Mike's back

Artificial disc replacement- a dream for chronic backpain sufferers or bonanza for surgeons?

2008-05-17T20:26:00.006+01:00

Dr Zeegers (right) and me

Alphaklinik, Munich

For countless numbers of chronic backache sufferers diagnosed with degenerated intervertebral discs, artificial disc replacement (ADR) is regarded as the preferred solution- High-Tec in contrast to the established alternative old-technology, vertebral fusion, and offers the dream of restoring a fully mobile, pain-free life. The growth of the internet has allowed back-sufferers the world over through glossy websites to learn about the new technology. It is not just by chance that simultaneously there has been a mushrooming in Europe of private clinics charging from £12,000 for a 1-level ADR to £32,000 for a 3-level ADR. Against the current background of a tightening of credit and a decline in economic activity in much of the developed world, clinics are competing for a growing but limited number of private ADR patients. One of the pioneers of ADR, Dr W.S. Zeegers, a Dutch surgeon (see above photo on the right) has recently commented that in their haste to milk this lucrative market, some of these clinics are offering ADR to desperate, vulnerable patients some of whose pre-operative back condition makes them highly unsuitable ADR candidates and asserts that a small but significant percentage of these patients in the months and years following their operation are coming to regret their decision.
My own case may be seen as a cautionary tale for would-be ADR candidates. It should be pointed out that ADR received NICE (National Institute for Clinical Excellence) approval in 2004 and there have been an increasing number of ADRs on the NHS but finding an orthopaedic surgeon with a large number of successful ADRs under-his-or-her-belt is difficult. I concluded that if I should contemplate an ADR it would be with a surgeon with a worldwide reputation who has carried out several thousand ADR operations.
It’s 8 o’clock one Friday morning in late April 2008 in the operating theatre of one of the leading ADR clinics in the world- Alphaklinik in Munich. The previous day over a 12 hour period after I had seen various specialists, undergone MRI scans and x-rays, a thorough neurological examination and cycled twice around Munich (it seemed) in the gym attached to a computer monitoring my heart and lungs, Dr Zeegers had concluded I should make a suitable candidate for ADR. Immediately ahead of my planned 2-level ADR operation it had been decided to carry out a discogram- a kind of medieval torture in which I was paying to allow a series of fine needles to be inserted under X-ray guidance, carefully avoiding my spinal cord, into my lumbar discs. The purpose of this diagnostic tool is to determine precisely which discs are causing pain and by injecting a water-soluble dye into the disc itself, to ascertain whether there is leakage from a disc rupture. Needless to say, during the procedure it is necessary to allow the patient to recover some level of sensation in order to ensure validity of the results. As each needle is inserted, withdrawn or just tweaked, as is expected with each degenerated disc, I screamed, faithfully leaped a foot off the operating table each time and was informed later I had at one point accidentally kicked the surgeon in the jaw. (Note-I must check the final bill to see whether I have been charged for dental restorative work!)
All apparently was going smoothly, with results as expected, when Dr Zeegers suddenly announced to a disbelieving theatre team that the surgery would not take place. I was taken to the recovery ward and the next day offered a thorough, 90 minute explanation for the decision (only the 3rd time he has called off an ADR so late in 10 years). He explained that central to his decision was his assessment of the probability of medium and longer term success. As he neared completion of the discogram he became concerned that my back’s instability would leave me vulnerable to a collapse of the ADR stack during golfplay and that were that to happen I could end up paralysed from the waist down. (There were additional issues of moderate scoliosis and poor soft tissue structure around the spine which had been taken into consideration earlier). He was simply not prepared to take the risk and though he felt depressed that I had had my hopes raised and then dashed, he was certain the right decision had been made.
Dr Zeegers left me drawing the conclusion that a different surgeon- perhaps less concerned with statistics and more concerned with profits might have decided to complete the operation. He commented that there are clinics which welcome older ADR candidates as there is a good chance they will pass away before the surgery fails!
Revision surgery for unsuccessful ADR operations is notoriously difficult and potentially dangerous. Worldwide there are a significant number of post-ADR patients who in the months following their operation run into a variety of subsequent spinal problems whose quality of life has not been restored (some with much-increased pain) and whose bank balance has been hugely depleted.
My dream (held for the last 10 years) of a successful ADR and a return to playing golf may have been dashed in Munich but I was able to shake hands with Dr Zeegers thanking him for his integrity and clinical judgement. The cost of my unproductive adventure to Munich was c.£5000 but I am left wondering whether this 63 year-old may have had a lucky escape. I am left contemplating the prospect of a spinal fusion operation in the next year or so on the NHS.

