Pain from disc annulus POST ADR?

[Carson]

[Katie]

Thanks for that Carson. But while it said that the goal is to remove all of the annulus, it seems to indicate that there is still disc material left along the left and right edges, that it is scooped out quite well in the center and especially front and back, but not to each side.

Maybe I am missing something? It certainly explains the procedure well. It is amazing that with all the internal tissue and material that has to be moved aside or gone through, that those instruments used for the insertion can be so precise. What talent and practice that must take.

[Keano16]

I will check this things with some of the doctors, and then let you all know.

[Carson]

Exactly. The narrator says to initially make an incision to perform an annulotamy just wide enough to accommodate the disc implant. Then at 1:30 into the video it shows the vertebral body spreader being used on one side to facilitate the discectomy on the opposing "contra-lateral" side. They do dig out the lateral annulus but seem to leave a narrow band of annulus on both sides. Interesting. I would guess the lower you go in the lumbar region the more annulus you could leave as the diameter of the vertebral bodies gets wider.

[Liz]

Thank you all so much for taking time to research this issue for me and for others that will benefit from it... i appreciate it! :thumpup: Keano, it will be interesting what you find out from doctors.

i know for 100% certainty that only the front of the annulus was removed to insert both of my Prodiscs, and the lateral and posterior part of it remained in place. My Prodisc surgeon is a very experienced Prodisc surgeon; plus it seems in line w/the Prodisc video that Carson posted.

When I got a 2nd opinion when my L4-5 Prodisc was tilted over (and I was in severe pain) the 2nd surgeon asked if I knew how much of the annulus was removed b/c he suspected too much was removed and that could have contributed to instability and the Prodisc failing. I asked my Prodisc surgeon and he said just the front of the annulus was removed, so he thought the failure was due to my scoliosis and height of the ADRs. I didn't question it much at the time b/c it seemed to be standard practice and I'm not a medical professional. Still, if i had understood the majority of the painful annulus was going to be left in I may not have had ADR.

My understanding is varying amounts of the annulus are left in to help w/rotation/instability of the segment. Anterior ADR destabilizes the spine, and this is compounded w/multiple levels, which is one reason patients can develop scoliosis that never even had it in the first place. There's an article by Dr. McAfee somewhere on this forum that best explains this issue.

This article discusses leaving posterior or lateral annulus intact for Prodisc ADR b/c it may improve stability, see
http://www.asbweb.org/conferences/2007/277.pdf

This article talks about a Maverick ADR that was fused in situ at L4-5 along w/a decompression b/c of posterior bulging of the remaining annulus and facet hypertrophy, see figure 2, section f...
Patient Safety in Surgery | Full text | Spine imaging after lumbar disc replacement: pitfalls and current recommendations

To further validate this annulus issue I recently asked my revision surgeon if he removed all of the annulus w/the revision; he said some of it was left in for stability. With my case he said very little was left at L4-5 b/c the anterior part was removed for ADR and the lateral part was removed for the revision to XLIF.

So I definitely don't think leaving part of the annulus in is as unusual as people here think. Please please ask your surgeons (IF you are having pain post-op); don't assume. You could also ask about surgical plans pre-op.

it's interesting that i went through countless injections after my Prodisc op and no one until now suggested I inject the annulus to see if it's a pain generator. At this point for me it's probably too late... i think you get one shot at a revision, esp if you endure complications like mine. I have not fused at L4-5 so that could be why the annulus is generating pain at that level or it could be from an adjacent level. Even if i had another massive revision i'd still have pain from damage to several nerves so i doubt i'll endure it. Hopefully this info will help someone else though. As i mentioned in my first post i'm not sure how annulus pain is remedied if it is deemed a pain generator after ADR or fusion.

i was hoping someone whom had a similar experience would chime in as i've never heard of this type of a discogram.

thanks so much!

Liz

[Jack-of-all-trades]

I can understand the rationale for leaving parts in place for stability but kind of wonder why since there is an anchor in both parts of the Prodisc. How and where are the remaining disc bits enervated? If there are no more nerves going to that part of the disc that is left in, and the prospects of re-enervation are low to non-existent you would think that there couldn't be any pain from that part of the annulus.

