Hi from a new member
 

Hi, everyone, I am so excited to find this online forum. My name is Lei and I have a history of 30 years of lower back pain with DDD, and now I have two bulging discs and annular tear at both L4-L5 and L5-S1. I have tried many non surgical ways for healing. Now at the age of 47 and lying down most of the time on couch to avoid pain, I am coming to the point of finding a doctor who can fix my back surgically.


I had a consultation with Dr Guyer at Texas Back Institute last Tuesday. He told me that I need a two level ADR. He says that it costs around $50,000 because my insurance Aetna won't pay for it. He also says that if money is the issue, I can do fusion at L5-S1 and one ADR at L4-L5 and it will cost the half.


I have read lots of reviews about Dr. Bertagnoli online but can hardly find many reviews about Dr. Guyer in the field of ADR. I wonder whether anyone here has done surgery with him and how does it work for you?


Thank you so much!

Hi Lei! Welcome to the forum! I am sorry to hear about your back pain.

I dont know much about Dr. Guyer other than he is an associate of Dr. Blumenthal. Is there any reason you didn't consult directly with Dr. Blumenthal? I called and requested him specifically, I'm sure you can do the same if it would make you feel more comfortable.

I got the green light with him, but decided to go with the co-inventor of the latest FDA-approved lumbar prosthetic, Dr. Rolando Garcia.

If I were you, I would do everything I could to not have L5-S1 fused. It's basically the junction between your upper and lower body. It will restrict you more than any other lumbar level fusion and increase pressure on all your surrounding joints.

As far as your insurance, Aetna is a pretty big carrier. You may be able to submit for reimbursement if you end up having to pay for the surgery yourself. The dual-level is a little bit tricky though. Insurance companies in the US are dragging their feet as hard as they can to not pay for them. Realistically you may not get it covered or reimbursed.

But this is America and you can always fight them and sue them to change the legal precedent because it's a load of malarchy they're not covering these kinds of surgeries in the first place. You could change the world for others in your situation. But that costs lots of money and comes with the risk of losing to a huge corporation with access to lots of high-powered lawyers.

In any case, I wish you the best of luck on your search and journey!

Welcome Leipan.

There have been instances where a one level fusion and one ADR have been reimbursed. Texas Back has a great deal of experience in these insurance areas and you should be able to speak with an insurance specialist there. You will have a far better chance of reimbursement there, or other higher volume clinic in the US than outside the US.

Though I generally for ADR, I also know many patients that have had lumbar fusions and have done will in the long term.

BTW, Guyer and Blumenthal are a few of the most experienced ADR spinal surgeons in the country. You would be in good hands with either IMHO.

ADR with Dr. Guyer
 

Thank you so much for your input. DR Guyer told me that if I do L5-S1 fusion, L4-L5 ADR, The insurance company will pay for the fusion part, which cuts the cost from $50,000 to $25000. BUt he says that if we can come up with the money, he suggests two level ADR if he was the patient. So at this moment, we would like to go with two level as he sugguested. It is good to hear that DR Guyer is very competent, that is the impression I got with just meeting with him once. My insurance covers DR Blumenthal as well. So maybe I can have a consultation with him too to have a second opinion.


At first, I was considering going to Dr. Bertagnoli since his name is out there, but after reading the posting here, I realize that if I can find a competent doctor in the US, it would be much easier for post-op care or if there is a chance of revision. As far as the cost, $50,000 for two levels at TBI is probably not outrageous comparing to DR. B.


I got comprehensive and scared after reading the revision stories, but try to remember to be positive and hopeful.

Leipan, your post makes sense to me. But don't forget to connect with their reimbursement specialist(s)! These appeals take time.

ADR with Dr Guyer at TBI
 

Do you mean that if I pay $50,000 for the procedure out of pocket, I can still try to get the appeal going with the insurance company? You mean the reimburse department at TBI might help me with that process?


Thank you so much for your suggestion.


Lei

ADR with Dr. GUyer
 

I forgot to ask about the cost of revision. According to your experience, if there is anything wrong after the ADR surgery, and a revision need to be done such as a fusion. Would the insurance company cover or I have to pay out of pocket again? How about the post-op PT stuff? I saw other people posting doing PT after surgery, would insurance cover that even if they don't cover the surgery itself?

