Am I a candidate for ADR?
 

Hi,

I had an L5-S1 herniation (left-side) since 1997. I toughed it out until January 2009 when I had the herniation trimmed.

That significantly improved my sciatica, but didn't help with lower back pain. I knew this would be the case beforehand, however, so I wasn't complaining.

I had a good summer walking and bike riding etc, but unfortunately in late July 2009, I reherniated the disc. The latest MRI shows another bulge in the disc.

I don't understand why trimming the disc ever works for anybody, since it loses all it's hoop strength once it ruptures, and trimming it only weakens it further. Regardless, apparently that's all some people ever need. I was told to do lots of walking after the surgery, and I did TONS of walking. Which, it seems to me, just peens the disc; of course it failed again!

Anyway, everytime I go in for surgery, I risk infection, surgical misshaps etc. Clearly this disc is going to continue all the way down to bone-on-bone. I don't want to repeatedly roll the dice and get discectomies. And none of this is addressing the fact that it feels like someone swung a baseball bat into my lower back.

EDIT: All other discs are in perfect condition. Just L5-S1 is messed up.

My question: Am I a candidate for ADR? All the investigations I've done say "no" because I have nerve compression due to disc herniation. I don't understand this. Do I need to keep having discectomies until it's bone-on-bone, and then if I have pain, pursue fusion or ADR?

Dave

Sounds like you need a second and or a third opinion. Many surgeons in the US are not yet comfortable with disc replacement. What I did was an internet search of all the neuro and ortho spine surgeons in my insurance provider network, then called their office and asked them. Something like "I need lumbar surgery and would like to know if DR XXX does disk replacement".

Hi Dave,

I'm sorry to hear you're back where you started and I always wondered the same thing with what I think of as "band aid" procedures. I think it's great that they work for some people, but in most cases I can't figure out how they could even remotely be a long term fix.

I'm not sure I'm qualified to say whether or not you're a candidate, but I'm curious what kind of investigations have you done that lead you to say you're not an ADR candidate? Have you gotten opinions from several ADR surgeons?

~Sara

Once the disc is removed there is no nerve compression
 

Dave,

Nerve compression has nothing to do with ADR sugery, because in ADR surgery they remove the disc and replace it with an artificial one. Once the original disc is removed, it obviously cannot be pressing on your sciatic nerve! As such, I do not see how having nerve compression can possibly stop you from having ADR surgery. It is true that some people that have ADR surgery do not have any nerve compression, such as myself (I only had lower back pain, my discs were damaged but were not pressing on any nerves), but others do. The key point I think is that when a person has nerve compression AND lower back pain, having a discectomy will only address the nerve compression (leg pain). It cannot fix the back pain because that is almost always discogenic pain, i.e. coming directly from the nerves inside the disc itself. The disc has to be removed completely to stop that pain, necessitating fusion or ADR surgery. Whoever told you that you are not a candidate for ADR because you have nerve compression does not know what they are talking about in my opinion, I know many people that had leg and back pain and were fixed with ADR surgery.

Good luck,

re adr
 

Dave,

Quick reply:
You do not want to have your disc go bone to bone. As I understand it, putting in an ADR in that situation is sometimes not possible.
Welcome. And I hope we can help and support you on here.
Here we get MRIs faster, but you can be denied the MRI in the first place. I was as my insurance refused to cover it.

So I have a working theory as to what that quote I gave above from AlphaKlinik means. I'm thinking it should really have said something like:

"ADR may be recommended if there is disc herniation and nerve compression, or if discogenic pain can be definitively proven in the absence of herniation and nerve compression."

I'm worried that they actually mean that a requirement for ADR eligibility is having no nerve compression due to disc herniation. i.e., that you need to have pain that is coming from the disc only, and that can't be proven unless there's no nerve compression.

I dunno, but I just submitted my online form at AlphaKlinik and uploaded my mri and surgeon reports. I guess in about a week, it'll be cheers or tears. If they say I'm eligible, I'll Fedex a copy of my mri CDs so they can be extra sure I'm a candidate before I fly all the way to Germany. It feels like my whole life comes down to this one piece of news. It's gonna be a stressful week of waiting.

Wish me luck!

