Pre-Dr. Bertagnoli, any other considerations?
 

I have been evaluated by Dr Bertagnoli. He recommends ADR for L5S1, with a discogram to go/nogo L45 and L34. Also ADR for C56 and C67. Cost for all 5 levels is $110K USD.

My concerns are as follows:

1. I'd much rather skip the discograms and commit to doing all 3 lumbar levels. Otherwise I have to go through all this 10 years from now and likely with a different doctor due to B's age.

2. I could probably save some money having the work done in the US, however I'm much more focused on outcome quality than cost. If the ADR devices covered in the US are less good, that's reason enough to go abroad, and I'd still be SOL on 2 of the levels on my lumbar.

3. Wiring a rental-house worth of money to an offshore account. How can I raise my comfort level that the guy on the other end won't just delete my contact info and buy nice things for his family?

4. For a 2nd option, I could also get evaluated by Dr Clavel, but it just seems like foot-dragging at this point. I don't have any concerns at all about Dr Bertagnoli.

Can someone just provide a little commentary if I'm missing anything important?

Much appreciated.

2) I really don't see how you'd save money in the US. Five levels in the US, including probably 5 days in the hospital... Well I imagine if you convinced your insurance company. But since only one level of ADR is approved by the US, I just never considered I'd get approval for 2 levels myself.


5) There is no doubt that Prof B is very competent. But I'd choose Clavel over his use of the LP-ESP over the ProDisc. That's just me personally. I realize Prof B might also be able to use the LP-ESP but it's not the one he seems to use most often.

1) There's been debate on whether you need a discogram if you're radiographically and pain/enervation symptomatic at a level. Feel free to push back on the need for a discogram on any level where it's plainly apparent intervention is required. If you're equivocal on X-ray, MRI, and examination, then the discogram or something to further assess you is probably worthwhile. There's also a body of evidence that a discogram into a borderline disk will push it over and encourage it towards DDD.


2) Obviously, we think well of Bertagnoli given that he put in both of Laura's cervical ADRs. Quality and skill in lining up multiple ADRs is critical. It's worth saying that, about a decade ago when Laura was needing ADRs, Zeegers said that Bertagnoli was the only surgeon he, Zeegers, would trust to put multiple ADRs into his own spine and Bertagnoli returned the compliment, albeit in separate conversations with us. Just because someone's experienced with single level ADRs doesn't mean they can do multi-level ADRs.


3) Way back when, we were able to wire money directly to ProSpine's account without the need for a middleman. In the intervening years, we've heard that the middleman is now required. If you're comfortable and your bank is comfortable with handling wire transfers, you might see if you can skip the middleman and go directly to ProSpine's account.


4) I'm not going to tell you that you should get a second opinion but, if your pain and disability level is such that you can wait for the 2nd opinion, it often helps. There are poster after poster who got very different opinions about what needed to be done when they saw different doctors. Sorting that out can be really difficult but it also points out whether you're clearly in need of surgery at every level or over the line on some and borderline on others.

Thanks for your response. Why do you consider the LP-ESP superior to the ProDisc?

Thanks for your detailed reply.

So many reasons.


6 degrees of movement vs 3 degrees of freedom.
Endplate material
Keel type design (on the Prodisc)



https://www.youtube.com/watch?v=zj-j2YjFjqI
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3567327/


This is just my personal opinion. The Prodisc has been on the market longer than the LP-ESP but the LP-ESP was first implanted (first gen device) in 2004, so there is a decent amount of history with the device.


There are a lot of people very happy with their Prodisc. Just who knows what their adjacent vertebrae is going to look like 15-20 years after implantation. It is a gamble either way, I'm just more willing personally to gamble with the LP-ESP. And I've researched this quite a bit.

Well dang it, I was almost ready to pull the trigger, now I need to do more homework. I like the LP-ESP lack of deep keels. As an engineer, I don't like stress concentrations that create a high-stress area in a critical material like a vertebrae. So I see why you wouldn't want a wedge driving against the middle of the bone for the next 30 years. And I want to start lifting again, so there's going to be a lot of force going through there. I do like the Prodisc non-elastic simple ball and socket joint. Giving up the axial degree of freedom does not bother me. I'd better go through the threads here on the devices to become better informed. Thanks again for your reply and the youtube video.

As an engineer - I have problems finding flaws in the LP-ESP.


I only worry about long term mechanical failure of the post / socket. That and the posts that stick into the nucleus to provide torsional freedom (within limits)...



Well even if I go through with it - I'll be VERY kind to my back over the next 40 years (god willing). No unnecessary lifting, etc...


I realize that's one of your concerns - being able to lift. Others do it with this disc I'm sure. Iris at lifeafteradr.com seems to be putting it through its paces.