ADR postscript

2008-04-27T16:39:00.002+01:00

Thanks for all the best wishes messages. I am sorry I was unable to fulfil my plans to blog the Munich trip. The bald facts are that my request for a 1/2 or 3 level ADR was turned down as too risky after 14 hours thorough testing all day Thurday and a discogram. My spine is too unstable to take ADR when seen against a backdrop of an active lifestyle. I return to the UK to review the options- maybe fusion at some point, make lifestyle changes and to learn to accept that at 63 I should realize that my body is trying to tell me to slow down and take it a little more easy.

2008-04-21T13:52:00.002+01:00

Last Wednesday I had on the NHS an MRI scan with dye contrast of my lumbar spine at the brand new high tech scanner at St Mary's Newport on the Isle of Wight (officially opened the next day by HRH Princess Anne). It had taken me 3 months nagging of my GP at my local GP centre to treat the suspect neuroma found at Xmas on the earlier scan as a potential cancer. Having had the scan I was given a copy of the images on disc but had to wait until this morning for the consultant's report. Over the weekend I had a call from Dr Zeegers whom I had emailed the images and we spent an hour discussing each image while he explained what we could see on our screens. Regarding the 5mm soft tissue neuroma he reassured me that it had not grown over 3 months and would be no barrier to back surgery. He also suggested he send the images to colleagues in France and the USA for a second opinion. This morning he emailed to say they too are sure the lump is benign. So all is set for the trip to Munich. Occured to me that the name of the local football team is Borussia Munchen Gladbach. Sounds as though that's exactly what I hope for my back!

2008-04-03T19:54:00.002+01:00

I have the date for my trip to see Dr Zeegers in Munich- April 24th for tests and 25th for surgery- possibly a 1-level ADR but maybe more. Travelling down by car with my brother as chauffeur stopping off enroute in Belgium. More like an adventure.

2008-03-06T14:22:00.002Z

Heard from my GP that the suspected neuroma found by the radiologist is nothing to be concerned about and most highly probably benign. However I am writing to her to ask that it is checked out ASAP on the Island. Meanwhile I am planning to go to Alphaklinik Munich after Easter for a discogram to determine whether I am a suitable candidate and if so, how many levels I need. Might only be a single level!

2008-02-23T22:14:00.002Z

Took a long call from Dr Z. of Alphaklinik this afternoon who has looked at my MRI and suggests I take a trip to Munich to investigate my back further. He thinks there's a chance that I might only need a 1-level ADR (or two possibly) but that discography will be needed to decide- OOCH! I can sense the pain already (where did I put those aspirins?).
Impressed again with his comms skills in English. I trust this guy not to urge me to go for the full ADR set (3) at 35K UKP just to line his pockets. Plan to go just after Easter if I can get a cheap flight.

2008-02-15T10:46:00.003Z

Decided to approach Alpha-Klinik, Munich- Dr Zeegers and filled in the online web form and also sent an introductory letter and the latest MRI scan summary and bone density results. Amazed that within 24 hours the phone rang and it was Dr Zeegers! Wow! I was surprised that they got onto my case so quickly. I suspect that it is a policy to get back within 24hrs as a "Good PR/Good Comms" policy and I certainly was impressed- especially when he and his secretary speak good English. (I hear that Alpha charge 10K UKP less for a 3-level than Pro-Spine.) though that is not my primary motivation for a second approach. I need a second opinion on my suitability for ADR. I expect to take the Alpha approach further by sending my MRI CDROM over the weekend and see what transpires. It's great that I can read daily update blogs on 2 American patients both of whom are under the knife this week with 2-level ADR's- one with Pro-Spine and the other with Alpha!

2008-02-08T20:20:00.000Z

Had an X-Ray bone density scan today and readings were taken of hip-bone and 4 vertebrae. Clever machine. According to technician my bones are OK density-wise for a guy of my age- whatever that means! Sent copy to Pro-Spine, Germany for their comments.

2008-02-04T12:01:00.000Z

I've received a response from Germany:-
Meanwhile I have now received (and attached as a jpg image) the consultant radiologist's report on my recent scan (you have the MRI images on CDROM) and would like to ask you to comment on his findings particularly regarding items
1. Are the presence of chronic and acute reactive endplate changes a contra-indicator for successful ADR?
Not at all – as long as they are not fully destructive. End plate changes are on the contrary a sign of clear discogenic degeneration – and thus confirm the expectation of ADR addressing your predominant pain generation.

