removal of bone spurring during cervical ADR

[rob_zzz]

Hi,

Has anyone thats had ADR or ACDF surgery had bone spurs removed during surgery? If so do you know how it is done, and how was your overall surgical outcome? Has anyone had surgery from Dr Bertagnoli that involved removal of bone spurring along with the disc - and how did you fare afterwards?

It sounds to me like removing bone spurs could be a risky procedure compared to just pulling out disc fragments - what are others opinions on this - or is it fairly standard practice?

thanks,
Rob

[fortitudine]

Rob,
Bone spurring is very common. In fact it is my main problem, spurs sticking into the cord. Most docs remove it - that's what Dr. B. will definitely do for me and I know he's done it for others.

[rob_zzz]

thanks fortitudine,

I'm not sure if I actually have bone spurring or not though the edges of the vertebrae do look like they're getting pointier and the last scan talked about uncovertebral joint spurring increasing. I wasn't aware of this before (no other radiologist has ever mentioned uncovertebral joint spurring - my surgeon did mumble the word osteophytes once when looking through my scans earlier on a couple of years ago but I didn't really catch what he was saying and knew very little back then).

Anyway its good to hear that removing them is a routine part of surgery. I'm assuming Dr Bertagnoli has the appropriate tools then. (high speed burr was mentioned elsewhere).

cheers,
Rob

[necknose]

Hi Rob, Fortitudine:

One wonders whether or not the large bone spurs (bridging osteophytes) that commonly protrude from the front of cervical vertebra can be removed without provoking a cascade of: more bone growth, inflammation and ultimately degeneration of the treated levels which may lead/contribute to "auto-fusion". Apparently certain (out of USA) Dr.'s use "bone wax" to suppress bone re-growth where bone has been "ground off".

Does "bone wax" do the trick/is it effective? Does it last? Can it it be used in the vertebra canal as well as around the anterior (in this case an ADR procedure is mostly anterior) surface of the vertebral body?

The common "lore" in USA spine surgery particularly ADR surgery is to avoid removing bone in the areas discussed above for fear of causing a degenerative cascade resulting for example in auto-fusion at the treated levels.

Thoughts? Opinions?

Good luck.



BTW: With all due respect to the fantastic practitioners who implant the Prodisc-C what is the bone "reaction" to the keel notch cut into the vertebral body? If there is fear of a growth/inflamation cascade due to the removal of osteophytes on the exterior of the vertebra are the same consequences to be expected from bone remove from the outside of the vertebra?

[mmglobal]

In the cervical ADR procedures I've seen, when anterior osteophytes were present, they were 'nipped off' with a tool that looked much like a pair of cobblers pliers. I'm standing next to the doctor asking the same questions you are asking here. The bone wax does seal the 'fresh bone', but will eventually be resorbed. When the bone wax is gone, there are several factors that will reduce or eliminate the risk of the osteophytes reforming.

• The osteophyte formation is the response to a structural problem. The body is trying to fuse the segment. With ADR, the collapsed disc space and structural issues should be resolved.
• The fresh bone is no longer fresh and osteoblast/osteoclast (cells that contribute to bone growth) release should be over
• The anterior longitudinal ligament that is calcified and participating in this bridging effort is gone.
• I'm sure that there are many other contributing factors. Here is the place for the 'I'm not a doctor, just sharing my experiences, yada yada yada."

The posterior osteophytes are a completely separate issue. The process of removing them is quite different because they are not right out in front like the anterior osteophytes. The surgeons are limited with the tools that they can get to the back of the vertebral body through the disc space after the discectomy is complete. It's relatively easy to get the typical osteophytes that form on the dorsal rim of the vertebral body. The bigger they are, the farther they extend down (or up) the vertebral body and it becomes more difficult to reach them. (The tools can't turn a corner to get too far up or down, away from the disc space.) This is why when the osteophytes get too large, the ADR option becomes more difficult or impossible.

I've watched the discussion change a bit over the years and some doctors are able to do more as they gain more experience. I am particularly interested in this because I probably need 2-level cervical disc replacement and I have large posterior osteophytes and am worried about losing the ADR option. I get a cervical MRI at least once a year to keep tabs on this.

I have resurrected an old post that discussed this, plus the need for adequate decompression during ADR surgery on the Rebound Myelopathy thread.

