No Surgery... Yet

[jss]

Drew,

You make me realize how lucky I was in that of the six opinions I obtained, five were identical. The odd man out wanted to do three fusions instead of two ADRs. Condolences on having to make this extremely difficult decision.

Boris has pointed out something very interesting; that these opinions could be viewed as "different", not better or worse. That they're all likely sound approaches to your dilemma. I know that doesn't help much, as you still have to pick. I don't know which one you should pick. While I admire Bertagnoli's integrity in suggesting a possible course that doesn't make him any money, in your shoes I'd throw out his four level ProDisc-L solution. Were he aware of your level of disability, he wouldn't have suggested doing nothing. Of the three remaining options, Clavel is the most aggressive, Zeegers the least, with Bierstedt in between.

Don't forget that you can probably modify any of the opinions. Example: if you're sweating an ADR at L5/S1, but for whatever reason want Clavel or Bierstedt, you can request them fuse L5/S1; and they'd probably acquiesce (or capitulate).

What are the reasons Zeegers wants to fuse L5/S1? As he does use the M6, why does he feel the Activ-L is better for your? I'd certainly want to understand that before making a decision.

Good luck, Jeff

[drewrad]

Originally Posted by jss

What are the reasons Zeegers wants to fuse L5/S1? As he does use the M6, why does he feel the Activ-L is better for your? I'd certainly want to understand that before making a decision.

I think Zeegers is open to either option, endlessly opinionated as he is. As to the M6 itself versus the Activ L, he made his idea clear to me.

He believes the Activ L is superior for spinal stability and doesn't buy the construct of the M6's ability to provide shock absorption. He also worries about its long term viability once implanted. He's really the most conservative of them all. And while revision is constantly on his mind, thus a paracentral, lateral approach with the Activ L(avoiding vessels at L4/5) he wants this to be a one and done procedure for the long term. He doesn't want me to ever have to come back. I like that a lot.

[drewrad]

So, funny story. I'm talking to this guy over the weekend from Canada who had a 4 level Prodisc with Dr. Bergnatoli a little over a year ago, who's doing great BTW. Anyway, I'm asking him how he's holding up. He says pretty good. I ask the obvious question, 'Are you in pain?'

'No', he says. 'Unless I overdo it.'

'What do you mean?' I ask. 'You mean if you carry the groceries in or something?'

'No' he says. Like if I'm at work at the shop and I have to lift something really heavy like 300 or 400 lbs.'

WTF? LOL.

[FranklySir]

Originally Posted by Stonewall_Boris

Drew,

Do you assume their is only one correct answer to your back surgery? Do you think investigating everyones MRI will provide you with more insight? Are you a doctor that can access those MRIs that you are requesting from so many?
When we spoke you said that you were looking for a doctor that was an artist. I told you that I considered Dr. B. to be more meticulous than an artist. So now you have four opinions from doctors/artists. Each choosing their own material and technique, choosing to paint the canvess their way. And now your upset they don't agree to paint it the same way with the same material?
The best doctor and procedure is the one that gets you better. I'd take the worst doctor, worst procedure that works for me over the best doctor, best procedure that doesn't work for me. Unfortunately, that's all 20/20 hindsight. The best you can do is put your money on the best bet.
You mentioned that you have the luxury of being able to review the posts of many here before you choose surgery.
Here's a secret, I didn't choose back surgery, it chose me, the only choice I had was with whom.

Drew,

Drew,

I'm not gonna send you MRI and X-rays. IMHO you are torturing yourself and crippling yourself with fear. you seem to be compensating by focusing on other peoples issues rather than your own and in turn driving yourself nuts.

Nobody here wants anyone to get surgery or suggests that you do so. I think everyone wants you, in their heart of hearts, to make an informed choice AND just to not be in pain anymore. In the end it will be made for you as you say. Your back is a mess as you say.

