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Benjaminrbecker 11-13-2011 07:38 AM

2 Level Lumbar DDD Considering ADR
 
I would be grateful to hear from any members inclined to share info related to two level lumbar ADR.

Considering doctors (Bertagnoli, Clavel, Pimento, etc.).
Disc: M6L, Prodisc, Freedomdisc
Anything else!

Many thanks!

Ben

JEVE19 11-13-2011 11:02 AM

Hi Ben and welcome.

Did you read the surgical outcome section?

Personally, I would not consider Dr. B.
He owns part of Prodisc so there goes an unbiased opinion.
You don't want a back factory.

Consider post op care.

If you read through surgical outcomes, post op care is important and not all docs keep the "care" one you fly back home.

laid up doc 11-13-2011 12:38 PM

agree w/ vicki - you don't want to be part of a factory, or deal w/ someone w/ a huge financial incentive to put in a particular device when other possibly superior ones are available. (main surgeon i know of w/ big financial ties is Bertagnoli to Prodisc). as far as i know, Boeree and Clavel use the M6 b/c they like it and have a stream of good outcomes using it. no financial ties, not factories...

some people have had good outcomes at Stenum - but many have had issues reaching ANYONE post-op.

my experience w/ Dr Clavel pre and post op has been better than any with any US physician period - speaking as someone who has to advocate for care by other physicians on behalf of patients. obviously given the distance, it isn't THE SAME as having your doctor there to see you for say, a wound infection (which i have) - but i have had no problems getting into a general surgeon about that. you have to feel comfortable having your post-op care at a distance if you go overseas, period. i am in a different situation than most, being a physician myself (and beyond that, in a specialty that deals w/ just about anything).

many others have great experiences w/ Dr Boeree. Out of the German surgeons, I think Zeegars has the fewest complaints? He uses the Activ-L, which wasn't an option for me.

good luck - it's a tough and very personal decision.

Jstuckey 11-13-2011 09:14 PM

Good luck on your search. I have a lumbar hybrid (6 weeks post op). You are welcome to look through my blog for info, and ask any questions publicly or private message. I had opinions (besides my local) from Pimenta, Bertagnoli, Clavel, and ultimately went with Boeree.

Benjaminrbecker 11-14-2011 01:15 PM

Dear Vicki, "Laid up doc" and Joey,

Thank you very much for the information.

I am currently corresponding with Clavel, Zeegers and am hoping to hear from Boeree soon.

The M6 seems to be the best hardware out there notwithstanding the shorter period it has been available. The shock absorbing qualities seem to make it superior to the pro-disc.

It's a pretty scary scenario to have to go through and it is extremely helpful and comforting to be able to correspond with you.

I hope that you all are doing well.

Many thanks,

Ben (34)

laid up doc 11-14-2011 03:41 PM

you might pm herron65 - he had a 2 level lumbar done by Dr Clavel. do a search and you'll find a few who have 2 M6's by Clavel or Boeree.

i fortunately just needed one... am your age so can empathize quite a bit about device concerns. unfortunately there's no crystal ball... but i think i made the best choice i could.

Texas Toast 11-14-2011 07:42 PM

Ben,

I'm still awaiting testing, but my research points to 2nd-generation devices like the M6 and Freedom Disc.

Not only are they shock absorbing like a natural disc, they allow movement that more closely resembles natural movement. The Pro Disc, I think, is a ball-and-socket joint, allowing too much movement in all directions, stressing facets and adjacent discs.

The 2nd-generation discs are also one-piece. The photos I've seen of the Pro Disc make it look like it's at least 3 pieces; too difficult for the surgeon (or dare I say engineer) to correctly place in many instances. From what I've read, the pieces of the Pro Disc can also slip out of alignment.

Different devices for different situations, but I will have a ton of questions if a surgeon recommends the Pro Disc to me. Sounds your on the right track!

silversurfer 11-22-2011 11:53 PM

Am in the same boat. DDD at L4-S1 and have been "evaluated" by Bertagnoli and given a quote of almost $45k. These are the first concerns I'm seeing about B being a "factory" and am equally concerned about the issues of 1st gen vs 2nd gen products. Whereas before I was ready to jump under any German scalpel I could find (I've been researching this for almost ten years and B and Z were the only ones doing it back then), now I think I'll continue my research and look into Boeree and Clavel.

Also Ben:)

jss 11-23-2011 01:32 AM

Quote:

Originally Posted by silversurfer (Post 91612)
... now I think I'll continue my research and look into Boeree and Clavel.

Also Ben:)

Ben,

I would certainly encourage you to pursue those two surgeons. There are two more I would recommend just as highly that you consider; Dr Luiz Pimenta in Sao Paulo, Brazil, and Dr Jack Zigler at Texas Back in Plano, TX. All four of those gentlemen turn out a steady stream of positive outcomes with very few complaints from their actual patients.

