and satisfaction using 10-cm line visual scale scores to determine a clinical difference if any between the 2 populations.

RESULTS: While patients receiving ProDisc at 2 levels scored marginally lower in all evaluation indexes, score differences in each category were also found to hold no statistical significance.

CONCLUSION: This study was unable to identify a statistically significant difference in outcome between 1- and 2-level ProDisc arthroplasty patients in a cohort from a single center. The equality of clinical effectiveness between 1- and 2-level ProDisc has yet to be determined.

Key Points
<LI> Patients receiving ProDisc at 2 levels did not perform statistically inferiorly to 1-level patients in this cohort.
<LI> Double-level ProDisc patients performed marginally worse in most outcome measurements, but these differences were not found to be statistically significant.
<LI> Further study will be required before multiple-level arthroplasty can be strongly recommended.

Quote
"Thus, the surgeon and the patients must both understand that, instead of expecting their VAS is to go down 50% over 2 years with a 1-level disc replacement, it is more realistic to see a decrease in VAS of 70% to 90% for some while only 10% for others."


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[OsteoRach]

Terry and Slackwater, thank you for your responses.

i wish and still hope that i dont have to go down the surgical path however 18months post incident i still have no lumbar flexion, very little sitting tolerance, limited work hours/tasks... despite umlimited access to probably the best practitioners in NZ. At 28 i fully understand the decision i am making however my life is on hold at the moment and honestly, i dont see any way out without surgical intervention. i have full confidence that the pain generators are my discs and that i have exhausted all conservative measures that are indicated in my situation. 18 months was my cut off mark in my head for any possiblility that time would heal the injury (based on tissue healing times).

Re PT, i am in a very fortunate position that my access to these resources is very good if not unlimited as i am a senior manager at the best healthclub/gym in New Zealand (www.bodytech.co.nz), an osteopath and our head trainer. I haven't yet spoken to our principle physiotherapist about rehab post surgery but will when i next see him around.

my biggest concern is that i find the balance between enough and too much as i have a tendency to overdo things. i am however also realistic with recovery and understand that it is major surgery with a long recovery time.

One of my main goals is to be able to sit at a table/desk comfortably and eat a meal/work. Being able to slouch would be great too however this is somewhat of a humourous goal as i understand the value of good posture and body mechanics.

Once again, thanks for the responses and if anyone else can shed light on their recovery experiences / post op instructions that would be great (I do follow the post surgery posts of several individuals with similar situations)

[Rosie]

Hi, I have a Combo. PM me if you wish, mind you you have an advantage of fast recovery due to your age.

[cathydownunder]

Rach, I have a hybrid, the only difference being my fusion is at L3/4 and Maverick at L4/5. I'm now 18 months post-op.
What can I tell you that won't have you running, screaming as far away from the hospital as possible???Hmm let's see?????
Seriously though, it's a tough surgery but as Rosie said, you're a lot younger than we were when we had ours and probably don't have the other "spinal and health issues" that beset us "older" ladies.
Yes there's contradictions between the get-moving straight away scenario of post-op ADR and the limited movement of post-op fusion. I can only tell you my experience.
The first 2 days were rough (once the happy juice IV was removed). Also if you have an abdominal incision it's very tender.
On day 3 I was assisted up with the help of a physiotherapist who came in daily to give me stretching exercises and walk me down the hallway. I continued seeing her at her clinic twice weekly then weekly for 6 months afterward as my surgeon has a program running with her doing clinical pilates for his patients. This started at 3 weeks post-op.Each patient's program is personally designed for them and consists mostly of stretching and strengthening.
I was able to drive when I was comfortable which for me was 3-4 weeks.
The golden rule of course is no bending, twisting or lifting. I Purchased a shower stool and over-toilet commode for this reason. I felt like a granny and there were a few comments made but who cares!
There's lots more I could tell you so send me a PM if you'd like a more detailed guide.
Take care Cathy

[OsteoRach]

Cathy and Rosie, thank you so much for your valuable insight.

i received all of the paperwork in the mail this afternoon, talk about your life history! It seems alot more real now...

my biggest concern with the post op recovery is that im allergic to a narcotic of which i dont know what it is (oral morphine makes me feel horrible but that may just be the normal response that people feel). i had an operation in 96 and had the whole anaphylatic reaction (couldn't breath, thought i was going to die) but i was never told what the medication was. i had a milder reaction to what we think is fentanyl during my discogram (its really fun when they provoke 10/10 pain and then say go home and take your normal pain medication while they've just given you adrenalin and hydrocortisol (sp)),Anyway, i am rather concerned about this as from what ive read post op pain is high and i want to make sure i have adequate post op pain relief with out any undue reactions to the meds. i asked my surgeon (whom i love, not literally) and he said that was a question for the anaesthetist,

rachel

[Fuzzy]

I had hybrid fusion L5/S1 with ADR at L4/L5. I was told to rehab the same as single ADR with 6 week restrictions. I was told fusion is screwed together and to not worry about it. Biggest discomfort was the bonegraft site. Post surgery pain at the fusion site was not a problem for me but there was 2 drains put into me one at the fusion ADR site and the other in the bonegraft site. So a little more trouble then ADR alone but it was not too bad. Again the most anoying thing to me is the hip bone harvest site which has a chunk of bone missing out of it which I feel every day as its right where my pants sit. At 2 weeks I was walking pretty good but was careful about everything until at least 2 month out. Never had PT. Doing good and still improving at 4 month post. It seems to be a good technique but put a ADR above a L5/S1fusion.

[OsteoRach]

fuzzy,

thankyou for your insight on the post op recovery. thankfully my sureon uses bmp so i wont have to go through the additional pain/recovery from the bone graft site,

rachel

[mikemcmanus57]

Rachel,

I had the HYBRID L5- S1 Fusion and a Prodisc at L4-L5. I am 3.5 months out. I have been doing PT for about 5 weeks now. They started me on land based therapy and I got quite flared up. We switched to the pool and things have been better. Pre surgery I had terrible pain in my right buttox and leg. I still have the same pain as before the surgery. The Doc says that it will get better with time. I guess the nerves are very slow to regenerate. My back feels great 0 pain. Pre surg I had some back pain but not much. Some days I think I shouldent have had the surgery, because after all the recovery time, I still feel the same as pre surg. But I was bone on bone at l5 s1 and l4-5 was on its way out also, So I am shure I made the right dacision. ( I HOPE ) Mike