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  #1  
Old 11-03-2008, 05:34 PM
Maddie Maddie is offline
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Default Arthritis, facets and ADR

Are there any patients out there who need either a fusion or ADR who do NOT have some level of arthritis in the facet joints?

I had one doctor say that mine were too bad to consider doing ADR, but when I called the surgeons in Germany that I am trying to see, they said that mine were very mild, and that many if not most patients have arthritis, if I understood them correctly.

I think Terry commented in one thread that if we went by North American standards, no one would be a candidate for ADR here.

How bad is too bad in North America? I think most of our doctors only want to deal with the 'ideal' case, so as not to ruin their records of success. Sorry if I sound jaded, but I have had so many negative comments from doctors here...
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C3/4-5/6- Mod. ant., severe posterior bulging w. nerve root compression. Sev. narrowing of spinal canal with cord compression.

L4/5/S1- Mod. narrowing, bulging disc, significant hypertrophy of flava lig.

Highly allergic to all metals.

NEW: 3/16/2010: Successful surgery in Brazil w. Dr. Pimenta; Nuvasive NeoDisc at C5/6, and XLIF & ALIF at L4/5/S1 w. PEEK cages. No rods, screws, plates. Non-metal lumbar ADR not available at present time, so went with fusion.
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  #2  
Old 11-04-2008, 07:35 PM
annapurna annapurna is offline
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More of an answer than you thought you'd get:

In real life right now, I can't think of too many people who can tell something is wrong with their back early enough to be able to go through the whole medical game and wind up with a surgeon ready to operate without having had some degree of facet arthritis develop. As experience develops and surgeons and GPs become more aware of ADR and facet replacements and as experience with those techniques develops, I suspect that we'll see people having surgery offered to them earlier and easier. Back when knee fusion (yes, KNEE fusion) was the only technique available, knee surgeries were delayed as long as possible. Now that everyone is aware of multiple techniques for knee repair, knee surgery is generally offered really early into the diagnosis and treatment plan. I suspect that ADR and facet replacements will lead to the same gradual change.

As for why facets are read as severely damaged in the US and mild in Germany, some of it is experience and being able to judge when too bad is too bad but some of it could easily be the view of malpractice. The US surgeon could be sued just because you, the patient, thought you could get away with it. The Germans can really only be sued if true mistakes can be shown so they might be willing to accept more risk. It's also true that many inexperienced people compensate for their lack of experience by being very conservative. I see it a lot with young engineers at work. Of course, many go the for opposite end and take inappropriate risks, so it's still up to the patient to figure out if the surgeon is doing the "right" thing.
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Laura - L5S1 Charitee
C5/6 and 6/7 Prodisc C
Facet problems L4-S1
General joint hypermobility

Jim - C4/5, C5/6, L4/5 disk bulges and facet damage, L4/5 disk tears, currently using regenerative medicine to address

"There are many Annapurnas in the lives of men" Maurice Herzog
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  #3  
Old 11-04-2008, 08:00 PM
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Harrison Harrison is offline
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Default Wow...

I wish I had the time to add my two cents to Laura's comment! Lots to say...hope to in the near future.
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  #4  
Old 11-04-2008, 09:11 PM
annapurna annapurna is offline
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Thanks Rich, but Jim wrote that detailed reply. I'll just add something to his replies.

I've noticed that the more experienced ADR surgeons like Dr. Bertagnoli tend to be less conservative about facet condition when considering ADR candidates. If you'd like a second opinion from a non-US surgeon you might want to ask Dr. Zeegers. He's one of the most experienced ADR surgeons in the world and did a fabulous job on my L5/S1 ADR.

I'll also give another opinion as to why the non-US surgeons tend to be less conservative about facet condition: they have more options in the event of post-ADR facet pain. There are several different devices ranging from posterior stabilization to true facet arthroplasty devices available in Europe that are only in clincal trials here. Although no surgeon wants to consider a re-intervention, it's easier to balance the possibility of retaining motion (ideal situation) with non-optimal outcome from facet pain when you have something other than revision to fusion to address that pain.

If you have questionable facets, you should ask yourself how you would deal with facet pain post-ADR. Although there are lots of devices and procedures available to deal with this problem, they're all new and many would require a trip overseas. At worst, you could face a tricky revision to fusion. If you don't feel that you could handle that possibility, then I'd think twice about ADR. If you're willing to live with the possibility of post-ADR facet pain, I'd ask Dr. Bertagnoli what he could do if you needed additional treatment for facet pain. Arm yourself with information.