For me the degrees of freedom are relevant in order to prevent adjacent segment disease.


I'm most interested in Dr. Desai, but there are other capable doctors out there. Seems to me that the LP-ESP is growing in popularity.. There seems to be a number of physicians that (2? more?) that use to mostly use the M6... But moving to mostly use the LP-ESP.


8 years ago it had 7 years of clinical experience. While nowhere near as many implantations as the M6, you'll be hard pressed to find someone clamming the design of the LP-ESP... Questioning it's safety.


But it's a gamble... Any of these are a gamble.

I sent my information via snail mail to Dr Desai today. Appreciate all your information.

Responding to a PM where the member's inbox is full:
It appears you have read several posts on this forum explaining this. Among many reasons:

1. USA uses older, inferior ADR devices.
2. USA limits you to one lumbar level and two cervical levels.
3. Getting your insurer to pre-certify and pay the claim is a major undertaking.
4. By the time you pay your deductible and out-of-network penalty, there's no guarantee USA will be any less costly.
5. The US doctors try to bait you with ADR and then perform fusion on some or all of the levels.
6. The top US ADR doctors are much less experienced than the top European ADR doctors.
7. US doctors' number one priority is medical malpractice fear, number two is crowbarring their work into what the insurer will pay for. This leads to ultra conservative or non-ideal care that's not in the patient's best interests.

There's plenty more.

Fbss
 

funcrew;

You forgot one FBSS / Failed Back Surgery Syndrome. Apparently if your surgery goes south , you might have contracted the dreaded FBSS. If this wasn't so pathetic it would be comical. The fact that this term even exists is reason enough to go to Europe.

SAD UH? :confused:

Jack,

[EDIT: Upon reading the 2012 follow up study on the ESP that you linked, it looks like they flexed the device 40 million times per direction under 30 to 300 pounds of force, with little to no performance degradation on the elastic core and no failures. That works out to about 3,000 flex cycles per day for my foreseeable remaining lifetime. It still makes me nervous, but I'm going to stick with the ESP.]

What about the non-replaceable cores on the ESP device? You're betting that the flexible core can withstand (in my case) 40 years of flex cycles without failing. If it does fail, then I would need someone to drill out the plates and start over with new ADR or fusion. That seems like a very long service life for a flexible part. Surgery is in 2 days. I meet with Dr. Desai today, will ask whether he would consider a pro disc. Dr. Bertagnoli's salesman Tim Vicknair does not like the ESP for this reason, but he's not an unbiased source.

Compare the "Literature summary of biomechanical simulations for wear" table at:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4705139/

I'm concerned about the PCU aging and plastic deterioration. But when you compare the (apparent) debris generated alone from the ProDisc vs the ESP... And all that metal and plastic that would be thrown out from the ProDisc comparatively...

To be fair there are pros and cons to all of the discs out there. I think the risk vs reward of the ESP is the best. How many completely independent super-respected doctors still use the ProDisc...

Desai, Clavel, Berg, others in Germany, Switzerland... Using the ESP.

And unless we're running, few of us are putting 300lb of pressure on the disc. I know some people go back to weight lifting, etc... I'm going hopefully enjoy my discomfort-free life, improved ROM, etc... And not press my luck.

Good luck - please post an update when you feel up to it in the coming days...

While I agree with the basic premise: every ADR has its pros and cons, I do need to comment on your statement about forces on the ADR. If you're living a normal life, you're putting 300 lbs of pressure on your ADR. The biomechanics of lifting ordinary loads, hopping up on a step, etc. generate a lot more force on your spine than you'd think. You may not hit 300 lbs every hour of every day but you'll hit it a lot more than you think you will. The person/being/committee/(whatever your belief system is) who did the original design of your spinal column was pretty smart in how it withstands loads without letting you realize how high those forces are.

Let's say the average mass about L5-S1 is about 120 lbs.


I absolutely do agree that walking will put more than 120 lbs of force on your spine. Just not that every step generates a force of 300 lbs.

It's got me wondering now actually what those forces would be though...

Regardless I don't plan on testing it. Live my life, do some light resistance training... brisk walking... But that's about it.

Activities of Everyday Life with High Spinal Loads

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035320/

Wow there's papers on just about everything.


I guess I'm going to need to be extra careful when lifting anything of any real weight going forward.

My view is that if you receive fusion surgery (standard in the USA) then Failed Back Surgery Syndrome is very likely to occur in adjacent levels within 5 years. My father-in-law, a gentleman I no longer contact for any reason, is the poster child for FBSS. He does whatever his insurance-paid Texas back surgeons tell him to do. Dude has very little remaining mobility in his entire spine, and constant severe pain.

Surgery update
 

Funcrew,
Did you have your surgery in March as planned. If so, how is your recovery going.