Choosing ADR or fusion

[sharman]

I am considering whether to do ADR or fusion at L5/S1. I probably wouldn't consider fusion at all, but for this being a single level, and the level where (I believe I've heard) preserving motion is least critical. Some of the new minimally invasive fusions look to me a lot less traumatic than ADR, tho surgical trauma is only one of many factors to consider.

There are a million points on which to compare the two procedures. I am mostly laying out the questions here, and will really appreciate hearing any thoughts or information you have.

Both procedures should be equally effective at eliminating a discogenic pain generator, as in both the symptomatic disc is completely removed. (Or does ADR leave a piece of the annulus in place?--that always bothered me.) So the questions are,

(A) What are the risks of each procedure/device.

I see five main categories here, the first three being the most common: Damage to (1) adjacent discs (advantage ADR over fusion, which puts increased stress on adjacent segments); (2) facets (a risk for ADR, less so for fusion?); and (3) nerve roots (from the surgery=equal risk in either ADR or fusion? Perhaps the new fusion technique, approach through the sacrum, offers the least neurological trauma. trans1.com.) The choice among these first three risk factors might be dictated by what each patient considers most vulnerable in his/her own body.

Also to be considered is how fixable each of these three problems is. (1) No one wants more discs to fail after major surgery to correct the first failure. But at least we know discs can be fixed (fused or replaced). (2) Pain from damaged facets appears much more difficult to relieve. Nerve ablation is painful, hit-or-miss and must be repeated when nerves grow back. There appears to be one interesting treatment, cryotherapy, but I know little about it. (3) Nerve damage is also difficult to fix, though frequently resolves in time. The treatment, drugs, is not a pleasant one.

(4) The fourth category is damage to structures other than the three listed above. In fusion, there is a risk of hardware loosening or otherwise causing damage, any one know of any others? In ADR, there is the risk of subsidence, poor placement, etc. Osteoporosis is a risk for ADR, is it also for fusion?

Is the trauma done to surrounding tissues and bone worse in ADR (cleats or keel, major abdominal surgery) or fusion (pedicle screws, removal of bone both in the spine and elsewhere). One of the biggest disadvantages of fusion in my mind is the need to harvest bone, with the resultant complication of donor site pain. I do not know what strides may have been taken toward eliminating or diminishing that risk.

With fusion, if the segment does not fuse, where does that leave the patient, and what are the options?

The big question in my mind is an issue I'll call fit, for lack of a better term. Patients come in all sizes, ADRs only come in a few sizes. Do some ADRs turn out badly because the device did not fit well? Is fusion inherently more likely to fit each patient's anatomy? Or do the cages/whatever inserted into the disc space, or the screws, used for fusion also create issues of fit.

Should a patient's body type influence the choice? I have a gut feeling that tall, long-waisted people do better with the ADRs, perhaps as a direct result of the difficulty of fitting or implanting the device in us short, dumpy guys.

(5) The fifth category is long-term and unknown risks. In ADR, there is the risk of the device failing (like artificial hip joints), and the unknown effects of particulate wear from the device. Fusion has a lot of problems, but it's a known commodity.

(B) What are the implications for future surgeries, or revision?

Advantage to fusion here? You burn bridges having that major abdominal surgery for ADR, scarring down the blood vessels so that the approach cannot be used again. Now one thing I do not know, does that mean only that it is now more difficult (or impossible) to access the same level from the abdomen, or would it affect access to adjacent levels too? A not remote issue, as one can foresee needing surgery on L4/L5 some years after an ADR at L5/S1.

(C) What are the relative discomforts of the surgery and recovery?

It should not be a deciding factor, but it's not meaningless, which procedure is more difficult to go through and recover from.

Some of the minimally invasive fusion techniques appear to be easier to go through than ADR. Certainly, it would be nice to avoid abdominal surgery. The incisions are smaller. The new trans-sacral fusion claims to have patients out of the hospital in one day, and back to work in 15.

On the other hand, your new ADR is ready to rock and roll from day one, while a fusion must fuse, over several months' time. At the least, that probably means one's activities are more restricted, and corsets must be worn longer and more faithfully.

One issue on the comfort list is advantage to fusion: The possibility of finding the surgery you want in the US. For ADR, there remain many things not available here, like the newer discs and vertebroplasty compounds.

Any thoughts most appreciated!

[ans]

You elucidate what I think about in a rather deranged way. I do not know what the truth is re: if ADR (or what disc type) creates less of a domino effect on surrounding levels. As an aside, I went for a PT evaluation and to my surprise, she palpated my S1 joint that hurt.

Good luck and thanks. I have been told that I'll need fusion vs. an ADR at this level but wonder if this is more for insurance reasons.

Be well, ans

[Maria]

Sharman,
Like ans I was impressed with the clarity of your questions. As far as answers go I will let the scholars (those with wisdom in this area) reply.

Last surgical recommendation for me was fusion at L5S1 and ADR at L4. Since I'm not working and had been doing well w/medication only I had put surgery on hold. Good decision or not I'm not sure as seems like life is on hold but when not having back pain and just able to take long walks and be a social creature I'm happy. Probably too easily pleased these days!

As I stated on another forum.. I've become complacent. Glad to see you're seeking answers and moving on!!! Good luck! Maria

[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