Me, well I'm 15 weeks out tomorrow and feel FANTASTIC!!! Seriously zero back pain, zero facet pain zero pain meds. The only lingering thing was the stomach approach which is normal and the past 5 days that has eliminated almost 90% which Clavel and my PCP said it takes 3-9 months depending on the person.

Drew, if you ask if I had fear the answer is yes. My fear was when my neck was done. I, really, honest to God and (Italian thing) on my kids eyes had NO fear whatsoever when doing my lumbar especially given that I couldn't move my bladder and had to make a choice of permanent bladder issues or get the back fixed.

I know its easy for me to say now and shouldn't mean much to you. I am today so very thankful and happy I fixed myself. I feel and am strong as an ox now finally after 14 weeks. I was doing KATA over the weekend and felt awesome with no pain after or since. I'm BAAAAACK!!!

I know we spoke on the phone and I was completely honest with you as I am being here. I don't want you to need to get surgery I just want you to stop draining your energy because you will need it for any surgery or to continue to hang on without.

I look at what has been proposed and you do have consensus to a point. L3-5 ADR and either Fusion or ADR at L5-S1. As Stone said depends on the artist. In your gut you feel something wrong 5S1. Your MRI is obviously a mess.

I just want you to feel peace of mind and feel better. Nothing more nothing less. I do really know it ain't easy my brother........ as does everyone else that has been done already. It can drive gagootz

Frank

[pittpete]

Dre, my apology for bringing up the Micro-d again. I keep forgetting about your disc heights after rereading your thread.
You have a tough decision my friend.
I will put this out there, from what i've researched i believe the longer you wait to do something about the nerve pain the longer it takes to heal or risk permanent nerve damage.
I am sick of this FN back also. I have a few bad days every month where i just want to fly to Europe and do this already so i can live the rest of my life.
If you're near NY, let me know... If you can wait till after youth football season in November i might just be going...My wife won't go with me so i'll have to go alone.

[drewrad]

Thanks guys. I'm glad I can still pee, but I worry if I don't get this figured out then I'll be in that situation. Just have to grab a Slurpee straw and shove it in!

I don't want to raid the Roth IRA so I've been saving up gobs. Almost halfway there for a three. Kaiser sucks! The rest I'll get creative I suppose.

[adrigail]

Drew,

I agree with Frank, you are killing yourself with worry. no matter what information you get from any other person, it will never be sufficient for your situation.
I'm 10 month's out from 1 level, starting to feel pretty good now that nerves are starting to die down. I've got a 3 level ahead of me, and I can't wait to get it done.

Pick a day, any day, to end your self torture and go with your gut. You probably have far more information at this point than anyone on here. We don't want to see you in pain. We've all been there/done that.

Just a little un-solicited advice from someone who can over-think a little himself.
Mike

[ian]

Drew, I tell you what. I can save you a whole lot of money and stress. Come down to LA. I'll set up a makeshift table in my garage. I've got a bottle of Jack you can chug, a steel pipe to bite down on, then I'll go to work with my ultimate set of tools.

I can fix it

Sorry dude, I figured you could use some levity. You've done the legwork, probably more than anyone on this site. And I agree with what's been said. There's probably no one best decision. Each surgery might offer different outcomes, but not necessarily better. I'm sure you'll experience relief regardless which surgeon you choose. And yeah, it's going to be a tough decision. But once you make that choice, don't second guess yourself. You have done the research, now it's time to choose what's best for you.

[Stonewall_Boris]

