Decisions, decisions, decisions.........

[Tim]

Rosedee

I'm so sorry to hear about your current situation. It must be so frustrating having had your ADR surgery with a top surgeon and for it to have had no effect..

Mark do you have any direct knowledge concerning the different facet technologies currently in trials or in development. The Fenix system by gerraspine certainly looks interesting and I like the idea that ‘no bridges are burnt’. If this system is effective and can be implanted without causing excessive ‘collateral damage’ then it looks pretty promising.

Mark from your experience, talking to the top world surgeons, does there yet exist an accepted protocol for ADR revision? Do the majority of surgeons favour the safer option of leaving the ADR in place and fusing posteriorly (supposedly via a gutter fusion) with rods and screws? If so what sort of results are they getting?? Have you personally witnessed or discussed the real world feasability and safety of removing the ADR via an ALPA/XLIF approach and replacing with an interbody fusion?

Rosedee, I can’t help but be somewhat surprised that Dr Z. apparently missed your advanced facet degeneration. It will be interesting to hear his response to your current predicament.

Whatever decisions you make for your future treatment I wish you all the best and hope you can stop by now and again to give us an update..

All the best
Tim

[rosedee]

Thanks for your post, Tim. You ask some interesting and pertinent questions. I realise how much more I need to find out if I'm going to be able to make a valid decision about what to do. It's also clear that if I am going to have any more surgery it's important to get Dr Zeegers opinion about it generally and, in particular, whether it would be better to leave the new disc in situ or not.

Of course I know, and knew, that spinal surgery is always a gamble to a greater or lesser extent and that the outcome could have been worse. But the fact that my decision to have the ADR was based on so much research and thought and had such apparently strong evidence in its favour makes it feel even more difficult to trust that I can reach a meaningful decision now.

Mark, I would really value your thoughts on all this.

[mmglobal]

Tim, I'm not sure about the "no bridges are burned" aspect of anything spine. I remember when the ADR doctors said... "sure, no problem, try ADR and if they don't work you can pop 'em out an fuse... no options lost".

I have spoken at length with several docs about the Fenix system. Looks good... looks minimally invasive. I guess you could say, 'no bridges burned' if you believe that the facets are already completely shot and are your pain generator.

At the conferences, everyone seems to understand that the facet repairs are going to pay off for the failed ADR patients. However, the product development process does not allow that to be the focus... only plain vanilla cases... all the talk about ADR revisions is pretty hushed. I think that the facet replacement and repair technology will be huge. The surgeons I know who are involved in the clinical trials seem to be pretty surprised at how well the patients recover. However, it's still early and we'll see about long-term when we get there.

I don't think that there is accepted protocol for ADR revision. Sadly, a substantial part of my business is dealing with failed ADR clients. (Even more sadly, most of them have problems that could have been avoided... some are just unlucky and their complications would have happened no matter what they did. But, I still see the lions share of problems being from poorly implanted devices or poor patient selection ... easy to say in hindsight.) I've taken the same clients to multiple surgeons and have listened to compelling reasons why one would absolutely explant the prosthesis, while the other would leave it in place and fuse behind. I have also seen posterior stabilization behind failed ADR and will see more soon. I have seen anterior ADR revisions both cervical and lumbar. I have seen lateral procedures, but not ADR revision. I will soon see lateral ADR repositioning... can't/won't give details until it's over.

The decision on how to remove the prosthesis will be impacted by what else needs to be done. If another total disc will be implanted (say between 2 ADR's), then you are already there for anterior surgery and an anterior access retrieval will make sense. Now, you can consider a lateral ADR, but I've only seen Pimenta talking about that. Each case is unique and revision strategies will not be consistent.

Rosadee... I'm so sorry to have watched you go through such difficult times and not finding relief with ADR. You are living the nightmare that we all feel. It's amazing to me how, as I deal with many difficult cases that span years, how the diagnoses change. A surgeon sees something that seems obvious, but he's missed it before and other surgeons have missed it before... then it turns out not to be the culprit???? Spine is so complex and many cases will never be understood. I don't think that means we should stop looking. But it does mean that Rosadee's caution is well placed. When we are desperate, we will do surgery based on wishful thinking. Some of us may be so desperate that that is not unreasonable. However, getting clear diagnoses... proving them out... will help increases our chance of success. Unfortunately, it's only an increase... nothing brings it close to being a sure bet. What I see is people having surgeries based on clear indications. It makes sense that when tests prove a pathology, when that pathology is certainly the most likely cause of your pain, give high confidence for a positive outcome. However, that does not mean that you don't have another generator for the same pain that will not be addressed when the obvious issue is dealt with.

I don't know how we are supposed to deal with this except by doing what we are doing. Expend the effort necessary to get as much information as possible so you can make an informed decision. Then proceed with the full understanding that 70, 80, 90% chance of success may sound good, but it's only good if you are not one of the unlucky ones.

All the best,

Mark

[rosedee]

Hi Mark and thanks for your post. The information you have gained about facet repairs and ADR revision from your talks with doctors is very useful to hear about.

I think one of the hardest things in trying to reach decisions is that invariably each doctor you see has at least a slightly different stance/emphasis on your situation. As you know, 4 different surgeons each agreed that L3/4 was my main pain generator (in all probability) and that ADR was an/the appropriate treatment. Of these, I had confidence in the opinion of 3 of them, each of whom was very experienced and well-regarded. And yet there were also differences in their opinions about my overall back problems. The view that the more docs you see the more opinions you get still holds true. The other side is that while I value the opinion of each of these doctors still, I have certain reservations about each of them now, for different reasons.

In addition, now that diagnostic injections using local anaesthetic are known to be unreliable for me, I am always going to be missing important data for decision-making. This will, then, increase my likelihood of being one of the "unlucky ones".

In relation to the facet replacement, my thinking currently is that I would be mad to go with it at the present time - not only is it to soon for there to be meaningful outcome data, but my back is nothing like those discrete problems that the trials are focussing on. Do I really want to be a guinea pig?

On the other hand................... I can't bring myself to have another fusion in the forseeable future......... perhaps a year's sabatical is the answer ........ but what if......... back and forth and round and round I go!