Advice/this is sorta a Dad (Mark) question

[ans]

I shall consult the Man soon. Meanwhile, any advice is appreciated.

Fusion at L5-S1 and a ProDisc at L4-5 were recommended by Laureyssen and Regan.

I'm losing my mind b/c I cannot get aerobic relief, it seems, by anything - the latest trying to swim in place in the deep end. I am waiving b/w the physiological dangers of not working out (and my anxiety that has no proper outlet which eats my guts) vs. leaping.

Not sure what to do. In light of Justin's post that both Charite and ProDisc do cause adjacent segment damage (I have lotsa DDD), is fusion such a bad option? Also, my facets on MRIs show "moderate degeneration" but two excellent docs say that they are fine but get more facet injections (previously didn't help = great!); what concerns me are the cases of post-ADR delayed facet damage that has been reported.

My sense is that ADR would emulate natural movement but for these two levels, would fusion create huge unnatural stress on a higher and lower (S-1) levels?

Also, I have osteoporosis in my left hip yet my back scores approach osteopenia a bit. I heard from a smart person that hip scores are used as a proxy for spine osteo-health. Is one screwed bigtime (literally by the screws if one has fusion w/osteopenia?).

So, why does fusion suck much more than ADR?

Thanks - Allan

[Maria]

Allan,
As you probably know this had been determined to be the surgery proposed for me as well. Dr.Delamarter had said I could get the fusion w/o the hardware which to me sounds ideal as I hate the idea of screws. Not sure how well the fusion would work w/o hardware but I did like the idea. Also proposed BMP and bone stimulator I believe.

My BMD is (or was at last check) a -2.2 in lumbar spine and I've not been taking my Actonel or calcium supplements but had been weight bearing and walking quite a bit on a daily basis. Have worse BMD in hips and my GP in San Diego had said to quit worrying about my back so much and worry about future hip fractures and get on the osteoporosis prevention bandwagon...

I should have at least been taking the Actonel faithfully but all kinds of calcium supplements bother me greatly it seems, mostly since on Methadone and it's effect on my gut (despite laxatives).

I really don't like the idea of fusion either but it seems that from 2003 when I could have had the trial 2 level ADR done and last year, there had been a change in the facets at L5S1 which made at least the surgeons here in the US feel that I should not undertake ADR at that level. Of course it could also be that one level ADR is all that is FDA approved and I'm going thru WC to get this done...

What it seems I have read in some of the spine information has been there isn't that much motion at L5S1 so fusing it isn't going to stop the motion there significantly. Also that fusing L5S1 and L4 is going to put more strain on the SI joints and there would be more liklihood of probs/pain at SI joints and esp. if some is already existing/problematic.

At least this is what I believe I've retained from things I've read at this forum and maybe others ~ of course, Mark is the man as far as giving us the best updated info from the spine surgeons he has been working with so I too will wait to see what he replies to you~

I usually can walk quite a bit but right now, even walking is limited..bummer, pain sucks!

[ans]

Maria:

I know that this has been suggested for you 'tho our history is world's apart. I wish you were on that creepy Fosomax and I'm sure a doc could prescribe it if you really wanted it. I never knew that there is a "screwless" means of fusion; those things truly give me the creeps! Not sure if using bone from the iliac crest that growth stimulator is best; I know for Rebekah from Australia, she had too much bone grow from stuff/stimulator.

I wonder how good hip measurements are as a proxy vs. the higher lumbar regions for BMD accuracy.

Both of us were scheduled for a two-level ADR in 2003! Odd and too bad too that both of us are wondering about our facets. May I ask what surgeon told you to go for fusion vs. ADR b/c of potential facet problems (nah, doesn't matter).

I haven't considered too much S1 joint problems too seriously and have no idea, outside of epidurals, how this is handled.

I heard that Active-L causes less pressure on the facets but I could be way off here and who knows when that'll be approved (Laureyssen likes it; did/does clinical trials w/it).

So I'm afraid that both of us are in Mark territory and you certainly have legitamate concerns. What an idiot shame that the FDA can't permit off-label use of Cortoss one one is opened up - in case. Or maybe another vertebroplasty cement would do - 'tho I've heard negatives on this too.

Too similar: I "swam" in deep water (ran in place in deep water) and am munching Vicodin. Too bad you lost your months of a near-remission. My next step will be fast walking; the last time I did this on an incline, I was beached in bed for almost a week.

Didn't we used to go to the gym like crazy in our previous lives?

Yap, I'm going to speak to Mark after I get another DEXA and maybe MRI. This is Mark territory indeed.

