North American Spine Society, 2006 Annual Meeting

[Jim M2]

Mark,

Here's some questions.
What are possible end-game scenarios for a post-ADR patient who has significant facet pain? Will the pain stay forever? Will the facets wear down to bone on bone and then fuse?

Jim

[mmglobal]

Jim, there was some discussion about using interspineous spacers (specifically coflex) to open facets. There is also some consideration for Dynesys to open posterior elements and restrict motion. These configurations have been done in a handful of cases. The good thing about the posterior systems is that the collateral damage is small and revising to fusion is simple. However, there is discussion about fusing failed ADR, getting good fusion and still not getting relief. This would tend to indicate that the problem has always been inability to diagnose the pain generator. The speculation is that even with successful fusion as the first surgery, the patient would not have gotten better. When asked about this situation at the complications poster session yesterday afternoon, Dr. Bertagnoli indicated that if there are not clear indications for fusion, he would still consider fusing the failed ADR patient as a last-ditch effort, but only after casting the patient, INCLUDING ONE leg. This immobilizes the lumbar spine. If this substantially reduces the pain, that gives more confidence that the fusion will help.

I'd be surprised if the facets will fuse spontaneously on their own in the presence of a highly mobile segment. I'll ask.

Mark

[Jim M2]

Mark,

A body cast? Dr. B is very innovative. The fact that one leg needs to be casted to immobilize the lumbar has meaning to me. That part of my pain that's motion dependent is highest when the legs are moving apart, for example when walking. The longer the stride, the higher the pain. The pain is always on the back-foot side of the spine. What I mean is, if the right foot is behind me, the right side of the L5S1 level spine gets sharp pain.

It would seem unlikely for the facets to self-fuse. Dr. Zeegers told me at the GPN seminar ('05 in Fountain Valley) that fused ADRs weren't very successful because even with backside fixation the level isn't immobilized enough to eliminate the pain. I'm grasping at straws trying to imagine how this plays out long term. Usually the body finds a fix but it takes a long long time.

That is an awesome post you made. It is the last word on the state of this problem. I hope others find their way to ispine soon.

Many thanks,
Jim