I spent Monday afternoon and all day Tuesday in Phoenix for the Minimally Invasive Spine Surgery Conference. It was awesome.

http://www.aamisms.com/annual_meeting.htm

I wish I could have gone for all the days. I missed some really interesting topics. What I saw was fantastic.

There was a Dr. from Sweden (Wolfgang Rauschning) who retired from spine surgery to become an 'anatomist'. He started taking cadaver spines and sectioning them in order to identify pathologies that cannot be identified on imaging studies. His slides were fantastic and he did identify many types of pain generators that aren't typically diagnosed yet. He's going to provide great advances in our knowledge and understanding of our spines.

It was great to meet Dr. W. If you think he's out goofing off at these conferences, I've got news for you. I wish I'd gotten to spend more time with him, but the one day I spent there was quite busy for us both.

I got to spend a lot of time with Dr. Bertagnoli, including a 2-hour, private lecture/QA session on disc replacement technology. He was very personable and truly seems to be interested in the patient's perspective. He's doing a lot to advance many forms of spinal treatments, not just the ProDisc:

> He's been using Bryan Cervical discs for 2 years.

> He'll be implanting his first ProDisc-C (cervical) on Saturday!

> He showed me films of a successful, combination 3-level Dynasys / 1 level ProDisc procedure. This type of procedure - multi-level with the appropriate procedure for each level - will provide great hope to the people with a variety of multi-level problems.

> He showed me films of an unsuccessful 2-level PLIF that he CONVERTED TO A successful 2-level ProDisc!!!

> He's done 150 PDN (prosthetic disc nucleus) procedures in the last 5 years. He uses the Ray device and has made many advances in that technology. I wonder if that would have been a better first-step for me, rather than the total disc replacement that I got. I think this technology is going to make a lot of spine surgery unnecessary - AND it's going to be very, very minimally invasive.

Dr. Rauschning discussed MRI's with reverse traction (weighted). He showed films of patient's that have completely benign structures, that generate significant nerve compression when weighted. I'm sure that they look like psych patients to the average doctor.

One thing that I hope to see soon is that with the more successful treatments, people won't have to wait until they can't stand any more before submitting to procedures. As the discs break down, they become hyper-mobile. As they break down further, they become hypo-mobile. When that occurs, the posterior elements (read facets) become damaged. Once that occurs, the less extreme treatment options (like PDN or ADR) become less attractive. Hopefully, we'll get to the point where we can nip the initial problems in the bud, avoiding the further breakdown that can make our spine a train wreck.

Dr. Bertagnoli asked if I'd speak during his presentation. I told my story and became somewhat of a mini-celebrity there. All afternoon, doctors were pulling me aside to congratulate me on my success and ask me questions. Dr. Yeung even gave me a cool 'bolo tie' that was the gift for each speaker. Dang it, now I've got to go by some boots!

All in all, it was a great couple of days. I didn't know what to expect, but it was worth the time and money to go.

Take care all,

Mark

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*** L4-5 and L5-S1 Disc Replacement (SB Charite III) 9/20/02 by Dr. Zeegers, AlphaKlinik, Munich, Germany ***

2/25/00 Microdiscectomy/laminotomy L4-5, 10x15x7 mm left paracentral protrusion

9/23/00 CANCELED L4-S1 360 fusion CANCELED

9/15/01 emergency microdiscectomy L5-S1, 14x13x10 mm left paracentral protrusion

Both discectomies resolved hip/leg/foot symptoms, but left the underlying back pain. Residual left foot pain and numbness. Lost axial reflex (left ankle).

Researching artificial disc options. ProDisc vs. SB Charite III looks like a toss-up, but you can see which one won.

*** The AlphaKlinik was wonderful. My expectations were high, but the clinic, it's staff, and Dr. Zeegers far exceeded them!!!

*** L4-5 and L5-S1 Disc Replacement (SB Charite III) 9/20/02 by Dr. Zeegers, AlphaKlinik, Munich, Germany ***

Now, you get some accolades from a group from beyond your peers and it must be nice. I have followed your hard work that has led to your success. Cool!

Do you have a medical background or did the spiny experience put your there?

Take care.

Thanks for sharing this with us. It sounds very encouraging. You're our very own spinie celebrity!

Did you get any sense of how long it might be before 2-level cervical disk replacements are available in the US? I'm not quite holding my breath but I'm still hoping.

I have several questions for you.

The first one is easy: Can you tell me more about Dr. Bertagnoli? Where does he practice, does he have a website, etc.?

Second, is reverse traction MRI available yet anywhere in the world, much less the U.S.? I was told by most who reviewed my films that my disc herniation was "tiny" and that it should not be causing me any problems. I feel great when I am laying down, but when I sit, stand, or am otherwise active, the symptoms get much worse. Adding a force to the imaging procedure seems like so much common sense, it will probably never happen.

