[Artificial Disc Replacement / Cervical] 4 level cervical ADR (Dr. Bertagnoli)

[Margie]

Dear Jeff
Thank you so much. I really appreciate your keen observations. So here's what I've done so far. Mostly phone calls to far away places and local mD's. I went to see Dr Lauryysen hoping for some pearls but after the long trip sort of disappointed.. Nice guy but not too technical in his explanations. So long trip with neck pain not so helpful. He advized me to get 3 levels of prodisc.
What is your understanding of the diagnostic workup required? The MRI is clear but I am confused on the validity of the epidural injections. A lot of surgeons ask for discograms and yet an expert here told me that there are a lot of false positives but the sensitivity of the test is good. Well heck if I did a discogram no doubt 3 levels would be positive. How would that help?i.e. that is rather common. Plus there is some risk of injury--already have that.
So here are the two polar opposite approaches with little time to decide unless I postpone the 8/26 surgery date. Dr Zigler wants me to have a selective nerve block at c6-7. And then a discogram if that doesn't work BEFORE the first appointment--haven't seen him yet. When I spoke with Dr. Yue at Yale he also seemed to agree with Dr Boeree except he wanted me to get a CT scan to better visualize c5-6 which I am getting tomorrow. My head is spinning. I live in california and I'm suppose to go to texas and maybe yale before england? What concerns me is I'm in pain --it's hard to think clearly. It's easy enough to get a CT scan for Dr Yue. Dr Yue and Dr Boeree did not think it would add value to get a selective nerve block. i have to say I am rather confused because I KNOW C6-7 is a major problem because there is a clear herniation there. I've had that for years. So Dr Zigler ordering an injection at that level I'm not convinced will be of any value. Looking back did you feel your epidural was useful in the diagnosis? I am so sorry you must be blurry eyed from reading all this if you even got to this point!!
So trying to organize my thoughts if that's even possible now
1) Are epidurals really helpful for diagnostic workup? Unsure they can really be precise and can't find any studies looking at that.
2) I am confused. What do you make of this? I have also read about facet joint problems with ADR's and yet Dr Boeree and Dr Lauryssen deny the clinical relevance.
I have never had to sort out so many issues to try to make sense of things. Politics, conflict of interest in the device playing a role, and confusion in the field about the best way to do a diagnostic workup. I think maybe i'll just get on the plane and head to africa and find a good voodoo witch doctor. Or pray to maybe a Roman neck god. I understand at this time there are riots in London. That should add to this party like atmosphere.
What's a girl to do? Maybe I'll flip a coin?
margie

[runagain]

MARGIE,

I will take a quick stab at your questions:

1)You are in cervical territory, and I am a lumbar girl at the moment. So as far as epidurals, us lumbees had to have epidurals because they are less traumatic than surgery and the insurance companies want you to try them before you have surgery. It is try all these things and see if they work. Some people, the epidurals (ESIs) work. (which is really good, no surgery. You have to be in a lot of pain to have surgery.) Not me, but I might have had a slight improvement.The facet joint injections, helped rule out that the facets were not pain generators. There are multiple pain generators in your spine and the doctors need to rule out as many as they can to insure a good operation, if they can.

As far as discos, IMHO, they work. I went to one doctor few yrs ago, and he was antidisco, but he also worked as a so-called, "Independent surgeon" for the insurance review. To show what a paid doctor he was, he determined I could go back to a back-breaking job as I was fine. Tomorrow, ASAP. You should know these doctors get around 6K to write up a report that is full of...As it was finally determined, I am totally disabled.
Hopefully, not forever.
Back to ESIs. I gather they may be a little more trickier in cervical discs because of the spinal cord being there. If you have one, be sure you have a darn good doc that uses good protocol. Fluoroscope is a must. I am on my second pain doc , divorced the first one, and this one is so much better than the first. Although the first one, looked attractive on first glance, LOL. The second one is a spine specialist, enough said.

