Spine Osteoporosis

[Harrison]

Something I mention on the new video DVD (filmed a few years ago, if you can believe that) is the problem of localized osteoporosis. It continues to be a serious issue for some ADR patients - even after many years of doctors performing ADR. Why is that?

Case in point: I watched this video on youtube and was troubled by it for a few different reasons:

1. Does every patient get a DEXA (or similar) scan in Germany (regardless of clinic)? Does the patient get a bone density test result for their spine? How about here in the US?!
2. If this diagnostic measure is always performed in Germany, why is serious subsidence still occurring?
3. The spine broker’s description of the video below is concerning; why would a doc not actually check the very area of the spine that IS DISEASED?! Maybe that is the case and it was just not explained carefully.
4. Dunno if Cortoss is still the preferred “drug of choice” for spinal osteoporosis for Dr. B and others in Deutschland, but I’d like to see more information on this injectible polymer. Please note: this cement was approved by the FDA for fractures; not diseased bone.

See the link and the confusing marketing message here:

http://www.youtube.com/watch?v=5O2HiCcCmRA

"...A bone density test should be taken before any artificial disc replacement surgery. For lumbar patients they are done on a wrist. You want to test the part of the body, which was no disease. Lack of bone density can be corrected by Dr. Bertagnoli before surgery, but not correcting this problem can lead to subsidence of the prosthesis..."

[2cool4U]

Sometimes bone density measurements taken at a level that has significant degenerative disease can be artificially elevated due to sclerosis of the bones secondary to the adjacent disc disease. Also, there can be osteophyte (bone spur) formation that can lead to artificially elevated measurements. In that setting, taking only that measurement might lead one to miss significant bone density loss.

It would seem to me that it would be prudent to measure two or three areas. Typically, the lumbar, hip and wrist are used. I agree that localized osteoporosis should be excluded, and then a hip or wrist measurement could be used to give a better indicator of systemic bone density status.

-tc-

[Harrison]

Thanks Tim. Regarding your comment, for which imaging technologies would your observations apply?

I don't know all the newer refinements from the last two years, but I know that there are a large number of possible imaging techniques for patients, e.g., DEXA, CT/XRay or MRI with/without contrast, etc.

Most concerning (obviously) is why osteoporotic vertebrae are not identified on whatever imaging processes are being employed to screen the patient before surgery. This problem was identified over two decades ago with artificial disc surgery complications -- so why this is still happening is a shame for a long list of reasons.

[2cool4U]

I'm specifically referring to DEXA scans. These are reported out with overall mean bone densities in the areas examined, typically the lumbar spine and hip. However, each level of the spine is examined and reported out with the bone density at that level in grams/cm2. Each level is then compared to a young adult population and an age-matched population, yielding scores that indicate whether the density is above or below average and how many standard deviations from the mean each level measures.

The information is there on every DEXA scan to allow for review of each specific level and to focus on the level of anticipated surgical intervention. The numbers should be reviewed, but the index image should also be reviewed for any of the complicating factors I listed in my previous post, lest the reviewer be mislead about the true bone density.

I had a pre-op DEXA scan and reviewed my specific values in the lower lumbar spine before turning it over to my surgeon for review. I am of the opinion that it should be a standard pre-op test for ADR patients.

Hope this helps, or did I make things as clear as mud?

My standard hedge applies here: much like MRI physics, I have a basic knowledge of bone densitometry, but I don't keep up with the cutting edge techniques.

-tc-

[katherine]

Hello--
I have been cleared for a two-level lumbar (L5-S1 & L4-5) ADR. Review of my case included Xrays (dynamic and normal); MRI; and bone density scan.
The DXA bone density scan results taken at levels L 2,3,4 have an average total T-1.8.

However, the spine surgeon I met with yesterday for a second opinion before taking this gigantic step said I do not meet the industry's standard qualifications for ADR---that my DXA has to be T-.1 or lower. Are there industry standards? How do I find out what the standards are? Who do I trust for truly objective guidance so that I can make a good decision?

katherine

[Harrison]

This is an important topic I am refreshing in case some of the new folks missed it. This is a VERY critical issue, as we've seen cases of "localized" osteoporosis with patients in this community that were not caught by pre-op scans of any kind. Some of these problems were missed, overlooked or not diagnosed. Some of the subsequent surgeries led to devices subsiding into the vertebral bodies.

Though this is not a common event, it is still happening. I've been saying this now for FIVE YEARS. There's no excuse for this continuing problem! Doctors at SAS: what are you doing to prevent these risks? Charging MORE money for a revision is NOT acceptable!

People, are you watching the video we produced for YOU? Please also read the first topic in this forum on risks and study it carefully. Read it several times!

[Fuzzy]

I had a dexa for my lumbar because a german doc ordered it. T -2.0. I was decided to redo both a dexa and then a CT on the area to be operated on by another doc. Dexa the same and the CT said T -1.9 for those areas. Surgeon (Germany) said its ok to go ahead, Active-L has more contacting surface the previous designs, less chance of subsidence.