I have post-ADR pain in both my lumbar and cervical spine. Could be facets, or muscles, or ligaments, or all three. Diagnostic injections haven't returned any consistent results even though I've gotten enough to feel like a human pincushion. If I could isolate my pain to the facets, I would personally have NO problems trying out any one of the many different facet replacement devices now available in Europe one the surgeons have a bit more practice. That's just me. I don't mind getting lots of surgeries as long as I have reason to believe they'll do me lots more good than harm.

If you're interested in facet arthroplasty, check out the news flashes on Facet Solutions and Archus Orthopedics websites. Both have facet replacement devices that have been used successfully with ADR's. Big step for spine patients and all that. Wouldn't go out and get them tomorrow, but an example of how many new facet options are arriving.

Hope this helps. Feel free to PM if you want to chat facets or anything else.

Best wishes,
Laura
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Laura - L5S1 Charitee
C5/6 and 6/7 Prodisc C
Facet problems L4-S1
General joint hypermobility

Jim - C4/5, C5/6, L4/5 disk bulges and facet damage, L4/5 disk tears, currently using regenerative medicine to address

"There are many Annapurnas in the lives of men" Maurice Herzog
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  #5  
Old 11-05-2008, 10:36 AM
Maddie Maddie is offline
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Thanks Laura/Jim. And Richard, I hope you are able to somehow find time to add to this discussion.

I'm in Canada, where we are much less litigious, for better or worse. I have seen cases where there should have been serious repercussions for the professionals involved, but we usually just have a different attitude up here .

I am quite prepared to undergo a second surgery for facets if necessary, if it does what it is supposed to...but then the first one should have been enough too, shouldn't it I am not prepared to live with more pain. The medications are making me very ill...I am intolerant to almost every one we have tried so far, life threateningly so, with anaphylactic reactions. But the pain without them is intolerable, as it is with most people.

I guess what I am questioning is the 'grading' of the damage in the facet joints. My latest (three-phase??) bone scan, done to see if I was a candidate for injections, showed mild to very mild arthropathy in the left L4 and bilateral L5 facet joints.

How does this translate into being much too severe to consider any treatment other than fusion or injections?

I understand and agree with what you said..there are fewer options here...but those opinions above are radically different. I guess that is why I am so set on going to Germany right from the start, instead of having them trying to fix any messes that are made here because of lack of experience.

You said:

If I could isolate my pain to the facets, I would personally have NO problems trying out any one of the many different facet replacement devices now available in Europe one the surgeons have a bit more practice. That's just me. I don't mind getting lots of surgeries as long as I have reason to believe they'll do me lots more good than harm.

If I end up with facet pain, I would have to agree with you and your position. But shouldn't most or all of the pain from herniated discs be relieved when the new discs decompress things by restoring the space between the vertebrae? I haven't been able to get a doctor to give me a satisfactory answer to this.

But back to my original question...doesn't everyone who needs ADR or fusion have some arthritis? Doesn't it go hand in hand with the damage to our spines? Does DDD include herniation, arthritis, stenosis, etc (all inclusive)? Or does the diagnosis of DDD only have one or two symptoms? Sorry if I'm not being clear...I am pretty foggy this morning. Your first paragraph in your first post suggests that, and why.

But the surgeon I spoke to suggested otherwise. If mine is very mild, and he said it was too severe, what in the heck is acceptable over here?

How many people here have had post-surgical facet pain from ADR surgery done in NA compared to surgery done in Europe? (I assume most have gone to Germany here, to various surgeons?)

I guess until I came to this board, and recently spoke to a surgeon who first brought up the facets as a reason to not do surgery, I had not put much, if any, thought into them.

Thanks for getting this far in this rambling post. The more questions I get answers to, the more questions I find.............
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C3/4-5/6- Mod. ant., severe posterior bulging w. nerve root compression. Sev. narrowing of spinal canal with cord compression.

L4/5/S1- Mod. narrowing, bulging disc, significant hypertrophy of flava lig.

Highly allergic to all metals.

