What made you so sure ADR was the right decision?

[laid up doc]

So I have now had 3 different orthopods tell me that I should absolutely not have a lumbar disc replacement. see my signature, my bad disc is L5/S1. 2 of them do cervical, used to do lumbar ADR's, but stopped. of those 2, 1 is academic and the other community. both cited worse outcomes, and one voiced concerns about putting a weight-bearing metal-on-metal device in a woman of childbearing age, and doesn't even do cervical ADR's in young women.

The neurosurgeon I saw wants the ADR guy in his group to review my case, but would gladly do a MIS TLIF. Still waiting to hear back on that one.

I gave none of them a heads-up on what the others had said and expressed no preference of anything - just wanted their opinion. other than the anti-discogram geezer, they all thought that the only option i had left was surgery. i know that my interaction is a little different b/c i'm also an MD... i didn't get any strong feeling of "bias", just wanting to do the right thing.

am looking at having to move to cut costs while i schedule and have surgery, then recover enough to do my active job. fwiw, all have quoted different return to work times as well (3 wks to 3-6 mo). i think the "3 wk" guy underestimated the amount of lifting i have to do (i am an ER doc, so i have to do or lift just about anything - just the other day it was the leg of a 500 lbs woman - honestly i couldn't have lifted that thing on a good day )

Metal allergy concerns aside - trying to figure out how much of this is a regional thing - b/c many of you w/ worse bone and disc dz have said that you consulted multiple surgeons and they all said ADR. I know that TX and CA are much more pro-cut than the midwest and mid-atlantic/SE.

SO - how did all of you "know" that ADR was what you wanted? from reading things here? consensus of docs' opinions? seems a good # of you have gone to huge lengths to have an ADR.... financially, travel, etc. what made you SO SURE??

i welcome any thoughts, PM's, whatever.

[janaya3]

My decision was multi-factorial. Basically weighing risk vs. benefit in each model (spinal fusion vs. ADR). For me the biggest advantage of having an ADR was the motion preservation that it offered vs. a spinal fusion. My age was also a contributor and at only 36 YO I felt that I should at least give the ADR a try since it was covered under my insurance as long as certain criteria was met initially while other insurances in my past did not even offer ADR. I too am in the medical field and have taken statistics during my course of training/career and in the end you could argue either way however once you have a back fusion or if it was not partially-completely successful then it was irreversible from my understanding. You really couldn't undo the fusion while on the other hand if you had an ADR and you were not completely relieved of pain then you could revert back to a fusion. What I did was read all current medical literature that I could get a hold off especially the ProDisc L since at the moment it is one of two disc currently available for implantation in the US. The Charite is the other. I made a side by side comparison as well as the pros and cons of each disc with one another and comparison of a back fusion to an ADR. I took into consideration recovery time, physical and biomechanics of each, duration of time (AVG) that I would be out of work, limitations after a "full" recovery, possible long-term sequela associated with a fusion or ADR, etc, etc....

All in all and in the end, my decision in a right state of mind as well as with the help of my family (wife, mother, father, etc) was the ADR surgery appeared to be the best choice for me after it met all my criteria. Additionally I was sitting at the office of the neurosurgeon for my pre-op visit and in comes a gentleman with basically the same history, characteristics (age, wt, ht, body frame, etc.) and diagnoses as me (L4-5 DDD with mild facet hypertrophy) and we start a small conversation. Without going into the full details I was remarkably surprised and impressed that the man had just recently had the same surgery with the ProDisc L a month prior and he stated that he was pain free and back to work. He admitted that he was still recovering and doing very well. He really looked healthy and normal. This further solidified my decision to have an ADR performed.

I will also tell you I am only 6 days post op with the ProDisc L and can attest to the fact that the once nagging constant discogenic pain a I had 24/7 is gone. I do have other aches and pains mostly from the distraction of the the two disc that that people write about but have been slowly progressing. I do have hip, groin and some leg pain but I think it is all associated with having major surgery as I did. I walk alot, I can sit (unlike a fusion), don't require a brace and seem to have some of my energy back. I really can't wait to see what the future holds for me. I also think my little ones are ready for daddy to be ready so we can go play. Good luck on all your endeavors and I believe that whatever choice you make will benefit you in the long run.