Those are all very good questions. Yes, you can still appeal even if they completely deny the procedure. As Harrison mentioned, get the ball rolling immediate because the entire process can take months, and speak with the reimbursement specialists at TBI. You dont have to wait until you get the surgery to do this.

I'm sure Dr. Guyer is stellar, but if it were me, I would want to go with the absolute best. Do you know if it would be any more expensive to go with Dr. Blumenthal?

In my case, I am in the first step of the appeal process. I will be starting PT this week and as far as I know, it will be covered. Not sure about the other stuff.

ADR with Dr Guyer
 

Thanks so much for the advice. I wonder whether you paid in advance for the entire surgery in one payment before the surgery ? The way I was told sounds like I need to pay in advance the entire amount.


I have no idea whether Dr. Blumenthal is more expensive or not. I visited Dr Guyer for the first time only one week ago and I am still trying to process the idea of having an ADR surgery soon. He is the first surgeon I have ever visited. Does Dr Blumenthal do more ADR than Dr. Guyer? How can one tell that which one is better? (sorry, I am so new in this area.) Mine is a two level, maybe the actual number of cases the doctor has done counts? If yes, where can you find the info?

You're welcome, I am happy to help.

It is hard to answer these specific questions. When I asked my doctor, he didn't even know himself how many he has performed. I got him to answer in a ballpark range eventually. It turned out to be in the 700 range.

I didn't have to pay for my entire surgery fortunately, but the portion I did have to paid did need to be paid in full before the surgery or the surgeon would not schedule it. I imagine if your insurance company is not going to cover it, you will need to pay in full.

Now, you have more options here. Most of the people on this forum who opt for lumbar disc replacement and have to pay for it themselves go to Europe because it is cheaper. You will not have the same legal protection as here in the states and it may prove more difficult to fight for an appeal, but it could save you a bundle.

If you are interested, I would recommend Dr. Pablo Clavel in Barcelona as a good place to start if you are interested in a multi-level abroad. He is among the more affordable and more experienced.

If you are still interested state-side, you may want to do some more reading on Dr. Blumenthal and why he may be your best choice. Just Google him. If he is local for you, even better, because he is probably the best in the region.

reference Dr Guyer
 

Thank you again for your advice. I am checking out how to contact Dr. Clavel's office and also find out Dr. Blumenthal is covered by my insurance. He and Dr. Guyer are both 2 hours away from me which is a huge blessings.

Once I have my discogram done, I can for sure consult Dr Blumenthal as well about the surgical plan. I also have received some high remarks from Dr. Guyer's former patients from this forum which is very encouraging. For me, if there is not a huge price difference, i would prefer to stay in the US just in case there is any issue after surgery.

Dr. Guyer has prescribed facet joint injection to rule out facet joint issues and then I will have a discogram and then a consultation right after. It will be in Jan due to the holiday season. I will update my situation once the surgical plan is out.

Thank you again for your advices and support. It means a lot to me.

You're welcome!

It sounds like you are taking things into your own hands now. I will be looking forward to hearing about your progress!

Best of luck!

facet joint injection
 

Hi, I had my facet joint injection done on Dec 12, 2018 mostly as a diagnostic tool. I did not feel any improvement for the first 24 hrs and the later one week. However, i notice that I can stand and walk longer time now which is 2 weeks later. Yesterday, I even went to mall with my daughter walking around on and off for almost 2 and half hours. In the past, I could only walk about 45 mins top without too much pain. Of course, after the mall trip, I came home laying flat on my heating pad to reduce the pain which is very much expected.

When the doctor examined me asking me doing forward, backward and left, right bending, I did not have any extra pain. My pain is always related to walking and standing and some times sitting for too long. That is why doctor Guyer does not think my pain source is the facet joint but the degenerated discs. But he still wants me to do the injection to rule out. When I did not notice improvement right after the injection, I assumed that the pain is not facet joint related. Now, I am not so sure. Another reason is that I also went to NCY to see a surgeon for a second opinion. His name is Russel Huang. After he saw my MRI and X-ray, he concluded that he would not do anything for me since he thinks that my MRI does not look bad to the point that a surgery is needed. Maybe because of the reason that I had a discseel procedure early this year, I am having good disc height and mild bulging on the image.

