[sharman]

ADR-Damaged Facet Syndrome (ADFS). If an acronym hasn't been coined yet, this is my suggestion.

Like everyone considering ADR surgery, I'm sobered by the conventional wisdom that ADR is hard on facet joints, and one has only traded the risk of adjacent segment degeneration (ASD) with a fusion, for same level facet degeneration with ADR. To make it worse, facet damage is very painful, and much more difficult to fix than ASD (if the disc at the next level goes, you can always do another ADR or fusion). This has been to me the one most significant respect in which fusion looks better than ADR.

ADFS as a significant ADR risk is seemingly confirmed by studies showing degeneration of operated-level facet joints several years after ADR. This conjures up in my mind an image of a facet-shaped Sword of Damocles hanging over the patient's head: Is it just a matter of time and luck before s/he starts a new era of back pain, after 3 or 5 or 10 or? years of ADR relief?

As I did some reading and thinking this weekend however, a whole new picture of ADFS emerges in my mind. In particular, my ideas were changed by the study presented by Dr Charles Rosen, reporting on 24 ADR patients with ADFS www.ispub.com/ostia/index.php?xmlFil...2/failures.xml

All 24 of the patients in the Rosen study, very much like the unfortunate ADFS patients on this and similar forums, experienced the onset of their problems fairly quickly after surgery, within the first year. Maybe I'm just missing the data, but is there any significant population of ADFS patients whose symptoms did not manifest until many years after surgery? Can we then conclude that ADFS is a risk factor only for the first year after surgery?

Yes, there are studies reporting radiographic signs of facet degeneration in ADR patients. I just read the abstracts on two new ones. One is a 10-patient, all-Charite' sampling. Of those 10, "a startling number" exhibited facet degeneration over pre-surgery levels. But, if I read the abstract correctly, none of these degenerated facets was painful. The other is from a Korean hospital, at the 5-year mark, again apparently showing radiographic, but not symptomatic, facet degeneration.

So these studies, sobering tho they are, do not tell us that a significant number of ADR patients will succumb to facet disease down the road. Indeed, these studies don't even tell us that the patients are experiencing progressive degeneration. All they show us is that operated-level facets show a degree or two of degeneration relative to pre-surgery. For all we know, this may be the result of the surgical trauma, and the damage could be staying level or even improving.

I have read only one study abstract about patients getting revision surgeries many years after ADR (3 to 16 years, with 9 the average, 17 patients in the group). This study reported only on the prevalence of wear particles that could be causing inflammation (conclusion: very prevalent, certainly something to be concerned about, but a different topic). Since the abstract did not mention any other pathology requiring the revision, presumably this group of post-ADR, new-back-pain patients were suffering painful inflammation from wear particles, not facet degeneration.

[Of course, please note I have not tried to research this at all, just reacting to some studies I read recently. If I'm way off base here, I apologize, and will welcome better information. And I apologize for not being able to figure out the URL. I can't get my computer to copy)

So if I'm reading this information correctly, even if there is a ADFS Sword of Damocles over the ADR patient's head, once you get past the one-year mark, you may be out of the woods.

Now the Rosen study offers even more good stuff.

Rosen claims to see radiographic confirmation of specific pathologies in all 24 patients in his group. All 24 patients showed either compression or distraction of the operated level facets, and in many cases fractures. These pathologies don't sound like slowly-progressing degeneration from hyper-mobile joints, but rather, a dramatic abnormality very quickly resulting in acute symptoms. So first of all, this seems further confirmation of my first theory, that unlike ASD (adjacent segment degeneration) with fusion, ADFS manifests in the first year after surgery, not gradually over several years.

Noteworthy second about the Rosen study is-if he's to be believed--these pathologies are readily visible. Certainly, the pictures included in the study were convincing.

Best of all are Rosen's ideas for revision surgery (posterior, probably minimally invasive? disc left in place). He claims to have acheived excellent results in 5 of the 24 patients whom he revised to fusion. If I had ADFS, I would certainly want to talk to this guy.

These observations suggest to me (i) If you make it past the first year, you're probably in pretty good shape facet-wise. (ii) ADFS should be something you are vigilantly on the lookout for in that first year. (iii) ADFS should not be that difficult to diagnose (both radiographic imaging, if Rosen is correct, and diagnostic injections work well). (iv) If you do get ADFS, maybe you want revise into fusion ASAP. I can't help wondering if a quick response might increase the odds of a successful revision. (v) Maybe the art and science of treating ADFS is finally getting there.

Sure, I'm trying to spin all this into a narrative that will allay my fears about ADR. But tell me your thoughts. Is this not some good news?