Seeing is believing, or is it?

[Crystal33]

Although I have been unable to work and mostly housebound for about a year, I seem to have developed an increasing determination not to have any spine surgery, and to let my body take me where it will. Thoracic is bad area. I try to love my pain to keep my mind from multiplying it. Eugene Carragee has written of this aspect.
I could barely stand up last year but now walk gently up to 1 mile.

I am wondering what others think of the attached MRI images, whether they are REAL...or maybe they have been doctored (no pun intended). Someone like Job13 might have the technical skills to know for certain. I enlarged a few images for comparison.

MRI images of disc regeneration are a rare thing and if it can result from just taking some tablets for a few years then it is the biggest breakthru in the spine history. Yet in the years since the paper was published there are no similar follow up studies and the topic is ignored by spine medical community.

The images came from here.
PubMed Central, : BMC Complement Altern Med. 2003; 3: 2. Published online 2003 June 10. doi: 10.1186/1472-6882-3-2.

The complete paper is here. Authors are very highly qualified which leads me to think the results could be real.
Glucosamine and chondroitin sulfate supplementation to treat symptomatic disc degeneration: Biochemical rationale and case report

I also have included an early image of Job13 injured disc before any of her surgeries. She did everything right by the "system" with thorough research of the (best??) doctors, and then the system took all her money and severely damaged her health and life in the process.

I guess where I am coming from ...is she an example of someone who might be healthy, active and much richer today if she had initially been strongly advised to stick with conservative care, go easy on back, and take certain supplements??

[Aaron]

Dr. Hoogland had a procedure where they scrape the endplates which in theory remove arthritic buildup and allow nutrients to enter discs better. Does it work , I have no idea but the idea is interesting. But from someone who has taken fish oil, glucosamine chondrotin, multi vitamins, some pill called disc renew for 6 years to no success I am a skeptic. I also have thorasic issues, but I do not know the time frame it might take so I don't see any downside in trying it.

[Keano16]

Its called endoscopic disc abrasion, and in theory it should help... Not sure whats the situation in practice.

[Job13]

RIP Freedom of Speech

[Maria]

I have long believed that you can find people with terrible spinal films who feel great and people with not so bad spinal films/findings that feel horrible.

I think I was the latter for a while and now I'm the former or rather even tho my films show marked DDD, moderate facet arthopathy at several levels and endlplate changes that happen with increased degeneration I still feel better than I have in years.

Why? the only thing I can attribute it to is that over a long period of time and with some hastening of the process thru discectomies my L5S1 has autofused and is giving me far less pain/problems.

This level may look much more degenerative (L3 and L4 too) but I feel much better.

Waiting to have back surgery and not having it seems to have worked for me, at least thus far. This is the best I've felt and functioned in years.

And currently I'm taking one third the dose of Neurontin that I've been taking in the last 12 years and the same dose of pain medication (low) once daily that I started on 9 years ago.

Back in '06 there were at least 3 concurring opinions with regard to proceeding with a hybrid surgery at L4 and L5S1. Prior to that in early 2000 there was recommendation for a 3 level global fusion.

I am very glad about my decision to wait and not have more surgical intervention however I had a very mentally and physically traumatic 2nd spine surgery which failed and had I not gone thru this I'm quite sure I would have jumped at the chance to have multi level disc replacement.

I take no supplements. Have had 2 right knee surgeries and 2 spine surgeries and currently am warding off bilateral posterior tibial tendonitis which can be such a royal pain because my spine does so well with walking. Sitting is even improved.

My right knee is hanging in there and has not been a problem for a long time tho can exaccerbate every once in a while with either pain or weakness or both. Goes away with some rest, quad exercises and ice packs.

They used to scrape the underside of the patella back " in the day" and I had that done and was told I'd need it done every 5 years or so.. well my 2nd knee surgery (patella tendon release) took a lot of out me with a very prolonged recovery and I'd not consider letting anyone near my knees either without very extremely good reason/arguement or only if the pain was something I couldn't tolerate or limitations. No "preventative surgeries" for me on knees either. The surgeon who did the patella tendon release argued that I would have needed it when I was 50 (had it when I was 35) and here's a fact... medicine changes every so often and what is done one year may not be done the next 5 or 10 so I'm never falling for that one again!!!!!

Hanging in there with what I have ~ good bad and the ugly spine as long as things are doing OK.

[mmglobal]

Technically, the images are quite different. Look at other landmarks and you'll see that the contrast, sensitivity, and resolution is very different. (look at the dark outline around L5-S1 and also the tissues in front of the L4 body both look very different from before to after.