I wonder whether anyone of you have the similar injection and how soon usually it shall start to work if you do have the facet problem. My discogram is scheduled 3 weeks later and I am going to see Dr. Guyer in two weeks. I am still debating whether I want to have the surgery at this point of my life.

Dr. Bertagnoli also gave me the estimate and diagnosis about two weeks ago. His diagnosis is very similar to Dr. Guyer's, a definite L5-Si ADR and a possible L4-L5 depending on the result of discogram. Dr. B will use prodisc. I will find out what Dr. Guyer would suggest when i meet with him in two weeks.

Longevity of prodisc, or activ-L
 

There are several reasons that I am struggling with the decision of the surgery.

1) I am concerned about the longevity of the prodisc or activ-L if these are the discs I end of having. I am currently 48 years old. I don't know whether these discs can last for the rest of the life. If not, what are the solutions? (that would be the question I will also ask when I meet with Dr. Guyer)

2) Currently, due to the fact that I don't work, I can manage my pain level by not doing the things that will aggravate it, which are walking and standing on my feet. For instance, I can walk my dog for 30 mins and then lay down on my heating pad for relief of the pain. I manage not to take any pain med so far. If I have to do prolonged walking which is more than 1 or 2 hours, I always try to bring my wheel chair. If I travel, I always use my wheel chair for getting around. I gave up any sports such as tennis or running long time ago.

I guess sooner or later, I would have to have a surgery since it can only get worse. I just wonder postponing it for a while might give me more options? I will have a discussion with the doctor, but at the same time, I would love to hear what you guys think.

Obviously, the Activ-L isn't old enough for its longevity in real life situations to be challenged. The Charite has been, though, and performed well for over 25 years since it's early days. Rich/Harrison, Laura, and Sir Alistair have all had theirs in for over 15 years. There are others but all three of those are of the same vintage so it's easier for me to talk about them.

Delaying surgery can make surgical intervention more difficult or render it impossible to resolve all of your pain once you do get surgery. The decision to pull the trigger is up to you but there's risks associated with going too early or with waiting too long.

right timing to get the surgery
 

Thank you so much for your insight. I guess the right timing is definitely the key which I am not sure of. Dr. Pauza who did the disc seel procedure on me commented that my discs don't look that bad compared to my age group. He is puzzled why I am having so much pain after the procedure. But Dr. Guyer thinks it is the discs that are causing the pain. I might need to get more opinions so that I can be more confident on my decisions.

This is from a while back but it's worth bringing up again. Zeegers came to the US west coast for a conference about ADR surgeries over a decade ago, back when sources of information like this board were few and far between. Because of that, many of the potential ADR patients attended conferences in hopes of learning about the state of the art ADRs and surgeries.

On one slide, Zeegers threw up a MRI image showing a patient with a horribly desiccated and collapsed disk immediately below another disk with an extremely mild bulge then challenged the audience to point out which of the two were causing the patient pain. The mild bulge was the source of all of the pain the patience experienced. His moral of the story: pathology isn't the best predictor of pain.

If you feel your disks hurt and you're willing to go through to make sure it isn't nerve impingement or facets, then seek treatment for the disks and don't buy in to a doctor telling you that they shouldn't hurt because they aren't "bad enough."

disc pain
 

Dear Annapurna,

Thank you so much for your input about Dr. Zeeger's lecture. It is very enlightening to me. I guess lots of the doctors have not realized this aspect of diagnosis yet. I went to a different doctor in NYC and I was told that my MRI really does not look bad. He told me that he won't be willing to do anything for me since he is not sure. From the image, the level of degeneration is concordant to average people in my age group. (I am 48) He also said that the discogram is not that reliable so that they don't really do many discogram. This doctor works at Hospital of Special Surgery in NYC.

I am going to see Dr. Guyer soon and I have tons of questions for him. After reading some of the failure cases, I am terrified. I will update once I have the consultation with him.

Thank you again for helping me out here.

Do US doctors use adhesion barrier and Bone ceramics for ADR surgery?
 

Does anyone know that whether surgeons in Texas back Institute use specific techniques such as
1) adhesion barrier
2) AMP vertebroplasty (bone ceramics) if the bones are weak
3) thrombin agents to reduce surgical bleeding
4) bone wax to remodeled bone or adr preparation site to prevent osteophytes from forming?

