Choosing ADR or fusion

[LC in UK]

Thanks for posing questions that I and many others would like answers to, if possible.
I am facing cervical fusion at 3 levels and presume the same criteria applies?
Will follow this thread with great interest,
Lynette

[dshobbies]

Sharman,

I found your thoughts and questions quite thorough. While some answers may not be known for a while, they are nontheless important considerations.

I have three more points to include;

First, ADRs aren't covered by American ins. co.s whereas fusions are. If finances are a primary concern, that may well be your final answer. Going to Germany, the cost is about half and you'll have the world's best doctors.

Also, long term studies are beginning to show adjacent segment deterioration with ADRs too, but at a much slower pace, 10 years or so and not affecting everyone???? (Sorry, I don't have the links anymore)

I could be mistaken but I don't believe your own bone is harvested for fusion anymore.

As for the healing process, though my experience is very limited, it seems that ADR patients heal faster and return to whatever their normal life will be quicker. I've heard patients from both sides say they were happy/miserable with their decisions. Ideal candidates can do poorly and vice versa. Your best bet with either procedure (and with all procedures) is the quality and experience of your doctor. In fact, I'd say this choice is more important than the procedure you ultimately choose

I wish you the best of luck in both your decision and your surgery.

Dale

[teg]

Hi Sharman,

Thoughtful post and some very good questions. I can share with you what I have learned during the past 5 years in my spine research.

ADR has a quicker recovery time that fusion procedure of similar levels. A criterion noted in FDA approval.

The bone matter that is cleared away for the keel is reabsorbed by the vertebral bones. I asked this question before my ADR surgery.

The facet joints are removed during fusion surgery. Facet joints, in most cases return to normal function after ADR. If facet degeneration has not started prior to surgery, it is unusual for ADR to cause facet degenration.

Nerve damage during surgery is a by product of how the surgeon gains access to the spine. Any access point to the spine, anterior or posterior, will have some nerve involvement. For men, the anterior approach for fusion or ADR carries and additional risk.

Osteoporosis is usually a result of oral steriods and medications. I have not heard of osteoporosis being linked to a surgical procedure. Can you verify?

Consider the cause for surgery - was the painful disc created as a result of trauma or degenerative process? Degenerative process can cause adjacent level disease quicker than trauma-related disc pain. I had a single level fusion done in my neck and I experienced adjacent level disease in less than a year post op.

A fusion can be performed on previous ADR site(s) without removing ADR. I believe it is important to research the ADR implants and their associated failure rates.

Lastly, I found that selecting my surgical procedure was my first step. Once I found my surgeon to do the procedure that I preferred, I was confident that the surgeon had the experience for proper placement, size selection, and everything else. Your concern on this topic is right on target, but please not that it applies to ADR and fusion. Even though fusion is a more common procedure, a good surgeon will use good hardware and have great surgical acument.

Best of luck to you.

[sharman]

Thank you all so much for the invaluable input and, of course, kind words. I'm looking forward to thinking about what you've said, googling a bit, and then talking to you all more specifically. (Mariaa, I've followed your story. I've been just where you are right now, so often in the course of my gimphood. We could talk forever.)

Right now, I'm most focused on the risks of adjacent level degeneration and nerve damage. Certainly, fusion has the rap for adjacent segment syndrome. The statistics are grim, but I would like to see the stats for single level L5/S1. Sure enough, without much google effort, I found a pro-fusion guy confidently asserting that, at L5/S1, "there is minimal motion, so fusing does not significantly change the biomechanics of the segment."

Nerve damage I have a lot of questions about. Both procedures involve distracting the disc space during the surgery. And--this I've never understood--both also proudly claim to permanently "jack up" the disc, "restore disc height." Now, from the pictures it appears to me that both fusion cages and ADRs stretch the space, not just more than pre-surgery, but more than normal. This is a good thing? Why do I want to grow an inch after surgery? That just seems awfully brutal on the nerve roots. I could understand if a patient has radicular pain due to a disc space so flat, there was impingement on the nerve roots. But that's not my case. I don't have any leg pain.

So which is worse for nerve damage, fusion or ADR? It seems to me I never heard of "distraction pain" before ADR. But nerve damage is considered a not uncommon complication of fusion. And there are so many variations on the fusion theme, who knows what outcomes correlate to what flavor? Perhaps some of the new procedures succeed in minimizing the trauma.

Finally, this is a weird factor to ponder. I've somewhat suspected that fusion is for patients with great loss of disc height, and ADR for patients who still have good height. And that's not just because the other option is ruled out, but because those respective symptoms work best with the two respective procedures. Now, in the same article from the pro-fusion guy I quoted above, very strong confirmation: "The two findings on the MRI that correlate best with a successful postoperative outcome is the presence of disc space collapse and cartiliginous endplate erosion. Findings such as disc bulge, disc dessication or an annular tear do not correlate well with a successful outcome." Isn't that weird?

To be continued.

[ans]

Yes, weird and disturbing.

Good work!

[sharman]

ans

Wouldn't you know, I had to google to find your thoughtful posts, a few months ago, on the subject I'm pondering now.

For what it's worth, here are my thoughts about one of your options, fusion at 5/1 and ADR at 4/5.

I've found no specifics yet in my google searches, to confirm that fusion increases the risk of adjacent segment degeneration, even in the case of fusion at 5/1. But I would argue we have one very significant statistic already: Is it not true that 5/1 is the level that most frequently fails? And what is 5/1, but the disc that has solid bone, not another shock-absorbing disc, beneath it. So, isn't 5/1 analogous to the level adjacent a fusion: any level that does not have a shock-absorbing disc adjacent (especially below) is going to get more stress and be vulnerable.

However, let's think about fusion at 5/1 with ADR at 4/5. The vulnerable level is 4/5; that's the level that meets solid bone. But your 4/5 will be plastic and metal, able to stand up to the abuse (and no innervated annulus to complain). So, that would be an ideal situation in which to have 5/1 fused, if fusion appears the best option at that level.

That's my first thought. My second has to do with your statement that you have a lot of DDD. Do you have vulnerable levels in addition to 5/1 and 4/5? It is my current hope that borderline discs can be saved with one of the biological therapies just now coming available. Especially combined with ADR, we might be the first generation of back sufferers to need major back surgery only once in our lives.

[Blairsara]

I had Charite ADR in 2004 @ L5/S1. A few months later my facets started to go. First one side than the other. Than things started at L4/L5. The same facet problems as L5/S1 and also bulge. The longer time went on, the more "destruction" to the facets at L5/S1 and at L4/L5 it became bilateral. If that doesn't show a domino effect, I don't know what does. Things were just going to get worse if the Charite didnt come out. And so it did.. and now I don't have the pain I did pre-revision.

Blair