Mark

[fortitudine]

NN

"The common "lore" in USA spine surgery particularly ADR surgery is to avoid removing bone in the areas discussed above for fear of causing a degenerative cascade resulting for example in auto-fusion at the treated levels."

I'm curious as to your sources for this info. It doesn't seems to make a lot of sense. The hip and knee orthopods do tons of bone removal and set in place metal prostheses without these kinds of issues being significant. I can't see that there's much of a difference, physiologically. Can you enlighten me?

[necknose]

I can't cite "scholarly refs", just the response to my questions regarding the obvious.

Dialog:
Patient:
"Dr., why not remove those giant "bird beak" bone spurs from the front(s) of the cervical vertebra?"

Doctor:
"I'd advise against removing those spurs as their removal will destabilize the affected level causing a reactive cascade: including increased inflammation and increased bone spur production." "Don't mess with the spurs if it can be "avoided"".

Bone Wax:
Not sure if Mark refers to bees' wax and parafin, or Ostene as "bone wax". It would be great to get his clarification.
*******************************************
Below is some research on the "bone wax" issue.

Bone wax is made of beeswax <http://en.wikipedia.org/wiki/Beeswax> containing a softening agent such as paraffin.

Bone wax is used to mechanically stop bone bleeding during surgical procedures.

The bone wax is smeared across the bleeding edge of the bone, blocking the holes and causing immediate bone hemostasis <http://en.wikipedia.org/wiki/Bone_hemostasis> through a tamponade <http://en.wikipedia.org/wiki/Tamponade> effect.

Bone wax is supplied in sterile sticks, and most often requires softening before it can be applied. Once applied, it essentially never goes away. Although inexpensive, easy to use and immediate, bone wax has a number of adverse reactions associated with it.

Bone wax inhibits formation of new bone osteogenesis <http://en.wikipedia.org/wiki/Osteogenesis> and acts a physical barrier preventing bone union.

[1] <http://en.wikipedia.org/wiki/Bone_wax#_note-one>

[2] <http://en.wikipedia.org/wiki/Bone_wax#_note-two>

In the presence of bone wax, osteoblasts <http://en.wikipedia.org/wiki/Osteoblasts> will be absent in a bone defect.

[3] <http://en.wikipedia.org/wiki/Bone_wax#_note-three> In defects where bone wax was applied and removed after 10 minutes, there was complete inhibition of bone regeneration.

[4] <http://en.wikipedia.org/wiki/Bone_wax#_note-four> For this reason bone wax is almost never used in areas where bone fusion is critical.

[5] <http://en.wikipedia.org/wiki/Bone_wax#_note-five>

Bone wax increases infection rates and impairs the ability of bone to clear bacteria.

[6] <http://en.wikipedia.org/wiki/Bone_wax#_note-six> In the presence of bone wax, the number of bacteria needed to produce osteomyelitis <http://en.wikipedia.org/wiki/Osteomyelitis> is reduced by a factor of 10,007 In a recent study of infection rates following spinal surgery, surgical site infections occurred in 6 of 42 cases in which bone wax was used, and in only 1 of 72 cases in which it was not used.

[7] <http://en.wikipedia.org/wiki/Bone_wax#_note-eight>

Infection and non-union are a particularly important problem in cardiac surgery <http://en.wikipedia.org/wiki/Cardiac_surgery> .

[8] <http://en.wikipedia.org/wiki/Bone_wax#_note-nine> According to the American Heart Association, the incidence of deep sternal wound infections <http://en.wikipedia.org/w/index.php?title=Sternal_wound_infection&amp;action =edit> is 1% to 5% of patients undergoing coronary artery bypass surgery <http://en.wikipedia.org/wiki/Coronary_artery_bypass_surgery> , with a mortality rate of about 25%.

[9] <http://en.wikipedia.org/wiki/Bone_wax#_note-0>

Bone wax remains as a foreign body <http://en.wikipedia.org/wiki/Foreign_body> for many years, and can cause a giant cell <http://en.wikipedia.org/wiki/Giant_cell> reaction and local inflammation.[

10] <http://en.wikipedia.org/wiki/Bone_wax#_note-ten> In skull base <http://en.wikipedia.org/w/index.php?title=Skull_base&amp;action=edit> surgery, bone wax has been reported to cause granuloma <http://en.wikipedia.org/wiki/Granuloma> formation and CSF <http://en.wikipedia.org/wiki/CSF> fluid leaks.