I am going to have a consultation with Dr. Guyer in TBI. I am not sure whether it is rude to ask for the information since these are used by Dr. Bertagnoli in Germany.

Any info will be appreciated. Thank you!

Leipan,

It's been years since I was really close to the OR techniques, so I will only speculate based on what I learned from patients within this community.

1) adhesion barrier: the adage "less is more" fits here. Early on, meshes were used and some proved disastrous, complications and law suits followed.
2) AMP vertebroplasty (bone ceramics) if the bones are weak: if cracked, yes. But not for restoring bone mass or density. This is more popular with Euro surgeons.
3) thrombin agents to reduce surgical bleeding: not sure, but blood thickness/viscosity is carefully managed pre-op; any bleeding is obviously monitored and managed in the OR.
4) bone wax to remodeled bone or adr preparation site to prevent osteophytes from forming? Again, more of a Euro practice. Early on, there were infection problems.

adhesion barrier
 

Dear Harrison,

Thank you so much for replying. So according to your observation, adhesion barrier is not necessarily beneficial due to the fact that it might cause more troubles? I wonder what kind of adhesion barrier Dr. Bertagnoli uses. Do you happen to know? Is it a certain instrument or a technique?

Now I understand there are truly some technique differences between European and American doctors. When i read on the "superior surgery" page on Dr. Bertagnoli's website, I was unconsciously taking his ways as the "Golden Standard" without knowing that there might be some downside to the approaches too. Thanks for pointing out.

I struggle between the two options a lot. (Dr. B or Dr Guyer at TBI). At this moment, I don't know what to choose. I wish there are more public information about the surgical outcomes and techniques employed by US doctors. But I do find out a paper written by Dr. Guyer and Dr. Zigler that says "In the series of 1,707 patients, there were 17 patients who underwent TDR removal (0.99%) and 3 additional patients underwent TDR revision (0.17%). The rates based on the total number of 2,023 TDR devices implanted in the 1,707 patients, were 0.89% removals and 0.15% revisions. " These are the patients from last 17 years.


The link is below if anyone is interested.


http://www.isass.org/abstracts/isass...-during-a.html



Thank you! I would love to hear what you think and your perspective!

question about metal sensitivity test
 

update: I saw Dr Guyer yesterday and asked him a bunch of questions. He will use Activ-L for me based on my specific bone shape. He says it is a really good disc. He also said that he does not use adhesion barrier, bone cement, bone wax etc. He also does not preserve the anterior longitudinal ligament. Their revision rate is 1%. 90 precent of the people have 50 percent improvement of pain level. I asked him a bone density scan and prescribe a metal sensitivity test with Orthopedic Analysis.

He thinks it Orthopedic Panel one is sufficient for the test. However, i believe there is a titanium coating on the activ-L as I recall. I called the manufacture of Activ-L and asked for a list of metals in activ-L.

Does anyone have a metal sensitivity test with Activ-L at all? which panel do you use?



The panel one include: aluminum, cobalt, chromium, iron, molybdenum, nickel,vanadium, zirconlum
panel two include the above plus: Titanium alloy particles, cobalt alloy particles, bone cement particles, bone cement liquid

thank you!

metal sensitivity
 

I called the manufacture of Activ-L and was told that there is a 1/4 mm coating made from pure titanium power on the end plate. I called the Orthopedic Analysis and asked which panel is better. They just won't tell me. She kept saying that whichever the doctor orders. I am not sure whether Dr Guyer is actually awared of the fact that there is actually pure titanium power on the device.

It is funny that Orthopedic analysis people just does not want to help with simple stuff like that. I asked who else I can talk to but she refuses to tell me.

Can anyone help on this matter?

Lei

It might be that Orthopedic Analysis doesn't have a doctor on staff and thus can't give medical advice. Or, they've been ordered by their lawyer(s) to not offer such advice.

I didn't research the Activ-L so this is likely to be 90% my opinion with 10% fact but often the pure titanium powder is added to produce a hydroxyapatite surface which bonds well to bone. That said, there's a potential for titanium ions to go into your system from it. I'd suggest panel #2 would be a wiser choice. It's very rare to react to titanium but there have been other posters who did.

panel two
 

Thank you so much for your help! I think it would be safer to go with Panel 2. Also there is one more element that that is in Activ-L, but not in any of those panels . It is tantalum. Do you know anything about tantalum? unfortunately it is not even in panel two either. I will try to upload the pdf file in the next message. I don't know whether I should worry about it or not.

