Two level ADR in the San Francisco Bay Area

[msf]

I'm new to this forum and very impressed by the amount of great info. Trying to figure out if I should have a two level (L4/5 and L5/S1) fusion or a two level disc replacement (or a hybrid procedure). I've done a lot of research and am pretty familiar with the pros and cons. I was hoping to find someone here who has had a two level ADR done in California/on the West Coast and could give me a name and a place. I am considering flying to Germany to have it done but was hoping that I could get it done locally.

[Slackwater]

Originally Posted by msf

I'm new to this forum and very impressed by the amount of great info. Trying to figure out if I should have a two level (L4/5 and L5/S1) fusion or a two level disc replacement (or a hybrid procedure). I've done a lot of research and am pretty familiar with the pros and cons. I was hoping to find someone here who has had a two level ADR done in California/on the West Coast and could give me a name and a place. I am considering flying to Germany to have it done but was hoping that I could get it done locally.

I have not had surgery, yet.

The one gentleman I know personally with a two-level from the SF Bay area is a sailor post-surgery, skippering a boat, pulling on lines and riding a motorcycle. The fellow went to Germany and had two (2) Activ-L (Aesculap) put in his back. My limited recall is I took a picture of him 60-90 days after surgery, skippering a boat, doublehanded, and pulling lines.

Ask your selection of orthopaedic surgeon for references to patients that had the ADR/TDR procedure so that you may have a dialogue. The issue of seeing patients with a two-level ADR/TDR is you are outside of the FDA approved guidelines, so you may be asking for something that is not possible, or rare, further limited by insurace company coverage. Does your insurance cover ADR single-level, two-level, or hybrid fusion-ADR?



Other:

Dr.Bozic & Dr. Vail of UCSF wrote a paper related to joint replacement, surgical volume and procedure, process items after analyzing 180,000+ primary surgery TJR patients. The Orthopaedic Research Society gave the paper an award at the 2010 Annual Meeting, award going to Dr. Bozic, well-deserved. Dr.Vail, Chair of the UCSF Department of Orthopaedic Surgery, also helped design one of the Aritifical Hip Replacements devices, DePuy ASR XL (MoM), to my limited understanding.


2010 Orthopaedic Research Society (ORS)
Annual Meeting Awards
ref: http://www.ors.org/web/Awards/AwardWinners.asp


Link ( 12KB )

The Influence of Procedure Volume and Adherence to Process of Care “Quality” Measures on Patient Outcomes in Total Joint Arthroplasty (TJA)

+1 Bozic, K J; 1 Maselli, J H; 1 Vail, T P; 1 Auerbach, A A
1. University of California, San Francisco

"One of the key elements of TJR clinical care pathways is adherence to processes
of care derived from evidence-based clinical practice guidelines, such as the
process measures we analyzed in our study. Our results suggest that
standardization of care via clinical care pathways is most effective when
adherence to the pathway is greatest, that care pathways can improve
patient outcomes independent of surgeon and hospital outcomes, and
that process standardization may even magnify benefits related to
hospital or surgeon procedure volumes."

"In summary, our data suggest that although higher surgeon and
hospital procedure volumes are unquestionably correlated with improved
patient outcomes in TJR, maximizing adherence to process of care
measures is also strongly associated with better patient outcomes and
more efficient resource utilization. Therefore, we believe that process
standardization could help optimize quality and efficiency in TJR,
independent of hospital or surgeon procedure volume."



See UCSF Spine Service

[msf]

Since I have some perineural scar tissue on my previous microdiscectomy site, I was told by one of the neurosurgeons (who has done a lot of ADR's) that there is a significant chance of having new post-op leg pain after getting my 2 level disc replacement. I don't have any leg pain right now-only miserable back pain. The reason for the possible nerve damage would be a "stuck" or scar tissue covered nerve being stretched from it's current position next to a collapsed L5-S1 disc to its new height next to a artificial disc (which is usually higher than the diseased disc). Did any of you "pre-operated" ADR members have this experience? Obviously, everyone is different but it would be great to get an idea how frequent or serious this outcome is.

[Slackwater]

Originally Posted by msf

Since I have some perineural scar tissue on my previous microdiscectomy site, I was told by one of the neurosurgeons (who has done a lot of ADR's) that there is a significant chance of having new post-op leg pain after getting my 2 level disc replacement.

Agree with the surgeon you cited, there is a risk. Surgeons get the view inside near the spine. Surgeons may see microdiscectomy adhesions, scar tissue during secondary surgery and know this data point as absolutely valid without it being reported in the literature. Secondary surgery on the same site faces the challenge of adhesions, scar tissue.

