Revisability of fusions?

[mmglobal]

I'm in Straubing now with a client who has been severly disabled for years because of severe back pain when he stands, followed by the onset of leg pain and weakness if he's up and about for more than just a few minutes. It's OK with him if I share some of his story.. "If it will help someone else, please do it", he says.

I won't tell his story now, I'll leave that to him later, but I do want to relate an important issue. Dr. Bertagnoli believed that the top of the fusion hardware was impinging on his facets and that the disc(s) above the fusion may be painful. We were disappointed that the discography at both levels above the fusion was negative. No smoking gun there. However, the facet injections at L2-3 were VERY effective... almost eliminating his pain for more than 2 hours. Unfortunately, removing large posterior constructs like a 3-level lumbar fusion is a big ordeal, so they are highly motivated to do as little surgery as possible. We were hoping that Dr. Bertagnoli would be able to remove just the top 2 screws and part of the rods above the second set of screws. Remember that all the fusion hardware is unnecessary once fusion is complete and this patient did have good fusion. He was disappointed that some of the hardware would remain, but glad that he'd have a less invasive surgery. There are so many trade-offs, but this seemed to be a good one.

The surgery was very interesting. Upon exposing the upper levels, it was very clear that Dr. Bertagnoli was right. While you couldn't see such great detail on imaging, direct viewing showed that the hardware was indeed impinging the facets above and the facets had responded with a great deal of osteophytic bone growth... rendering the facets mostly immobile and deformed. I've observed this type of surgery before, but this was the best view I've had. I learned a great deal about what we are talking about when we talk about collateral damage from invasive surgeries.

There are MANY different fusion systems out there. Like all things spine, there are compromises everywhere. The hardware has to be VERY sturdy or it will break. The 6mm titanium rods require a substantial bolt cutter to provide enough leverage to cut the rods and very sturdy jaws to take such a high load. If the surrounding tissues are pliable, relatively small access will povide enough room. If not... a larger opening must be made. Because of the design of the hardware, you cannot remove one set of screws without being able to cut or remove the rods. When creating wider and wider access, there comes a point where it is more reasonable to remove everything than it is to cut the rods. During the surgery, I asked, "if you had to do a multi level posterior fusion today, would you use a modular system so if revision is necessary, you can remove just the components you need to remove?" The answer was, "ABSOLUTELY! With a modular system, you can remove components with muscle splitting techniques. You don't need to open everything like this."

We won't know the outcome of this surgery for some time. It may be the case that the lower hardware was a significant part of the patient's pain, so it was actually better to remove everything. We hope that the balance between pain relief and collateral damage leaves the patient with substantial improvement. Seeing him walking around at less than 24 hours post-op gives me great hope. Still, it will be a tough recovery and only time will tell.

We see a lot of different designs that represent different balances. Less invasive here... less revisable there. When considering ADR, we talk about "what if I have to have it removed?" We should ask the same question when considering fusion. There are many different systems out there and many different motivations for surgeons to use one system over another.

Do your homework... make informed decision....

All the best,

Mark

[sahuaro]

Mark:
Thank you for posting this information which qualifies as a "clinical pearl."
Wishing your client the best for a successful outcome.

[KL Aguilar]

Mark, it is hard to tell by looking at the pictures how big those screws and other pieces are. Are they longer than 3 inches?

KL, now 12 years and 10 months into my journey to avoid a three-level fusion with plate and screws. Laminectomy with no hardware scheduled for August 7.

[mmglobal]

KL, on my screen, they show slightly larger than actual size. The longest screws are slightly larger than the short dimension of a credit card. (Standard card size is 2 1/8 inches, so my guess is that the larger screws are about 2 1/4 inches total length including head.

I'm looking forward to hearing of your successful surgery!!!

All the best,

Mark

[mmglobal]

Sunday night in Straubing... The surgery had been on Thursday... I wrote the original post Friday evening, when I had no idea how things would go. Friday had been a tough day. By Saturday, the patient was already doing better than we could have anticipated. It was clear that there were no new neuro issues or pains. Post surgical pain was substantial, but it seemed that he moved easier, walked and sat more comfortably than pre-op.

Earlier today... he left the hospital. We went out for lunch and walked around a bit. I still can't believe how he's doing. It's still early, but all good so far.

Mark

[mmglobal]

I've been asked about a dozen times already, what the hardware looked like before removal?? You'll see it below. The client went home already... almost a week before he had planned. We never expected him to be in shape to travel so early. He's still hurting from the surgery, but still better than pre-op. I hope he'll come post in a few days. AMAZING story!

All the best,

Mark

Note the spinal cord stimulator leads implanted in his t-spine. A control unit/battery pack is implanted in his rear-end and is very painful if he sits wrong or bumps into something. With any luck, he'll be able to get it removed in a few months.

[ans]

Is the the standard amount of hardware used in most fusions? If so, no wonder people prefer ADR's lesser imprint.

I hope this can save anyone who goes through a revision.

Allan

[mmglobal]

Allan,

That looks pretty standard except that you don't see the cross bracing in more recent fusions. 4 screws for 1 level, 6 for 2, 8 for 3, etc...

It's not so much about the hardware... it's about he invasiveness of the surgery. Newer techniques strip less muscle away from bone and leave more of the surrounding musculature and ligaments intact.

I almost did 2-level 360 fusion with anterior surgery for cages and posterior surgery for screws and rods. Then, I almost did a 2-level BAK only fusion... anterior surgery with cages, no posterior instrumentation. I believe that the chance of success for that surgery is very low... especially in a tall, active guy... no posterior instrumentation to stabilize???

Now they do STALIF or cages and anterior plates for anterior only fusions that are sturdy enough that no posterior instrumentation is needed. (I don't see anterior plates in the US... maybe they are done, but I don't run into them or doctors that use them.) Or, they'll do PLIF or TLIF procedure to accomplish 360 fusion from posterior only... don't violate the anterior approach. Muscle splitting approaches for posterior only surgeries are great, but you can't gain access to the canal area decompressing very well unless you violate more structures with more invasive access.

Compromises everywhere....

Mark

PS... I'm not a doctor... yada, yada, yada... (I wonder what the people who don't know what yada, yada, yada means think when they read this?)

[mmglobal]

Originally Posted by mmglobal

I almost did 2-level 360 fusion with anterior surgery for cages and posterior surgery for screws and rods. Then, I almost did a 2-level BAK only fusion... anterior surgery with cages, no posterior instrumentation. I believe that the chance of success for that surgery is very low... especially in a tall, active guy... no posterior instrumentation to stabilize???

I must point out for some people who may be reading this that when I say, "I almost did a 2-level fusion", I'm not suggesting that I perform surgery. I was a spine patient with years of pain, disability and multiple surgeries. I'm talking about having surgery performed ON me.

Sadly, some need this clarification.

Mark

PS... yada, yada, yada

[rosedee]

Hi Mark,

Even though the imaging wasn't clear, was there some evidence on the scans of impingement? Or was it a process of elimination that led to the facet joints being injected?

[ans]

Thanks Mark. Truly scary - Dark Ages.

Is there any fusion method that seems most palatable, granted that all are none? Also, are the best means, in your opinion, in Europe vs. here?

Appreciate your time. - Allan