NEW: 3/16/2010: Successful surgery in Brazil w. Dr. Pimenta; Nuvasive NeoDisc at C5/6, and XLIF & ALIF at L4/5/S1 w. PEEK cages. No rods, screws, plates. Non-metal lumbar ADR not available at present time, so went with fusion.
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  #6  
Old 11-05-2008, 05:48 PM
2cool4U 2cool4U is offline
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Talking Facet degeneration

The topic of facet degeneration and back pain is a complex one. I think part of the problem stems from variability in imaging of the spine before surgery. Some background first: Facet disease is detectable by lumbar CT best, MRI next and regular back X-rays last. Further, it is seen on regular Xrays typically on "oblique" views, which are often not performed pre-op. Usually, lateral flexion/extension (bending) views are done. Generally, back pain patients receive MRI to assess for disc disease, and treatment is then prescribed based on those findings. In most cases, this works well. Regular lumbar spine X-rays generally aren't helpful unless you have had a significant injury or you have advance malignancy or in a few other unusual situations. Some of the medical literature has shown that up to 70% of back X-rays are unnecessary. Most physicians can check their patient's histories, do a physical exam, and then either try conservative treatment or go straight to MRI, skipping regular X-rays. Bone scans, as mentioned by Maddie, aren't used much in the U.S. for back pain, although they are very useful for bone infections, malignancies, stress fractures, and in a few other processes. They offer limited anatomic detail of smaller parts, including the facet joints. This can be offset somewhat by specialized cameras, but their use just isn't widespread here. They are relatively inexpensive, and it may be that they are easier to get in Canada than CT's or MRI's. In the U.S., it seems like every hospital, doctor's office and forward-thinking business professional owns an MRI unit, a CT scanner, or both, but bone scans use injected radioactive material which is regulated by the NRC, so it isn't as easy to buy the equipment and offer the service.

If a patient fails to respond to all of the various conservative treatment options, and everyone here knows what those are, then surgery may be the answer. In traditional fusion surgery, it is really not necessary to evaluate the facets. However, in ADR, as we've read, it can be important. If facet disease is advanced, then the MRI that was done prior to starting PT, etc. may show it. If it is mild or moderate, it may not be visible, as MRI is not as good for bony abnormalities as CT.

However, pre-op CT's are rarely done. Most of the time, they are unnecessary and would simply add to medical costs and expose the patient to unneeded radiation. Indeed, if a discogram is done and is positive, or if facet injections have been tried without success, evaluating the facets with imaging before surgery is probably not needed.

Further complicating all of this is the fact that there is a tremendous variability in the appearance of both disc and bone abnormalities of the spine and actual symptoms experienced by patients. Many (many, many) journal articles have been written on this topic, and definitive research has yet to be performed that allows a high reliability in determining what findings on what studies accurately correlate with what symptoms. Many patients have severe degenerative changes at multiple levels and yet respond to gentle stretching, heat and walking while others can have mild or moderate degeneration at one level and be almost incapacitated.

This is why we all have had X-rays, MRI's, CT's myelograms and discograms, sometimes with conflicting results, and why no surgery has a 100% success rate.

Personal soap box here: In addition, the medical community has a wide variability in approaches to back pain management and physician education for such. We don't have a "Back Pain Awareness" month, and high-profile celebrities don't kick-off large fund-raising campaigns. There is no "Race for the Cure" for back pain, and Oprah doesn't have shows devoted to it. All of this despite overwhelming numbers of people suffering from back pain and billions of dollars spent per year for back care, a considerable amount of which is spent on treatments that may either be unproven or possibly even harmful. 300,000 fusions/year with a success rate of 60% is just unfathomable! Off my soapbox now.

OK, despite that last paragraph of negativity, it looks like ADR may be poised to change some of this. As to whether ADR will relieve all of the symptoms, it depends on how much of the total pain is "discogenic" and whether there is are other "pain generators." This can be a very simple matter of ADR relieving most or even all of the pain, or ADR (or fusion, for that matter) may relieve a variable percentage of the pain, from most to very little. As pre-op screenings improve and physicians are more educated about what to look for before ADR, results should be more reliable to predict . Indeed, this will be absolutely necessary if we want to see ADR succeed as viable surgical technique for the long term.

