3 Year ADR Update

[annapurna]

Jim,

About what happens to degenerated facets behind an ADR, I don't think that anyone really knows. I asked Dr. Fenk-Mayer this a couple years ago and she said that the fate of arthritic facet behind and ADR is one of the great mysteries of spinal medicine.

If you think about it, though, you could really only get two outcomes: better or worse. In the first case, the normalized loading and motion permits some sort of joint healing the pain eventually subsides. This is known to occurr in patellofemoral joints in the knee following patella alignment surgery. In the other case, the arthritis progresses as you described and you get spurring that leads to stenosis. At that point, pain from the facet joints would probably take backseat to the nerves being pinched by the bone spurs.

At that point, you could choose a wide decompressive laminectomty with fusion or with a motion preserving device such as TFAS, AFRS, TOPS, or one of the many follow-on devices that will no doubt be in use by the time we have to worry about stenosis.

Best of luck to you and Blair and all of us facet-spineys. May the new year bring hope for better spine health to us all.

Laura

[Jim M2]

Laura,
Thanks for the excellent info. Looks like all I can do is hang on to see what unfolds, better or worse.

For now I'm getting used to limitations. I continue to manage myself better to keep control of discomfort and pain. I'm still improving at an excrutiatingly slow rate, and I think I'm just plain getting used to dealing with it.

If I ever decide to have a surgery it will be for pain. I can deal with limitations. At some point pain controls me.

Jim

[Blairsara]

Jim
Getting used to being in chronic pain is very difficult, but what has worked for me is to try and focus on anything that will take your mind away from your body. For me, the past few months was law school and throwing myself at work. What about taking up a hobby tht doesnt make your pain worse?
I hope you have a great new year!!!

[djscal]

Jim, Blair, Laura,

Yesterday, I had Dr. Fuller (a local pain mngmnt doc) try to aspirate the cyst on my right side L5-S1 facet joint. He tried 3 different entry points but could not get the needle into it.

I'm hurting from all of the poking around and frustrated. Fusion is sounding better and better. I will give it until the summer I suppose.

The question becomes if I fuse. Do I go for a 360 degree? I'd be scared to only fuse the back for fear that there would be enough motion in the front to cause problems. Also posterior fusions can have issues like screws loosening and not enough bone growth in between the vertebra. If I remove the Charite and fuse from the front there may be enough motion in the rear to cause me facet pain.

My head hurts!

[Blairsara]

David,
I'm sorry to hear that Dr. Fuller wasnt able to aspirate the cyst. I have been going to Dr. Fuller for all of my facet blocks and my last rhizotomy. He's absolutely wonderful and definitely one of the best of what he does in LA.
I don't really know the different kinds of fusions, I actually didnt know there were different kinds. What did Dr. Fuller say about the fusion and your other doc (I think Regan right?)?
I hope that whatever you decide to do it helps! Happy new year!!!!!!!!!!

[annapurna]

Dave,

Sorry to hear about your painful facet(s) at L5/S1. Perhaps your pain management doc could perform a rhizo and, at the same time, give the cyst aspiration another try?

As far as fusion goes, it's really an individual choice. Here's the breakdown of post-ADR facet options that as I know it.

*Fusion: ADR revisions to fusion, with or without ADR removal are complex surgeries. As far as I know, there is still some controversy concerning continued painful micro-motion with a posterior-only fusion. Removal of the ADR is definitely a "big deal" surgery, although experienced surgeons have done it successfully. Needless to say, you lose the motion at that level with all the issues that may or may not be associated.

*Posterior Stabilizaiton: Posterior stabilization devices address facet pain by "sharing" the axial load with the facet joints and preventing improper motion. Yes, the painful facets remain in place, but, with the posterior stabilization device taking a good deal of the load, the facets can calm down and quit hurting. Surgical approaches are far less invasive than a fusion revision or facet arthroplasty.

*Facet arthroplasty: These devices work by simply replacing the facets and/or the entire posterior spinal element with a mechanical device that does the same job. These devices are VERY new with little or no clinical data, depending on the specific device. At the same time, for someone with an ADR and symptomatic, end-stage facet arthritis, these devices represent the only alternative to fusion. Surgical approach would be similar to posterior-only fusion or laminectomy.

*Rhizotomy: Works by simply cutting the nerve signals that feed the facet joints themselves. Facet rhizotomy can be very effective for reducing pain from the facet joints. The technique is percutaneous (just a needle), and, therefore, represents the most minimally-invasive of all the possible procedures. Despite the fact that rhizo is only a pain management technique, it can indirectly provide real, structural benefits in that it permits better physio and muscle strengthening which can, in and of itself reduce the very instability that may have been causing the facets to be painful.

Personally, I'm not in a hurry to do anything more than rhizo, even though I have fairly advanced facet arthritis behind my ADR at L5/S1 and at the non-ADR level above at L4/L5. Although I'm a huge fan of joint replacement technology, I'm simply not comfortable with the idea of using devices that have so little clinic data. I'm not happy with a fusion because, in addition to a revision of my ADR, it would mean losing motion at not one, but two levels. Even though I'm no longer young (39-years old), I'm not yet willing to accept the activity restrictions a two-level fusion would require.

Hope this helps and bear in mind that I'm certainly no expert - just another patient looking for information.

Best,
Laura

[Jim M2]

Dan (djscal), Blair, Laura, Dave,

I'm with Laura on waiting. At the 2004 GPN seminar Dr. Yeung reminded us that there wasn't always back surgery and people usually get better. Now with the ADR I'll not fuse naturally so we're a different group. There will always be the motion that hurts the facets. Still at almost 3.5 years post op I continue to improve although at a snail's pace. I'm voluntarily limited in what I can do to keep from flare ups. I feel lousy but I don't have the 24/7 oppressive, distracting, horrible pain that was with me for so long.

Laura, thanks for the concise list of options!

Jim