It was already decided to do a fusion at the lowest level. Post op report show him commenting that the vertabrae at S1-L5 in particular had a soft nature to it but L4/5 (the ADR level) was "better". Surgery was sucessfull, no subsidence. With my neck I was told it is not nearly the problem it is with lumbar (3 german surgeons) and no problem (1 US surgeon). Previous surgeon suggested redoing dexa for my neck surgery due to my history with the (sucessful) lumbar ADR. I ddn't, surgery ok so far.

Dr. Zeegers (Munich, Germany) told me that the "cement" was only for an absolute last resort and not something to plan on when planting an ADR into suspect bone quality.

[Harrison]

Fuzzy, you raise some interesting points here, so thanks for posting this. We've talked about this tricky issue frequently: there are significant differences among artificial disc designs. It seems that the spine world could have learned more from the many experts in knee and arthroplasty fields, whose efforts (R & D, trials, hundreds of thousands of surgeries, patient complications, articles) taught us so much in the last fifty years. Some patients seem to be learning the same mistakes over and over again.

If I recall correctly, Dr. Zeegers helped design the ActiveL and ActiveC, which explains why the end plates better conform to vertebral bodies; as this design would seem to:

- Distribute the weight & stress of the human spine load more evenly across the vertebral body;
- increase the size of the "sweet spot" in implant positioning, being more “forgiving” than keeled devices;
- thereby minimizing the risk of subsidence of the device.

This is a bit of syllogistic reasoning based on both engineering principles and marketing messages. That said, I cannot recall if any patients here have experienced Active L or C devices subsidence; but the number is negligible or non-existent (at least reported here). Also note previous discussions that concerned revision surgeries with a keeled device: they are not easy, even with a skilled surgeon. Add bone cement to the equation and it gets worse. Much worse.

I am not an orthopedic engineer by any measure, but I am still partial to a non-keeled design. The stories from patients and the (seemingly) arbitrary studies I’ve found seem to coincide with this notion. Also, cutting into bone does cause blood loss and stimulate an immune response that may explain why some patients have an inexplicable, inflammatory pain response after surgery (not to mention HO in a small number of cases).

When disease is present, especially in the bone, and the device subsides, should we wonder why such a violent inflammatory cascade of pain tortures the patient? Add in MRSA or other microbes from the patient’s body – or possibly from the hospital environment & procedure - and you get, well, what happens to a some patients here in this community.

These occurrences make me frustrated and at times angry. But that’s why I started this community five year ago -- to get the issues out there and discussed. Though by my standards, these issues have been standing still. But more and more health professionals are part of this community as both patients and readers, so I’ll settle for ANY progress.

OK, I have to go back to my admin role now. I hope this post helps in some way.

[Harrison]

I am bumping this topic for Jamie and a few other folks. Please read this topic carefully if you've not already.

If anyone has received a DEXA scan and is willing to share it, I'd like to post it so people can what a spine DEXA scan report looks like. You (or I) can white out the personal information.

It's amazing to me that such a small percentage of patients will get a DEXA scan of their spine before artificial disc replacement. Given the nominal cost (less than $300) and additional diagnostic data, it's an absurdity that it's not a required procedure.

Pre-operative patients: please ask your doctor about this imaging study!

[Toebin]

Ohh gosh, here we go.. It's been a long time since I've posted here but I do skim the topics once in a while and this one is near and dear to my heart.

I did not have an ADR, was part of a clinical trial and was randomized for a 2 level cervical fusion instead.

I did have DEXA scans x 2 prior to surgery (don't have the results with me) that I was told were normal. HOWEVER.. they were done on my hip, not my spine ... and they were done as follow up to a cervical spine and chest xray that showed severe osteoporosis .... which my medical team thought was just poor technique instead of me having any severe disease.

My Doc's believed the DEXA scores and we proceeded with the fusion.

A year after surgery and I still wasn't fused.. go figure.

Come to find out I had a severe Vitamin D deficiency along with a very rare (and huge) Parathyroid tumor.

Gotta love 20/20 hindsight...

After removal of the Parathyroid tumor and massive Vitamin D replacement I had complete fusion of my cervical repair within 2 months.

I thank my lucky stars that I did NOT receive an ADR repair.. it is my firm belief I would be in a much worse spot now if I had.

DEXA scans totally depend on the area that they are scanning. They MUST be done in an area that conveys the bone health of the area to be repaired or they are worthless...

Just an fyi.. prior to having the Parathyroid tumor removed I had yet another DEXA (done on my hip)... and it was finally picking up signs of osteoporosis ... the tumor I had tends to suck all the calcium from the spine and ribs first and then starts depleting other bones after that..

Sorry Harrison, I know this did not answer the question you posted, but it does give some personal insight into the Bone Density issue and localized Osteoporosis, that can severely impact the recovery from spine surgery.