You be well Maria.

Allan

[mmglobal]

3am here and have to pack and leave at 4:30 for a 6am flight. I'm giving up on sleeping, so I'll take a few minutes to respond to this.

It is frustrating for me to watch some discussions go on without having the ability to weigh in on them.

This study reminds me of the 50% HO with ProDisc-C experience that was recently published in ESJ (I think... not checking up on minor detail.) You all remember the study.

It's interesting data, but there is one take home message from that study. DON'T GO TO THOSE GUYS FOR CERVICAL ADR... ESPECIALLY IF YOU ARE INTERESTED IF PRODISC-C!!! Is there a more important message buried in there? Are they exposing a dirty little secret and the thousands of PD-C procedures are getting done with massive HO rates somehow being hidden? Or, do THEY just get lousy results?

Wednesday morning, Delamarter reported his results with 1, 2, and 3 level PD-C procedures at his site only. He discussed site specific data. There were 14 sites in the PD-C clinical. 10 of the 14 sites had ZERO HO. His center had the lion's share of the cohort and has ZERO HO.

Does this mean that HO doesn't exist or is not an issue? Absolutely not! As we've been seeing from day one with lumbar ADR... it's about getting a good job done more than the device used. All of the prostheses have serious potential issues that may be amplified by poor technique. Unfortunately, we'll continue to see disasters.

I've seen several studies over the years by the same group that Justin posted on ADR support... similar data with outcome numbers that is way worse than reported elsewhere. The presented a mini-paper at SAS-7 on Friday that reported horrible results with Charite' and Prodisc... different paper, same horrible numbers. Look at the number of surgeons listed... is it 10? How many are on their learning curve... just to make up some numbers call it 1/2. Learning curve with ProDisc and Charite???? that's 5 each, times 2 discs, time 5 surgeons... 50 learning curve patients included? Obviously, I'm making up these numbers and I could be 100% off base with this.

However, just because a study reports almost 50% HO with PD-C or a mini-paper reports "52% failed to meet success criteria" does not mean that the sky is falling.

Data is not the holy grail. Much of it unreliable for a whole variety of different reasons. I find it astounding that I see data presented on devices that are clearly inferior... so inferior that most industry people that I know expects it to ever be FDA approved... yet they show results that are similar to approved devices. These studies present some good info... they advance the science. Often bad numbers studies are dishonest anti-science designed to reduce the attractiveness of competitors products. (I'm not suggesting that in this case.)

Bitan presented a paper on hybrid surgeries with combined fusion and ADR.

Much more interesting stuff this year... This was the most interesting SAS with some real innovative products... very cool stuff. More later.

Allan... I have your name on one of the lending library Abstract book... you'll get it after I get home.

Please consider changing the title of your post to something that will describe the content. Titles like these make searching difficult, because you get hits on things you should look at, but the title doesn't give you a clue about what's inside.

All the best...

Mark

[ans]

Thanks Mark for the perspectives.

Looking forward to seeing some literature/stuff.

Be well - Allan

[Maria]

Allan,
Let's see, *hybrid surgery* offered by my current OS in Long Beach
Dr.Bae at Dr.D's office
Dr.D
Dr.Regan
Neurosurgeon in La Jolla whose name I cannot recall
Ortho in San Diego whose name I can't recall at the moment either

Actually Dr.Regan seemed to think I could go either way with the ADR at L5S1 or fusion. He seemed to give it some serious thought while reviewing the films with Mark which I sincerely appreciated given I was a squeezed in cash pay patient.

Dr.D. said something about the change in my facets at L5S1 from my films in '03 to '06 and therefore he thought the fusion at L5S1 was the way to go. I recall Mark asking him if the insurance would pay for ADR at that level would he do ADR there as well and he stuck to fusion at that level. At least I believe I'm correct in what I'm paraphrasing here. Probably Mark's memory may recall what he said more clearly~

[ans]

Hi Maria:

Thanks for your information. I was told by Dr. R. that my L5-S1 was too much of a mess for an ADR but he didn't go into detail (I did mention two out-of-pocket ADRs is too much). Odd that we were ok'd around the same time for a two-level ADR - in the "old days" when they were more approved.

I guess we've seen a few doctors.

Running..take care. Wow, it's hot outside.

[ans]

Hi Maria:

Thanks for your information and good luck.

++++

Mark: When you're in town, I'll call you for a consult. My questions are justified, nobody can interpret the research as who can decipher who funds, and I am confused. That's where your experience comes in.

Allan