Explantation of ADR from L4/L5 level

///Explantation of ADR from L4/L5 level
Explantation of ADR from L4/L5 level
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  • alexinca
    Participant
    Post count: 4

    Dear Dr. Corenman,

    I had a Prodisc-L ADR put into me around 2005 at a hospital in San Francisco, CA. No adhesion barrier was used (none was FDA approved at that time). The ADR failed and caused facet destruction after about a year. I couldn’t find anyone at the time to explant/remove it, and the implant was fused in place. Severe LBP and sciatica worsened following this surgery. L2-L4 levels were eventually seen in grotesque arthritis and were fused. Recently, XLIF instrumentation placed several years ago between L2 and L4 (adjacent segment disease) was removed, and an infection has been found growing as a biofilm on the surface of the metal (even though the wound looked clean). There are suspicions that the ADR at L4/L5 may also be infected, in addition to possible stenosis (artifact makes it difficult to properly evaluate that level). The big question is: are you able to explant Prodisc-L ADR from L4/L5, and revise to a fusion? I’m in 10+/10 back pain and sciatica, with tremendous difficulty managing the pain and survive in a worsening disability. Pain management now does not consider me a candidate for the SCS or the pain pump due to the infection finding.
    I’m 46, and don’t know what can be done. So, I’m looking for any help. Big thanks for your reply!

    Donald Corenman, MD, DC
    Moderator
    Post count: 6574

    I am sorry you had a failure of the artificial disc replacement (ADR) implant in the lumbar spine. Your story is the reason I don’t implant lumbar artificial discs but I diverge. The degeneration above the ADR is due to your genetic makeup and most likely not from the ADR.

    First, did the XLIF fuse (XLIF is extreme lumbar interbody fusion, a fusion performed from the side of the body where implant cages are placed between the vertebral bodies in front with no instrumentation from the back)? If there were no screws and rods placed from the back to stabilize the XLIF, the chances of fusion from the XLIF are reduced.

    You first have to determine the pain generator or generators. Do you have a solid fusion at the levels operated on (the L4-5 level where then failed ADR is implanted and fusion at the L2-4 levels where the cages were removed/rods removed????, finding of infection??? What was the organism found from culture.

    Removing an ADR from the lumbar spine can be a high complication type surgery as the vena cava (the thin-walled major vein that returns blood from the pelvis and legs) could be scarred down making it impossible to mobilize this vein or remove the ADR.

    I also have questions regarding the L5-S1 disc as you have multiple segments that have failed and the L5-S1 disc commonly follows this path too.

    You can determine the canal stenosis even with an artificial disc implant with a well performed CT myelogram. This test will also indicate the fusion status of the previously operated levels.

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
     
    Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
    alexinca
    Participant
    Post count: 4

    The infection in biofilm is Anaerobic 2+ Propionibacterium species.

    The L2-L4 XLIF was reinforced with posterior screws and rods that were most recently removed after the determination of a “solid fusion”. Infection growing on the removed instrumentation was a surprise finding. L5/S1 level had been fused front and back at the time of ADR placement at the level higher. A computer merged report for the SPECT/CT study a year ago said:

    IMPRESSTON:
    1)L1 L2 L3 L4, and L5 and upper sacral-laminectomy defects with partial facetectomv defects and
    incorporation of posterior element bone graft.
    2) posterior fusion hardware with discectomy bridging L2-L3 and L3-L4.
    3) Anterior fusion with discectomy and anterior plate placement at L5-S1.

    4) At L5/S1 there is disc bulge osteophyte complex lateralizing to the neural foramina wiih severe bilateral neural foraminal stenosis L5/S1.
    5) L4-L5 anterior fusion with discectomy and laminectomy defects with moderate to severe bilateral
    neural foraminal stenosis.
    6) There is no significant central canal stenosis.
    There is a 7 degree levoscoliosis L2-L3, L3-L4. There is a 5 mm grade 1 spondylolisthesis L5-S1

    I’ve been told the SPECT/CT has unexplainable multiple “hotspots” (tracer uptake), especially on the left. Left leg, has been progressively worsening: weakness and pain.

    I’m hearing the situation is very complex, the epidural scarring is extensive, and there is a great deal of abnormal extra bone that may be causing stenosis. It is believed the fused levels have been fused well. ADR level evaluation is said to be radiologically limited. Myelogram caused severe multi-month pain flare, and did not have remarkable findings – no central canal stenosis.

    Legs are getting weaker, pain is becoming more unbearable, and I’m losing function.

    I can’t find anyone to help (decompress the nerves, etc.)

    Donald Corenman, MD, DC
    Moderator
    Post count: 6574

    P. Acnes is a very common organism to infect the spine as it lives in the skin and can be introduced easily. It is however a low virulent organism which is why you probably don’t feel “sick” (fevers, chills, sweats).

    I am confused in that earlier you noted XLIFs at L2-4 but there is no mention of the cages in those vertebra in the report.

    Did you have a fusion of L5-S1 initially due to a spondylolisthesis (degenerative or isthmic)? Was the fusion a PLF, PLIF, TLIF or ALIF (see website for explanation).

    Is your pain local back pain, buttocks or leg pain and when does it occur?

    You indicated an ADR at L4-5. This does not coincide with the radiological statement “L4-L5 anterior fusion with discectomy and laminectomy defects with moderate to severe bilateral
    neural foraminal stenosis”.

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
     
    Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
    alexinca
    Participant
    Post count: 4

    There are titanium cages between L2 and L4 that fusion bone has grown through (Osteocel was used). Instrumentation used along with the XLIF to accomplish posterior fusion L2-L4 with pedicle screws is what was most recently removed and lab tested for infection. The cages is the only metal at L2-L4 at this point (after posterior screws/rods recently removed, as solid bone fusion has succeeded between those levels). There is still hardware implanted at L4/L5 – irremovable Prodisc-L ADR, and anterior ALIF instrumentation at L5/S1. In the past, L5/S1 had front and back instrumentation after a 360 fusion (due to spondylolisthesis), but posterior hardware was subsequently removed during an attempted decompression (many years ago).

    Pain is constant and very severe. Initially, it was mostly in the legs. Now it is equally terrible in the lower back, upper buttocks, pelvis, and legs. A muscle that connects lower abdomen with the pelvis is constantly in a spasm – like a thick cable. Pain is worsened by sitting and walking. Standing for a short time is better, but the legs are always spasmed and give out. Pain is very severe in bed as well (insomnia). In the past several years, there is more and more pain and spasm in the quads and upper buttocks. This is on top of the previously dominant posterior thigh pain, and hamstring tightness. Back pain has been worsening.

    Donald Corenman, MD, DC
    Moderator
    Post count: 6574

    You have so many possibilities for problems it is hard to know where to begin on a word-based website. I assume that the fusion has been proven from L2-S1 and there are not any possibilities for a non-union at any one place which is the first thing to look at. Flexion/extension X-rays might be helpful.

    The second thing to look at is the L1-2 disc, whether it is degenerating and causing compression to the conus, cauda equina or exiting nerve roots.

    The third possibility is any arachnoiditis or confined chronic nerve root impingement as noted by the dictation “severe bilateral neural foraminal stenosis L5/S1”. Possibly, this compression can cause some of your symptoms. This can be partially diagnosed with SNRBs of the L5 roots. See https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic/, https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/, https://neckandback.com/conditions/arachnoiditis/,https://neckandback.com/conditions/chronic-radiculopathy/ and https://neckandback.com/conditions/lumbar-foraminal-stenosis-collapse/

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
     
    Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
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