Think my 2 best options are.... Any Advice?

[longroadahead]

A lot to think about for sure.

I have seen Dr. Bertagnoli and he recommended fusion with the STALIF at L5/S1 with optional prodisc at L4/5. He based this on 2009 and 2010 images and ordered a new MRI which I had. Still waiting to see if his recommendation is still the same after the new MRI.

Have filled out the forms for the consultation for SED but the $250 it cost for them to review your files for 1-10 minutes gives me pause and haven't sent them.

[Maria]

When is this used (routinely w/SED)? Criteria? It may already be here somewhere or I can google it although sounds like Keano knows much about it as I'm sure Mark does.

[mmglobal]

The SED procedure was developed by Dr. Yeung through the 90's and 2000's. It stands for selective endoscopic discectomy. There is much about it that is different from a traditional discectomy or even another endoscopic discectomy.

The 'selective' part if it has to do with injecting indigo carmine. This is like a PH indicator that stains the degenerated nucleus material as the degenerative tissue has a much more acidic PH than does healthy nucleus tissue. Because his equipment puts him INSIDE the disc with a video camera, he can selectively remove only the degenerated tissues, leaving the healthy tissues.

All references to SED procedures that I've seen (and I've had dozens of clients with SED), have been for SED with Thermal Annuloplasty. The thermal annuloplasty component (TA) is an integral part of SED. Because they are inside the disc and can see the annular tear, they have the capability to apply laser or RF energy to the 'granulation tissue' and posterior annulus UNDER VISUAL CONTROL. The granulation tissue is erratic tissue (not normally present, like erratic boulders that are carried 'downstream' by glaciers) is what causes the pain in painful discs. Naysayers for SED will say that it's like shooting a fly with a machine gun. This in an uninformed concept. I've attended the training for SED and have observed dozens of procedures. There is no shooting of machine guns. They are LOOKING directly at the tissues they are ablating. They are looking at the annular tear. Typically, when they apply energy to the annulus surrounding the tear, the annulus and the tear will shrink. If it does not go in the right direction, they can see it right away and stop. All other forms of TA that I know of like IDET and Biaccuplasty are done blind. They are cooking tissues that they can't see, so they can't be certain about probe placement and cannot see what is happening (real time or not real time.)

Unlike other endoscopic procedures, SED is ‘INSIDE OUT’. They are working inside the disc and can see what they are doing. As discussed above, not only can they be selective about the tissues they remove, but the can also see the annular tears and see what is happening during the TA step. They will be pulling herniations back into the disc, then out through the canula. The more experienced SED surgeons can safely chase sequestered herniations out into the canal area, but this is something that I would not want anyone but Tony Yeung or maybe Chris Yeung attempting on me.

SED naysayers will point to studies that tested ‘cutting’ the annulus, making a hole the size of the SED tools, then relating it to future ‘recurrant hernaiation’. This is a red herring. There is no cutting of the annulus to get into the disc with SED. They start with a needle and use a series of ‘expanding canulas’ to dialate a hole in the annulus. There is no wholesale cutting of fibers as there was in the studies that are pointed to. I’ve seen discography done on SED’d discs with the doctor able to squeeze the syringe as hard as he could with a firm endpoint and no pain. Compelete negative and sealed disc years following SED. (Read Ann C’s story on the GPN story pages.)

There is a HUGE talent factor and experience factor with SED. This is not for the average surgeon or the general spine surgeon. This is for the endoscopic specialist who does these nearly every day. I have observed surgeons with 400 procedures under their belt doing surgeries thinking that would be more than enough experience. There is such a dramatic difference between them and the guys who developed the procedures, made the early mistakes, and have thousands. I don’t know how we can assess the experience level of the other surgeons. I know of many who have purchased the systems, done the training and started doing procedures; but never stayed with it long enough to get through the learning curve…. They ultimately gave up on it. It’s not that the procedure is not excellent, it is that it takes a lot of experience and a very high talent level before you have a chance of getting good at it.