The disc is somewhat of a paradox. The sclerotic bone in the anterior portion of L3 would suggest very advanced DDD, but even the before image is nicely hydrated (especially for such a severely collapsed disc space.)

This is the presentation of a single case, not a study. I've seen other films of regenerated discs after abrasion surgery, traction therapy, ADCT, IDET and other treatments. I wonder what else the patient did in the intervening years. (Traction, PT, eating Wheaties?)

Why did the G&CS help the L3-4 disc, but not L4-5?

While I do sound skeptical, I've discussed this with MANY of the doctors I know and none would discourage me from taking it. I have taken it on and off through the years and would recommend it for anyone who's in Crystal's shoes.

BTW, annapurna likes a liquid G&CS supplement that can be bought over the internet. I don't remember the name...

All the best,

Mark

[Crystal33]

Thanks for responses.

Aaron…..Six years is a good test of time. Is your DD minor and disc herniation ‘contained’ type. These are supposed to be best criteria for success of G&C. On the other hand if DD has not worsened over the years, possibly it has been helping.

Job13…It is hard for me to see how disc abrasion was a useful suggestion for you. Your disc injury and initial slight loss of height was from physical disc injury, not from any problem with nutrient supply, unless you had calcified endplates.

Micro disectomy is often referred to as the ‘gold standard’ compared to other surgeries and likely this is true but only in respect to short term pain reduction. Otherwise the procedure is damaging to the biology and mechanics of the disc. Effective annular repair might help but is rarely attempted. Result is that micro disectomy often leads to ADR or fusion later on. I think putting holes in discs and invading the nucleus, is something to be strongly avoided where possible. In my case I had grade 5 tears and disc fragments squeezed out so I carried out microdisectomy on myself.

IDET or any form of intense heat I don’t like. Don’t know how the biology of the disc would respond to something so extreme. As you have said, ask for list of former patients to contact, but at least 2+ years after treatment would be best. Risk is doctor would pick only good outcomes anyway.

A few places do offer injection of G&C into discs and results (published by themselves) sound good, better than IDET.
http://www.treatingpain.com/diagnosi...vs.%20IDET.pdf

Again, it raises question of why no follow up studies?
The cynic inside me wonders if they receive payment by ADR and Fusion industries not to do any more research or publish any more about the subject. Healing discs would not be good for business.

Mark…I agree the images could be better, but as two of the authors were PhD, and they declared no competing interests, I guess the images are real, which still leaves the questions hanging. The authors themselves suggested follow up trials/studies and they should be very easy to do, but no one has.

They did address the question why L4-5 disc was not able to regenerate…“not in the almost fully degenerated L4-5 disc, where probably little or no functional chondrocytes are left.” A relevant study Differential recovery of glycosaminoglycan after I... [Arthritis Res Ther. 2003] - PubMed result

If you could point towards some other locations of images of disc regeneration I would be grateful. I saw one on Dr Hoogland abrasive technique website though this procedure did not go well for Job13.
Willkommen im Alpha Spine Center*-*HERNIATED DISC

I am more skeptical when someone claims regeneration, and they also make money out of the procedure. Still if they have numerous clear MRI before and after images, that certainly would warrant close attention.

[Aaron]

My herniation is a celephad extruded herniation, never got a straight answer from doc but I think that means not contained. And again with my DDD it is which doc I see. I have multiple tears that leaked dye so I guess it is not great for my age 32. I also have some stenosis and smorls nodes that make it hard to discern the source ( to me). I think smorls nodes are underestimated even though its the same, some have them without pain while others have them with pain. I mean they are in essence herniations or endplate disruption which you would think cause constant irritatiion
One question is that with endplate abrasion they scrape the endplate but what about the rest of the vertabrae, is it not the same biological material as the endplate and why would it not loose its porosity also. I myself have been thinking about the oilfield, when the perforations ( holes in the formation that oil flows into the well through) gets plugged with salt deposits we circulate an acid through them and it opens them up. If there was someway a non destructive acid (if there is such a thing)could be circulated through the vertabrae. Probably never work but I just cant get it out of my head.

And in the instances where regeneration happens I just wonder how you differentiate from a natural healing that would have happened anyway, no matter if you had the disc abrasion done or not. I would have to see the amount of time they had been suffering and the amount of time the regeneration took.

[mmglobal]

Crystal, you are discussing abrasion as THE treatment. This is another one of MANY procedures I call a "discectomy with a twist." There are a large number of twists, with lasers, RF treatments, electrothermal annuloplasty, chemical chasers, and more.