Maybe someone who has a Prodisc could contact the manufacturer or the sales rep/tech for them. I don't know about discs per-say but many are very knowledgeable about there products and even scrub in when introducing a surgeon to a product that is new to him/her. I'd love to hear how this decision was arrived at, i.e. leaving part of the annulus inplace.

[Keano16]

Liz, I am reading your files with interest, especially 277.pdf ("BIOMECHANICS OF THE PRODISC ARTIFICIAL DISC USING FINITE ELEMENT ANALYSIS"). They really mention:

"Preserving the posterior portion of annulus or the lateral annulus may improve stability".

I am aware that was written by surgeons that know much more than me and than any of us here... But how this makes sense when we all know that posterior annulus contains painful nerve endings, and leaving them there would obviously cause pains after the successful ADR surgery?

[Keano16]

I've just discussed something with dr. Zeegers, this are his replies to some of our questions:

Disc height is not a critical matter of consideration; 80% of annulus is undisturbed and left in situ, entrance is closed after implantation, see my pictures in book Springer verlag 2004 "Artificial Disc", chapter 11. Dorsal annular ruptures cannot be closed, would be of no sense, slipped disc particles, sequesters also, are taken out from the front. Activ L implant is so wonderful because of minimal risk of distraction or nerve root impingement.

And when I asked him about the annulus, sinu-vertebral nerves and pains post-ADR surgery:

This question is a completely mis-understanding, it is all about the endplates, (Modic signs!) not about the annulus innervation!

[trkdoc714]

From what Dr. Z is saying I gathered his determination is for the Active L. I wonder if all implants are the same or if the manufacturer (or surgeon) has different criteria for prepping the vertabral bodies for implantation.

The examples in the medical paper struck me as being necessary due to improper placement of the device and not and example of remaining annulus tissue. As the training video for the Pro-Disc illustrates leaving the lateral portions of the annulus intact, it leaves me to wonder if that is for a basic surgical plan that has to be reviewed and modified for each patient.

As each patient has a different pathology, I don't think a "one size fits all" procedure is a wise choice. The surgeon should evaluate each patient specifically and address each issue that patient has via a surgical plan prior to surgery that addresses each aspect of that pathology. A surgeon that over simplifies a complex procedure such as spine surgery (ADR or Fusion) would be quickly eliminated from my list of potential surgical choices.

I believe in cases of the annulus having multiple "scars", injuries or tears (as in my case) the removal of the affected portions of the annulus prevents future issues with fragment migration. The L5/S1 disc was pretty much gone while the L4/5 disc was explanted anteriorly.

As DDD causes discs to "dry up" it would make sense to remove the diseased portion(s) of the disc annulus to prevent migration of fragments (especially posteriorly). The posterior portion of the disc being removed would also provide access for decompression of nerve roots as well as removal of bone spurs and/ or injury or surgical debris.

Throughout this thread it appears the discogram would be fruitless as the annulus is compromised due to removal of some or all of it. It seems to me the effects of a discogram would be like trying to blow up a balloon with a hole in it. Any diagnostic pain would be generated from nerve exposure to the pressure of the injection and/ or nerve irritation from the solution injected.

Bob

[Phylly]

Having had severe pain after L4-L6 supposedly perfect prodisc implantation and L4-6 decompression and hemi-laminectomy 9 months later by the same Dr. who used my discogram as part of my diagnostic workup. No mention of annulus being the pain generator was made, probably because I had not asked the right question. I was told the failure of these surgeries to alleviate pain would necessitate a fusion leaving the prodiscs in. I did have the prodiscs out through an anterior approach and a posterior fusion with another Dr. and I assume that more of the annulus was removed by this procedure but will ask at my next visit. I still experience bouts of pain at times similar to the initial pain although more controllable now. I wonder if this is due to more of the annulus being removed with that procedure? I agree that this is something that all patients should know about for both ADR’s and fusions. It seems to come down to what really is the pain generator. Maybe that’s why some patients do great and others are considered failed back surgeries. Liz, Thank you so much for bringing this topic up.
Phylly