Good luck, Jeff

Benjaminrbecker 11-28-2011 02:19 AM

Gents,

Thanks for your posts.

An update and some info.

Dr B gave me a quote of EUR 32.

I have also been in touch with Dr Pimenta in Brazil, Clavel, Zeegers and Boeree. It is very difficult to know how to proceed from here.

Z has provided by far the most comprehensive review and diagnosis of my condition (at a cost of EUR500; Boeree also charges, GBP250). The one sticking point I have with Z is that he recommends Active L, which is not second generation (not shock absorbing). He suggests Active L because he says that it is custom made for each recipient, whereas all others are not.

Regarding Drs Bertagnoli, Clavel and Boeree there seem to be many positive and happy patients.

I would appreciate any advice, info or update you may have as well.

Best of luck.

Ben

Harrison 11-28-2011 04:05 AM

In case you missed this important topic...
 
http://www.adrsupport.org/forums/f51...ications-9620/

:look:

Slackwater 11-28-2011 04:37 PM

Quote:

Originally Posted by Benjaminrbecker (Post 91716)
Gents,

Dr B gave me a quote of EUR 32.

also Dr Pimenta in Brazil, Clavel, Zeegers and Boeree.
It is very difficult to know how to proceed from here. (~Agree)

Z has provided by far the most comprehensive review and diagnosis of my condition (at a cost of EUR500; Boeree also charges, GBP250). The one sticking point I have with Z is that he recommends Active L, which is not second generation (not shock absorbing). He suggests Active L because he says that it is custom made for each recipient, whereas all others are not.

Best wishes for your side.

reference Activ-L documents, LINK

The biomechanics of lumbar levels varies slightly between L4-L5 and L5-S1. There is more compressive shear at L5-S1 because of vertebral angles, in general, and this can be erased by individual biologic variability of vert.angles and facets (angles) add another variable x person within ranges.

Look at the BBraun site / docs and you will note there is a specific mention of L5-S1. I

The Activ-L S1 plate is an additional option for the surgeon to address patient`s anatomy.

There are patients who have a sacrum with a rather round or egg shaped cross-sectional footprint.

For those patients the S1 plate has rounded posterior edges and can therefore be placed close to the posterior rim of the S1 vertebra without these edges protruding into the spinal canal.

This might enable the surgeon to use a larger size compared to the standard plate, which reduces the risk of subsidence and nerve root
irritation.

The S1 plate is just an option, there are of course cases, where the standard plate will fit better. X-ray templates are available which can be used for preoperative planning in order to define the appropriate plate type.

Anterior or oblique insertions are possible with a minimum disc height of 8.5mm.


Fixation: activ-L can have a keel like ProDisc or spikes. There are biomechanical tests showing better long term stress results, less chance of hiccups with spike-only. It is only lab testing, not in-vivo.

Dingie 11-28-2011 08:15 PM

Hi,

I am in a similar position, I believe I may be looking at a 2 level l3-l 5. I am having my discogram on 12/1/11, hopefully will know more. I have pretty much decided on Dr. Clavel assuming he wants my case:)

It is a long arduous and scary decision making process, I have found this site to be extremely helpful. Good luck with your decision process. In the end we all make what seems best for us:look:

Dingie

christinlal 11-29-2011 01:57 AM

Hi Ben,
 
I have just had a 2nd adr surgery with Mr. Boeree, and thank God every single day. I have alot of issues with a ProDisc C but I do not know if the the lumbar ones are problematic.
I would absolutely recommend Mr. Boeree, it was the best decision I have made in my life, and I spoke with Drs B, Zeegers, both analyzed my case, dr zigler in tbi, the fda limits the adr to only prodisc, and I would NOT want to chance having another one in my spine.
I wish you safety, and a pain-free future.
Christine

Slackwater 11-30-2011 09:03 PM

Quote:

Originally Posted by Slackwater (Post 91723)
reference Activ-L documents, LINK

DEL.TEXT noted -> minimum disc height of 8.5mm.

An interruption made me post before finishing the draft response above.

The minimum disc height ~may be of interest depending on a patient's MRI translation into a metric measurement. There is talk of over distraction pain that I acknowledge. Maybe the posterior longitudinal ligamet is innervated. The facet joints need to line up is a major factor.

The footprint Anterior-Posterior (AP) and Lateral is ~important so the ADR / TDR sits on cortical bone, not the cancellous (or trabecular, soft porous interior) bone.
http://www.delawarebackpain.com/pati...anatomy_17.gif
Small or incorrectly sized implants will lead to subsidence, sinking into the vertebrae. Subsidence will mean the facet joints will not line up correctly. Subsidence will be a reason for re-operation and defaulting to Fusion.

