L4S1 super hard to decide!

[Fraben]

Hello, Everyone!

I'm new here, so it's great to meet you all. A bit about me: I’m originally from Spain but currently living in Andorra, a small country nestled between Spain and France.

After 8 years of back pain—two of them with 24/7 discomfort—I’ve decided it’s time to take action. My L5S1 disc is severely degenerated, with no movement and very little disc material left. This has put extra strain on my L4L5 disc, which is starting to show signs of wear, though its height is still intact. The MRI is inconclusive about a tear. My symptoms are mainly low back pain on the left side with some tingling in my left leg, corresponding to the L5S1 left bulge. The L4L5 right bulge, however, isn’t causing me any issues.

A few months ago, I began researching artificial disc replacement (ADR) and decided to go with a ball-and-socket design—either the ProDisc L or ActivL—because I’m cautious about the LP ESP implant. I’ve read concerning cases about osteolysis, particularly in males at the L4L5 level, and there’s a lack of long-term data for ESP discs.

FDA-approved mechanical discs seem to have a more extensive track record. For example, this [20-year study](https://cuellarspine.com/wp-content/...1-Patients.pdf) shows just a 1.26% removal or reoperation rate for mechanical ADRs.

After consulting with several top surgeons in Europe, I’ve narrowed down my options. Money is not a constraint here since I'm lucky to have good insurance. Here’s what I’ve found so far:

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1. Patrick Tropiano (France)
- Pros: Highly experienced and takes reasonable aftercare of his patients.
- Plan: Recommends replacing both L5S1 and L4L5, even though the latter might not be a pain source despite showing early DDD.
- Concerns: I feel he is rushing it and does not provide detailed answers to questions.

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2. Dr. Bertagnoli (Germany)
- Pros: World-renowned, operates on high-profile patients, and has vast experience. Suggested a discogram for L4L5 to confirm whether it’s a pain source, unlike Tropiano, who assumes it needs replacement.
- Concerns: Poor post-op care. There are reports of patients being abandoned after surgery, with little to no communication or support from ProSpine if complications arise.

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3. Dr. Ricart (Luxembourg)
- Pros: The most ethical and honest surgeon I’ve consulted. He’s thorough with diagnostics (he also recommends a discogram) and not pushy about surgery. He’s confident and skilled in revisions, including removing discs and performing fusions if needed.
- Cons: Limited experience with my preferred discs—he’s placed around 80 ProDiscs and 20 ActivL, alongside about 600 ESPs. While he has been performing ADR since the 90s, I’d prefer someone with more ProDisc or ActivL experience (even though he says 20 implants is enough to master the device if you have experience with other implants).

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Bonus: Dr. Schmitz (Germany)
- Pros: A skilled surgeon with a great personality. Offers both ESP and ProDisc.
- Concerns: Poor communication after surgery and has been known to abandon patients with complications (e.g., a case of osteolysis with ESP, which I believe later Ricart explanted and fused).

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The remaining options, like Dr. Clavel or Dr. Rischke, primarily work with ESP or M6 implants, which I’m not comfortable with.

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What I Need Help With
I have to decide soon, and I’m torn. I know surgery success largely depends on trust in the surgeon and his skills, but I’d appreciate input from anyone who has experience with these doctors, particularly for ProDisc L or ActivL surgeries.

What would you do in my situation?

Thanks in advance for your thoughts!

[annapurna]

Laura and I have limited recent experience with ADR surgeons but there's two thoughts I could share. First, Bertagnoli was seemingly at his peak not too long after he put in Laura's cervical ADR around 15 years ago; old enough to be very experienced but young enough that his age didn't impede his surgical skills. Add fifteen years to that and it's a fair question of whether his age is a factor in the surgical suite. I don't know if you'd get a straight answer about his physical capabilities but you might be able to ask in a round-about way by querying how many hours per day and days per week he operates. Hopefully, he's begun limiting those and in so doing limiting the effect his age has on skills.

Second, at the very beginning of the spread of ADR usage worldwide (2000's or so), it was generally assumed you needed over a hundred operations to really be "good" at ADRs for some arbitrary definition of good. It sounds like Ricart is on the cusp of that with the ADR styles you want. I also believe that he's correct to some extent - the hundreds of surgeries with other ADR styles do add to his experience base.