Questions about lumbar disc options and docs in Los Angeles

[Amapola]

Hi everyone!
This is my first post and certainly not my last. I have been doing a lot of research, but there is so much information to sift through, so just a few questions initially:

Lumbar discs available: My understanding at this point is that there are only 2 discs in clinical use in the US: the Charite and the Prodisc. Of all the discs in trial, all are randomized against fusion, with the exception of Kineflex which is randomized against Charite and Activ-L which is randomized against either Charite or Prodisc. If any of this is incorrect, please let me know!

I do not want fusion and I do not want Charite. So this leaves me with either Prodisc or Activ-L (with Dr. John Regan, who randomizes against Prodisc).

It appears that most of the doctors in Europe are now preferring the Activ-L. From what I've gathered, it seems that the Activ-L's design might be better for the facet joints. Are there any other benefits of Activ-L over Prodisc? I don't think I've read any negative stories about Activ-L -- any negatives out there?

Necessity of discogram: Dr. Anand made his diagnoses just by my symptoms and looking at my MRI. At least 80% of my pain is in my back, with increasing pain the longer I sit. The rest of my pain is sciatica down my right buttock and leg. Is it necessary to get a discogram before ADR? I have never had back pain before and my injury was pretty clear cut and the MRI shows the herniation at L5-S1. I'd like to hear whether or not people had a discogram before their ADR.

Doctors in LA: I loved Dr. Anand and I'm very impressed with their prompt replies to my questions. Dr. Anand even called me up to ask if I had further questions. He has done 30-40 Prodisc surgeries. I think I would like to go to someone who has done more than that. I have an appointment next week with Dr. Patrick Rhoten, as he was recommended along with Anand by my orthopedist. I have also made an appointment with Dr. Regan, as the Activ-L trial is very intriguing to me. If I decide that Prodisc is the better option for me, I think I will get an appointment with Dr. Delamarter. I've read very good things about Regan and Delamarter. If anyone has had a negative experience, please PM or email me. Am I on the right path? Is there anyone else out there I should see?

Many thanks in advance for your guidance. It is very overwhelming to become a spine expert overnight!

[CharlesinCharge]

To my knowledge, most good surgeons will not perform ADR or fusion surgery without a discogram first. Although you clearly fit into the profile of discogenic pain, it is best to be as sure as possible before they cut you open. One spine specialist I went to told me that he has seen several MRI's where patients had huge disc tears and herniations and they were in absolutely no pain at all, and he has also seen many MRI's where there was nothing abnormal at all and the person had so much back pain they were bedridden!!

There are literally dozens of causes of back pain and while it is likely that yours is discogenic based on your MRI and pain pattern, I would very highly recommend a discogram to verify this diagnosis. Although there is much disagreement in the spine community about the validity of discography, most agree it is still the best thing going to verify if the disc is the pain generator.

[ThomasL]

It is my understanding that LA Spine Institute is performing the surgery you are looking for.

Dr Rick Delemarter is part of that practice and I watched one of his surgeries with a Prodisc product last night that was conducted in 2007. I am in the process of scheduling an interview with him to discuss his practice, proposed treatment plan and experience.

If you want to really expand your knowledge. Invest $300 in the book I am discussing in this forum. It will answer all your questions and a whole lot of ones you never though of.

thanks!
Thomas

[mark-perth]

http://www.ncbi.nlm.nih.gov/pubmed/19121822

If you have a look at that link, the full paper is a real eye opener. The abstract doesnt tell the results in detail but for certain movement directions the loading increased the most actually with the Activ-L with it increasing the load on the facets during lateral bending 453% more than a human disc where the Charite was only 32% more than a natural disc. It explained that every disc had a problem in a certain direction. The prodisc and Activ-L had similar loadings in the same directions as there design are similar. Some directions the discs caused similar or less loads than the natural disc. Basically each disc had positives and negatives with none being perfect. Please send me a PM if you cant get access to the full version.
Goodluck,
Mark

[JudyW]

I had a discogram and I'm glad i did. I had several orthopedic surgeons in Orange County pretty much insist that my pain was coming from L5-S1 and wanted to fuse it. I had the discogram, which is painful, and my pain generator turned out to be L4-5 and no pain response at L5-S1. I had prodisc on 7-31-07 and I'm very happy I did. I don't have anywhere near the pain I had before. I don't think i will ever be pain free and I have to work at it all the time but it was well worth it. I love my surgeon, Dr. Robert Watkins Jr. Marina Spine Center in Marina del Rey. He and his father are very well known in Los Angeles. Good luck.

