Pain from disc annulus POST ADR?

[KBear]

I had no idea anything was left in the disc space. I'm gonna have to go back and watch the Charite surgery that Dr. Bitan did several years ago. I am happy that Dr. Zeegers feels that way about the Active L though, since thats what I have.

[Jack-of-all-trades]

Disc Anatomy

[Katie]

I've got a few questions re: anatomy of the spine.

- there have been several referrals of the remaining parts of annulus giving support to the ADR. It was my understanding that there is at least one large ligament that runs along the length of the spine. Not to mention the psoas muscle. Are these not enough to provide that necessary support? And as was already mentioned, what about the keels, etc. of the artificial disc; surely that would provide enough support as well?

-Is it common practice to leave in the disc material when doing a fusion vs ADR?

-How often are PEEK cages used, with or without additional support, for fusions? (And again, are the discs totally removed for this?) And what are the post-op pain level differences between these two? One of the things that turned me off fusions initially were the stories of prolonged healing and pain vs those of an ADR surgery. At four months post-op, I'm feeling pretty darn healed with both the fusion sites and the ADR. It is going better than I expected, except for regaining core strength and stamina.

[Carson]

Agreed; thanks for bringing up this topic. I would guess most surgeons assume we're not going to know our annulus from our anus so they don't always bother explaining these details.

Excerpt from this PubMed

Some papers describing numerical models of the lumbar spine after TDA are available in the literature. An increase in the ROM at the treated level was observed in some studies. The hypermobility was related to a major increase of the forces in the facet joints, for semi-constrained disc prosthesis, with pressure values exceeding the ultimate strength of the articular cartilage. A strong sensitivity of the facet forces to the anteroposterior positioning of the disc prosthesis was also observed. The authors suggested the preservation of as much annulus as possible during surgery (in contrast to the mentioned radical preparation leading to iatrogenic scoliosis), as a good practice rule, in order to avoid instability and non-physiological loading on facet joints and ligaments.

Old post from Annapurna Oct. 2006

Varying amounts of disk annulus are left behind depending on the type of ADR used to help provide additional stability. You've heard of unconstrained, partially constrained, and contrained ADRs on this forum, hopefully. Using some of the disk annulus can help with constraint as it requires some force to twist or bend the annulus fibers. Also, constraint typically refers to the degree of motion, not the amount of force required to move. Leaving some annulus behind increases the amount of force needed to bend/twist that segment and makes it more likely to behave like a normal segment. Or at least that is the theory behind leaving it in.The other reality is that you've left behind tissue that's really pissed off at best or damaged at worst and possibly left behind a pain source.

[rebeccawlaw]

I also have pain which I believe is from portions of a disc left after ADR. I have a Prestige disc at C3-4. Does anyone have experience with Prestige and know what the protocol is for removal of the annulus?

My CT myelogram showed that I still have a disc bulge at the ADR site, which confused me. I asked my neurosurgeon and he said that the bulge is from when he had to put the Prestige disc far back in order to preserve stability of the spine. Please read my post on this: Please Help! How can I have a disc bulge where there is an artificial disc?

Personally I think my neurosurgeon is trying to cover himself for messing up my ADR and I am trying to find another doctor to get a second opinion on this. Does anyone know of a doctor who has experience with ADR around the Chicago area? (Besides CINN- that's where the ADR was done) I don't mind traveling a bit if it's for someone good.

I would appreciate anyone's help/ advice as I am in a lot of pain and very confused about how to find a doctor I can trust. Thank you all!

[Jack-of-all-trades]

Sorry I can't be of help with a surgeon. My understanding is that it is SOP to leave the outer portion of the annulus in place. The rationale is that our bodies don't like empty space and will fill the space with scar tissue or heaven forbid bone after artificial disc replacement. I have always wondered why the artificial discs could not be made in enough sizes to fill up the space but I'm sure there is a reasonable explanation. It's hard to say how much fault there would be with your surgeon. Sometimes people can do everything right and stuff just happens. On the other hand, he could have been talking or not paying attention to what he was doing. Unless he was drunk or something it might be hard to prove. I would put my energy into trying to get it fixed rather than going for a lawsuit. Even if you find a surgeon that thinks it looks like a botched procedure he/she might not fess up for fear of spending time away from the OR in court. Once you get it fixed, then you may have pictures taken during the repair procedure, if a repair can be done. I don't know if any of this is valid advice. I'm just brain storming.

If you have insurance, you may be able to find other surgeons in network but not from the office of the surgeon who did the surgery. Most insurance companies have a web site with a listing of docs.

[Katie]

You can always send your images out to various surgeons, even internationally to get a third, fourth and fifth opinion...they never hurt. I wouldn't limit myself to those within my area, at least for the consult. Other opinions from those above may help to give you a better perspective on what the best treatment will be. It has worked for many of us on here. Then maybe you could discuss the expanded options better with a surgeon that is closer.

[rebeccawlaw]

FYI - I just got back from an evaluation with a neurosurgeon (Dr. Geisler in Chicago) who said that what the radiologist read as a disc bulge at the level where I previously had ADR might actually be some of the tendons that hold the two vertebrae together. Also, he said that some of disc annulus gets left behind with any type of ADR.

I just wanted to keep all of you updated. Good luck to all.

[rob wilson]

Even if the disc is 100% removed you can still have pain in arm or leg due to stenosis. The stenosis is difficult to remove when performing the ADR from the front.

[Justin]

Even if the disc is 100% removed you can still have pain in arm or leg due to stenosis. The stenosis is difficult to remove when performing the ADR from the front.

This is a very good point.