DIAM vs ADR

[Katie]

A second doctor has recommended DIAM spacers instead of ADR in my lumbar area, because of a difference of opinion regarding arthritis in my facet joints. One thinks it is pretty minor, and the other says it is too bad for ADR and will cause more pain.

I've talked to the manufacturer, and they said that the spacers do provide a fair bit of motion, almost as much as the artificial disc, and certainly much more than fusion.

I'm torn as to which way to go. Opinions?

[steve55]

Diam Spacers as an option over fusion and ADR??? WOW. Ive never heard of this before. Im sure Mark (MMglobal) will know though.

[Katie]

I don't think they (DIAM spacers) are approved in the US, but are in Canada, at least for trials, so I don't know if Mark knows much about them (but I'd love to learn more if I'm wrong!). The manufacturer said they were being used here, but I didn't ask specific enough questions.

The spacers are not as invasive. They are less expensive. They are easy to take out if necessary (but I don't know what they would use as a replacement).

The pro DIAM doctor said the ADs would cause more pain if we used them because of the arthritis. The other doc said that the arthritis was not bad at all, not a problem for the artificial discs.

I don't know who to believe. I'm ready to book a trip, as I think I have sorted out the financing. HELP!

[mmglobal]

Diam was one of a huge crop of interspineous devices that came out several years ago. Wallis, X-Stop, Diam, Coflex, ISS, Wellex, Dynafix, Spineos, BacJac, In-Space, Superion and I'm sure there are others that don't come to mind right now. Diam was somewhat different because it is a soft silicone spacer that is designed to support the posterior elements.

When I first saw Wallis, I think back in 2004, I thought that it would keep most of us from having ADR. If you could do a discectomy and somehow jack up the disc space, offload the posterior annulus (where so much of our low back pain is generated), and stabilize the system with a minimally invasive surgery, what could be better?

5 years later, I'm still waiting for the flood of data and the rush to do this. I've observed Wallis and Coflex procedures. It does seem to be relatively small compared to ADR, but the philosophy is completely different. These devices are designed to take away motion, whereas ADR is designed to restore motion. With these devices, you will not address discogenic pain. Originally the theory was that offloading the posterior annulus would relieve the stresses that were painful, but I think that pans out in only a small percentage of the cases. If you leave all the painful tissues and put a rock between the very back of the system, I think the disc may still continue to collapse (now with a kyphotic alignment). With sagittal balance off and motion severely limited, what does that do to the adjacent levels?

Also, I don't believe that these devices are appropriate for L5-S1 and that is almost 1/2 of lumbar disc disease.

Having said that, I believe that X-Stop and other devices have been very effective at dealing with typical old person's stenosis. The folks who get leg pain when they stand up, and have to walk leaning forward seem to get great relief from the interspineous devices. It basically forces just the level with the stenosis into flexion and offloads the structures that cause more buckling of the ligamentum flavum that lights them up when they stand or go into extension.

It's all about indications. They are different for ADR, dynamic stabilization, interspineous devices, etc... The proponents of the devices tend to over use them across too many indications.

I have to go now... This is all off the top of my head... I'll look some things up and post later.

Mark

[Katie]

Mark, thank you very much for your input. I asked why the opposite edge of the disc didn't get 'squished' when the back part was lifted, and didn't get a good answer, just was told that the disc itself maintained the space.

They do remove the herniated part of the discs, where they are pushing on the ligamentum flavum. They did say that because it is made of soft silicone, that it offers more range of motion than the other brands. It looked pretty simple and effective to me too, but I haven't heard enough about them to form an educated opinion. I really need help.

Most people who have had ADR have some arthritis, correct? Even when it isn't indicated for surgery by the manufacturer, they have been mostly successful, from patients I have talked to.

They want to put the DIAM spacers in L3-L5/S1, but will put an artificial disc in the C5/6 level. They claim a 97% success rate.

[mmglobal]

I don't believe that there is any spine surgery that even approaches 97%. I discussed the interspineous devices with a leading surgeon yesterday and asked, "Why have these devices not lived up to the promise we saw in them 5 years ago?" My layperson's understanding of what was said is that the interspineous devices are great for stenosis in old people who's spines are largely immobilized anyway. Most of the interspineous devices really limit motion are are often like fusion devices. The way they force the segments into kyphosis (forward tilt) reduces your lordosis and can generate flat back syndrome. Flat back can really cause problems. They used to fuse in that position, but abandoned that because of the problems caused by loss of spinal balance when you reconfigure it so substantially.

Mark