Failed Artificial Disc Replacement, need revision surgery

mark-Perth · 05-22-2009, 12:11 PM

Hi Everyone

I have had a Maverick ADR put in at L3/4 that was put in incorrectly causing my spine to develop scoliosis which is getting worse quiclkly. My pain is through the roof and my surgeon wants to do a posterior fusion leaving the disc in place ASAP. He also has doubts about whether it will help the pain but is concerned about the scoliosis and wants to stop that progressing. I have read alot about the revision operations and posterior fusion doesnt sound like the best option. He doesnt want to remove the disc unless there is still pain after the fusion due to the dangers, especially with no patch on the great vessels. Is this even possible to remove an ADR after a fusion?
He said I would know after the fusion if it worked but would imagine I would be in pain from the fusion for a while to know if the disc needs removing. Does anyone know how much pain I would be in after an extensive posterior fusion and for how long?
The disc has been in about 6 months now so I would like to have it removed sooner rather than later. Its also siting on a pretty bad angle so I cant imagine fusing would help when the disc is in the wrong spot.
Anyone have any ideas?
Thanks for the advice,
Mark

**Justin** · 05-22-2009, 01:15 PM

Originally Posted by mark-Perth

Hi Everyone

I have had a Maverick ADR put in at L3/4 that was put in incorrectly causing my spine to develop scoliosis which is getting worse quiclkly. My pain is through the roof and my surgeon wants to do a posterior fusion leaving the disc in place ASAP. He also has doubts about whether it will help the pain but is concerned about the scoliosis and wants to stop that progressing. I have read alot about the revision operations and posterior fusion doesnt sound like the best option. He doesnt want to remove the disc unless there is still pain after the fusion due to the dangers, especially with no patch on the great vessels. Is this even possible to remove an ADR after a fusion?
He said I would know after the fusion if it worked but would imagine I would be in pain from the fusion for a while to know if the disc needs removing. Does anyone know how much pain I would be in after an extensive posterior fusion and for how long?
The disc has been in about 6 months now so I would like to have it removed sooner rather than later. Its also siting on a pretty bad angle so I cant imagine fusing would help when the disc is in the wrong spot.
Anyone have any ideas?
Thanks for the advice,
Mark

Hey Mark,

I'm sorry to hear about the possibility of a revision surgery for you in the near future. I hope you are getting at least some pain relief through all this--I can't imagine what you must be going through. We are here to support you in any way we can.

A couple questions:

1. How many posterior "revisions" has your surgeon done with leaving the disc in place, if any?
2. Are you going to see any other surgeons concerning your case?

Is this even possible to remove an ADR after a fusion?

I would say it is possible. Surgeons either choose to do, 1. a fusion with the ADR in place, or 2. explant the ADR and do a fusion, as you very well know Mark. However, I think when a surgeon decides which "path" they are going to take in regard to revising an ADR they ultimately go into surgery with the understanding that if either operation fails, the most likely next step would be chronic pain management. (If there were unique circumstances in which explanting the ADR that was fused in place was absolutely essential, then a surgeon would subsequently perform an operation to address this unique situation.)

Leaving the ADR in place and doing a posterior fusion greatly complicates any future attempt of explanting the ADR (in my opinion, of course). If a posterior fusion is done to "revise" an ADR surgery, this will most likely require extra hardware, especially if your surgeon is attempting to stop the progression of ADR-induced scoliosis. I think you would be hard pressed to find any surgeon that would be willing to explant the ADR after already leaving the ADR in place and revising with a posterior fusion. However, if your surgeon did the revision and you still were experiencing continued ADR-induced scoliosis I think they would attempt to explant the device. A discussion between you and your surgeon about under what circumstances he would feel comfortable & felt it was a medical necessity for your previously-fused ADR to be explanted. I believe this is a vital detail that needs to be "agreed" upon before your revision operation is performed.