[11] <http://en.wikipedia.org/wiki/Bone_wax#_note-eleven>

[12] <http://en.wikipedia.org/wiki/Bone_wax#_note-twelve>

The FDA has recently approved a new water soluble bone hemostasis material designed to look and feel like bone wax.

[13] <http://en.wikipedia.org/wiki/Bone_wax#_note-1> This material is comprised of a sterile mixture of water-soluble alkylene oxide copolymers <http://en.wikipedia.org/w/index.php?title=Alkylene_oxide_copolymer&amp;actio n=edit> , derived from ethylene oxide and propylene oxide. These copolymers have a long history in the medical and pharmaceutical fields, and they are considered inert <http://en.wikipedia.org/wiki/Inert> . These compounds are not metabolized <http://en.wikipedia.org/wiki/Metabolized> , but eliminated from the body unchanged. It is anticipated that with the introduction of these new hemostatic materials, the incidence of surgical bone infections <http://en.wikipedia.org/wiki/Infections> , non-union <http://en.wikipedia.org/w/index.php?title=Non-union&amp;action=edit> and inflammatory <http://en.wikipedia.org/wiki/Inflammatory> complications will decrease with time.

The alternative to bone wax is called Ostene. It does not have any of the complications known to occur with the use of traditional bone wax. However its overall efficacy as a "replacement" for bees wax bone wax remains undetermined.
=============================
Although lengthy, these citations bring into question the safety of the use of bees wax as "bone wax", and alternatively, the unclear efficacy as a replacement, of Ostene.

This may be why the US docs that I've consulted have shuddered when I've mentioned the removal of large osteopyhytes OUTSIDE the vertebral canal e.g. around the vertebral body as part of any anterior surgery esp. ADR.

Let me assure you that there is no one in Dodge who is more interested in having bone spurs removed than this reporter, but between their (osteophytes) "function(s)", supporting the failing and increasingly unstable vertebral column, and the purported dangers of their removal, one may reasonably pause to consider the consequences before blithely advancing forward into the OR and having them (please God) removed.

I hope that Mark, our unparalleled expert on all things spinal, will weigh in on this important and distubing topic. I for one have a great deal at stake in getting this issue resolved. In the meantime I will personally consult several US top docs on this issue and when I have their responses they'll be posted on these "pages" ASAP. In addition I hope that you will bring your considerable savvy, experience and the powerful access your beat confers to bear.

I hope I've gone a little way in answering your previous post.

Good luck!

[mmglobal]

Please remember that I'm a layperson... a spine patient... not an expert.

I hear the doctors referring to 'bone wax'. I don't know the brand or exact compound. I've asked the obvious question about how long it lasts and it's my understanding that it will fade away in time and that it's usefulness is only in the weeks following surgery when cell production has been stimulated by the bone remodeling that takes place during surgery. After a few weeks, that has slowed down or stopped and the bone wax is no longer needed to 'seal' the newly exposed surfaces.

As far as removing necknose's osteophytes, it seems to me that they would be referring to ONLY removing the bridging structures on the front of his cervical spine. It seems to me... (I'm not a doctor, yada, yada, yada...) that removing those structures would be the equivalent of removing a leg on a three legged stool. However, remobilizing a segment, removing the bridging structures (front and back), restoring disc space and restoring natural motion; that is like rebuilding the entire stool instead of chopping off one leg.

I am not suggesting that this is appropriate in his case... I have no idea if he's a candidate for surgery or not.

Mark

[necknose]

Hi Mark:

Your three legged stool analogy is helpful in forming a picture of the structural realities confronting the ADR surgeon who is tasked with "remodelling" vertebral bone and implanting ADR's.

The issue of "bone wax" is vexing because the complete removal of osteophytes is, as I understand it, the key to a successful multi-level ADR surgery. E.G.: there's no sense in having an ADR implanted if the implanted level is only going to auto-fuse sometime soon, say within a decade of the ADR implantation, especially when there are multiple levels implanted. Thus my concern about osteophyte removal and the prevention, in a "healthy" manner, of the regeneration of these pesky bone deposits.