Wow, only a few posts on this site since I joined, they're all too long! Maybe I should go back to lurking!
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L5-S1 rupture 11/04, left leg pain for 2 wks
Regular exercise/pain-free until 2007
L5-S1 degen. disease w/constant pain since 6/07
PT, ESI, SI jt injections, 3-level nerve root inj. x 2
Massage, heat, ice, TENS, etc
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New back pain in upper back though.
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  #7  
Old 11-05-2008, 07:12 PM
maz maz is offline
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I can hardly post this as compared to the knowledge of you all I feel really ignorant. I have had a 2 level cervical ADR and am getting some positive results. I had a full MRI which showed bilateral acet degeneration and a cyst on the exit foramen of L5/S1 (which may or may ot be compressing nerves). My symptoms say "yes "it is compressing the nerves I have buttock pain on sitting only, and electric type heel pain when I am upright, but not any pain if I wear 3" heels..nnThis is getting in the way of my walking to get fit so its hard to see the end to my misery. The question I want to ask the professionals is, " is my pain more likey to be facet related or cyst related." The MRI shows it is fairly largel although its been reported as "small " the surgeons who have looked at it cant rotate the image so have given up and said its small but I can on my computer and it gets bigger on rotation and looks significant to me. I would appreciate any input and know its just suggestion and experience not diagnosis thanks Maz
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Left Arm pain 2007 spread to the right after 10 months
Misdiagnosed x 3 then diagnosed as DDD related July 08
Active C ADR 2 levels 18th Sept 08
pain remains in shoulders and neck but is better than before (level 2-6)
arm pain resolved
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  #8  
Old 11-05-2008, 09:35 PM
annapurna annapurna is offline
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Quote:
Originally Posted by tconner94 View Post
Some background first: Facet disease is detectable by lumbar CT best, MRI next and regular back X-rays last. Further, it is seen on regular Xrays typically on "oblique" views, which are often not performed pre-op.
I'd like to make one clarification: CT are best for detecting the boney changes typified by advanced arthritic changes. That's true of any joint. MRIs are better for detecting the early stages or arthritis such as loss of cartilage, joint effusion, or inflamation. This is less true for facets because it's simply so hard to focus on the small area of the facets unless the scan is taken specifically to look at them but it is still more or less true. The delay between the cartilagenous changes, which are hard to spot, and the boney changes, which are easier, is often why someone may have substantial pain for a long time without any detectable cause. Of course, the reverse happens as well: lots of boney changes and advanced arthirits without any detectable pain.
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Laura - L5S1 Charitee
C5/6 and 6/7 Prodisc C
Facet problems L4-S1
General joint hypermobility

Jim - C4/5, C5/6, L4/5 disk bulges and facet damage, L4/5 disk tears, currently using regenerative medicine to address

"There are many Annapurnas in the lives of men" Maurice Herzog
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  #9  
Old 11-05-2008, 09:43 PM
annapurna annapurna is offline
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Quote:
Originally Posted by maz View Post
My symptoms say "yes "it is compressing the nerves I have buttock pain on sitting only, and electric type heel pain when I am upright, but not any pain if I wear 3" heels..
I can't for the life of me imagine why 3 inch heels would change your pain on their own but if you can pardon the ignorance of a male who's never worn heels, do you hold your shoulders, neck and head differently with the heels on?

If so, you might find that you're decompressing it by your posture and could take that information back to your surgeon. Another thought is to borrow a laptop, bring your images in and rotate the cyst to get him/her to answer your concern. You could also try rotating and printing multiple images as the image is rotated but that would take a surgeon who's willing to take time to think and it's not sounding like you're blessed with that.
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Laura - L5S1 Charitee
C5/6 and 6/7 Prodisc C
Facet problems L4-S1
General joint hypermobility

Jim - C4/5, C5/6, L4/5 disk bulges and facet damage, L4/5 disk tears, currently using regenerative medicine to address

"There are many Annapurnas in the lives of men" Maurice Herzog
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  #10  
Old 11-05-2008, 10:42 PM
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Terry Terry is offline
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I started wearing MBT shoes well over a year ago. This stands for Masai Barefoot Technology which forces the person to feel like they are walking in the sand.

For two weeks I went back to wearing my old shoes which place a lot of pounding on the facet joints and started causing pain again.

I went back to the MBT shoes and the pain is lessened again. Coincidence? I think not. The principle is sound where pounding on the lower spine takes place with conventional shoes.

I would encourage people to try these out.

Terry Newton
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1980 ruptured L4-L5
1988 ruptured SI-L5
1990 ruptured C5-C6
1994 ruptured C6-C7
1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic
Bicycle Accident 2004
MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram.
Stenum Hospital Surgery November 4, 2006
Prestige Disc C5-C6, C6-C7
Maverick Disc S1-L5, L4-L5
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