[Jstuckey]

All of the above, plus a 2-3 level fusion was not something I even wanted to consider. Family doc and ortho doc both agreed that fusing that length of lumbar spine at my age and activity level was not going to give me the motion or long-term success I wanted. I would be fused over and over again through the years, right up the spine.
So, when hybrid surgery was recommended (l5-s1 facets too damaged for motion of an ADR) and my insurance company said no x3, I ended up with overseas options.
Hence, the huge investment, travel, etc. I believe I am getting a far better surgery in a few weeks due to the course of events that lead me out of the country: Better disc, better surgeon. My Midwest ortho doc agreed that the US is behind the times on this particular subject and gave me names of ADR surgeons around the world. Shocked me.
That's my story, and we'll see if I am still sticking to it in a few months!

[jss]

Doc,

I'd already had two cervical ACDF's and now I needed two more; and the MRI showed that I'd probably need a fifth in a few years. The life changes of having my neck fused into a 2x4 were simply not acceptable when a viable, proven alternative existed. (I was 46 at the time)

No more ultra-endurance sports, no more SCUBA, possibly no more driving, no more looking left/right/up/down without moving my whole body. Plus, no one could tell me the impact that four (and then five) cervical fusions would have on the atlanto-occipital and atlanto-axial joints. After damage from years of five cervical fusions, would they require fusing also?

In my case there was simply no upside to more fusions, and very little down side with cervical ADR which by 2009 had proven so effective.

Good luck, Jeff

[laid up doc]

thanks all for your input.

janaya3 - my understanding is that taking out or revising a lumbar ADR is risky as hell. i asked the surgeon i saw today if he did revisions and he looked at me like i was crazy. to me, they're equally irreversible - hence my hesitation. i'm even younger than you, 33, and have zero other lumbar spine disease. part of me thinks hell, if i'm gonna end up w/ a bad L4/5 X years into the future... better to have a TLIF now and keep my abdomen and vessels pristine. the surgeon i saw today really discouraged looking too far down the road, b/c the most important thing to do is what is best for me to do NOW.

and jstuckey - i'm fortunate (ha) in that i have to choose... though the metal allergy thing may end up choosing for me. i hate that so many people here suffer to the point of such severe disease.

just found out today that i have "very mild" bulges at C5/6 and 6/7 - basically i have an abnormal reflex that i've known about since med school started 10 yrs ago, but when the NS detected it and found out i have left upper back pain and some lt arm tingling - demanded i have an MRI prior to having my neck extended for anesthesia. but again, bones are pristine.... and "very mild".

[JJames]

Doc,

Thank you for asking this question. I've read all the replies and look forward to reading more as they are posted. I will keep this short, but basically I am stuck in "survival-mode". I cope well enough with my daily pain to maintain my employment - paycheck, medical insurance, 401k, etc - as I have a wife and 2 children (10 & 14) counting and depending on me. I have zero "life"! I know the day will come, and one way or another I will likely be forced into ADR or fusion surgery, but I am simply stuck right now. Sometimes I consider it may be out of fear of the unknown outcomes or perhaps my lack of medical knowledge. Regardless, I sure find it insightful at what leads others with these horrible issues to their very courageous decisions.

Thank you and good luck to you!

Jeff

[Vicki_in_Florida]

What swayed me towards ADR over fusion is the fact that right now, I only have one degenerated level.
I've had several doctor's tell me that the one thing they don't like about fusion is the damaged long term to the discs adjacent to the fusion.
If I look at it from that viewpoint, I am a good candidate for ADR and what's the worst thing that can happen if the disc doesn't work? I will end up with a fusion anyways.
At least it gave my adjacent discs more time away from screws and more pressure and possibly more degeneration.
The hard part is deciding what doctor and which disc.
The US doesn't have a lot of options.
Charite was pulled off the market in the US.
Is the Prodisc next or will it be proven to hold up and not cause more damage to the facets? Time will tell.
Talking to Dr. Boeree who has no monetary gain from using one disc over another, prefers the M6-L for my situation.
I would highly recommend a chat with him.
Very non biased and backs up his theories as to why he likes one disc over another.

[Cirobi]

Why did I choose ADR over fusion?

This is an excellent question. Actually, when I finally got to the point of needing to and had the opportunity to speak with a surgeon, I was actually hoping that ADR was going to be a suggestion.