Dave

Dave,

I think you're mis-interpreting the statement because it seems to clearly say nerve compression is part of what would trigger an ADR recommendation. Basically, as far as I can tell, that statement means those are two of the common conditions in which ADR is appropriate. The most obvious one is herniation and nerve compression. I'm no expert, but I would imagine that any kind of nerve compression is a prime target for surgical resolution since the last thing you want is damage to your spinal cord.

However, the other one is a little more subtle. You can have fairly normal looking disc height (my case) and little to no nerve compression but still have a disc worthy of replacement. That's what a discogram is for, determining whether or not the disc is the cause of your pain regardless of whether or not nerve compression exists.

For example, to my knowledge, a herniation to one side or the other may not demonstrate nerve compression or associated symptoms. I've gotten that just from reading a little here and there about this stuff. Now, my own herniation was central and there were the beginnings of some minor nerve compression because the herniation was toward my spinal core. The compression wasn't too terrible yet, but certainly would have been in the long run. I kind of like to think I acted just in time to avoid major nerve damage. Disc height was ok which I think is what prompted the way my MRI report was written (that it was all minor herniations) which then triggered my initial surgical contact's reaction to say I wasn't a surgical candidate. That was based off of the written report alone, not a look at the MRI images. The second surgeon I spoke with took one look at the MRI pictures and said flat out that unless PT and such were helping, I was indeed a surgical candidate.

Once an actual spine surgeon takes a look at your MRI pictures, you'll likely get a much better diagnosis and plan of attack. At least, I would hope so anyway.

~Sara

Not an absolute contraindication to ADR
 

Nerve compression can complicate the ADR surgery, but it does not prevent the attempt. My disk was pushing the left S1 nerve root around, although I only had S1 symptoms for a few weeks after the initial injury in 2004. My surgeon reviewed the MRI with me and pointed out that he would have to dig a little more to get all of the disk material, as it had also migrated a little inferiorly behind the top of S1. The contingency was that if all of the disk material could be removed, he'd do the ADR. If any component could not be reached, he would change mid-operation and perform an anterior fusion.

I was told that fusion would not result in much chance of pushing the remaining disk material around but that the ADR, with the moveable disk insert, could put pressure on any disk material left in the spinal canal, possibly causing recurrent or new symptoms.

See a qualified surgeon and review the MRI with him/her. Good luck.

-tc-

Thanks for your great responses guys!

Dave

Screwed
 

"Dear Mr. XXXXXX,

Thank you for sending your pain history. Dr. Wagner has reviewed your documents. An artificial disc replacement is not recommended, because of a hemilaminectomy before. The only indication is a fusion."


I don't get it. I had the disc trimmed. To get at it, the surgeon went in from the back. He had to cut some bone to get in of course. There's no other way in. So why do I see everywhere that you can have ADR after having the disc trimmed, but yet I'm ineligible?

Figures. This is devastating news. I'm so upset I can't even tell you.

The operative (disc trimming) report states:

"The patient was given a general anesthetic in the supine position. He was flipped prone on the Hall-Relton frame. The back was prepped and draped in a standard fashion. The skin was injected with 1:500,000 epinephrine solution. I performed a left-sided L5-S1 interlaminar dissection. A portion of the inferior lamina of L5 was removed, as was the superior portion of the lamina of S1. The ligamentum flavum was removed. A portion of the inferior articular facet of L5 was removed. I identified the traversing S1 nerve root. I used a Kerrison to follow this nerve root across the lateral recess to the level of the neural foramen. I then mobilized the nerve root medially. There was a moderate disk protrusion present here. I made a rectangular incision into the posterior annulus of the disc space. I then removed the disc material by piecemeal. There were some prominent fragments posteriorly, so I used a reverse-angled curette to push these fragments into the disc space. Once this was done, I then used a pituitary to safely remove the fragments. At the end of the posterolateral decompression and discotomy, the left S1 nerve root was completely free of undue pressure. I could easily mobilize it medially and laterally to the level of the neural foramen."

This doesn't seem to me to be a hemilaminectomy, as the MRI report stated. On the web, a hemilaminectomy is where they remove the entire lamina on one side. He only trimmed it. I can see it myself on the images.

I just sent AlphaKlinik the operative report. Maybe that'll help. I also asked...nay begged.....if I could Fedex my MRI CD to them so they can see the images for themselves.

I'm seriously crapping my pants.

Sorry for all the endless posts.