Activ-l
 

Attached is the metal info about activ- l I got from aesculap . It shows the element of tantalum

draw blood
 

I have trouble finding places willing to draw blood for me for my metal allergy test or charge high price for the simple drawing( $200). Is this a normal price for blood drawing?

I can't see the alloy breakdown that you posted well enough to know how much tantalum is present. It's typically a minor alloy addition. It's relatively inert and corrosion resistant so my guess is that the likelihood of allergic reactions to it is relatively small. If you were going to roll the dice and hope you don't have an allergic reaction to any given element, tantalum's a good one to risk.

tantalum
 

Dear Annapurna, thank you so much for your help. I really appreciate it. I tried to upload the excel file on this site so that it is more readable but failed multiple times. I wonder whether the file size is too big? (The picture is quite bad after being loaded)

But you are right. Tantalum is a minor addition in this case. I decide to "roll the dice" and keep my fingers crossed that I am not allergic to those other major elements in the implant. I will order the panel two and hope to find somewhere to draw my blood for the test.

Hopefully, Dr. Guyer's office can help me with the blood draw.

thank you again. I truly appreciate you helping me out the entire time ever since I got in the forum.

Lei

bone scan result
 

Finally, I got my discogram done yesterday and it shows my L5-S1 causes 10/10 pain and L4-L5 causes 7/10 pain. That is good news. But bad news is that my bone scan T number is only -1.9 for spine and -2.1 for hip. Based on my understanding, this number will disqualify me for adr. But I am not for sure yet until I meet with Dr Guyer next week.

I am very disappointed with my bone result and decide to do everything I can to improve. I know it is not a overnight fix and I don't know how long I can stand the pain... Maybe I can consider some docs overseas with the bone cement technology?

Any advice?

geez
 

BERTAGNOLI is about 65000 and he is your best chace at a full uncomllicated recovery. supprised no one adressed you questions on him hmmm. harrison is a keep it in usa man n he is ok guy. but I am beginning to think he is thrifty.

Prof Bertagnoli is your best chamce at a painfree life n full recovery he has the mist experience this isnt wven a question if you have 60000 go to him n live a oainfee life

bone scan result
 

Thank you for replying to me. I am currently doing a metal sensitivity test to see whether I am allergic to the metals in Prodisc. If I am , then I cannot go to Dr. Bertagnoli any more. I don't know whether my bone scan result is a trouble. Did you check your bone density before you went to him? thank you!

metal sensitivity test
 

Finally I got my metal sensitivity test today. I am reactive to Nickel and Cobalt, and mildly reactive to chromium. Basically, this rules out prodisc and activ-L. I don't think I can get the surgery in the US in this case.

I am also mildly reactive to titanium alloy particles. I don't know whether this also rules out any titanium discs. My number is 3.3. (See the report) 4 is the max number for being mildly reactive. 4 and up is being reactive.

I am going to consult doctors to see whether I can still get a titanium alloy disc such as ESP. Any input is welcomed.

Ask carefully what all of the components of any ADR are. Some of the non-titanium ADRs still had a titanium compound added to the bonding surface to improve integration to the bone.

titanium adr
 

At this moment, I am only considering LP-ESP now due to the sensitivity issue. LP-ESP is made of titanium alloy (Ti, Al, VA) and coated with a thin pure titanium T40 coating, and sprayed with Hydroxyapatite. I think I might do another titanium allergy test with MELISA if it is possible. All the discs in US are ruled out, unfortuntately.

ESP surgeons
 

I am trying to choose a surgeon who uses vertebroplasty and ESP disc. I have contacted 4 of them and I am waiting for them to respond to me. They are Dr. Rischke, Dr. Schmitz, Dr. Desai and Dr. Clavel. Dr Rischke is very fast at responding and very personal. I am still waiting for the rest of them to write back to me and give me an estimate.

Dr Rischke has really impressed me with how effective it is to communicate with. He wrote me back personally and was super quick. He is going to have a clinic in Hamburg to have surgery with international patients. So hopefully it can bring down the cost. His patients seem to be very happy with his care, even after they come back to US.