Ligaments and annulus sacrifice during ADR?

[annapurna]

The previous topic on ALL cutting during cervical ADR started making me wonder how much of the connective tissue support is typically removed for ADR? I know that the ALL and PLL are really important for front-to-back stability and the disc annulus is important for torsional (twisting) stability. I wonder if the facet-type pain issues some of us get post-ADR could be due to the loss of the torsional and front-to-back stability from the loss of those tissues during ADR placement? I know that neither the Charite nor the Prodisc provide and torsional resisitance, so, theoretically, if the whole disc annulus was gone, then the facet capsule would be taking a LOT of torsional stress and could start hurting.

I remember Dr. Zeegers showing me the tiny window he worked through and the little window in the ALL that he used to get the ADR in, but, I assumed that almost all of the annulus had to be removed in order to permit placement of the prosthesis on the cortical (load-bearing) bone.

Any thoughts?

[Carolina]

I remember this discussion coming up before...not sure if it was here or at another board. I seem to remember some differences in procedure in terms of annulus removal, but can't remember the exact details. Some docs left a rim of annulus, placed the device inside...which applied to the Charite, I think. That technique provoke alot of discussion due to some research showing aberrant nerve fiber growth through the damaged annulus, thus the question of whether pain would continue post-op from the firing of these nerves. I think I also remember hearing of docs removing all but the most posterior portion of the annulus, and trying not to touch the PLL if possible.

Wow. I thought I would never forget all the little details, procedural pros/cons I read leading up to Kevin's surgery.
But obviously dementia has set in!
hopefully someone with full mentation will post-
Carolina

[Jim M2]

Laura,
As you know I strongly suspect my facets are a pain source. I just did a twisting experiment sitting here at the computer.

When I twist to the left I do get discomfort in the lumbar, left of center. It is not immediate discomfort but it builds up and is still with me several minutes later. I also get some heat and squeezing sensation in my left leg and foot. So is this the left L5S1 facet, or the left-side tear/bulge/small-herniation in the L4-5 disc, or both?

When I twist to the right there's a little bit of discomfort.

Typically I don't twist very much at all. It's a habit I developed because twisting seems to contribute to discomfort. The twisting I just did was beyond my normal range but it was not extreme, in fact it's probably a frequent motion for most people. So certainly this dosen't refute your theory. I would say it supports your theory except there are other factors involved.

I'm a little tired right now. I'll think about this more over the weekend.

It's an interesting theory.

Jim

[ans]

I'm not sure I fully understand your question Laura but it sounds good to me! I'm going to ask this to my doc soon. Best, Allan

[mmglobal]

The ALL and anterior annulus are severely compromised to create the 'window' into the disc. Zeegers and Bertagnoli both close the window and stitch the ALL back together. They both admit that restoring structural strength is questionable, but also like the additional layer of insulation it provides. There is also a general philosophy that one should restore to as close to natural as possible. Other surgeons take just remove the flaps.

On the posterior side, the surgeons I've seen will attempt to keep the PLL and posterior annulus intact. It is not always possible. If the segment is difficult to mobilize or if a great amount of posterior decompression is required, they'll have to remove the PLL and posterior annulus in order to get the job done.

Many failed ADR surgeries may simply be inadequate attention paid to endplate preparation, posterior decompression, etc. Really fast surgeries may sound attractive, but I'd prefer that my surgeon not be rushed. I'd rather keep the PLL and posterior annulus if possible, but if your surgeon needed to remove it to remobilize or decompress, you should be glad that he did.

Bertagnoli talks about the desire to leave as much ligament and annulus as possible "because it provides additional tension bands." This helps to keep the system stable. But, if it is not there, you should still have enough surrounding structures to provide the stability you need.

Compromises are everywhere.

Mark

[paulam310]

Mark, are you referring to both low back and cervical surgeries? The doctors use the same procedures for the ALL regardless of the area of the spine? or is there a difference?

[Harrison]

In my ADR in June of 2004, my L5-S1 was starting to fuse and it was a bit "messy." The doc had to do a partial corpectomy to clean up the mess, and I believe completely removed the entire annulus. This might explain why I had 0 pain thereafter; as all possible pain generators were removed. Who knows...

[annapurna]

Jim,
Sorry to hear that you're still having so much trouble. I'm getting quite a bit worse and can really sympathize with you as I get more and more limited in what I can do. I've been seeing a chiropracter who tells me over and over that I should have just let my L5/S1 self-fuse and I wouldn't have half the pain that I've been experiencing. At first I thought that he was nuts, but then I started wondering if he had a point assuming that most of the annulus and ligaments were removed to insert the ADR.
Has anyone considered Dynesys or Wallis for post-ADR instability or facet pain? How well did it work?

[Jim M2]

Laura,
My earlier post was misleading. I'm better off today than I've been in 3.5 years (1.5 yr pre-surgery + 2 years post surgery). I'm still uncomfortable and restricted in activities. I'm very happy about this. I don't mind being restricted if I'm not having ugly pain levels. Beyond the recumbant exercise bike I can now do the stair stepper. When I get outside of my little activity 'box' I get into pain.

I've had the exact same thought on fusion. In hindsight I probably would have let L5S1 fuse naturally and then maybe had a right side L5S1 foraminotomy to clear up my numbish and achy leg.

When making the ADR decision 2 years ago one piece of information I didn't properly understand was surgical fusion after ADR. That procedure is usually only performed under dire circumstances. Had I known this I probably would have gone fusion; either natural or surgical.

Jim

[Jim M2]

Now more about your theory with the ligaments.

I've had a strong preference since ADR to be curled up, or in other words to have my lumbar flexed. Could this be related to compromised ligaments and annulus? Flexing is known to unload the facets. If the ligaments and annulus are not doing their job to stablize the spine, then this need to flex makes sense.

The pain I associate with the facets feels mechanical in nature. It is especially sensitive to certain motions and positions. It has qualities of stiffness, soreness and achiness that compares somewhat to a recovering jammed finger or badly sprained ankle.

The MRI, CT-Myelo and x-rays I've had since ADR do not reveal a pain source. I'm still scratching my head.

Here's hoping the best for you (and all of us),
Jim