[CharlesinCharge]

Mark makes a REALLY great point that ANYONE who is having ADR or thinking about it needs to consider. Every single model of the artificial disc out there has some impact on the facet joints, none of them perfectly match their original disc, and the loading issues have the potential to be a problem for some that get ADR. I asked several surgeons if there was a way to tell in advance if someone would get Adjacent Segement Disease (the levels above and below a fusion going bad) when they had fusion surgery, and they all said NO---it almost seemed to be random. They said that many studies had been done to try to figure out if certain things predisposed someone to get ASD, but they have never been able to establish a conclusive link. Basically, if you get a fusion you "roll the dice" as to whether or not you will get Adjacent Segment Disease down the road. Everyone knows that over a 15 year period after fusion about 35% of patients develop ASD, but no one can say which ones will and which ones will not.

From what I have read and heard from surgeons, it is the exact same with ADR and facet joint issues. Every disc out there has had patients that had facet problems (some to the point that they needed revision surgery) and every one has also had great success stories. You are truly rolling the dice if you have ADR surgery when it comes to your facet joints, and I did not learn this until AFTER I had my ADR surgery. I was one of the lucky ones who did not develop facet issues (for now, knock on wood), but my surgeon said there is no way to be sure ahead of time if you will or you won't, no matter what kind of disc you use. He has seen patients with no pre-op facet issues develop severe ones after ADR, and he has seen patients with compromised facets go ahead and have ADR anyway and do great.

Does not give one much comfort, does it??

[Harrison]

We've been having this conversation since 2004, but I am not so sure patients, docs or researchers have come to any new conclusions! Thanks for the reminder on the recent abstract, now below. Notice that the last paragraph uses "interpretations" rather than "conclusions."

That said, as short as this abstract is, it reminds me of my lack of biomechanical expertise! Meaning, I have more questions after I read abstracts like this; after reading this it is hard for me to make any comparative assessments that suggest one disc is any better than the other...

Charles, for what it's worth, I've heard about 3% degeneration per year as a rough indication of the rate of ASD for fusion -- but I think these benchmarks are dangerous -- as they are based on so many variables.

Amapola, back to you. Most spine surgeons require a discogram, as it is considered a best practice to confirm the source of the pain. Given the invasiveness of the ADR surgical procedure, it's not a bad investment of your time. Also see the FAQ forum for the discogram topic.
_______________________________


Influence of different artificial disc kinematics on spine biomechanics.

Zander T, Rohlmann A, Bergmann G.
Julius Wolff Institut, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany.

BACKGROUND: There are several different artificial discs for the lumbar spine in clinical use. Though clinically established, little is known about the biomechanical advantages of different disc kinematics.

METHODS: A validated finite element model of the lumbosacral spine was used to compare the results of total disc arthroplasty at level L4/L5 performed by simulating the kinematics of three established artificial disc prostheses (Charité, ProDisc, Activ L). For flexion, extension, lateral bending, and axial torsion, the intervertebral rotations, the locations of the helical axes of rotation, the intradiscal pressures, and the facet joint forces were evaluated at the operated and adjacent levels.

FINDINGS: After insertion of an artificial disc, intervertebral rotation is reduced for flexion and increased for extension, lateral bending, and axial torsion for all studied discs at implant level. The positions of the helical axes are altered especially for lateral bending and axial torsion. Increased facet joint contact forces are predicted for the Charité disc during extension-- influenced by the existence of anterior scar tissue--and for the ProDisc and the Activ L during lateral bending and axial torsion. The studied artificial discs have only a minor effect on the adjacent levels.