Drew,

I agree with Frank, Mike and Ian. Oh wait a moment not Ian, definitely not Ian about going to LA! The rest of the stuff yeah. I've been party to some members here that have ripped themselves apart before, only to get to a descion on a doctor that I knew they would end up going with when I spoke with them. It wasn't a pleasant experience.
I don't no your timeframe for getting surgery. When surgery picked me and I knew that was the case it was the worst moment in my battle with my back pain. I had the doctor responses, knew their proposals, knew of some of their practices. My head was spinning so much that I couldn't search the net on ADR for days if not weeks. I HAD to disconnect, I NEEDED silence. As a Canadian we are programmed not to get, or pursue back surgery. So I was also dealing with a cultural issue. A huge cultural issue. I made a very difficult descion to go with a doctor that by all means was relatively unknown at that point. The entire doctors process was a work in progress and I definitely felt that going in. I needed absolute silence to make a call. Originally my wife was unable to go with me and I was planning a solo trip like zenmunk and Ian. At the last moment the timing worked out and she was able to go with me. There was the unspoken tension of going to a different country for major surgery. It intensified at the airport to a point where I couldn't stand it. Our flight was delayed and that just exasperated things. When we finally took off I left out a big sigh of relief, no turning back now. Something was eating at me during the trip, half way over the Atlantic I leant over to her and said "if something goes terribly wrong don't bother bringing the body back, I want to be cremated there". We had our wills redone just prior to leaving for Germany so my mind, exhausted, got some relief. I couldn't go on with the way I was going on.

[drewrad]

Again, thanks for the responses. I appreciate them all. I am close to booking this thing, but then things like this trickle in and get me backtracking a bit. I'll just post it in its entirety.

From Dr. Bergnatoli. Actually, his go-between, Andrea:

Dear Mr. Drewrad

Prof. Dr. Bertagnoli has used multiple ADR types.

But he firmly recommends Pro Disc L in your case. All reasons that speak for this model in his judgment are esp. relevant in your case (“easy single level cases” probably work perfect with any model).

· He has co-developed the model and its tooling (not the least of importance in a manual skill like surgery).
· On top, the number of past implantations world-wide and long-term experience speak for this model. Knowing a device long and long-term is an advantage. ·
· He also does not favor unconstrained disc replacements, which have been under discussion a lot recently. Esp. not for multilevel: Having a “free core” means no guidance of movement by the ADR, which is intended. And which is close to a physiological discs, which does not have a fixed centre of rotation either. But: degenerated discs are not virgin discs. They as a rule lack the necessary external guiding structures. A natural disc IS guided in it`s movement by ligaments, annulus and facets. It`s not “wobbling freely”. Exactly those structures are involved in the degeneration process, and either are slack, or calcified and tense. In ADR implantation with a good mobilization and regain of disc height e.g. the dorsal and lateral annulus has frequently to be resected.


One should not compromise on nerve liberation to keep them unresected. And hence the additional guidance of a semiconstrained disc (like Pro Disc L or Acitve L etc.), are highly appreciated. ·


These factors are the more relevant in multi-level, where positioning can positively influence spinal alignement in semi-constrained ADRs. ·



These factors in Dr. Bertagnoli`s judgment far outweigh the lack of a “cushioning function” in ball-and-socket concepts. Cushioning in the spine is predominantly provided by the global s-shape.


I hope this was of help. Just awaiting your further data.

Dr. med. Andrea Fenk-Mayer,
Fachärztin für Orthopädie und Unfallchirurgie
Schwerpunkt Wirbelsäulenbehandlung

Pro Spine
Dr. med. univ. Rudolf Bertagnoli

94327 Bogen
Deutschland


This was preceded by this communique:

Dear Mr. Drewrad,

Permit to introduce myself: I am Dr. Andrea Fenk-Mayer, spinal surgeon and consultant with Prof. Dr. Bertagnoli.


I am responsible for preparing your medical evaluation as an international patient with him.

And due to your kind cooperation and Mr. Vicknair`s comprehensive profiling Prof. Dr. Bertagnoli could already view your medical data. I am here to pass on his surgical recommendation.

Your imaging shows moderate degeneration more or less in your whole lumbar spine to the same extent. Positively without major secondary deformity. There is no signs of rheumatoid/systemic inflammatory disease out there (still I may ask you whether CRP and HLA B27 have ever been tested due to your history and typical age group).

Surgery is of course possible, but would have to include l2-s1. Either you go for a (maximum) fusion, which fully eliminates mobile function, and disc and facet triggers. But the dorsal and ventral tissue damage can produce pain by itself, so can muscles and ligaments.