Have you found a good resource for information about cervical ADR? I know the Bryan is in trials here, but where? Where is it available elsewhere in the world? Which surgeons are doing it, and which have the most experience? Does PDN exist for cervical? I have only heard of it for lumbar.

Finally, let me say that I agree with you philosophically about surgery, and when a patient should submit to it. Most physicians are conservative when recommending spinal surgery, but this is not necessarily good. Would cancer patients be better off if they waited until the pain was unbearable to pursue treatment? I realize it is not a perfect analogy, because a lot of spinal problems won't kill you, but cancer will. But let's face it, a spinal problem that has deteriorated severely leaves us in bad enough shape that we wonder if we would rather be dead.

I chose to have CED before I was at the breaking point, and I am not sure yet if it worked. But I don't second guess my reasoning for having the surgery. I am asking all of the questions because I recognize the possibility of future degeneration, and I want to understand disc replacement.

Thanks for the great post.

It is good that you were there to observe our Dr. Whitworth soaking up knowledge I just wish a lot more Drs would continue their education we need Drs that are not only good but that care and that does describe Dr. Whitworth.

I am envious that you were able to spend some time in the desert I just love the colors and the smells and Phoenix is a beautiful city.

On my first trip through Phoenix there were stop lights that seemed to be every block and it was just brush but on my last trip through there it was beautiful with all of the landscaping along the interstate, it would be nicer than these gray skies and the train going by right now.

I appreciate the information it does give me some hope that in the near future if I can stay off of the table I may have a better choice with a better chance for a good outcome, in the meantime I am off to the Y and into the pool to help Mother Nature help me.

The Bryan is being trialed at 20 sites around the US. It's manufactured by
Spinal Dynamics in Seattle WA. They are
in the phone book.

I don't understand why more "cervically concerned" people here haven't taken
the same path as I did; 1) contact S.Dyn and find out if there is a trial participant somewhat nearby, 2) set up a consultation with the participating surgeon at that clinic if possible.

I had a great consultation with that surgeon near me, unlike the many "drug and plug" fusionists or ultra conservative types I met with beforehand.

quote:

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Originally posted by nutt:

Have you found a good resource for information about cervical ADR? I know the Bryan is in trials here, but where? Where is it available elsewhere in the world? Which surgeons are doing it, and which have the most experience? Does PDN exist for cervical? I have only heard of it for lumbar.

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Could you explain what the PDN procedure is?
and why you wonder if that might of been a better "first step" for you?

thanks....
that's cool that you had your "15 mins. of fame"....

I really don't know about cervical disc availablity. All of my research has been for lumbar ADR. One of the sad thoughts that occurred to me during the conference was that the mainstream American doctor will still be doing the obsolete surgery for years.

Newsie, you keyed in on the most important aspect of the trip (that I failed to mention.) I was attending sessions from 8am to 6pm without squirming. I drove to the airport, returned the car, took the shuttle, waited at the ticket counter, got something to eat, waited at the gate for an hour, flew home, waited for the shuttle, drove an hour home.... and still felt great!!! I am a person again. I can meet interesting people in the jacuzzi and talk about interesting things - without even mentioning my back!!! I can smile and laugh. It still feels funny to smile naturally - not force it out through a grimace. Yes, just the fact that I could consider attending such a conference is amazing. 3 months ago, I couldn't go see a movie!

Nutt, Dr. Bertagnoli can be found at his clinic's website:

www.aesculap.com

I don't know about reverse traction in the US. Flag down Shar-pei, I believe that she had a 'standing MRI' in Long Beach??? If you are dealing with low back pain and the doctors are looking at MRI's telling you they look OK, you are going through the same crap that I did. An MRI isn't going to show the source of discogenic pain caused by a 'defective' annulus (perhaps caused by an injury.)

I don't know anything about cervical ADR trials or cervical PDN... that just hasn't been my focus.

Early surgery will only be a good option when the surgeries are less risky. Up until now, waiting has probably been your best option. If you've got a symptomatic disc bulge and an otherwise healthy spine, in the future - an endoscopic discectomy/neucleotomy or a similar procedure may solve the problem with minimum risk. That will arrest the further degeneration. In the future a hyper-mobile segment caused by collapsing disc space will be stabilized and disc height restored with PDN. Hopefully, this all isn't too far away. For some of these technologies, I still wouldn't want to be an early guinea pig, but if the current options are worse, maybe it's still worth doing.

I sure hope your CED works out well for you!

Joey, our decent into Phoenix was through an overcast. It was cloudy all day on Monday, but the cloud bases were at about 20,000 feet. That put the desert in shadow even though it was mid-day. Without the direct sunlight it was spectacularly clear. The desert was even more beautiful than it normally is. (I love the desert... my wife and I were married in the Hidden Valley campground in Joshua Tree National Monument.)