2) I have heard of some people having increased (more deteriorated) facets after certain ADRs. I don't have that problem and hopefully I never will.
The multiple diagnoses, plan of care from surgeons is due to multiple reasons. One of the reasons is that spinal surgery is not for the faint of heart and some surgeons will only do the surgeries that they are comfortable with. For ex, Not all surgeons will do anterior *belly* surgery, probably afraid of the complications possible in this approach. Some surgeons, specialize in different spine surgery such as for scoliosis and do fewer fusions for DDD. ADRs are generally more complicated, requiring greater surgical skill. ETC...
Don't give up Margie. Keep researching. Only do surgery if all that pain is interfering with your life or surgery is an emergency. M6 seems real popular in other countries and of course, it is not on the USA menu yet.
good luck.

STOGNER,

Hi. Congrats on your surgery outcome. So far, very good.
I am an ex-chiropractor goer. Before I knew how bad my back was and before my body let me know. OUCH. I went to a chiropractor for several years. Just before the doomsday of my back, I had been going to less chiro and more massage and felt the massage was helping. What no one recognized, was that my muscles were in little knots because my L4/5 and L5/S1 had DDD and they had tears in them and my muscles were compensating for my messed up discs.
After my back hurt so bad (the doomsday), I went to my chiro to pick his mind and he offered an adjustment and all I could think, was "No Way". He was totally against surgery but I think he could not see how much pain I was in. He was not understanding of ADRs or fusion. He was one of the first docs that told me that I was risking my life if I had lumbar surgery as the ADR could come apart and tear my aorta and deposit me at the pearly gates.
Luckily for me (well, it wasn't luck really, it was design), I did not listen to that part of advice but after getting 5-6 doctor opinions, I understood what I should get for my back. ADR.

I appreciate chiropractors, my mother-in-law goes to one faithfully, but I try to avoid twisting or bending back of my back and I don't like people touching my back anymore.
As for getting ADRs in the good ole USA, the FDA is holding technology back and in some instances, they are doing non-inferiority studies and the insurance companies turn around and say non-inferiority studies do not show the validity of ADRs. Ughhh. I would say, in my opinion, that insurance companies are holding back what are valid, "non-experimental, investigational" devices. These are FDA-approved devices, which should mean that the FDA panels after careful, exhausting research and studies, have given the devices a stamp of approval. How many years do the ADRs have to be used here, before spinal surgeons can use them in indicated cases?
And when will the insurance companies, pick up the bill--or at least some of it?
We need more accountability in this country.
Did you catch the news about the congressman who just had a "fusion" with stem cells in between. Yup, he used a procedure which is not approved by the FDA and is considered experimental and is not in trials in the US (as far as I know). And my question is, did his "cadillac" insurance pay for it???

All right, now I am stepping off my soap box.
Here is to you and other recoveries, staying healthy.

Runagain

[jss]

Margie,

I went to see Dr Lauryysen hoping for some pearls but after the long trip sort of disappointed.. Nice guy but not too technical in his explanations. So long trip with neck pain not so helpful. He advized me to get 3 levels of prodisc.

If I'm counting correctly, you have two prescriptions for triple ADR, one for double ADR and one for a single level?

What is your understanding of the diagnostic workup required? The MRI is clear but I am confused on the validity of the epidural injections. A lot of surgeons ask for discograms and yet an expert here told me that there are a lot of false positives but the sensitivity of the test is good. Well heck if I did a discogram no doubt 3 levels would be positive. How would that help?i.e. that is rather common. Plus there is some risk of injury--already have that.
So here are the two polar opposite approaches with little time to decide unless I postpone the 8/26 surgery date. Dr Zigler wants me to have a selective nerve block at c6-7. And then a discogram if that doesn't work BEFORE the first appointment--haven't seen him yet. When I spoke with Dr. Yue at Yale he also seemed to agree with Dr Boeree except he wanted me to get a CT scan to better visualize c5-6 which I am getting tomorrow. My head is spinning. I live in california and I'm suppose to go to texas and maybe yale before england? What concerns me is I'm in pain --it's hard to think clearly. It's easy enough to get a CT scan for Dr Yue. Dr Yue and Dr Boeree did not think it would add value to get a selective nerve block. i have to say I am rather confused because I KNOW C6-7 is a major problem because there is a clear herniation there. I've had that for years. So Dr Zigler ordering an injection at that level I'm not convinced will be of any value. Looking back did you feel your epidural was useful in the diagnosis?

What the doctors are trying to do is to prove that your pain is coming from a certain place. It is tragically common for someone to come out of spine surgery with a perfectly performed surgery, but zero relief from the original problem because the surgery was performed on a level other than the pain generating level. EVERYONE wants to avoid that. Here are the tests that have been proposed to you as I understand them....

