Pain from disc annulus POST ADR?

[Liz]

I heard some disturbing news from my pain management doctor recently... for the vast majority of artificial disc replacement (ADR) operations and fusions the disc annulus IS LEFT IN. My surgeons informed me of this fact at some point after my ADR op and I was told it probably helped maintain stability w/my scoliosis that the lateral and posterior annulus was left in and it was just removed from the front.

My pain doc explained that surgeons really can't remove all of the disc annulus b/c of risk "disrupting" the spinal fluid and causing a spinal fluid leak (permanent severe headache, etc); i forgot the technical terms for what would happen if surgeons tried to remove the posterior annulus. He said surgeons just try and remove as much as possible of the nucleus and then by fusing the annulus in place they hope to eliminate any pain from it, but obviously w/ADR movement is a huge issue. It's interesting that some people do very well w/ADR while others never do well, and i'm just thinking of potential pain from the annulus right now and not pain from the facet joints, which is a separate issue.

It was recommended that I have a discogram on the remaining annulus at L4-5 and L5-S1... i still have a Prodisc at L5-S1 and I removed my L4-5 Prodisc for fusion, but it's not fused and there is still disc annulus there to test via a discogram. I guess radiographically the discogram will be positive in terms of leaking dye, but docs are interested in if I have a positive pain response to provocation of the annulus.

The problem with this situation is IF i test positive WHAT am I going to do to remedy such pain? You can't remove the annulus, so I could try and fuse my L5-S1 Prodisc in place (i can't remove it b/c of the vena cava tear) or I could try and re-fuse my L4-5 fusion (it has a pseudarthrosis/area of non-bone fusion, w/what appears to be scar tissue), but this is a big undertaking after all i've endured. I have a lot of permanent nerve damage causing pain that will not be relieved by more fusion so I'm not sure yet how i'll proceed. Plus, it's rec I test my L3-4 disc but as this disc is the apex of my lumbar scoliosis fusing it would be problematic so I'm not sure about poking it either. I'm all for discograms as part of the diagnostic work-up if there is a feasible operative plan, but if not they are invasive, non-therapeutic tests. My pain doc would prefer to skip the discogram and put in a Spinal Cord Stimulator, but he's leaving the decision on how to proceed up to me. I'm leaning toward the discogram but we'll see.

I'm sorry but this is a huge mess and definitely not something that I understood before I had ADR. I assumed ADR meant the entire disc, including painful annular tears; I hope everyone else understands this issue better than I did. It is yet another reason I would be cautious with lumbar ADR.

Does anyone have experience with this???

Anyway, I just wanted patients to be aware of this if they suffer post-ADR (or with failed fusion) that they may consider having a discogram on the remaining annulus to narrow down pain generators before further interventions, and also a positive/negative response may better gauge what type of further intervention is best suited for the patient.

cheers,
Liz

[JK2234]

R U Serious?

Sadly I think I will be joining the club of "had to have my pro-disc taken out".

[trkdoc714]

Liz,

I don't think your pain management doctor is informed enough to make that claim. The implantation of current ADRs requires the disc space be cleaned out prior to implantation. The process of implantation could cause any remains of the disc to be relocated into proximity of the spinal cord or nerve root(s).

I hope others will chime it doesn't sound right.

I don't have the file any longer but a surgeon (as a patient) sued another surgeon for not cleaning out the disc space properly. This resulted in permanent nerve damage to his nerve root(s) at the affected level. I do remember it was a Maverick disc implantation that took place in an eastern U.S city. The suit was won by the patient for $600,000.00 if I recall correctly.

Bob

[Liz]

JK... i hope you don't need a revision... try and stay positive for now that things will improve.

Bob, thanks for the response. I just clarified the first paragraph of my post as it might have been unclear that my Prodisc surgeon and others are the ones that informed me the annulus was left in (just the front section was removed), not my current pain doc. I think you'll be surprised that it's not uncommon that the annulus is left in, but it will be interesting to hear any feedback.

I have permanent nerve damage for a long list of potential reasons. Sorry to hear about that surgeon.

best,
Liz

[trkdoc714]

Liz,

You may want to get the surgical notes from your ADR procedure from the surgeon. I spent a few hours researching last night and this morning. Everything I found regarding both cervical and lumbar ADR surgeries requires complete removal of the disc, both nucleus and the annulus. If yours was left in, that could possibly be the reason for your continued pain.

I hope you get your answer(s) soon as you have had more than your share of suffering.

Bob

[Keano16]

Well said... ADR requires full disc removal...

[Jack-of-all-trades]

The following is an excerpt of an article on Spine-Health by Peter F. Ullrich, Jr., MD

Discs are actually composed of two parts: a tough outer portion and a soft inner core, and the configuration has been likened to that of a jelly doughnut (see a healthy disc).
The outer portion of the disc (annulus fibrosus) is the tough circular exterior composed of concentric sheets of collagen fibers (lamellae) that surround the inner core.
The inner core (nucleus pulposus) contains a loose network of fibers suspended in a mucoprotein gel.
The annular fibers hydraulically seal the gelatinous nucleus and evenly distribute pressure and force imposed on the structure.
The outer portion and inner core of the spinal disc fit together like two concentric cylinders and are interconnected by cartilagenous end-plates.
At birth, 80 percent of the disc is composed of water. In order for the disc to function properly, it must be well hydrated. The nucleus pulposus is the major carrier of the body’s axial load and relies on its water-based contents to maintain strength and pliability. Spinal Discs

I really don't see how it is possible to leave part of the disc in place for fusion or ADR.

[Phylly]

Liz,
I have been mulling over your thread all day. How can Drs. insert prodiscs with the keels if they don't remove the entire disc and annulus? How disappointing to all those with annular pain if this is true. If this is the cause of your pain perhaps fusion of the the lower ADR would help?

I hope that your tests find the cause of your pain soon. You have definitely suffered enough. You also have so many big decisions to make.
Best,
Phylly

[runagain]

Liz,

Your post got me thinking too when I saw it.
I checked my surgeon's notes from my ProDisc surgery.
It specifically says he removed all the cartillous endplate (spelling is wrong but I cannot get up as i am rubbing my hubby's feet) and took posterior annulus down and completely removed it and removed part of the ligament.
something like that...just read it yesterday.
What you are saying about leaving annulus in during ADR surgery does not make sense.
Sorry. I hope you find out soon what is going on.
I mean in ADR surgery as many have said on here, you want to get rid of the annulus because of the painful nerve fibers and the space has to be cleaned up so the device can be put into place there.

R

[Keano16]

Painful nerve endings are located in posterior annulus. For example, if some of annulus is left anterior this should cause no pain. In theory of course...