Thanks for the info HA.

NBird, the PDN is a fibrous pillow that contains a hygroscopic gel. The PDN can be inserted laparoscopically, then it absorbs water and expands. It expands with enough force that it will restore some disc height. Then the compound remains stable. If your annulus is intact, this gives you the chance to restore disc height, restabilizing the disc, without giving up the shock absorbing properties of the disc.

ADR is a compromise. They have no shock absorbing properties. The ProDisc doesn't mimic the normal motion of the joint. The Charite does a better job at normal kinimatics, but still not the same as the original disc.

Also, it's just a less invasive procedure.

Pain-free vibes out to all,

Love,

Mark

Is it a 2/3 - 1/3 trial like the Charite and ProDisc?

Thanks,

A great experience indeed for you.
Wish all of us spineys could have been there with ya,

Thanks for sharing,

I'm now trying to give Dr. Jho's decompression procedures as much time as possible to give me pain and muscle spasm relief. I just reviewed my follow-up mri films. To my layman's eye, it looks like he well-decompressed the two nerve roots (on one side) as well as spinal stenosis. On the flip side, I fear that the approx 5mm "dog leg" that now appears on the bottom of left c5 *might* disqualify me from ADR if I need to pursue additional surgery. I hope this is just my ignorance....

Another point; The Bryan appeared to have a great deal of cushioning built it. From what I've read, I think it might lack in the ability to "jack open" the area as much as a fusion plug, and the literature stressed the surgeon's need to meticulously remove spurs from the level.

Did you learn any specifics about cervical ADR or Dr. Chiu's cervical bone spur removal (thought I saw that in the schedule) from the conference?

Thanks for sharing information - H.A.

quote:

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Originally posted by mmglobal:
House Arrest, are you going into the trial?

Is it a 2/3 - 1/3 trial like the Charite and ProDisc?

Thanks,

Mark

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My lay-impression about bone spurs is that removing them is not the issue, it's that they don't stay gone. They are like scar tissue.... it can be cut away, but that often causes it to grow back worse. BUT, I'M THE WRONG GUY TO TALK TO ABOUT BONE SPURS!!!

No specific info about cervical ADR.

The big questions is timing - how long will it take for them to typically grow back. And the alternative - ADR or fusion to "jack open the area", might be more problematic as Dr. W. suggested in:

http://neuro-mancer.mgh.harvard.edu/ubb/Forum259/HTML/004571-2.html

"The main concern I have regarding either cervical fusion or ADR is in revision surgery for osteophytes. It is a very tight space in the cervical spinal canal..... "

That thread is a few months old. Unless the good Doc has a new opinion, I'd guess the point is that you can remove the spurs, and remove them again if they grow back, but if you obscure access to the area with fusion or ADR, you might end up with bigger problems. I would think that an AD might be removable for revision surgery, but I only know the wrong end of the scaple....

quote:

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Originally posted by mmglobal:
My lay-impression about bone spurs is that removing them is not the issue, it's that they don't stay gone. They are like scar tissue.... it can be cut away, but that often causes it to grow back worse.

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As explained by Dr. Zeegers, most of the nerves are in the softer tissue on the interior wall of the dorsal annulus. The dense outer wall of the annulus contains no nerves. They scrape away all the softer tissue that contains the nerves - removing the pain generator. They leave the outer annulus because it is a large component in the support structure that is required to keep the spine (with or without the prosthesis) stable. They access the disc through a window that they cut in the anterior portion of the disc. They even sew the window closed in order to preserve the anterior portion of the annulus.

So, with PDN, they'd do the same thing, but through a scope instead of in an open procedure. They'd remove the tissues that contain the nerves that would be my pain generator. There is a question about whether or not my annuli would be 'competent' enough. They were both leaking dye on discogram, but the tears were relatively small.

I hope this helps. I continually find that I didn't really understand what I though I fully understood a few months ago. It takes a long time for all of these concepts to sink in.

Take care,

Mark

The PDN you speak about. I'm curious if there was something used quite a few years back that sounded rather similar. When I first unjured, blew two discs and consequently had fusion (94)..I was originally informed that an infiltrated hydrogel sponge (pillow I guess) could be inserted into my disc space. On visiting the NS "cowbone" fusion was done. Yeh, guinea pig variety, but that was back in 94!