I don't think there is an indication for abrasion. As I understand it, there are indications for discectomy and some people may benefit from the twist.

IMHO, if you are a good candidate for a discectomy, it matters little what the twist is. If you are not a great candidate for a discectomy, the twist matters little.

I do know spine patients who have benefitted greatly from the twists, but for the most part, successful SED's, Abrasions, IDET's, PLLD's... and on and on, are simply successful discectomies.

Aaron, your cephalad extrusion would be one that travels up towards your head, instead of caudal, or down towards your sacrum. I believe you are right that it is likely not a contained herniation, so there is disc nucleus material in the canal area.

Mark

[Crystal33]

Aaron,
I understand that extrusion is a full thickness herniation including thru the outer annulus fibrosis but the herniated material is trapped beneath the vertical posterior ligament. Because it is trapped it is harder for the body to attack, break down and resorb the material. However I have seen a MRI case study where even after two years the extrusion was slowly still reducing.
I don't think any type of acid would be a good additive for discs. It is already acidic environment for the nucleus, and also acidity is one cause of leaking disc pain I think.

Mark,
With respect, the reference to abrasion referred to that specific procedure only and was in reply to Job13 posted experience about it and also bearing in mind that it has some disc regeneration claims, which was subject of thread.

Separate paragraph was referring to micro discectomy in general, at least all the aggressive forms, that involve invading disc and removing or otherwise destroying of part of nucleus.

Prior to aggressive micro discectomy, are patients advised there is increased risk of accelerated disc height loss and degeneration associated with the procedure, leading to possible future pain and more surgery? I think they should be so they can make most informed decision. Job13 is an example where such procedures contributed to rapid loss of disc height, which then led to the other operations and outcomes.
This is one of the articles I read months ago.
Two-year outcome after lumbar microdiscectomy vers... [Spine (Phila Pa 1976). 2008] - PubMed result

[Keano16]

Retrospective one year study of PLDD versus micro-discectomy (interlaminectomy), dr. Robert Saftic and his team:

Percutaneous laser disk decompression – our experience with the usage of the diode laser

Patients included in this study all had contained disc herniation.

It shows little higher success rate with PLDD and of course less complications ... but imagine how much tissue damage occurred during micro-discectomy comparing to PLDD.

2 year follow-up results are to be published in near future.

[Aaron]

Crystal

Thank you. I have looked in the past but could not get a understanding of the celephad extrusion. And the acid I was thinking of would be circulated through the vertabre itself to increase porosity not into the disc. I know some would go but it was just one of those things I saw done to something and thought of its application elsewere. Just curious.

And Keano, the more I read about the studies throughout the world they sound so good, but in reality it is a very complicated selection process is it not? Like ADR the selection process of elimination is one of the most important aspects of a successful outcome. And more and more these studies look to be tweaked for the doctors benefit. The idea itself is great but how could these doctors do an unbiased test? How would you disprove the results and verify they are not selecting the results they want to show. Are there any of these trials/studies that are done world wide at the same time and those results compared? This is an area I have not looked into as there are so few thorasic studies it would seem.

[Crystal33]

Aaron,
I didn't know what the term 'cephalad' meant though found it included in this site with good descriptions and MRI images of herniation types. It would be a dream to have an Fig.1 spine. Almost need sunglasses to view T2.
cme

[Keano16]

Originally Posted by Aaron

And Keano, the more I read about the studies throughout the world they sound so good, but in reality it is a very complicated selection process is it not? Like ADR the selection process of elimination is one of the most important aspects of a successful outcome. And more and more these studies look to be tweaked for the doctors benefit. The idea itself is great but how could these doctors do an unbiased test? How would you disprove the results and verify they are not selecting the results they want to show. Are there any of these trials/studies that are done world wide at the same time and those results compared? This is an area I have not looked into as there are so few thorasic studies it would seem.

Yes, unfortunately it is. But, some doctors for some reason expand indications. All researches and studies should be considered with caution of course. For example, for PLDD there are multi-center studies and they all prove the same: PLDD is safe and effective for contained herniations.

For thoracic studies, have a look at Wooridul Spine Hospital web site. I have seen a lot of scientific papers about T-spine.

[Crystal33]

Keano,
PLLD is not always safe unfortunately.
Salvage operation for persistent low back pain and... [Photomed Laser Surg. 2006] - PubMed result

It appears to compare well against microD and better for patient due to minimal invasive and outpatient procedure, and less risk of complications.
Comparison of results of 500 microdiscectomies and... [Photomed Laser Surg. 2006] - PubMed result

Don't know why it is not used more often. Maybe surgeon training, or open surgery is more profitable.

