ADR revision - 2-level Dynesys behind Charite'

[mmglobal]

I just spoke to a client of mine. He's a couple days shy of 2 weeks post-op from his revision surgery.

He had 2-level Charite' done 1.5 years ago with good result... good relief from both back and leg pain. Implantation looks OK... off midline, but very much within tolerances and we see much worse without the tilt.. 1 year post-op, numbness in legs and feet starts along with nagging low back pain. The vertebral body between the prostheses has taken a substantial tilt.

For the last 6 months it had gotten progressively worse. It was to the point where he was questioning his ability to continue working. He could not take the typical meds because of his job (pilot).

Everyone feared the Dynesys solution as Carmen's situation with 2-level Dynesys behind 2-level tilted Charite' was thought to be in trouble. When it became clear that at 2 years post-op, Carmen's configuration was stable AND successful, everyone started taking another serious look at this revision possibility. (Carmen's story is incredible and I hope she'll come post here.. it's too much for me to explain now.)

In any case, speaking to this gentleman at one day post-op was very encouraging. "As soon as I woke up, I could tell that the numbness in my legs was gone." Now, at 12 days post-op:

• "back pain and leg pain are gone."
• "feeling pretty darn good!"
• "I took a flight today" (That means back to work! maybe light duty, but hey, this isn't even 2 weeks out.)
• "I hope to take a hike in the woods with my dog tomorrow."

It's still early and we don't know the long-term result, but this looks very hopeful. I know that others are considering similar revisions for different reasons. It's nice to feel that there are options.

I hope the patient comes and posts on his own. I'll post more as I learn it.

Mark

[Alastair]

I find it interesting,because I have a patient who had Dynesys which was starting to fail, revision surgery was done and it was replaced with 2 level ADR done from an anterior position as usual. That is over six months ago and I await an e-mail to hear how they are progressing.

Revision surgery can be done, but it's very dangerous, and requires a lot of competence from the medical team
best,
Alastair

[Maria]

Mark,
Is this being done in the US? (this is probably a dumb ?)
Best wishes for continued great recovery~

[mmglobal]

Maria, yes, this in the US. I'll leave it to my client to provide as much or little detail about him or his doctor as he would like. I have the OK to share info about his case that may help others.

Alastair, thanks for the post. Do you have any meaningful details about your 'patient', like how the Dynesys was failing or did they leave the Dynesys in place or why was Dynesys selected in the first place, etc.????

Mark

[Alastair]

Hi Mark,
The Dynesys implant was not allowing the patient to stand as erect as they wished to stand, so ADR was done about six months after Dynesys and then six months after the ADR the Dynesys was removed.

I think the Dynesys was a poor surgery, but having so said I had not met anybody in the UK that has had a "good" Dynesys surgery there have always been complications.

I am awaiting an e-mail, to let me know how this patient is getting on 12 months after the removal of the Dynesys
best,
Alastair

[Bobb0]

Mark,

• Is there a difference between revision and add-on?
• Will you be able to bring more information concerning diagnoses, and identification of causal factors leading to decisions that add more devices to the existing prosthesis?
• Are these experimental 'shot-in-dark' attempts to solve the pain generators?
• Are the pain generators identified? How?

Thx
bob

[mmglobal]

>>> Revision vs. Add-on? I think this is semantics. I'll be making this up as I write. These ideas may not be fully baked. I think that a revision surgery is any procedure that you do after surgery that changes the configuration.

The easiest revision may be a 'clean-up'? After ADR, if a laminotomy or other relatively minor decompression surgery will help, is that a revision? I think if its related to the original procedure, I guess it is.

Bob's question intimates that adding some new hardware represents a different level of surgery than explanting the prosthesis and performing a 360 fusion. Absolutely! Adding Dynesis is a relatively easy surgery compared to the big explant/fuse surgery.

>>> More detail? Remember that each situation that requires a revision is still pretty much a 'one off'. All the revision situations I've been involved with have been completely different situations. In this case, the vertebral body between the 2 prostheses had taken a big tilt. Imagine the foraminal spaces... 2 above and 2 below. 2 will be opened up (upper side a, lower side b) and 2 will be closed down (lower side a, upper side b.) If this progresses to a stage where the exiting nerve roots are being impinged, that will bring leg pain, numbness or other radicular symptoms. Low back pain may also increase... especially facet pain because they are being opened or crunched by the tilt as well.

Typically, myelography would be done to help assess the level of nerve entrapment. (I'm not exactly sure how much can be seen of the exiting nerve roots.) Diagnostic injections can help to isolate problem areas. Again, each situation will be a one-off and the diagnostic process may yield clear positive, clear negative, ambiguous and even conflicting results. In the presence of clear indications, along with clear diagnostics and imaging that all point in the same direction, the decision process will be easy and the confidence in the surgery will be high.

>>> I don't think that this procedure was a shot in the dark. It was based on pretty clear indications. I believe that the surgical decision for revision is much the same as it should be for the original surgery. "Do the lease invasive procedure that stands a good chance of a positive outcome." Easier said than done... especially when indications are less than crystal clear. No surgery based on wishful thinking. I think that the bar is higher and it's harder to pull the trigger on a revision. You are likely to have lower confidence in the surgery, along with a greater (and healthy) relucatance to do more surgery.

>>> I hit a lot of this question in the second bullet above. In this case, the cause of the numbness in legs was clear... the surgery was all about resolving the tilt, decompressing the exiting nerve roots that were clearly being compressed because of the tilt.


I caution everyone to realize that we do not yet know the long-term outcome here. It looks great a 2-weeks out, but that is not what we are after... it's all about long-term results.

Mark

[Alastair]

I am just catching up with you here folks, I heard from my patient who had dynesys removed and replaced with ADR, she is doing absolutely fine, totally out of pain and making a really good recovery and enjoying life again
Best,
Alastair

[Arlopilot]

Hello Mark and to all. I am 3 weeks out and feel great! The pain and the numbness is 98% gone. I have not felt this good in many years. I am still very cautious and will not be doing any jumping jacks for some time. My wound is still tender and will take another few weeks to heal. I have been walking every day for the last week and have been slowly increasing the distance every day. I will post again in another few weeks when I start getting into the physical therapy.

Best,

Karl

[Arlopilot]

Hi Mark. It has been 3 weeks and I am doing very well. The pain and numbness is essentially gone. My wound is still tender but I anticipate this will clear up in another week or two. I am still very cautious and limit myself to short walks. I will post again when I start physical therapy next week.

Best,

Karl