The argument against explanting ADRs and revising with fusion is, unfortunately, a good one -- this operation is potentially life-threatening because the great vessels of the body (the abdominal aorta and inferior vena cava) become "scarred down" on top of the vertebral column as a result of the initial abdominal approach during implantation of your ADR making it a very delicate operation with the potential to tear these vessels.

Does anyone know how much pain I would be in after an extensive posterior fusion and for how long?

As you know, pain is a very subjective entity. I would bet that your tolerance to pain is extremely high, especially with the current pain you are experiencing. I've never had a fusion, so I can't give you first-hand knowledge about pain post-fusion. However, I have spoken with many patients and, to be honest, post-operative pain is all over the place. Some people do extremely well and some don't do as well and there are people anywhere in between.

In terms of duration of pain, I would say that you would start to feel significant improvement anywhere from 3 to 6 months post-op. Fusions generally take a longer time to recover from than ADR based on the inherent difference in the procedure and what's actually trying to be accomplished. I've spoken with many patients that felt really good pain-wise at 1 month post-op, but they had to consciously take things slow as to give their body the time needed to heal correctly.

One last thing: some surgeons choose to explant the ADR and fuse to eliminate the continued "micro-movements" of the ADR if it is fused in place (and hopefully eliminate any continued pain from the ADR[s])

A good first step in your situation would be to get more opinions from qualified surgeons that are experienced in ADR revision.

I wish you the very best Mark, and please don't hesitate to contact me if I can be of any help.

PS We have a member on the forum that recently had explantation & revision of a lumbar ADR...search under the name "Phylly" for her contact information. She is always willing to help and is very empathetic to people facing similar decisions that she made just recently.

**KBear** · 05-22-2009, 02:05 PM

Mark, Welcome to our board, you have come to the right place. Sorry that it is under these circumstances that we have to meet.

Did your surgeon use a vein guard when the ADR was implanted?

Kathy

mark-Perth · 05-23-2009, 05:25 AM

Hi Justin and Kathy,

Thanks for the welcome, im glad to be here.
There is definately NO vessel guard which really sux.

MY surgeon has said that he has had to remove 1 disc and revised 2 to fusions leaving the disc. It didnt sound like the removal was very easy and didnt turn out the best and he was satisfied with the posterior fusions but did say they were now pain management cases no. He is a vascular surgeon as well as a neurosurgeon and has done plenty of repeat anterior operations but not regarding removing ADRs. He seemed very confident that he would be able to do a repeat anterior operation if needed but didnt want to take such a huge risk if it can be avoided.

Im definately going to get other opinions regarding this and have already consulted with several but noone from near me has much experince with it. There are only 4 surgeons that do ADRs in my state and 1 refused straight out as the 1 removal he attempted the person died, he said he would only do PLIF's now. The others both claim they have never had failures so havent needed to do any yet and didnt want to have to fix someone else's failures but also said they would probably do PLIFs anyway due to the risks. Most have agreed that a posterior fusion wont help but have concerns with removing the disc as they dont have experience with it and I dont want someone operating on me that has not done it before. I have 2 appointments coming up in the next few weeks and have contacted most of the revision specialists overseas and are waiting to hear back from them before making my mind up on the best choice but dont want to leave it to long. Ive also got a few more surgeons on the other side of AUS that im waiting to here back from who have both done ADR revisions. Most surgeons dont seem to want to help someone elses failure it seems as it may look bad for them if they arent able to fix it.

Ive been talking to Phylly already, she has been a great help. Hi Phylly hope you are continuing to get better.