As you have mentioned in the past the methods surgeons use to prevent the regrowth of these spurs is the application of "bone wax" to the area where bone has been removed, especially bone which has been removed aggressively thus probably triggering the body's tendancy to just as aggressively attempt to replace this "missing" bone. One doesn't simply want a latent problem replacing an overt one, nor to end up with exactly what one sets out to avoid, auto-fusion. The dynamics of this aspect of spine surgery, osteophyte removal and the prevention of their regrowth, are complex and far beyond my understanding of this ssurgery. However as can be seen from my previous posts gaining a basic understanding of this issue is in my view essential to the responsible treatment of one's spine disease.

It would be fantastic if you could consult your top docs about the material they use for "bone wax", and in their opinion the cons if any, arising from the use of this material.

Happy Thanksgiving!

Good luck.

[mmglobal]

Saturday, I had Zeegers as a captive teacher for many hours as we traveled trom Munich to Nijmegen (Holland) together... about 4 hours in transit. We discussed the use of bone wax pretty extensively. He's used it for decades in various orthopedic applications. Zero infections.... never had a problem related to bone wax. It's an interesting compound that is frequently misused. It must be used sparingly... apply it and wipe it all off.... the minor amount that remains does it's job.

[necknose]

Originally Posted by mmglobal

Saturday, I had Zeegers as a captive teacher for many hours as we traveled trom Munich to Nijmegen (Holland) together... about 4 hours in transit. We discussed the use of bone wax pretty extensively. He's used it for decades in various orthopedic applications. Zero infections.... never had a problem related to bone wax. It's an interesting compound that is frequently misused. It must be used sparingly... apply it and wipe it all off.... the minor amount that remains does it's job.

Reminiscent of that famous Bill Clinton campaign slogan: "it's the economy stupid".

It seems that no matter what the aspect of surgery the single most important qualitative variable is the: THE DOCTOR!!!! I think we in this country tend to forget this being subjected to wholesale 15 minute slivers of "medicine". We are taught little commonsense, how much do kids get commonsense from a 5-10 hr a day diet of GrimTime TeeVee? And how much commonsense have you gotten from your doc lately? So mostly the bone wax (does Zeegers use bee's wax & paraffin?) is a tempest in a candlestick holder. And so it goes.

Mark: as usual, thanks for the info..

Good luck!

[mmglobal]

I got to spend some time with Dr. Bertagnoli last week. We discussed the use of bone wax and the potential for infection. Said Dr. B:

If my infection rate was zero before I started using bone wax, and zero since I started using it, I think it's safe to say that the use of bone wax does not cause infection.

I questioned further about his experience. He's been using it for over a year... approximately 60 case.

Mark

[Roz]

Originally Posted by mmglobal

In the cervical ADR procedures I've seen, when anterior osteophytes were present, they were 'nipped off' with a tool that looked much like a pair of cobblers pliers. I'm standing next to the doctor asking the same questions you are asking here. The bone wax does seal the 'fresh bone', but will eventually be resorbed. When the bone wax is gone, there are several factors that will reduce or eliminate the risk of the osteophytes reforming.

• The osteophyte formation is the response to a structural problem. The body is trying to fuse the segment. With ADR, the collapsed disc space and structural issues should be resolved.
• The fresh bone is no longer fresh and osteoblast/osteoclast (cells that contribute to bone growth) release should be over
• The anterior longitudinal ligament that is calcified and participating in this bridging effort is gone.
• I'm sure that there are many other contributing factors. Here is the place for the 'I'm not a doctor, just sharing my experiences, yada yada yada."

The posterior osteophytes are a completely separate issue. The process of removing them is quite different because they are not right out in front like the anterior osteophytes. The surgeons are limited with the tools that they can get to the back of the vertebral body through the disc space after the discectomy is complete. It's relatively easy to get the typical osteophytes that form on the dorsal rim of the vertebral body. The bigger they are, the farther they extend down (or up) the vertebral body and it becomes more difficult to reach them. (The tools can't turn a corner to get too far up or down, away from the disc space.) This is why when the osteophytes get too large, the ADR option becomes more difficult or impossible.

