ADR-Damaged Facet Syndrome

[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?

[Sonata]

Hello Sharman

Thank you for this info. It's good to know everything when you are an ADR candidate (like me). I have been to various websites about Rosen and have read the news section http://www.charlesrosenmd.com/press.php . It is so sad to see how some play around with patients for money. I really wonder if they would have invested all that money in testing human to human disc transplantation, how advanced the treatment would have become today..no screws, no metals..just the natural thing back into your body. The preliminary trials coming from China look promising but still a long waaay to go before it can become available. But it certainly wouldn't generate enough money/profit for the companies and parties who are more interested in their financial gain than doing a favor for the human race. It's sad.

Lucky for those whose ADRs are doing a good job. I really would love to hear from those who had cervical ADRs and big success 5 years after replacement.


Sonata

[jinya85]

Thank you so much for this information. I had ADR surgery March 2009 at C5-C6. I had tried physical therapy as well as 3 blocks...all unsuccessful for a herniated disc. I had experienced pain in my neck and shoulder blade as well as down my arm. They told me this was all due to the herniated disc. The numbness in my hand and pain in my arm vanished immediately after surgery. However, the pain in my neck and shoulder blade has never subsided and has, over the last year, increased so significantly that I feel worse off than when I began. Since my surgery was done out of the country I have not been able to talk to well informed doctors. The last visit I had, we noticed that my ability to move my neck (specifically upwards) has diminished greatly. The doctor believes that I have Facet Syndrome. He also believes that I had this prior to having the ADR surgery, but the symptoms were overlooked.
My question, I guess, since this seems to happen to others as well, is what do I do now. I am allergic to pain killers, so I have had to take days off work so that I can lay down and wear a neck brace, but even that does not stop the muscle spasms.
Has there been any research that you've found about what my options are?

[dshobbies]

These are my understandings only;

ADR implantation can worsen or cause facet deterioration, the Charite specifically, perhaps others as well. Was there any deterioration before implantation and was ADR surgery contra-indicated but performed regardless?

Choosing your doctor carefully is probably the single most important decision in back surgery (and others as well), but also does not guarantee positive results.

My research also revealed the risk of adjacent segment deterioration is slowed, not stopped, with ADR implantation. Long term studies are hard to find because ADRs haven't been around that long. However, absolutely everyone is different and success rates vary from person to person. Surgery performed on less than an ideal candidates skews all studies - and having had two previous surgeries, I was less than an ideal candidate myself with an ADR success rate of 60-70% for which I am still grateful. From what I've read, most ADR candidates are less than ideal which would probably involve a virgin back injury.

ADRs and other disc/facet remedies are still in their infancy. Not enough is known about nerves. In fact, modern medicine in its entirety hasn't been around very long. The use of lasers is also relatively new.

The fact is, back or other sufferers can only utilize the knowledge at hand. We can wait a year or more for something new on the horizon or 5-10 years for something even newer, suffering all that time - or we can educate ourselves as best as possible on the current remedies, make our decisions based on what we feel is best, and then hope for the best. Some results will be disappointing, some maybe more debilitating but most offer some level of relief. Even choosing the best doctor and product guarantees nothing.

Discussions such as this one provide food for thought. But we all must keep in mind that today's advancements were not available yesterday and tomorrow's are not available today. In another 10-20 years ADRs may no longer be used in favor of the latest and greatest, or they may be so perfected as to guarantee a certain result - or not.

My father was lucky enough to be saved from pneumonia by a brand new drug - penicillin. Now those damned bugs are getting stronger. 65 years ago, saving premature babies in incubators caused blindness. 50 years ago, radiating tonsils instead of removing them now causes cancer and other health problems. 150 years ago, blood-letting caused death. Side effects are unknown until studied but we do have to keep on trying until medical sufferings are a piece of past history and people like us, trying something new, guina pigs though we might be, are medically necessary.

J85, welcome to the forum and I'm so sorry for your disappointing results. Even though your surgery was performed outside this country, you can still consult with American doctors. Dr. Regan, Los Angeles, comes to mind. You'll need current x-rays & MRI. You might want to contact Mark, GPN Artificial Disc Replacement ADR for assistance in internet consultations. Good luck,

Dale

[mmglobal]

Was the doctor's suspicion of facet pain confirmed with injections?