[Keano16]

Yes, you are right. I was speaking generally.

Key for success with PLDD is:
1. Proper patient selection
2. Surgeons technical skills and knowledge of the anatomy

Its not used more often because STILL most of spinal surgeons don't trust in minimally-invasive methods. Some of them tell me "I don't do minimally-invasive, it's new" ... Its not new! Its around us for 40 years already!

Some of them are scared because already mentioned anatomy problem. Not all bodies are the same, and every single percutaneous minimally-invasive method carries significant risks. Recently I attended a two level PLDD (L4-L5 and L5-S1). Doctor Saftic had big troubles reaching L5-S1 disc space, but in the end he succeed and patient is now completely pain fee (he had two level annular tear).

And third - Not all cases are for minimally-invasive approach. So, surgeons still do the gold standard micro-surgery.

[Aaron]

Yea, Keano I always think about knee surgury and how many were against the less invasive techniques in the begining and now that way is so accepted as the norm and so successful.

[mmglobal]

Crystal, I googled "hoogland abrasion" and was pleasantly surprised by the first result:

Dr. Hoogland's abrasion procedure. Restored disc height? - ISPINE.ORG Forum

I wrote this in 2006 and since then have gotten to spend several more days in the OR with Dr. Hoogland. There are several articles linked at the bottom of my post. I'd be happy to learn that I'm wrong, but as I understand it, the access to the disc for abrasion is endoscopic... the same as for his endoscopic discectomy. The idea of doing the abrasion on a disc that is not far enough down the degenerative cascade doesn't make much sense to me. I suppose it's possible, but I'll be surprised if its common. I don't know what the indications would be for abrasion that would not be considered a discectomy with abrasion. Remember that discectomies may not remove much disc material at all.

My wife had done in 2007. It was wildly successful for 3 months, then she started having leg pain on the other side and she had ADR a few months after that. I would not call this a failure of Hoogland's procedure. Diane's disc was far too severely compromised prior to the discectomy / abrasion. (Bertagnoli called this, but we did not listen to him and still started with the less invasive procedure.)

No surgery is always safe. Not every failure is attributable to surgical technique and/or improper diagnosis. We do less invasive surgeries hoping to salvage the discs and avoid more invasive surgeries. Most patients in the online communities who have had fusion or ADR and had prior, less invasive treatments would consider the earlier treatments a failure.

I wonder if I can dig up Diane's consent form for her 'abrasion' discectomy. I'll be surprised if it does not adequately disclose potential outcomes. I've gone through the consent process with clients for Hoogland, Zeegers and Bertagnoli. In each case, the surgeon walked us through the disclosure forms and discussed all possiblities. In some cases, we hear the parts that we want to hear and don't remember the rest.

Spine surgery sucks. Do your homework, make informed decisions.

Mark

[Crystal33]

Keano,
I would be interested to learn how PLLD helps annular tear issues. Does it seal the tears?

Mark,
I guess I view minimal invasive spine surgery (for discs) as needing to be minimal on two fronts:
1. minimal flesh wound not larger than endoscopic, and
2. minimal puncture of disc ie one that is likely to heal and not initiate new or accelerate degeneration.
If an endoscope is used but surgeon creates a box incision through annulus to remove some nucleus material, I would regard the surgery as major invasive as far as the disc is concerned, with increased chance of fusion or ADR required in future.

The Dr Hoogland ‘abrasion’ includes.... “a percutaneous transforaminal approach to the posterior segment of the involved disc was performed using special reamers up to 7.5 mm” 7.5mm sounds like a large opening needing to be permanently sealed somehow.
This is study outcome of 5mm animal puncture model…
Nerve fiber ingrowth into scar tissue formed follo... [Spine (Phila Pa 1976). 2006] - PubMed result

Even fine needle holes through annulus have been identified as posing a risk of initiating disc degeneration.

SMALL AND LARGE GAUGE NEEDLE PUNCTURE AFFECTS INTERVERTEBRAL DISC MECHANICS AND BIOLOGY IN AN ORGAN CULTURE MODEL -- Costi et al. 91-B (2): 351 -- The Journal of Bone and Joint Surgery (Proceedings)

2009 ISSLS Prize Winner: Does Discography Cause Accelerated... : Spine

Following paper is very interesting as it reports on short term disc outcomes where unintended discs were punctured by mistake during surgery.