"A portion of the inferior articular facet of L5 was removed."

I think that's key here. ADR requires sacrificing of the anterior longitudinal ligament, thus slightly worsening the support structures of the spine. The posterior support must be intact. Absence of a facet would result in some loss of stability, probably more so in rotation but more motion would occur on the surgical side with flexion/extension, as well.

Don't consider it as an absolute blow to success. L5-S1 fusions have a higher success rate than other levels. You also will likely be able to get care locally or regionally rather than head overseas. Good luck.

-tc-

Just so everyone is aware, if you're thinking of getting a disc herniation trimmed now, and then plan to get an ADR later at AlphaKlinik if necessary, THINK AGAIN.

"Dear Mr. XXXXXX,

Hemilaminectomy is a common procedure and how you have said, it was cut the part of the bone and removed the slipped disc herniation. General our surgeons don’t do it ADR, when the hemilaminectomy or laminectomy is done in the same level.
If you want, you can send the MRI to us, but the recommendation stay the same.
We offer also the fusion in our house."

Dave

Alpha Klinik is not the only game in town.
 

Dave,

It may be that Alpha Klinik will not do an ADR after a hemilamenectomy, but I know there was a member on this site (Terry) that had one and later had a two level ADR at Stenum. It would certainly be CRAZY to go all the way to Germany to have a fusion, you can have one done here and your insurance will pay for it, they most certainly won't pay for you to go out of the country to have it done. But, I would check with other ADR surgeons and hospitals, I know that Alpha Klinik is not the only game in town and their opinion is just that---their opinion.

ADR Surgery: Science & Art
 

Dave,

By now, I am sure you have read this thread in the most active forum:

ADR Risks, Complications, Disqualifications

In my opinion, this is one of the most important topics on this site. Though posts go back to 2004, this 2008 topic is a good summary of possible contraindications for ADR. That said, as we've seen, there continues to be significant variances in "patient selection" for ADR surgery. More specifically, some surgeons may be accused of "cherry picking," rightly or wrongly. This is more apt to be seen in clinical trials, where adherence criteria may be more strict -- because the guidelines are more detailed.

Keep searching and learning if you can. If you find that you are tired from sitting & reading, find a few meaty topics and print them out for reading when you are relaxing. E.g., for this topic, go to "thread tools," then click on "printer-friendly" topic.

Jack, Sara, Tim, Kim, Charles -- thx for helping Dave think through some of these difficult steps. :angel:

Thanks everybody.

This week has been an emotional rollercoaster. But I'd be wandering around in the dark without your site, Harrison.

I did take a look at Stenum, but there seems to be an abundance of horror stories (at least, more so than for AlphaKlinik), and the website heist really grinds my gears. Harrison took the gentlemanly route and threw the law in their face. I'm more childish, and with a knowledge of computer in/security, I would've hammered them into the ground that way. Either way, Stenum is not for me.

The crazy thing is, there was a newspaper article here in Toronto a few months ago (near the end of 2009) which said that the current waiting time to get a fusion here is 10 years. That's right....years! Insane. I suppose a newspaper won't make that stuff up. They focussed on a woman who went to India to have it done. Worked out well for her. India, however, not for me.

I'm seriously considering going to AlphaKlinik for fusion. If Zeegers will do it, I would say I'm definitely in. Why have the bozos around here do it?

Thanks again to everyone for their support - truly a life saver, and I mean that literally.

There's so much suffering on this board, it boggles my mind.

Anyway, even though I'll probably do fusion, I'll keep updating in case it's of some interest.

Dave

I found the article.
 

I had the wrong newspaper. It was in the Toronto Star.

If you Google "toronto star" and "Woman got my life back after surgery in India", you'll see the state we're in over here.

Dave

Hmmm. On my original issue about whether disc herniation with nerve compression disqualifies someone from ADR, Dr. Bitan's website reads,

"The disk involved has to be studied with an MRI and a discogram. The main complaints should be back pain, which eliminates cases of severe spinal stenosis, and acute nerve compression by a herniated nucleus pulposus."

The word "acute" is interesting.

Dave (more confused than ever)

You may be mixing things. A laminectomy removes part of the vertebral body, which would really mess you up for future ADRs. A discectomy removes the bulged part of the disc, which shouldn't affect future ADRs.