My manager had actually found info about it online when he faced a 2-level cervical fusion and when my back was really bad, he mentioned it and the concept behind it. As a 27-yr old formerly athletic person (former because of my lumbar issues), it seemed like the ideal solution. Chance to keep mobility without potentially causing more problems? Yes please! Chance to work my way back into being closer to the slimmer athletic build I had enjoyed through early college? Yes please! Chance to truly resolve my pain issues? YES YES AND YES!

Little did I know there was actually degeneration at other levels at the time. And, that part solidified the choice even more. Chance to preserve other disk levels as long as possible? Yes please!

Was I concerned about anything? Sure. Seeing folks with facet issues and other issues that made ADR not the best solution, sure, it was a concern. My surgeon assured me that I did not fit those potential complication patterns. I even asked the question about pregnancy. Since I was only 27 at the time of my surgery and knew for a long time that I wanted children someday, it was a major concern. He wasn't able to draw from experience on that question but said that he saw no reason why I couldn't be able to bear children with an ADR.

Once my significant other finally proposed, I searched feverishly online for accounts of other women with ADR who have gone through pregnancies. There's actually one woman who posted her account here and had a lot of pain issues. But, I was able to find accounts online where women had children pre-op and post-op and stated their post-op pregnancies were much less painful. Painless? Heck no.

Do I still have concerns now that I'm pregnancy with an ADR? Sure. I have to pose some questions to my surgeon for my OB's benefit. But from the first appointment I've expressed the fact that I'm much more comfortable with the idea of a c-section than regular birth just to further preserve the disk levels that I know could give me problems in the future.

Overall? I felt like there was more hope of a return to normalcy for the long term with ADR than there would be with fusion. I didn't like the idea that a fusion at L5/S1 could cause a chain effect up the rest of my spine.

I'm over 3 yrs post-op, age 30 and 15 weeks pregnant and can proudly say the only spine aches thusfar are when I sleep too long or in an odd position (mostly on my stomach-ish while trying to avoid a mid-night potty break, haha).

~Sara

[annapurna]

First, if you're willing to consider stem cell or stem cell-like treatments, you stand an excellent chance of not having to look down the road to mandatory surgery for a L4-5 or cervical problems. Those techniques are still being refined but they seem to be capable of heading things off if you can treatment early enough to reverse DDD or annular weakening instead of attempting to rehydrate a shriveled prune of a collapsed disk. Don't mean to say that it will work for everyone but I'd see if that's something you could keep a professional eye on given your metal allergies. Stem cell techniques have certainly been established and have multi-decade history of use in other joints.

Laura pursued ADR for all three levels she's had done because she simply had DDD with no facet problems. She was, though, found to have mild facet problems at L5S1 but that was post-MRI/x-ray but pre-surgical, back when you could be accepted as a surgical candidate with old imaging studies; not something that can happen now. She was young and athletic and it seemed like a good match. The local hacks had told her she was too young for fusion so refused to consider treating her so we had nothing to lose by pursuing long distance options.

[laid up doc]

so apparently the ADR surgeon in this neurosurg group finds no reason on my imaging that i wouldn't be a candidate for ADR. his trial nurse called me b/c they're recruiting for the freedom vs prodisc trial - but i still have this lingering metal issue, plus i have a lawyer b/c of the MVA and if i plan on suing her insurance company for thousands in lost wages and pain/suffering... can't do a trial. when i had more detailed ?'s about the metals, outcomes... she deferred to the doc, whose call i am very anxiously awaiting.

i have probably the most ADR-friendly insurance - Aetna - to the point where they are denying fusions for DDD/discogenic pain. i dug up a guy on the SPS site who had a fight w/ aetna, trying to get logged in over there to contact him. clearly i'm in the minority, but i did find this letter from the Am Acad of Neurosurg:

http://aans.org/~/media/Files/Legisl...r%20FINAL.ashx

challenging their anti-fusion stance. makes one wonder which insurance companies are in bed w/ whom. couldn't find any clear rebuttal, but Aetna's clinical policy dated 8/12/11 isn't promising. don't know what will happen if i am indeed allergic to those metals... but my allergy hx makes me fearful regardless.

maybe some of us can trade policies? i'll take a MIS TLIF for your ADR!!! opening bid = even trade! haha!