Dave,
Sorry to hear about your painful facet(s) at L5/S1. Perhaps your pain management doc could perform a rhizo and, at the same time, give the cyst aspiration another try?
As far as fusion goes, it's really an individual choice. Here's the breakdown of post-ADR facet options that as I know it.
*Fusion: ADR revisions to fusion, with or without ADR removal are complex surgeries. As far as I know, there is still some controversy concerning continued painful micro-motion with a posterior-only fusion. Removal of the ADR is definitely a "big deal" surgery, although experienced surgeons have done it successfully. Needless to say, you lose the motion at that level with all the issues that may or may not be associated.
*Posterior Stabilizaiton: Posterior stabilization devices address facet pain by "sharing" the axial load with the facet joints and preventing improper motion. Yes, the painful facets remain in place, but, with the posterior stabilization device taking a good deal of the load, the facets can calm down and quit hurting. Surgical approaches are far less invasive than a fusion revision or facet arthroplasty.
*Facet arthroplasty: These devices work by simply replacing the facets and/or the entire posterior spinal element with a mechanical device that does the same job. These devices are VERY new with little or no clinical data, depending on the specific device. At the same time, for someone with an ADR and symptomatic, end-stage facet arthritis, these devices represent the only alternative to fusion. Surgical approach would be similar to posterior-only fusion or laminectomy.
*Rhizotomy: Works by simply cutting the nerve signals that feed the facet joints themselves. Facet rhizotomy can be very effective for reducing pain from the facet joints. The technique is percutaneous (just a needle), and, therefore, represents the most minimally-invasive of all the possible procedures. Despite the fact that rhizo is only a pain management technique, it can indirectly provide real, structural benefits in that it permits better physio and muscle strengthening which can, in and of itself reduce the very instability that may have been causing the facets to be painful.
Personally, I'm not in a hurry to do anything more than rhizo, even though I have fairly advanced facet arthritis behind my ADR at L5/S1 and at the non-ADR level above at L4/L5. Although I'm a huge fan of joint replacement technology, I'm simply not comfortable with the idea of using devices that have so little clinic data. I'm not happy with a fusion because, in addition to a revision of my ADR, it would mean losing motion at not one, but two levels. Even though I'm no longer young (39-years old), I'm not yet willing to accept the activity restrictions a two-level fusion would require.
Hope this helps and bear in mind that I'm certainly no expert - just another patient looking for information.
Best,
Laura
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