Subsidence was listed as a significant factor in the early ADR / TDR operations. "Complications of Artificial Disc Replacement: A Report of 27 Patients with the SB Charite´ Disc" van Ooij et al, 2003 Journal of Spinal Disorders & Techniques, Vol. 16, No. 4, pp. 369–383.
"subsidence of the prosthesis in 16" © 2003 Lippincott Williams & Wilkins, Inc., Philadelphi
A personalized disc replacement is a good concept. Biologic variabillity is normal. Subsidence does not appear to be a major ADR / TDR issue today because of surgical training or awareness created with the earlier patients where the literature comments by surgeons mentioned "size mis-match".

The latest Canadian study published 2010 (?) Link mentioned subsidence: average 1.7 mm (range 0-4.8 mm). Full text of the Canadian study is available (LINK). Figure 1 showing subsidence and radiographic disc size illustrates a ~possible footprint mismatch to my "untrained eye". The device sizes may be limited and that was the best match.
http://www.ncbi.nlm.nih.gov/pmc/arti.../0530408f1.jpgSubsidence was present in 44 of 53 (83%) patients at the L5–S1 level and was exclusively seen at the posterior part of the inferior end plate of L5. The mean subsidence was 1.7 (range 0– 4.8) mm, meas ured at 3 months after surgery. Although there was a marginal progression of subsidence beyond this time point, it was not statistically significant. Subsidence had no effect on the range of motion at the replaced segment and did not correlate with clinical outcome. In patients who underwent an L4–5 TDA, subsidence occurred at both end plates: mean subsidence was 0.9 mm at the inferior end plate of L4 and 1.75 mm at the superior end plate of L5.
The Chinese study Oct 2010, Zhonghua Yi Xue Za Zhi LINK, on 1 and 2 level Charite' for up to 60 months listed "no subsidence".

activ-L
"Clinical results show, that in approx 47.5 % the application of a small height (less then 9 mm) is indicated." (The activL quote is directly from the BBraun literature / pdf, this requires a look-up on pubmed for clinical reference? I believe the numbers on are on the hard disk)
S = (26 x 31)
M = (28 x 34.5)
L = (30 x 39)
XL = (33 x 40)

ProDisc II L (LINK) Product Insert
10 mm minimum height
m = (27 x 34.5)
L = (30 x 39)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~
LINK-Full Text
Eur Spine J. 2008 Nov;17(11):1470-5. Epub 2008 Sep 13.
Footprint mismatch in lumbar total disc arthroplasty.
Gstoettner M, Heider D, Liebensteiner M, Bach CM.
Department of Orthopaedic Surgery, Medical University Innsbruck, Innsbruck, Austria
~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Clin Biomech (Bristol, Avon). 1997;12 Suppl 1:S1-S63.
Precision measurement of disc height, vertebral height and sagittal plane displacement from lateral radiographic views of the lumbar spine.
Frobin W, Brinckmann P, Biggemann M, Tillotson M, Burton K.

Benjaminrbecker 12-05-2011 02:03 AM

Christine,

Thank you for your message. I take from your message that you did both procedures with Dr Boeree and that he used the Prodisc for you?

Many thanks,

Ben

Benjaminrbecker 12-05-2011 02:07 AM

Dear Slackwater,

Thank you very much for taking the time to write and provide such extensive information. I really appreciate it.

You have provided another important aspect to consider; subsidence. I have not reviewed the information at length yet but it appears to suggest that a "custom" fit option may be best given that each persons dimensions and issues are unique and due to the possibility of subsidence.

I will review the information at length.

Thank you again.

Ben

srajan0929 12-05-2011 05:24 AM

hi
 
i think nick does the m6L

Jstuckey 12-05-2011 11:03 AM

Yes, Mr Boeree is not a fan of the Prodisc, and currently prefers M6.

christinlal 12-05-2011 11:48 AM

Hi Ben,
 
My ProDisc C was done in 2009 here in Tampa.

Nick Boeree did the M6 a level above, and decided not to remove the (misaligned) ProDisc as it is doing it's job - removal is not a good option due to the large keels.

nanfromsactown 12-10-2011 08:56 AM

Quote:

Originally Posted by Benjaminrbecker (Post 91716)
Gents,

Thanks for your posts.

An update and some info.

Dr B gave me a quote of EUR 32.

I have also been in touch with Dr Pimenta in Brazil, Clavel, Zeegers and Boeree. It is very difficult to know how to proceed from here.

Z has provided by far the most comprehensive review and diagnosis of my condition (at a cost of EUR500; Boeree also charges, GBP250). The one sticking point I have with Z is that he recommends Active L, which is not second generation (not shock absorbing). He suggests Active L because he says that it is custom made for each recipient, whereas all others are

I think I can safely comment on the "custom made" comment by zeegers. For one thing, I believe he told me that the manufacturer has modified an implant intended for L5s1 with rounded corners instead of more square, because it makes the disc less likely to involve the nerve when using it for L4-5. I will try to get this clarified tomorrow when I see Zeegers. I do know that for me, and my spine, he implanted a disc size marketed and labeled for L5S1 into my L4L5 disc space. He said it was a better fit.


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