2 & 3 The report mentions twice "facet joint hypertrophy". I believe that pre-operation condition of facets are critical for ADR success and have heard that the thickness of the discs of less than 5mm are a contra-indicator for ADR success. What is your own view of the indications in my case?
Facet joint degenration is one item, that we closely evaluate when deciding on ADR. Facet joints physiologically only take over a minor share of axial spinal load. Disc height collaps brought about by disc degeneration will massively overload them. And foster degeneration.
ADR implantation is capable to restore disc height and renormalize the segmental movement pattern from what it has become by disc degeneration. So in our experience your degree of facet degeneration will be positively addressed by ADR. This biomechanical consideration is confirmed by Dr. Bertagnolis long-standing experience in his case series. Of course high-grade facet destruction would speak against ADR. Which is not at stake in you acc. to Dr. Bertagnoli`s judgment. I hope I could help you on.
I find this response curiously unhelpful. Maybe it's due to the problems of interpretation from German to English but I end up with the impression that whatever I raise as a possible problem the answer is "Don't worry!" Makes me question still further the quality of the answers and advice from the clinic.

2008-02-03T12:44:00.000Z

Interestingly I am in contact with a fellow sufferer who is awaiting his operation date for a 3-level ADR (similar in position of discs, his age 7 years younger) at the Alphaklinic in Germany with the other top surgeon Dr Zeegers. He has been on the same journey of doubt over ADR over a similar time period but has concluded he must have the op in order to regain his former active life-style. It will fascinating to hear how his operation goes and to talk in real time to him in his hospital bed about the experience via Instant Messenger. He will also maintain a blog (like this one) so others may learn. I have heard also from woman who had a 3-level ADR around March of last year and who is only just getting her life back- in her case the recovery was much slower than she had anticipated.

2008-02-01T16:58:00.000Z

Watched today for the first time an online "live" single-level lumbar ADR operation lasting about 100 minutes at a USA hospital in early 2005- The Beth Israel Hospital in which a Charite disc (there are several different designs in common used worldwide) was implanted in a middle-aged female. The video can be seen at any time at-
http://www.or-live.com/bethisrael/1245/
The skill required by the surgeon is clear to see particularly in the preparation of the patient's disc-space by clearing out all of the old disc and then the care with which the top and bottom plates of the titanium artificial disc are sited with great accuracy before the plastic core is inserted. The doctor commentating stressed that the op is not suitable for everyone and that those with scoliosis (me) are not suitable candidates! That was just a single-level ADR and I can't imagine how much greater is the complexity of a 3-level ADR (which is what I need). As a advert for the hospital the broadcast was impressive and I imagine their phones were red hot with prospective new customers. I couldn't see any report of how this patient has fared since the operation. Having seen the way in which the device is implanted I can imagine removal of a failed device is horrendous.

2008-01-31T08:41:00.001Z

The trouble with researching back problems and possible solutions is that you unearth an ever-larger can of worms. Today I was pointed to 2 articles (the most recent this month) in New York published newspapers which have discovered that many spine surgeons are investors in manufacturing companies making the screws, rods and artificial discs which augment the final bills for patients hugely. Typically a single screw in a fusion operation can be billed at 1000$ when it costs only 50$ at most to make. That on top of other research which throws light on the doubtful voracity of the results of so-called clinical trials which ignore bad outcomes from dozens of failed operations which then allow a particular device to receive a good rating. Take a look!
http://www.backpainsupportgroup.com/cgi-local/ubbcgi/ultimatebb.cgi?ubb=get_topic;f=1;t=012149
http://www.backpainsupportgroup.com/cgi-local/ubbcgi/ultimatebb.cgi?ubb=get_topic;f=1;t=012150
It never rains but pours!
I’m appalled that my GP seems not to have read the consultant radiographer’s report on my 28th Dec 2008 MRI lumbar scan (which I only caught sight of yesterday) at the end of which he records that close to one of my vertebrae he can see a soft tissue lesion 5mm in size which he suggests is probably a neuroma and should be “looked into further”. It is currently deflecting a bunch of nerves. A quick look on the net tells me that neuromas can be cancerous or benign so I’ve written to her and requested the finding should be referred to my local NHS hospital pronto!

