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 FAQ Artificial Disc Replacement (ADR) |
Frequently Asked Questions regarding Artificial Disc surgery at the Alpha Klinik in Munich Germany
drs.W.S. Zeegers, orthopaedic spine surgeon, Artificial Disc specialist since 1989
Drs. Willem Zeegers
Alpha Klinik
Effnerstrasse 38
81925 Munich
Germany Europe
zeegers@alphaklinik.de
(Consultations + treatments in Munich, Germany only) info: www.discprosthesis.com
Personal Assistant Netherlands
Mrs. Nicole Haesen Maastricht (English, Dutch)
Phone: +31 43- 356 04 45
Fax: +31 43- 356 04 40
secretaresse@alphaklinik.demon.nl
Ask for:
* arrangements
* scheduling
* FAQ
* etc …
(Consultations + treatments in Munich, Germany only)
or call our office in Munich, Germany:
Phone + 49 89 20 4000 200 (reception - english)
Fax +49-89 204 000 295
Explanation of long distance calling from the US Canada and the UK:
For example +49-89-204 000 200 what do the numbers mean?
+ = international access code, which for North America (the US and Canada) is 011 For the UK and the rest of the world it is 00.
49 = country code for Germany
89 = city code for Munich
20 4000 200 = local telephone number
I want to call the secretary of the Alpha Klinik: + 49 89 20 4000 200.
What do I do? You must add your International Access Code.
For the US and Canada, this code is 011. So from the US & Canada you dial 011 49 89 20 4000 200
For the UK this code is 00. So from the UK you dial 00 49 89 20 4000 200
I want to call doctor Zeegers personal assistant Nicole in the Netherlands Office: +31 43 356 04 45
What do I do? You must add your International Access Code.
For the US and Canada, this code is 011. So you dial 011 31 43 356 04 45
For the UK this code is 00. So from the UK you dial 00 31 43 356 04 45
International from US to Netherlands dial 01131, to Germany dial 01149. Skip always the 0 from the local area number. The secretary of drs. Zeegers is partially situated The Netherlands: 0031. Local telephonenumber secretary mrs Nicole Haesen is 043- 356 04 45, that will be international from US and Canada 011 31 43- 356 04 45 and from the UK 00 31 43- 356 04 45
On your mobile phone instead of 011 or 00 you can type + (plus-sign), than the international access code is okay from anywhere in the world
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Q: How experienced is drs. Zeegers in the Artificial Disk Replacement method (ADR)?
A:
Drs. Zeegers has over 17 years extensive worldwide experience since 1989, with > 1700 disc replacements, single and multi level procedures. He knows the pitfalls and conditions to be successful. Drs. Zeegers is able to select a treatment solution of a list of available options. Multilevel Artificial Disc Implantation (ADR) is common. Also he has experience with combinations of ADR, stabilization, fusion, and other treatments.
Q: Why do I need drs. Zeegers to have an Artificial Disc Replacement (ADR)?
A:
- Perfect diagnosis (in combination with neurologist)
- 17 years of surgery experience (1700 implants)
- Availability of wide range of spinal implants (not limited to special FDA rules or prosthesis brand)
Ad 1. Drs. Zeegers has over 30 years of experience with orthopedic surgery and more than 17 years with ADR. Through these years drs. Zeegers developed an expertise in setting a precise and accurate diagnosis. First of all you need a perfect analysis. The diagnosis is the key to surgical success.
Ad 2. You absolutely need a spinal surgeon with many many years of experience in artificial disc replacement to prevent wrong indications, avoide complications and disappointing results after this demanding procedure. Drs. Zeegers already started with this motion preservation technique in 1989. It has been proven that experienced surgeons have better outcomes with artificial disc replacement (Orthopedics today: 2004;24:1).
Ad 3. To reach high success rates without complications, the implant choice is also critical: nowadays drs. Zeegers is using the Active L artificial disc and due to constant improvements in surgical techniques and implants, success rates have reached over 85%.
Worldwide, different treatment options for the spine are available. Drs. Zeegers can choose from this wide range of treatment modalities. He can select the solution which is most suitable for you.
Q: Should I be doing anything before surgery that would make the operation easier? (Exercises, diet, etc.)?
