Am I a candidate for ADR?

[hey_look_its_dave]

Hi,

I had an L5-S1 herniation (left-side) since 1997. I toughed it out until January 2009 when I had the herniation trimmed.

That significantly improved my sciatica, but didn't help with lower back pain. I knew this would be the case beforehand, however, so I wasn't complaining.

I had a good summer walking and bike riding etc, but unfortunately in late July 2009, I reherniated the disc. The latest MRI shows another bulge in the disc.

I don't understand why trimming the disc ever works for anybody, since it loses all it's hoop strength once it ruptures, and trimming it only weakens it further. Regardless, apparently that's all some people ever need. I was told to do lots of walking after the surgery, and I did TONS of walking. Which, it seems to me, just peens the disc; of course it failed again!

Anyway, everytime I go in for surgery, I risk infection, surgical misshaps etc. Clearly this disc is going to continue all the way down to bone-on-bone. I don't want to repeatedly roll the dice and get discectomies. And none of this is addressing the fact that it feels like someone swung a baseball bat into my lower back.

EDIT: All other discs are in perfect condition. Just L5-S1 is messed up.

My question: Am I a candidate for ADR? All the investigations I've done say "no" because I have nerve compression due to disc herniation. I don't understand this. Do I need to keep having discectomies until it's bone-on-bone, and then if I have pain, pursue fusion or ADR?

Dave

[Jack]

Sounds like you need a second and or a third opinion. Many surgeons in the US are not yet comfortable with disc replacement. What I did was an internet search of all the neuro and ortho spine surgeons in my insurance provider network, then called their office and asked them. Something like "I need lumbar surgery and would like to know if DR XXX does disk replacement".

[Cirobi]

Hi Dave,

I'm sorry to hear you're back where you started and I always wondered the same thing with what I think of as "band aid" procedures. I think it's great that they work for some people, but in most cases I can't figure out how they could even remotely be a long term fix.

I'm not sure I'm qualified to say whether or not you're a candidate, but I'm curious what kind of investigations have you done that lead you to say you're not an ADR candidate? Have you gotten opinions from several ADR surgeons?

~Sara

[CharlesinCharge]

Dave,

Nerve compression has nothing to do with ADR sugery, because in ADR surgery they remove the disc and replace it with an artificial one. Once the original disc is removed, it obviously cannot be pressing on your sciatic nerve! As such, I do not see how having nerve compression can possibly stop you from having ADR surgery. It is true that some people that have ADR surgery do not have any nerve compression, such as myself (I only had lower back pain, my discs were damaged but were not pressing on any nerves), but others do. The key point I think is that when a person has nerve compression AND lower back pain, having a discectomy will only address the nerve compression (leg pain). It cannot fix the back pain because that is almost always discogenic pain, i.e. coming directly from the nerves inside the disc itself. The disc has to be removed completely to stop that pain, necessitating fusion or ADR surgery. Whoever told you that you are not a candidate for ADR because you have nerve compression does not know what they are talking about in my opinion, I know many people that had leg and back pain and were fixed with ADR surgery.

Good luck,

[hey_look_its_dave]

Thanks guys.

So far I haven’t talked to a surgeon about ADR. Indeed, finding an ADR surgeon is not so easy around here. I should mention that I’m in Canada. Our system is probably most comparable to the UK. This country had its first ADR performed in London, Ontario in 2001 by Dr. Kevin Gurr. I live in Toronto (about a 2.5 hour drive East of London), so I sent in a referral to his office. It’s been a couple of weeks and no phone call yet (though I’m a patient guy). I know at least one person who saw him had to wait 2 years for an appointment (…but not that patient).

Typically in Canada, it takes 2 or 3 months to see a specialist. Ideally, I’d like to find someone in Toronto who does ADR. I see my surgeon (who did the discectomy) on March 30, so I’ll ask him if he knows anyone. He only does fusion. I’m not interested in fusion because of the higher rate of adjacent disc syndrome. One concern I have though, is that in the ADR business, it seems from what I’ve read, that you really want someone who has done many of them. I don’t know that we have anyone with much experience in Canada.

Another option would be Germany, but I’m concerned about what happens, for example, if six months hence, I start having major pain problems. They do say you can send them MRIs and xrays, but I dunno. Worrisome.

