Lumbar L5/S1 - DDD w/annular tear - considering Medtronic A-Mav

[tenniskid]

Hello,

I have spent a considerable amount of time reading everyone's stories, experiences and concerns. I want to thank you all for posting your experiences and knowledge, as it has given me a lot of useful information. I also ordered the "getting back on their feet" DVD.

By way of brief background, I twinged my disc playing tennis last year in June. Had been up and down with my recovery from that but never fully recovered. Experienced SIJ pain and it took a long time to get a diagnosis of annular tear. Since October, pain levels were unbearable with difficult periods at work. This year have spent almost 60 days in hospital and rehab hospital from being run down to the bone at work - collapsed at work. The MRI shows a black disc and a massive annular tear in the L5/S1. MRIs of the SIJ seem perfectly normal. I have been off work since Feb this year and while I am managing my pain better now (despite the meds), I am considering my surgical options. Max sitting tolerance is 8 mins, standing is 10 mins and walking is 2.5 mins. I am now walking with crutches but am largely housebound and continuing with a home exercise program. I do hydrotherapy twice a week. My life has been significantly affected by this condition. I am going to go for my first coffee this Saturday since February! I am 31 and previously was a Div 1 college tennis player on scholarship.

I saw a neurosurgeon in May and he recommended I go with the A-Mav medtronic disc. He said I was the perfect candidate for the disc as I had no other contraindications. I then saw a neurosurgeon on Tuesday who gave me his concerns regarding the A-Mav, and recommended a minimally invasive "key hole" spinal fusion. His concerns were as follows:

• metal Ion wear for Metal on Metal artificial discs;
• as the patient reaches their 60s and 70s there is significant risk that the disc will sink into the bone; and
• concerns regarding facet joint degeneration after ADR.

Regarding the first concern, I have read previous posts on this topic, and would like to post a link to a more recent study that found not as much metal Co/Cr metal wear in ADR patients as compared to hip replacement patients (Metal ion levels in patients with a lumbar metal-on-metal total disc replacement: SHOULD WE BE CONCERNED? -- Bisseling et al. 93-B (7): 949 -- Journal of Bone and Joint Surgery - British Volume) although I don't have the full paper.

Question 1:
My question for Maverik patients or people in the know, what was your surgeon's opinion on these risks?? My original neurosurgeon seemed to think the A-Mav was titanium. I don't know if this is a new and improved version of the Maverik disc, but any thoughts would be welcome.

Question 2:
Secondly, regarding this sinking into the bone issue, it is my understanding that this can happen in fusion cages too with patients with osteoporosis. If this is correct, then is the A-Mav disc that much heavier than a interbody fusion cage that it has a greater risk of sinking?

Question 3:
Third, I am going in for a DEXA scan tomorrow to determine whether there are any facet issues or bone fractures in my sacrum/pelvic area. My MRI results show no signs of arthritis or osteoporosis. Both surgeons said I was a good candidate for their respective procedures and that the rest of my spine is apparently healthy. I am leaning towards ADR but given the risks above, I have become slightly uncertain. I guess I would like to hear your thoughts on the above issues. It seems that with the vast amount of research I do on both fusion and ADR I end up more confused. I know that both have risks, but I would like to hear your thoughts.

I am seeing my original neurosurgeon on 26 July. Regarding both of them, I would put my trust in both of them - they are both highly regarded surgeons. As for personality, I much prefer my original neurosurgeon who recommended ADR as he seemed much more concerned about my wellbeing and wanted to help.

Thanks in advance and good luck to you all.

[Hooch]

Historically the outcomes for fusion have been so poor there was a lot of interest in moving to artificial discs or anything that worked better really. These days fusion rates are much higher and less invasive ops.. for a single level at l5s1 it's hard to say if adr will necessarily have a better outcome than fusion after a year or so. In general the literature has supported that adr's have a slightly better outcome than fusion in the short to medium term.

Allergic reaction to the metal is considered very low risk, they dont test for it. Doesn't mean it wont happen. Ion build up over time is just one of those things. The same thing happens with hip replacements with metal. i'd be surprised if there is any definitive data anywhere.

The fusion cage is just a structure to promote the fusion, once the bone grows through it the cage is redundant. Most of them these days are PEEK which has a similar density to bone.

You're Aussie? If you're in Sydney I know a few names, but you sound confident in your doctors.

Honestly you could almost flip a coin in your situation, I'd be looking at the history and experience of my surgeon as this could likely have a bigger impact on the outcome... can he/she get there without damaging my sympathetic nerves (vascular surgeon or they go in on their own?), how many times they done the op etc.

For a single level adr the figures are about 85% happy with the op. That is fair. Make sure your facets are in good nick if you go that route, get a decent physio lined up, good luck.

[tenniskid]

Dear Hooch,

Thanks a lot for your detailed explanation and your clarification regarding the fusion cages. That makes a lot of sense now. Yes my ADR surgeon has had a lot of experience with doing ADR discs and specifically has implanted over 100 Maverik A-Mav discs (previously performed charite ADR operations), so I feel pretty confident in his decision. He also performs the surgery with a vascular surgeon. Yes I am an Aussie, based in Melbourne. I have also met many people that have underwent fusions with him and have all been pretty happy with him. Thanks for recommending a few names in Sydney though. As it happens, my pain level has decreased considerably in the past three weeks (not getting constant unbearable pain) and my mobility has gotten much better, so I am more than willing to consider other names and extending the time to go into surgery if it means I'll be in the right hands. Take care!

But thanks again for the info. I hope you have a nice evening.

[tenniskid]

Hi everyone. Just thought I would post a quick update.

The bone scans came back negative for any facet or joint issues, or any small fractures. Basically, my situation has not improved. Still unable to walk without crutches, and had a pretty tough time of it with flareups etc.

I saw my neurosurgeon again this week and we have decided to go ahead with the surgery. He is a really great guy and I have absolute faith and confidence in him. After making the decision, it is like the weight of the world had lifted from me. I am now so relieved and happy to be on the other side of the decision-making process. I have done the best I could, and now there will be a timeline for my recovery and a chance at complete recovery. I am excited about the prospect of walking again without crutches too, having been on them for 8 months. To be able to go for walks and sit for longer than a few minutes would be awesome too. There is so much of my lost life that I am so excited to reclaim!

I'll post in the surgical outcome forums once I have a date for surgery, and blog my progress from there. I'm very excited about getting a new Maverick disc!!

[Jstuckey]

Best of luck!