Or you go for an ADR L2-S1. Still major surgery, still certainly not reducing your pain sources to zero (a spine is more than discs).


The expectation can be pain reduction and less restrictions in an uneventful case.

This is important, because your report doesn`t give maximum non-surgical therapy so far. Degeneration is a slow process, so you do have all the time to add these:
e.g. adequate pain meds (daily basis, slow release opioids)
e.g. facet and/or peridural injections with local anesthetic and corticoid. You sure can have this locally.


e.g. light bracing for “bad spells” or major activities.

Multi-level ADR is possible and successful in very experienced hands. The more it is important to keep in mind, that it is not out there to avoid a Naproxen once in a while, if this is all that`s needed. In such a constellation the gain always would be smaller than the risk.


We are aware, that a written history can mis-judge your suffering. So I suggest you comment and//or parallelly have a non-surgical trial see above. Pro-spine`s mission is always to find the optimum treatment for the individual problem of you as our spine patient.

We thank you for your confidence into our work and are looking out for your reply.

Yours respectfully

Dr. Andrea Fenk-Mayer

And the one prior to that:

Dear Mr. Drewrad,

let me explain:


CRP and HLA B27 are screening labs to detect or exclude a group of systemic inflammatory disease (systemic spondylarthritis. The most frequent of these is Morbus Bechterew, but there are other similar). Your pain pattern and age gives hints for these. And if you have it, specific medication could change the prognosis and the pain tremendously.

So – with all humbleness because we did not see you clinically – there should be no surgery without testing at least these two lab values. Pro-spine`s mission is always to find the optimum treatment for the individual problem of you as our spine patient. And a surgeon should know and consider more than his/her tools.

For surgical technics:
no, Prof. Dr. Bertagnoli did not advice you to wait. Sorry, if we didn`t make our point.
He wanted to point out, that yours is no emergency surgery, and that decisions should not be made premature. And non-surgical treatment is ONE option, among others. (just imagine you DO have M. Bechterew, this would change everything, wouldn`t it?).


Your added info has helped a lot to come closer to a final recommendation. If it`s surgery, Prof. Dr. Bertagnoli recommends including l2-s1 (and not to confine to l4-s1). Let me lay out why: Very apparently your L23 and L34 are affected by disc degeneration as well, and not only to a “initial” degree. They do contribute to your pain. (If you wish to confirm this, one/we can do a discography. But in a very evident case Prof. Dr. Bertagnoli would not have considered this invasive test necessary. It would certainly confirm what we already know). The question is: are they bad enough to justify surgery? Prof. Dr. Bertagnoli thinks yes. Of course one must take into account, what surgery we are talking about, when answering this question. In his series 3 or 4 level ADR is not “far out” or impossible, not even rare. OR time would be around 4 h, which is what a fusion would take as well. And due to the vessel anatomy it is at least very demanding to re-enter l34 once an anterior approach to l45 was made in the past, even in very experienced hands. So for your long term future it would limit options considerably, if you confine to a l4-s1 ADR now.



These factors are the basis for Prof. Dr. Bertagnoli`s choice. Decision-making in surgery is always balancing facts, options, and expectations. With the same set of facts, there can be several solutions, even several good solutions. Other than in e.g. mechanical engineering, a choice must be made at one point by the surgeon and the patient. It is not possible to “treat the same patient with different procedures and compare the result afterwards”. So it was and is my task to explain the background of Prof. Dr. Bertagnoli`s recommendation. I hope I could.

At this time I will just wait for your answer and the lab.

Best regards

Dr. med. Andrea Fenk-Mayer,

So, it really couldn't get more strange. Is there really such a thing in re to multi-segmental lumbar patients like me of having instability issues if I go all-in on M6s?

And then, the CRP and HLA test, which I am doing. I will get them done along with the metal allergy this week.

Still going long with Dr. Pablo Clavel, but then when I get a curve ball I like to lob it at you regulars who know the backstory, esp in re to Dr. Bergnatoli. Would love your input yet again.