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Old 04-23-2005, 08:37 AM
Alastair Alastair is offline
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FAQ lumbar discprosthesis

**This is the Alphaklinik publication. How other Hospitals claim to do this surgery I don`t know**

Frequent Asked Questions about artificial disk surgery in the Alpha Klinik at Munich Germany
dr.W.S.Zeegers, orthopaedic spinal surgeon


Q: Should I be doing anything before surgery that would make the operation easier? (Exercises, diet, etc.)?
A: Keep fit, don�t take anti conceptive (somewhat higher risk of thrombosis) anti coagulants or aspirin-like drugs (high risk of bleeding). Try to lower your Bodymass-Index (BMI): in slim patients the approach and rehabilitation are easier, faster and with a lower complication rate.


Q: What is my Bodymass-Index (BMI) ?
A: Body-Mass index (� B M I�) measures your height/weight ratio. To determine B M I, weight in kilograms is divided by height in meters, squared. It is your weight in kilograms divided by the square of your height in meters. For instance, i f your height is 1.82 meters, the divisor of the calculation will be (1.82* 1.82) = 3.3124. I f you weigh 70.5 kilograms, then your B M I is 21.3 (70.5 / 3.3124). For Americans: height in feet and inches and weight in pounds. A result below 20 indicates that you may be underweight; a figure above 25 indicates that you may be overweight. A B M I of 25 to 29.9 i s considered overweight and one 30 or above i s considered obese. Almost every Playboy model is within the 18-20 area. People with B M I between 19 and 22 live longest, but remember, you can have a high B M I and a low body fat percentage. B M I is only one measure of your health. Body fat percentage, blood pressure, resting heart rate, cholesterol and other measurements are at least as important as B M I. For your general heal th condition you need to get the whole picture, but in slim patients surgical approaches and rehabilitations are easier, faster and with a lower complication-rate. The anterior approach can be critical in obese patients.
BMI What your BMI result indicates
Less UNDERWEIGHT
than 19 You are under optimum weight for your height. You could afford to gain a little weight.
ACCEPTABLE
You have a healthy weight for your height. Anterior spine surgery is a low risk procedure.
OVERWEIGHT
26 - 30 You are over optimum weight for your height. You may be facing health problems, so losing some weight would be a good idea. Anterior spine surgery can be somewhat more difficult with some higher rate of complications
OBESE
31 - 35 You are over optimum weight for your height. You may be facing health risks, so see your doctor to help you achieve a healthier weight. Anterior spine surgery is a medium to high risk procedure.
EXTREMELY OBESE
� 35 You are in danger because of your overweight. You are unfit for anterior spine surgery. Fat lowering drugs like Xenical are prescribed only in patients with MBI > 35


Q: With the discprosthesis, is the surgical approach through the front and the back, or only from the front?
A: Implantation of the Li nk artificial disk is only possible by an anterior approach, so through the front only.

Q: Can one get all the discmaterial out from just the front during a disc replacement surgery?
A: From the front all internal disc material which is in between the vertebral bodies can easily be removed. Even withdrawal of bulging material in the frontal spinal canal is possible. Only sequesters, that is loosened disc material i n the spinal canal , are sometimes difficult or impossible to remove from the front. The greater part of the ligament, the annulus, is preserved. Only a part the annulus at the frontal entrance i n between the lumbar endplates has to be removed to get the prosthesis in.

Q: What about scar tissue around a spinal nerve in the spinal canal?
A: Scar tissue around a spinal nerve itself will be undisturbed during implantation of a disk prosthesis. After widening up the lumbar segment by the implant there will be much more space for the nerve root and its surrounding tissue. Afterwards irritation by scar tissue is rare. For decision-making, the nature of the complaints are far more important then so-called scar tissue on the MRI . If leg pain is diagnosed as atypical and in the same proportion or less as backpain, then the scar tissue usually is not relevant at all. Even if you can see it on the MRI , because it is not causing the leg pain. I n all probability overloading of the dorsal annulus is mostly the source of that pain in back and legs. But� leg pain should not be attended with a typical radicular pain-pattern or the only and predominating problem. I n that case, usually the nerves are still compromised particularly by pressure and displacement: then decompression with or without fusion could be the better choice. Scraping off the scar tissue will not have a positive effect, but can be dangerous in damaging the underlying nerve root.

Q: For example if the pain is 60% in the back and 40% down the leg, is there an expectation that the surgery will relieve both pain elements, or only the backpain?
A: Hopefully and mostly both pain elements will be resolved, because of 1) restoring normal load on the dorsal lumbar segment and 2) restoration of the height of the intervertebral space around the nerve root.

Q: On my MRI it appears that there may be scar tissue attached to the tnerve root. Is there concern that the distraction of the vertebrae wil entail more risk than usual due to the constraint of scar tissue on the nerve?
A: Mostly the scar tissue is not very important, but � overdistraction and to much movement or more impingement can cause remnant pain. After normal implantation mostly it will not be painful l anymore.

Q: If one has had a collapsed disk for over 10 years, does this increase the possibility that re-obtaining normal disk height would increase the distraction factor?
A: There is almost no increase of over distraction risk. Sometimes some remnant irritation of the nerve root.