2008-01-30T10:25:00.000Z

Received further emails from patients suffering from the effects of ADRs which went wrong- just what I needed to hear! One from the very clinic I am considering! In one of the cases it looks as though there were many contra-indicators available before the op but the clinic paid them little or no attention at the point of persuading the patient to go for ADR. How can you be sure that the clinic don’t just have their balance sheet in mind when they advise a client?
Saw for the first time the full consultant radiographer’s report from my Dec 28th MRI scan and it makes depressing reading! Apart from the technical terms which go over my head- what is hypertrophy?- it is clear that my backbone is a mess—distorted with scoliosis, 3 bad disks with the rest going bad! It’s a wonder it works at all! I have sent a copy to Pro-Spine in Germany for their comments asking for their comments on the poor state of my facets and whether that suggests ADR may be inappropriate. It will be interesting to see their reply. The more I question them the more chance they will smell a rat- “We don’t want any of those internet-savvy patients who might give us a bad name!”

2008-01-29T10:15:00.000Z

This is the Dec 28th MRI scan of my lower back showing the state of three adjacent discs- i.e. narrowing

2008-01-29T08:59:00.000Z

I've been reading messages on the 3 leading forums to do with ADR and have had a few private messages (tend to be libellous stuff which they wouldn't risk putting up on the forums) from individuals telling me of disasters- people who have spent their entire savings, others who have been driven to re-mortgage their houses- to pay for surgery and revision surgery. It's all a little depressing and I am rapidly reassessing my options and have this over-riding thought "Is the risk of failure of going under the knife not simply too great to conclude that it would be in any real sense worth-it?" People are telling me of individuals who have gone to Germany and bitterly regret the decision- not only are they now broke but their backs are in a much worse condition now than before! They live in constant pain, are barely able to move from their beds and some have contemplated suicide. All very disturbing.

Others have urged me to look very carefully at the issue of facets- the boney, spiny, antlers- two of which are attached to each vertebrae and moderate the twisting motion of the spine (they cleverly, gently resist you twisting too much). The evidence is clear that these facets, and most particularly their pre-op state hold a major key to the chances of post-op success. Seems that narrowing of the height of discs (my problem) will have over the years have almost certainly led to a deterioration in associated facets. Much pre- and post-op back-pain can be blamed on facets.

Another area of concern lies in patients reporting that the mere fact of surgery triggered over subsequent weeks, months and years other types of pain and at different sites (often in their legs) which was sometimes much worse (if that were possible) than the original back-pain!

Sorry for all this negativity but that's how I feel this morning.

I am comforted by just one thought. I am not lying on the floor in agony needing pain-killers and a decision about surgery- I am grateful for this as it allows me time to consider whether I should simply do nothing. Sounds easy- doesn't it? But then the questions keep coming. If I delay ADR surgery, I have been advised that I may be considered too old at say 65 for this operation. It is possible that my back will deteriorate beyond the point at which ADR is an option. Thus I may miss the only chance of restoring my back so that I may play golf again.

I am off to the GP this afternoon to ask if is possible for her to "prescribe" on the NHS an X-Ray bone density scan which is a requirement of the German clinic who would not proceed if the reading showed I have crumbly bones. Possibly she will say that this test (as opposed to the more usual quick ultrasound test used in the UK NHS not acceptable to the Germans) would have to be ordered through an NHS consultant in which case I would need to get the test done privately.

2008-01-28T20:15:00.000Z

The options;-

Do nothing- means no more golf but by nursing my back and avoiding too much time in a sitting position I can live with the backache I currently suffer.
Have a fusion involving bone grafts across 4 vertebrae (on the NHS ie free)
Have a 3-level ADR (artificial disc replacement). I have a quote from one of the top clinics in the World in Germany (Pro-Spine) at a cost of c.£35K

The decision is complicated by several factors not least of which is what is the probability of success for options 2 or 3 (I gather from various web forums that one third report significant improvement, one third report no change and one third report deterioration i.e. there is a 1 in 3 chance I will wish I had not had the operation looking back say 18 months after either op!

But what if I do nothing? The best scenario is that my back might stay in a state which is liveable-with (not too painful) especially if I nurse it carefully.

Many people say that if you can possibly avoid it DO NOT GO UNDER THE KNIFE.

Introduction

2008-01-28T15:32:00.000Z

Here I am in the middle of the biggest dilemma I have ever faced- to go under the knife or not! I have been advised I have scoliosis (a warped back) due to progressive deterioration of my discs. Three are narrowed, dehydrated (hardened) and no longer do the job nature intended. Now the cause is almost certainly due to 35 years competitive tennis (I had a wicked serve which involved an arched back and at racquet impact sent a shock through my spine concentrated on the lower back zone) followed by 15 years golf (got down to a 12H/C) often 3, 18 hole rounds per week and would hit drives c.275yds. It's all my fault- but I wouldn't have changed a thing even if I'd known what would lie ahead. I've had to give up golf (gave up tennis in 1987) and need to decide what to do now about a back which is slowly deteriorating.