• MRI - There are four variations of this test, each of which is intended to show something different. All four variations are intended to show the position and condition of soft tissue; that is, your discs, soft tissue of the facets, thickening of the PLL (posterior longitudinal ligament), growth of scar tissue, etc...
• CT scan - This test better shows anatomical structures made of heavier compounds than does the MRI, and so gives a better view of osteophytes, calcification of the PLL, some kinds of tumors, etc...
• ESI - This is a treatment in which a pain killer and a steroid, usually novacain and prednisone (or cortisone) is injected adjacent to the offending disc. The steroid temporarily stops the body's natural process of inflammation, which sometimes allows the disc to retreat back out of the spinal or neural foramen, and stop it from pushing on the spinal cord and/or root nerve.
• Selective nerve block - This is the same procedure as the ESI, but is diagnostic rather than palliative. A much smaller volume of novacain and steroid are injected adjacent to the area that is suspected to be causing the pain. An amount sufficiently small that it will not immediately reduce inflammation anywhere but the suspect area. You will be asked to pay particular attention to your symptoms over the next six or so hours and report back to your doctor where your pain disappeared from over the time immediately following the injection. This tells them that the pain generator is or is not where the injection was performed.
• Discogram - This test is used to verify the integrity of a disc. It does not prove that pain is generated at that segment, but does show that the disc is or is not malformed in some way.

As you can see, these tests have greatly overlapping benefits. Different doctors like different tests for different reasons; which is almost certainly why different doctors are prescribing to you different tests which give the same information. I don't know which test is best, but suspect that different tests are best for different situations.

Yes, my selective nerve block with Dr Zigler was useful in that it verified what was already known from the MRI. In hindsight, if the test had not been done, I'd be exactly where I am today; a double M6 ADR by Dr Clavel and running marathons. With the multiple levels of DDD that you have, coupled with the fact that Dr Zigler is very very conservative, I will SPECULATE that he wants to surgically address only the level that is causing your pain, and that he wants to be 100% certain of the source of that pain so that you don't wake up in recovery with a perfectly placed ProDisc at C6/7 only to find that C6/7 was not your primary pain generator.

... I have also read about facet joint problems with ADR's and yet Dr Boeree and Dr Lauryssen deny the clinical relevance.

I have conversed with a couple of Dr Lauryssen's patients and many more of Dr Boeree's, and can tell you that I have seen reported from patients of both that they consider the level of facet degeneration before prescribing an ADR. Perhaps they perform ADR with more facet degeneration than other surgeons? I don't know. But do know that they view it as a factor.

I have never had to sort out so many issues to try to make sense of things. Politics, conflict of interest in the device playing a role, and confusion in the field about the best way to do a diagnostic workup

I'm not a doctor, but it does seem that the different doctors that you've contacted are all trying to get at the same information; they just seem to prefer different tests to get that information. You'll get tired of being poked and prodded, but this is the price of consulting multiple surgeons for multiple opinions. BTW: As intimidating as all of the tests are, I'd consider it a necessary evil, because it is essential (I believe) that you get multiple opinions in order to make the best informed decision that it is possible for you to make.

I think maybe i'll just get on the plane and head to africa and find a good voodoo witch doctor. Or pray to maybe a Roman neck god. I understand at this time there are riots in London. That should add to this party like atmosphere.
What's a girl to do? Maybe I'll flip a coin?

I'm told that the best Voodoo doctors are in Haiti. If you go that route, I'd suggest the Dominican Republic, which is on the same island. The Caribbean is nice this time of year (at least in between Hurricanes).

Sigh.... I know that this is intimidating and frustrating. But hang on... YOU CAN DO THIS, and come out the other side better than you went in!

Good luck, Jeff

[Carson]

So there are four types of MRI? I've been trying to get this figured out for years now, embarrassingly.

I've been quite confused by the various forms of image taking and tests (4 typs of MRI, CT, X-ray, discogram, etc); thanks for a brief outline and great post, Jeff. I'm going delve into the different variations of MRI to get on track with whats available today and write up a little summation of my findings. Jeff, you're always evidence to me that it's possible to survive our various spine difficulties and keep a sharp mind very well in tact. Some great info in this thread.