I can not tell from the lit.reports (Spine, The Spine Journal, European Spine Journal, JBJS) if the leg pain is possibly from a previous discectomy or other factors, similar to what happens with Fusions. The literature did not provide a link-correlation with previous microdiscectomy. May I suggest other patients have similar leg pains post-surgery (Fusion and ADR) without a previous micro-discectomy.

May I please ask, how many surgeons have you seen about ADR/TDR?
May I please ask, how many surgeons brought up this risk you mention above?

I'm just a patient. My request was for microdiscectomy (posterior access) to clear out bone spurs in the foraminal space, lateral recess, ... prior to a hybrid or 2-level ADR (anterior, transperitoneal or ... access). The last surgeon visited said yes, sometimes they do that, depending on what they see on the imaging.

[LBP]

I had 2 level lumbar adr by Dr. Westerlund in Encinitas CA but this dr has moved to the southeast coast. I believe his colleague Dr. Peppers at Core Orthopaedics also does ADR. Core participated in the Prodisc and Kineflex clinical trials.

Other CA frequently mentioned surgeons are in the LA area, Dr. Regan, Dr. Delamarter, and one or two more at the same practice with Dr. Delamarter.

Not familiar with any in SF area.

I do have left leg pain post 2 level ADR surgery. I did not have any prior back surgery. I'm finally getting some injections to help with the leg pain/nerve issues. I've also used ultrasound and hwave along with meds to help with ongoing back issues not fixed by surgery and the new leg issues post surgery.

If you look at page 3 of the ADR Frequently Asked Questions category you'll see a big list of ADR drs. don't click on FAQ at the top of the page but the category of Freq Asked Questions with all the common Q threads.

[msf]

Thank you LBP and Slackwater for your responses.

LBP, thank you for the doctor recommendations. I will go down to LA and see Delamarter. I am very sorry to hear that your are still dealing with leg and back issues after your surgery.

Slackwater. Agree that post-op leg pain is an issue with all fusion techniques as well as ADR's. I also think that that is one area where there may be a small chance that a surgeon who has done "a lot" of the procedure (ADR or any type of fusion) may make a rare difference.

To answer your questions: I have seen 5 different surgeons (4 neuro/one ortho). 3 of them do/have done ADR's (2 have a lot of experience, one has some/all have done 2 level ADR's with overall good results). 2 levels are not FDA approved so it is very likely that no insurance will pay. As a result, most docs won't even try to get the request approved by insurance.

Two of the three (ADR experienced) docs brought up the risk of leg pain issues after ADR surgery due to scar tissue from previous surgeries. One made it sound like it could easily be permanent nerve damage if there was a lot of scarring/fibrosis around the previously operated area. The other thought that the pain would most often be transient if one does not have any leg symptoms prior to surgery.

Finally, I definitely agree that if you ask enough surgeons you will always find someone who is willing to operate on you.

Thanks again.

[valandguin]

Hi, I had a hybrid procedure performed for my two level problem(fusion and ADR). I went to Texas Back Institute in Dallas six weeks ago and am doing really well. I totally recommend Dr. Blumenthal. Insurance covered the fusion and all hospital related costs and I had to pay for the Prodisc and implantation ($21,000). This is a great way to go for two level at L5-S1/L4-L5. L5 was fused to the already stationary sacrum and the artificial disc is at L4-L5 to prevent additional strain/degeneration at L3-L4 and for more natural movement.

Valerie Carter

Prodisc ADR @ L4-L5 - 4-2-10 Texas Back Institute - Dr. Blumenthal
Anterior Fusion @ L5-S1 4-2-10
Discogram - 3/2010
2 Spinal Blocks
Several MRIs
A million X-Rays
10,000 Lortabs / Percocets
Herniation and Laminectomy @ L5-S1 - 2008
2 years of physical therapy

[msf]

Hi Valerie,

Congratulations on making it to the other side. It is always great to hear success stories. The hybrid fusion/ADR seems like a great option. I am very happy to hear that you are doing well. It is also good to hear that there are options such as your surgery. My insurance has, as expected, denied my request for a two level ADR. Still not sure exactly what I will do but your story is one more important data-point in the overall equation. Thank you for taking the time to write about your experience! Best of luck with the rest of your recovery.

[valandguin]

Originally Posted by msf

I'm new to this forum and very impressed by the amount of great info. Trying to figure out if I should have a two level (L4/5 and L5/S1) fusion or a two level disc replacement (or a hybrid procedure). I've done a lot of research and am pretty familiar with the pros and cons. I was hoping to find someone here who has had a two level ADR done in California/on the West Coast and could give me a name and a place. I am considering flying to Germany to have it done but was hoping that I could get it done locally.

If you have a hybrid procedure, as I did at the same two levels, insurance will pay for your hospitalization and a lot of the costs. I had a fusion at L5-S1 and an ADR Prodisc at L4-L5 April 4th and I feel great!! All the fusion at that level does is extend your sacrum basically.