All the best,

Mark

[longroadahead]

Appreciate the very good explanation of the SED procedure and was ready to send my $250 for the SED but contacted DISC and they sent me Unitied Healthcare's policy on the procedure. Yeap, it is not covered.

On another note, finally got ahold of Dr. Scott Blumenthal's office and he thought my bone denisty scan was too low for a Prodisc. I am 37 and Bone Denisty is (1.7) - (2.4) range in L1 - L4. Could this be my underlying problem?

Say Dr. Andrew Dossett a few days ago and he said I should just have a microdisctemy and if that didn't fix the back pain he would leave it alone.

[Maria]

Mark,
thanks so much for explaining that and in terms one can easily read/understand. What would the inclusion criteria be for this procedure or exclusion? Does it depend on grade of tear/type of tear/location of tear/tear of many years vs. more recent tear/ tear unaccompanied by signficant loss of disc height??

[cp7959]

SED sounds interesting, especially since I have an Annular tear. I have a few questions if anyone has the experience to answer.

With the SED procedure, does the Dr. enter the disk from the back going thru soft tissue only or does he create a path thru bone?

With the endoscope entering the disk thru an access point other than the tear, does this create another week spot in the disk in which another tear can form?

How long does the SED last, is it a short term fix, what are the long term results?

And the $$$$ question, how much? I'm sure my BCBS insurance isn't on board with this.

Thanks in advance.

[mmglobal]

I think that most insurance providers will not fund SED. Having said that, I still think it's odd that a spine center will go out of it's way to tell a patient that another center's procedure is not covered. I would check with the SED provider. As I said it may not be covered, but I would not depend on the info received from a competitor.

Anyone considering SED should contact the SED doctors for inclusion criteria. From my memory (which cannot be trusted), discs with grade V tears are not good candidates. Discs with severe collapse and loss of disc height are not good candidates. Classic discectomy candidates are good candidates for SED. This leads me to the conclusion that if you are a good candidate for one, you stand a good chance for all of the procedures, whatever the 'twist' they add in addition to the traditional discectomy. Having said that, I believe that the thermal annuloplasty as the twist, gives SED a chance to deal with discogenic LBP that most other discectomy techniques don't. If I could go back and redo my 2000 and 2001 discectomies, I would do SED.

How long will it last... depends on how lucky you are. IMHO, if you get a few years out of it, you win. More and you win big. Like all discectomies, there is a substantial chance that success will last only a few months. The recurrant herniation story is very common. Even so, the alternatives (adr and fusion) are to be avoided if possible... so IMHO, good candidates for discecomy should try it first instead of opting for the bigger surgery first. If you fail that (like my wife did... her endoscopic discectomy was a great success, but only for 3 months) you are unlucky and lose the bet.

Mark

[cherylstewart67]

there are surgeon that only know one thing fusion and they won't tell you what the other options are. think about why for yourself...but me personally if they can't give me more than one i dont trust them anymore. if i had had a computor at the time i would have done more reserach, but i trusted my doctor. he failed to tell me what all was out there!

[Maria]

I really dislike hearing only one option is available to me. It might be true at this point (my age and how long I've let things go however if someone can give me a good reason physiologically/structurally/or medically why I'd not be a good candidate for other options that carries more weight but I dislike when surgeons discount one thing over another just because they don't or can't perform a certain surgery. That's not being considerate of the patient's true needs and I too say walk away and think about this while looking to get more opinions from surgeons that might perform fusion and ADR or at least be open to the idea and or suggest other options.

[cherylstewart67]

Originally Posted by Maria

I really dislike hearing only one option is available to me. It might be true at this point (my age and how long I've let things go however if someone can give me a good reason physiologically/structurally/or medically why I'd not be a good candidate for other options that carries more weight but I dislike when surgeons discount one thing over another just because they don't or can't perform a certain surgery. That's not being considerate of the patient's true needs and I too say walk away and think about this while looking to get more opinions from surgeons that might perform fusion and ADR or at least be open to the idea and or suggest other options.

i do not understand how in good concience a doctor would not tell you what else is out there, but mine didn't. keeping information from someone is the same as lying to me. i cant go back now though. but moving forward i pray there are other options...