I had to go to Buffalo for my last MRI. If you’ve had surgery, then you need it done with and without contrast. Currently, the waiting time in Toronto for MRI with contrast is 4.5 months. I drove over the border to Buffalo MRI, which does same or next day service on machines that are twice the resolution of any machine we have here in Canada. Remember back in the 80’s how we used to laugh at those wacky Soviets and their 1950-style telephones? Ha ha they’re so backward and we’re so awesome? Well, that’s where MRIs are in Canada. I couldn’t believe the difference. Sad.

The reason I was under the impression that nerve compression excluded me from ADR surgery was that in several places, I saw it mention that the criteria for being a candidate for ADR included back or leg pain without nerve compression. For example, this is what it currently says on the AlphaKlinik site:

“When is an artificial disc replacement reasonable?

An artificial disc replacement ie [sic] recommended if a painful severe degenerated disc without hernia is thoroughly determined.”

I’m not sure how to interpret this. I saw another site which said almost the same thing, although I can’t find it again.

Dave

[kimmers]

Dave,

Quick reply:
You do not want to have your disc go bone to bone. As I understand it, putting in an ADR in that situation is sometimes not possible.
Welcome. And I hope we can help and support you on here.
Here we get MRIs faster, but you can be denied the MRI in the first place. I was as my insurance refused to cover it.

[hey_look_its_dave]

So I have a working theory as to what that quote I gave above from AlphaKlinik means. I'm thinking it should really have said something like:

"ADR may be recommended if there is disc herniation and nerve compression, or if discogenic pain can be definitively proven in the absence of herniation and nerve compression."

I'm worried that they actually mean that a requirement for ADR eligibility is having no nerve compression due to disc herniation. i.e., that you need to have pain that is coming from the disc only, and that can't be proven unless there's no nerve compression.

I dunno, but I just submitted my online form at AlphaKlinik and uploaded my mri and surgeon reports. I guess in about a week, it'll be cheers or tears. If they say I'm eligible, I'll Fedex a copy of my mri CDs so they can be extra sure I'm a candidate before I fly all the way to Germany. It feels like my whole life comes down to this one piece of news. It's gonna be a stressful week of waiting.

Wish me luck!

Dave

[Cirobi]

Dave,

I think you're mis-interpreting the statement because it seems to clearly say nerve compression is part of what would trigger an ADR recommendation. Basically, as far as I can tell, that statement means those are two of the common conditions in which ADR is appropriate. The most obvious one is herniation and nerve compression. I'm no expert, but I would imagine that any kind of nerve compression is a prime target for surgical resolution since the last thing you want is damage to your spinal cord.

However, the other one is a little more subtle. You can have fairly normal looking disc height (my case) and little to no nerve compression but still have a disc worthy of replacement. That's what a discogram is for, determining whether or not the disc is the cause of your pain regardless of whether or not nerve compression exists.

For example, to my knowledge, a herniation to one side or the other may not demonstrate nerve compression or associated symptoms. I've gotten that just from reading a little here and there about this stuff. Now, my own herniation was central and there were the beginnings of some minor nerve compression because the herniation was toward my spinal core. The compression wasn't too terrible yet, but certainly would have been in the long run. I kind of like to think I acted just in time to avoid major nerve damage. Disc height was ok which I think is what prompted the way my MRI report was written (that it was all minor herniations) which then triggered my initial surgical contact's reaction to say I wasn't a surgical candidate. That was based off of the written report alone, not a look at the MRI images. The second surgeon I spoke with took one look at the MRI pictures and said flat out that unless PT and such were helping, I was indeed a surgical candidate.

Once an actual spine surgeon takes a look at your MRI pictures, you'll likely get a much better diagnosis and plan of attack. At least, I would hope so anyway.

~Sara

[2cool4U]

Nerve compression can complicate the ADR surgery, but it does not prevent the attempt. My disk was pushing the left S1 nerve root around, although I only had S1 symptoms for a few weeks after the initial injury in 2004. My surgeon reviewed the MRI with me and pointed out that he would have to dig a little more to get all of the disk material, as it had also migrated a little inferiorly behind the top of S1. The contingency was that if all of the disk material could be removed, he'd do the ADR. If any component could not be reached, he would change mid-operation and perform an anterior fusion.

I was told that fusion would not result in much chance of pushing the remaining disk material around but that the ADR, with the moveable disk insert, could put pressure on any disk material left in the spinal canal, possibly causing recurrent or new symptoms.

See a qualified surgeon and review the MRI with him/her. Good luck.

-tc-

[hey_look_its_dave]

Thanks for your great responses guys!

Dave