Q: What about the Discprosthesis versus so-called PDN device
A: Indications for disk prosthesis and PDN device are quite different. The Disc prosthesis (artificial disk) is used for total restoration of a painful l failed disk and implanted by the anterior approach, i. e. from the front. This is never accomplished during dorsal back surgery, but only in anterior back surgery. The disk prosthesis can be very succesful after failed back surgery and in primary degenerative disc disease. The PD N device is indicated only for the treatment of patients during a slipped disk (hernia surgery) operation who have also a degenerative disc disease. The goal of the PD N device i s maintainance or increase of disc height during herniated disk surgery f rom the back. The PDN device is used only as a dorsal spacer corresponding with slipped disk surgery (laminectomy). To be more clear: at the end of a lumbar hernia operation (slipped disk surgery) generally only the slipped part of the disk will be removed to relieve nerve root entrapment. I f the surgeon has the impression that filling-up the remaining intervertebral disk space will have a positive effect on the postoperative complaints, at that time a pair of PDN devices is implanted in the surgically prepared nucleus cavity during that dorsal (from the back) approach.

Q: Can one accomplish everything in one trip to Germany?
A: Yes, if one wants to do this in one tri p, the following schedule is most comfortable: arrival in or near Munich at Wednesday, overnight stay in a hotel or at home with relatives. Next day, Thursday, complete intake with X ray, M RI , discussion of all options, perhaps discography, laboratory tests and anesthaesist preview. The pre surgery anesthesiologist examination and tests should be done in Munich, that�s mandatory. At that Thursday evening before surgery you have to take an enema, and only a very light meal. Overnight stay in nearby hotel. Artificial disk surgery at Friday. Walking postoperative the same day. Discharge from hospital at Monday or Tuesday. Stay at the hotel or with relatives until second postoperative X ray and wound control on Thursday thirteen days after the surgery. Leaving for overseas flight from the fourteenth day on after surgery.

Q: When will the discography be performed ?
A: Usually in the afternoon on the day before surgery: Thursday afternoon. Right away after the discography the definitive diagnosis and treatment options will be discussed. Explanation about enema and diet.

Q: What are the optional incisions ?
A: Incisions are dependent of disc level: L23 vertical above the navel, L34 vertical around the navel, L45 vertical below the navel , L 5S1 vertical or horizontal below the navel . Combination of two levels: vertical incision.
Q: What is the significance of the possible incisions ?
A: Lower abdominal horizontal (transverse) bikini incision hidden under panties is an option in L 5S1. This horizontal incision however has some risk of a floppy skinfold just above that incision because of damaging skin nerves. Abdominal muscles not influenced by the incision: approach is al ways by vertical splitting of abdominal rectus muscles, independent of skin incision. Vertical incision keeps abdominal skin strong and flat. Vertical incision best option in upper levels.

Q: Is there a need of blood transfusion ?
A: Sometimes diffuse bleeding from the epidural space is inevitable. Vascular damage is rare, but happens. Therefore always two packed cells blood units in the background for security. Autotransfusion is only possible if prepared from 6 weeks i n advance. Please ask the blood transfusion centre at home.


Q: What about braces?
A: A special softbrace prescribed by the Backshop of the Alphaklinik is obligatory during the first 6 weeks postoperative period. If that brace feels uncomfortable because of the wound during the hospitalisation, one is free to omit that until discharge. The brace is necessary only during mobilisation at daytime, not at night.

Q: How about the postoperatieve check up?
A: For overseas patients an in between check-up 10-14 days after surgery i s advisable, just before taking off.
First regular check-up has to be done at the sixth week postoperative: X ray control of the standing lumbar spine can be provided by your physician at home. Pictures and comments send by mail or email to Dutch secretary mrs. Nicole Haesen, Postbox 4916.
6202 TC Maestrict. Netherlands
Next check-up in the same way one year after surgery.

Q: When can one start more strenuous exercise after a disk implant?
A: From the 6th week after surgery if the check-up is ok

Q: What type of restrictions should one follow from the 6th week after discprosthesis implantation?
A: I f the X ray check-up showed a good position of the prosthesis at 6 weeks, there are no restrictions anymore.

Q: Is MRI possible after artificial disk surgery?
A: Yes MRI is possible but not the first choice after artificial disk surgery, because MRI only shows a black shadow around the prosthesis in the sagittal view and in the transverse view most details near the prosthesis are not clear anymore. Some of the most recent MRI machines give better results already, but that is not common. In case of diagnostic pain-problems after artificial disk surgery CT (sometimes with contrast) is the best choice.

Q: Is the artificial disk procedure possible in the cervical areas?
A: Yes, but indications are very rare. Mostly a percutaneaous endoscopic procedure is a better choice, even if one has been scheduled for fusion or open decompression elsewhere.

Q: Is it possible to repair more than one disk?
A: Yes, but indications are relatively rare. Mostly the discography can discriminate between the painful and painless discs, even if they show some degeneration on the MRI . Results in double level are somewhat less reliable and the implantation technique is demanding. Nevertheless we had many very successful double level implantations.. More than two levels are not always successful .

Q: Is it possible to have a second implant on another level a few years down the road
A: Yes that is possible, but performed very very rare. Degeneration of a neighboring level is mostly not a problem, even not on the long run, if the discography was without typical memory pain on that segment.

Q: At what location are you performing the intake, imaging procedures, surgery and after treatment?
A: At the Alpha Klinik in Munich. All preoperative check-up and discography on Thursday. Surgery on Friday. Endoscopic procedures as an outpatient treatment, you stay in the hotel. Discprosthesis, cage and dorsal fusion procedures need a 3 to 7 days hospitalization in the Alpha Klinik.

Q: What about costs ?
A: First things first: exact costs information only possible after making up the indication and surgical possibilities. The costs depending on intake, hospital stay and type of operation. For information about global and exact costs: email: secretaresse@alphaklinik.demon.nl
__________________
ADR Munich 26th July 2002 L5/S1. Aged 82 now
Your best asset is your health
My story is here
http://www.adrsupport.org/alastair.html
Thank goodness for Dr Zeegers I am painfree
I am here to help,I live in the UK


I now run the UK spine site and can be contacted at

www.adrsupportuk.com/
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