I've watched the discussion change a bit over the years and some doctors are able to do more as they gain more experience. I am particularly interested in this because I probably need 2-level cervical disc replacement and I have large posterior osteophytes and am worried about losing the ADR option. I get a cervical MRI at least once a year to keep tabs on this.

I have resurrected an old post that discussed this, plus the need for adequate decompression during ADR surgery on the Rebound Myelopathy thread.

Mark

Hi Mark,

You seem to have alot of knowledge about these bone spurs. I had ADR C5-6 in august 2005 in Bangkok, Thailand. the surgeon Dr Nanthandej failed to remove the pre existing osteophytes prior to implanting the ADR. The result was auto fusion and nerve damage with the implant now subsiding according to Dr Bertagnoldi.

I asked him if it was possible to have a forectomy and he said NO because it does not resolve the problem and they will return. I cannot afford to treat in Germany and trying to have fundraisers to have the surgery but that is not going well due to the economy.

Do you know of anyone near Ohio ( Columbus) would take on a patient with no insurance- tried for Medicaid, am a student, with an international surgery that failed that needs the implant removed and replaced and the decompression done.

Do you have any information on whether it is medically necessary to remove the osteophytes that exist and that show severe forminal encrouchment even before the surgery prior to implanting the ADR is medically necessary? The hospital in Thailand did not disclose this and I never knew to ask.

Please advise

Roz

[ADR seeker]

Bone wax was used during the civil war. It is bees wax. It inhibits bone growth.

It is said that it also makes the bone unable to deal with infection and that Ostene a synthetic bone wax doesn't. Also I can't find is Ostene inhibits bone growth.

As far as I know bone wax/ bees wax is the only thing that inhibits bone regrowth. I'm not sure if that is true. You'd think that since the Civil war there would be a better alternative to bees wax.

[ADR seeker]

Long-term results of surgical treatment of dysphagia secondary to cervical diffuse idiopathic skeletal hyperostosis.
Urrutia J, Bono CM.
Source

Department of Orthopaedic Surgery, Pontificia Universidad Catolica de Chile, Marcoleta 352, Santiago, Region Metropolitana, Chile. jurrutia@med.puc.cl
Abstract
BACKGROUND CONTEXT:

Large, prominent osteophytes along the anterior aspect of the cervical spine have been reported as a cause of dysphagia. Improvement of swallowing after surgical resection has been reported in a few case reports with short-term follow-up. The current report describes outcomes of a series of five patients with surgical treatment for this rare disorder, with a long-term follow-up.
PURPOSE:

To study the clinical and radiographic outcomes of a case series of patients surgically treated for dysphagia secondary to cervical diffuse idiopathic skeletal hyperostosis (DISH).
STUDY DESIGN:

Retrospective review of a case series.
PATIENT SAMPLE:

Five cases from a University Hospital.
OUTCOME MEASURES:

Clinical and imagenological follow-up.
METHODS:

The records of five patients with dysphagia who had undergone anterior surgical resection of prominent osteophytes secondary to DISH were reviewed. Extrinsic esophageal compression secondary to anterior cervical osteophytes was radiographically confirmed via preoperative barium esophagogram swallowing study. All patients underwent anterior cervical osteophytes resection without fusion. Postoperatively, patients were followed-up clinically and radiographically with routine lateral cervical radiographs.
RESULTS:

Preoperative esophagogram showed that the esophageal obstruction was present at one level in three cases and two levels in two cases. The C3-C4 level was involved in three cases, C4-C5 in three cases, and C5-C6 in one case. There were no postoperative complications, including recurrent laryngeal nerve palsy, wound infection, or hematomas. All patients had resolution of dyphagia soon after surgery (within 2 weeks). Postoperative radiographs demonstrated complete removal of osteophytes. At final follow-up, ranging from 1 to 9 years (average 59.8 months, median 53 months), no patients reported recurrence of dysphagia. Final radiographic examination demonstrated minimal regrowth of the osteophytes.
CONCLUSIONS:

Although rarely indicated, surgical resection of anterior cervical osteophytes from DISH causing dyphagia produces good clinical and radiographical outcomes. After thorough evaluation to rule out other intrinsic or extrinsic causes of swallowing difficulty, surgical treatment of this uncommon condition might be considered.

Long-term results of surgical treatment of dysphagia... [Spine J. 2009] - PubMed - NCBI