What was offered to me was basically a posterior fusion and if that didnt work he expected me to get a morphine pump and SCS. I told him there was no chance I would accept that and wouldnt have surgery if that was going to be the only choice if that failed. I then discussed removing the disc and only when I told him that I already had another surgeon O/S that was prepared to remove the disc did he then agree to remove the disc but only after I tried a posteior fusion. He said I would know pretty quickly if it helped or not and in the first few months he would remove the disc if it was still a problem. I cant imagine that happening.
He planned to do an entire fusion of everything possible at the rear and also go thru 2 where the ADR is and on the side the discs isnt sitting much also fuse there. That really scares me cause I would imagine that would make a removal later pretty much impossible if it still hurts but may also stabilize that area. He said he would also put 4 pedicle screws in and 3 bars, 2 down & 1 across. If he was to do the anterior removal later he would have to go back into the posterior and loosen the hardware off but that would obvoiusly have to be done before the fusion was solid. He has even put it in writing at my insistance that he will remove the disc if there is still pain although I had to fight with his secretary to get a copy of the letter.
He seemed to believe that it wouldnt make alot of difference as he wouldnt be able to distract the vertebra that much to get it out and would have to cut some bone regardless of whether its fused or not.
That really means that he will put me thru 3 operation at least to get the disc out. That seems stupid to me.
He also has never done a Lateral operation but was extremely interested in the articles I had from Luiz Pimenta, his eyes literaly were bulging from his head as I had about 5 that he hadnt seen. That means that he has one less approach available if the anterior approach isnt possible or fails.
I would also think that there would be pain from the fusion for 3-6mnths so I dont know how I would know if the pain was from the fusion or the ADR. I feel he only agreed to do the removal to keep me happy for now but would probably tell me it isnt possible then and to get a morphine pump. I wasnt 100% confident that I would be helped later.
My pain is interesting, I think I have a high tolerance to opiates cause my back hurts even with huge doses of painkillers and my PS thinks I am hypersensitive to pain but cant explain why I can get huge bruises on me but I dont even feel it happen or he can hit or pinch my legs or arms and it doesnt hurt at all cause the painkillers stop that but my back hurts regardless. My pain is also alot worse with the more I do and certain positions which I just ovoid as much as possible. I cant sit upright in a chair for long at all as the pain is horrendous but havent been able to do that without pain for over 12 yrs, but its much worse now. I havent been able to lift more than 2kg for yrs and bending is bad but standing and lying arent as bad. Walking is not normal and hurtsl. I have had good pain relief though since adding topical Ketamine which I rub into my back so now my PS thinks im just extremely tolerant of opiates which I agree wiith. He cant believe that I am able to study on 300mg of morphine a day and actually understand it. I just have to stand thru my lectures and its OK.
Thanks for the input, I totally agree in the reasons why the posterior fusions have its merits, but also being the person that will have to suffer if it doesnt work has to be of serious concern. I have read over 30 full paper regarding ADR revision's and its seems obvious that I am in a pretty bad position regardless of my choice. Any option I choose could leave me worse than I am now, dead or maybe better. It seems like the best results are achieved thru removal of the disc thru an anterior or lateral approach and 360fusion but that also is the greatest risk. Having suffered for over 12yrs with chronic pain I would prefer to die trying that suffer more. A life on opiates is not something I enjoy but it has consumed me for 1/3 of my life already. I do doubt that I will ever be totally pain free and dont expect too either so dont have huge expectations. I just cant see how straightening up the back will fix everything when the disc is placed to one side. I still believe the load will be unevenly distributed to the discs below. I think if they remove it they can straighten it properly and then if needed do a PLIF as well.
I definately need to speak to a doctor that has experience with disc removal
Ill keep you informed how the doctors appts go.
Thanks for the advice,
Mark