Osteophytes, a problem that also results from fusion surgery. Mine appeared when bone graft resorbed..manifested as offshoots indenting subarach space rather than filling disc space. No-one has touched them even with re-do fusion because of difficulty with access. Too dangerous to go in that close to the spine..I was told. I suspect osteophyte location has alot to do with removal..or not. Posterior or anterior. I am thinking that minimally invasive procedures to deal with this type of thing can't be too far away. Yes, intruments and design are crucial to what can be achieved. I've also heard a spinal surgeon comment that he only does ADR as open surgery because it offers better access and view. No surprise when I consider ADR to be rather a bulky implant. I think he commented that minimally (endoscopic) invasive techniques were too risky for most spinal surgery needs. I can't remember exact words.

Cervical spine ADR is already carried out in Australia. Lumbar ADR has been in vogue, and in practice here for a couple of years. My OSS has had patients come from the USA specifically for him to do this surgery. He had a great deal of ADR information on his website but I noticed it has been removed this year. I don't know the reason for that and hope it's not because of failure. That did go through my mind.

Found your comments re MRI technique, and take on them, and take on them interesting. Even when an MRI doesn't look good one will frequently be told it's AOK. Mine looks dreadful but I'm suppose to be safe...at this stage. Did they show MRI's that look bad but don't require surgical intervention? I do believe that MRI's can also be quite misleading in terms of reading too much into them that leads to an unhappy surgical outcome.

Glad to see you feeling good and this info is much appreciated. Did you hear any Ozzie accents at that conference? Just wondering.

There were some pretty awful looking films, but I think they were all from people who had serious symptoms or were dead!

Yes, the prostheses are quite large. Endoscopic ADR is hard to imagine, especially if you've seen how the surgeries are done. I can't imagine doing them through a tube, but that will be commonplace in the near future.

Bertagnoli and I were having a long email conversation. He suggested that I go to Phoenix to meet him.

He had a very interesting comment. He cautioned the doctors not to consider it a contest to see who could do the quickest procedure or make the smallest incision. He seems to be very focused on 'the prize', pain relief - not fancy surgery.

Take care all,

-1998: first surgery,(ANTERIOR APPROACH) a COMPLETE DISECTOMY L4-L5 AND FUSION BY A CARBON CAGE
-pseudoarthrosis for failed fusion
-1999: second surgery, a POSTERIOR STABILIZATION l4-l5, by PLIF (a TITANIUM CAGE and SIR bars and PEDUNCULAR SCREWS).
-second surgery caused me a peripheral neuropathy
-at present, pain pharmacologic therapy: gabapentin, tramadol, amitriptilin, ketorolac
-Currently considering revision surgery ( removal of titanium cage L4-L5 by an anterior approach).

e-mail: anemoreb@tiscali.it

quote:

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One of the sad thoughts that occurred to me during the conference was that the mainstream American doctor will still be doing the obsolete surgery for years.

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One of the sad thoughts that occurred to me is that a high percentage of the people getting either obsolete surgeries or ADR, PDN, etc., for lumbar disc problems would not have needed any kind of surgery had mainstream medicine steered them into FVT in the first place.

That, of course, does not diminish my great joy as seeing you finally find something that appears to be working.

Like nutt, I am also interested in MRIs with reverse traction. My symptoms change so drastically from lying to standing, but the MRI report indicates minor problems.

I could not find “Dr. Rauschning” on the Internet. Where can I find more information on reverse traction MRI? Here is what I have found on axially loaded MRIs:

Spine 1997 Dec 15;22(24):2968-76 University Hospital, Sweden.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ uids=9431634&dopt=Abstract

Spine 2001 Dec 1;26(23):2601-6 University Hospital, Sweden. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list _uids=11725242&dopt=Abstract

Spine 2001 Dec 1;26(23):2607-14 University Hospital, Sweden. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list _uids=11725243&dopt=Abstract The diagnostic effect from axial loading of the lumbar spine during computed tomography and magnetic resonance imaging in patients with degenerative disorders. CONCLUSION: Axially loaded imaging adds frequent additional valuable information, as compared with conventional imaging methods, especially in patients with neurogenic claudication, but also in patients with sciatica if defined inclusion criteria are used. (no control group or outcome of surgery)

Spine 2001 Dec 1;26(23):2596-600 Department of Orthopaedics, University of California-San Diego (did not find any such service there 12/10/02) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list _uids=11725241&dopt=Abstract Lumbar spine disc height and curvature responses to an axial load generated by a compression device compatible with magnetic resonance imaging.

http://www.fonar.com/product_info.htm > "the statndup MRI" is a 0.6 T, sitting upright or standing, Vertically open MRI. For locations called 1-888-633-3674.

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~Wolfv~
I am a lumbie (leg pain from sitting or standing) without indications for surgery. My goal is to find a computer-programming job where I can do my computer work while lying down. In college, I did my computer programming assignments while lying on my side and I recently graduated with a degree in Computer Science. My resume: http://www22.brinkster.com/wolfv/default.htm