Does Incorrect Level Needle Localization During Anterior Cer... : Spine

I think maybe the back surgery industry keeps silent on using supplements for disc regeneration (even if they work), and on the importance of maintaining annular integrity, because it depends on a steady, preferably increasing, flow of new patients thru the door. It is critical comment, that would be good to be disproved.

[Keano16]

AFAIK, there are two possibilities with PLDD for annular tears:
1. Classic PLDD like for herniated disc. Needle in center of disc, creating lesion with 1000-1000 J of energy
2. Newer method for annular tears. Needle placed very close to tear itself, maybe in the tear. Also, needle tip is very close to other spinal structures. That is why only 300 J of energy is used in this method.

Not all endoscopic techniques are the same. As far as I know, currently in world there are three different endoscopic techniques for spine disorders - Yeung's, Hoogland's and Knight's.

Yeung's method is intradiscal procedure, so like you say, large hole of 0.5 to 0.7 mm is created in the annulus. This hole is sealed with RF probe just after the discectomy and decompression.

Hoogland's - I am not sure.

Knight's method is something different from booth of this techniques and doctor Martin Knight focuses on the foramen and his technique is called ELF (endoscopic laser foraminoplasty). More information is visible on his website Spinal Foundation - Home

[mmglobal]

The discussions and studies about incisions in the annulus are red herrings when considering MODERN endoscopic disc treatments. All of the endoscopic disc surgeries I've seen are without an incision of the annulus. A tiny needle is introduced and used as a guide for a dialator.

Think of it this way: If you put a needle through a silk blouse, you ruin it. However, you can put a knitting needle through a wool sweater and noone will ever see that it was there. The annulus is made up of criss-crossing fibers, much like a radial-ply tire. While I don't believe that there is any such thing as a 'freebie' access to the disc, in most cases, this access can be done with little or no permanent damage. Read AnnC's story on the GPN story pages. I should add an inset with my perspective. Her L5-S1 disc had been SED'd in the past and the surgical plan included ADR at that level. When the discogram was done, not only did L5-S1 generate NO pain, that was at MAXIMUM pressure. The surgeon was pressing on the syringe as hard as he possibly could and the disc would not not accept any more contrast (this is called a firm endpoint) and there was NO PAIN. Whatever damage had been done to the disc with the original annular tears and prior discography and prior disc surgery (SED), was completely healed. (Note that a unique aspect of SED is that the surgeon can apply laser or RF energy to the INSIDE of the annulus, while he is looking at the tear. If it shrinks, as is desired, this increases the chance of proper healing. Also, because he is looking at the tear while he is doing this, he can stop if it is not going in the right direction. Also, he can very effectively remove any nucleus material that is in the tear.)

If you look at the pre-surgery images posted of Job13's disc, you'll see a substantial HIZ (high intensity zone) in the posterior annulus. This is the bright white dot. In my "I'm not a doctor/layperson/take it with a grain of salt" opinion, this represents a substantial annular tear that may be worse than average. IMHO, this type of defect in the annulus substantially reduces the odds of a successful outcome. Even if you get a successful outcome with the first surgery, the next injury and the next surgery happen to a previously compromised disc, increasing the odds of failure with future MISS's.

Again, I'm not a doctor and may be completely off base... so take everything I say for what it's worth.

Thanks everyone for participating in this discussion... IMHO, this is why we are here and I hope everyone who participates or reads it will benefit from it. Special thanks to Crystal for starting so many great threads based on her amazing research. Also to Keano who has already breezed past me on MISS knowledge.

You all rock!

Mark

[Crystal33]

Regarding disc REgeneration I recently sent an email to Dr Wim van Blitterswijk, one of the authors of the case study in the first post of this thread. with disc regeneration. I asked why no one has done follow up research to confirm or refute the finding linking long term ingestion of GS with disc regeneration. His courteous response was….
“Lack of financial support and insufficient interest among (traditional) physicians are the reasons why no further clinical studies have been undertaken. Too bad.
I can only advise you to use these supplements. If it does not help you, it will not hurt you either. Good luck,
Wim van Blitterswijk”

It appears the spine surgeon community and their associations have no interest in investigating or knowing whether sustained nutritional supplementation can have a role in reversing early disc degeneration, a distinct possibility indicated by the case study.
I suppose it might pose a risk of reducing future spine surgeries and by a simple means that cannot be patented or monopolized by surgeons or industry. It might also generate more patient interest in biologics. Frightening thoughts!