**KBear** · 05-23-2009, 01:59 PM

Mark,
I agree that you need to speak to a dr with removal experience. While this is the most risky, I think it leaves you with the most options. If it were me, I would want the adr removed. Like you said, I would rather die trying than live in pain forever. You are already super tolerant to opiods (so am I), so over time, the doses will need to constantly be increased. Eventually, you will get to the point where you are at the top dose and nothing else can be done for you, thus you will just have to suffer. So, pain management isn't a really good choice either. There are many great revision dr's in Germany and the US, that have tons of removal experience, with great outcomes. I would check into them, at least send MRI's and get opinions on the best plan of action. Let them know that you don't have a vein guard and see what they think. I don't think that not having the vein guard rules it out, just more complicated; but possible. I wonder why your surgeon didn't use one? Maybe ignorance or arrogance? I asked my surgeon before surgery if he would be using one and he does. Of course, none of go into adr thinking we will need a revision; but that is a chance we all take.
Best of Luck,
Kathy

**Gilbert P** · 05-23-2009, 03:27 PM

HI Mark

I have to ask were did you have your Maverick disc installed???

You do not have to answer or you could P.M. me

Thanks

Gilbert P

**Justin** · 05-23-2009, 06:57 PM

Hey Mark,

Thanks for sharing more details. You are such a brave patient. I'm so sorry you have such a full plate right now. It sounds like you have done a lot of research concerning your situation. If possible, I would consult with some other surgeons--I know the ones close to you have limited experience based on your info...is there a possibility of ultimately traveling for surgery?

My only suggestion is don't let your surgeon "paint you in a corner." At the end of the day, it's your life and your spine. You will be presented with suggestions regarding revision, but it's ultimately up to you which operation you choose. I know this is much easier said than done.

Please know that we are here to support you in any way and we are rooting for you. Let me know if you need anything.

mark-Perth · 05-25-2009, 02:05 AM

Hi Gilbert

I really dont want to name my surgeon, I dont hold anything against him and understand that every doctor has failures. The surgery was done in Perth, Australia though.
Cheers,
Mark

mark-Perth · 05-25-2009, 02:13 AM

Your advice is spot on thanks. I would prefer to stay here to have surgery but dont think thats an option anymore. I think at the end of the day I have to travel which is going to be hard and expensive but I only have 1 chance with this. Im only 33 and to be made worse at this age is no good at all.
I agree that the surgeons you consult with are only going to provide options that they can do so arent going to always provide the best option. I especially dont want to have surgery that doesnt allow further options as that is not a good thought at all and a posterior fusion I dont think will leave many options if it doesnt work.
Thanks for the advice and support.
Mark

mark-Perth · 05-25-2009, 02:39 AM

Thanks for the advice, I totally agree that I am better to go with a surgeon with experience with this and have the disc removed.

Im not to sure why my surgeon didnt use a vessel guard. When I asked him he didnt know much about it at all. I also didnt know before my surgery that it was needed or would have insisted on one being used. My surgeon at that time had not had any bad results so I think that may have been part of the reason. He has also done 1 revision recently that didnt have the vessel guard so didnt believe it to make alot of difference. Before my surgery I did alot of research but didnt have access to the medical journals like I do now so wasnt able to find that out. I also was not looking at revision surgeries then as I wasnt thinking about it not working. I think I had been a bit blinded by all the positive stories to read alot of the negatives although I had read some but had also read alot more negatives about fusion as well.

Its so hard being so opiate tolerant. I was probably worse before surgery as I was on the max dose of Fentanyl, Ms Contin and Oxycontin each day and needed all 3 and a liquid morphine as breakthru pain because I was on the max dose of all 3. That was the only way my doc could prescribe a high enough dose was by prescribing several of them at once. You may want to ask your PS if you can have several at once or include a nerve pill as these help reduce the dose of opiates needed. I had a 4 day ketamine infusion in hospital which helps lower opiate tolerance very quickly. Ive luckily been able to lower my dose a little since my ADR surgery, I left hospital on 600mg a day of morphine and with the help of a topical ketamine Ive been able to half that and have beter pain control as well. You may want to ask your pain doc about that. Its not widely prescribed hear but is used on opiate tolerant people, mainly people with cancer though. Its also available in a lozenge which ill explain in a seperate post but that effects your whole body where the ointment is localized to where its applied.
thanks for the advice
Mark