INTERPRETATIONS: For some load cases, total disc arthroplasty leads to considerably altered kinematics and increased facet joint contact forces at implant level. The spinal kinematic alterations due to an artificial disc exceed by far the inter-implant differences, while facet joint contact force alterations are strongly implant and load case dependent. The importance of implant kinematics is often overestimated.

[kimmers]

It seems that some people develop facet problems and other don't. From what I understand, the load increases are on the posterior aspect of the disc.
Since i got an ADR, I try not to do any back bends and don't do anything that hurts.
I knew about the potential facet problem before i got my ADR. My facets had miminal hypertrophy.

So when i first started having injections for my new back pain back in January, the first injection procedure was an intraarticular facet joint injection. I had medial nerve branch blocks (the nerves in front of the facets) two weeks ago. The conclusion is my facets are fine.
I know that the famous German doctor, DR. B, has already done a facet joint replacement surgery so I think that is the future to prevent or "fix" facet joint problems.

Doctors in Los Angeles: I stayed away from the LA doctors as i don't necessarily believe it is a good thing to go to doctors who are like a spine factory. That is just IMHO.
There are well-known doctors that are not as famous as say Delamarter or Regan, that people on here have used.
I am really particular with doctors as I am a nurse. When i first learned about ADR and understood I was a candidate, I did get four to five opinions and one was a phone opinion. Initially, i was told outrageoous stuff like that the disc would come out and sever my aorta. This was like there was a real, huge chance of this happening. Doing research, I found this rare and not likely to happen.

Several doctors, I found were anti-ADR, and they really didn't know that much about ADRs. It was kind of surprising.

That being said, I found a doctor I trusted. My doctor is Dr. Sylvain Palmer in Mission Viejo, CA. I knew him prior to becoming his spine patient. He was actually my doctor, briefly, several years before. I worked with him a few times, knew people who knew him, my physical therapists recommended him highly. He is ranked among the top 20 neurosurgeons in CA. When i saw him on the first consultation, he cut to the chase and told me exactly what was wrong with my disc and how i could fix it and what my choices were. I felt very comfortable with deciding to have surgery with him.

There are a few doctors in this area that are good surgeons. I could have gone to a spinal doctor at Hoag Hospital in Newport Beach that has a good rep. Phylly on here goes to Dr. Carlson in Orange. You just have to find a doctor that fits what you want. I wouldn't put my life in the hands of just any doctor because when you have major surgery, or for that matter, any surgery, that is what you are doing. There are risks with any surgery.

As for discograms, I believe in them and think you should get one if possible before undergoing fusion or ADR. In the scientific literature, there are lot of questions about discograms but I found a discogram very definitive. Plus it is a good idea to get the CT after the discogram as that shows the morphology of the disc. In February, I saw a neurosurgeon who told me he didn't believe in discograms and didn't do them and he didn't believe in ADR, either, of course.

Kimmers

[ThomasL]

I guess one can look at it like a Disc Factory - whether it is in LA or in Bogen. From what I heard, no one in Seattle has done more than 12 ADR's. Perhaps a handful of multi-level ADR's have been completed. I don't have much of a choice except out of state. IF I'm going to travel - why not go for the best.

For my procedure. I'm looking for EXPERIENCE. I'd rather be #3501 rather than #4, #12, or #20. At this point, they are still learning all the nuances of the procedure.

A day for a patient stay in the Hospital: $20k. What is a surgeon paid for a procedure: 3k-5k. OUCH! Somethings wrong with that.

thx!
Thomas

[Cris009]

Hi ,
I had ADR surgery in LA on april 3 . I just went to my 6 week appt wednesday. I have NO pain and am going to start PT next week.
I strongly recommend Dr John Regan of Beverly Hills. His confidence and expertise all show through when you meet him. HIs credentials speak for themselves! He has been at forefront of ADR surgery for a long time.

Check him out ,youll be happy you did

cris