A:
Keep fit: don't take any anticonceptive (somewhat higher risk of thrombosis) anticoagulants or aspirin-like drugs (increases the risk of bleeding). Try to lower your Bodymass-Index (BMI): in slim patients the approach and rehabilitation are easier, faster and with a lower complication-rate.
Q: What is my Body Mass Index (BMI)?
A:
Body Mass Index ("BMI") measures your height/weight ratio. To determine BMI, weight in kilograms is divided by height in meters, squared. It is your weight in kilograms divided by the square of your height in meters. For instance, if your height is 1.82 meters, the divisor of the calculation will be (1.82*1.82) = 3.3124. If you weigh 70.5 kilograms, then your BMI is 21.3 (70.5 / 3.3124). For Americans: height in feet and inches and weight in pounds. A result below 20 indicates that you may be underweight; a figure above 25 indicates that you may be overweight. A BMI of 25 to 29.9 is considered overweight and one 30 or above is considered obese. Almost every model is within the 18-20 area. People with BMIs between 19 and 22 live longest, but remember, you can have a high BMI and a low body fat percentage. BMI is only one measure of your health. Body fat percentage, blood pressure, resting heart rate, cholesterol and other measurements are at least as important as BMI. For your general health condition you need to get the whole picture, but in slim patients surgical approaches and rehabilitations are easier, faster and with a lower complication-rate. The anterior approach can be critical in obese patients. |
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What your BMI result indicates
BMI less than 19: UNDERWEIGHT. You are under optimum weight for your height. You could afford to gain a little weight.
BMI 20 - 25: ACCEPTABLE. You have a healthy weight for your height. Anterior spine surgery is a low risk procedure.
BMI 26 - 30: OVERWEIGHT. You are over optimum weight for your height. You may be facing health problems, so losing some weight would be a good idea. Anterior spine surgery can be somewhat more difficult with some higher rate of complications
BMI 31 - 35: OBESE. You are over optimum weight for your height. You may be facing health risks, so see your doctor to help you achieve a healthier weight. Anterior spine surgery is a medium to high risk procedure.
BMI > 35: EXTREMELY OBESE. You are in danger because of your overweight. You are unfit for anterior spine surgery. Fat lowering drugs like Xenical are prescribed only in patients with MBI > 35
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Q: Is the surgical approach through the front and the back, or only from the front, when implanting the disc prosthesis?
A:
Implantation of a lumbar Artificial Disc is only possible by an anterior approach, so through the front only.
Q: Is disk replacement performed totally by keyhole surgery?
A:
No, it is performed by an anterior approach through a incision in your belly below the navel.
Q: What are the optional incisions?
A:
Incisions are dependent of disc level: L23 vertical above the navel, L34 vertical around the navel, L45 vertical below the navel, L5S1 vertical or horizontal below the navel. Combination of two levels: vertical incision.
Q: What is the significance of the possible incisions?
A:
Lower abdominal horizontal (transverse) bikini incision hidden under panties is an option in L5S1. This horizontal incision however has some risk of a floppy skin fold just above that incision because of damaging skin nerves. Abdominal muscles are not influenced by the incision: approach is always by vertical splitting of abdominal rectum muscles, independent of skin incision. Vertical incision keeps abdominal skin strong and flat. Vertical incisions are the best option in upper level treatment.
Q: Can one get all the discmaterial out from just the front in Artificial Disc Replacement (ADR) surgery?
A:
All internal disc-material which is in between the vertebral bodies can easily be removed from the front. Even the withdrawal of bulging material in the frontal part of the spinal canal is possible. Merely sequesters, that are loosened disc-material in the spinal canal are sometimes difficult or impossible to remove from the ventral approach (the front). The greater part of the ligament, the annulus, will be preserved. Only that part of the annulus where the implant enters has to be removed to get the prosthesis in.
Q: What about scar tissue around a spinal nerve in the spinal canal?
A:
Scar tissue around a spinal nerve itself remains undisturbed during implantation of a disc prosthesis. After the lumbar segment has been widened up by the implant there will be much more space for the nerve root and its surrounding tissue. Afterwards irritation by scar tissue is rare. For decision-making, the nature of the complaints is much more important then so-called scar tissue on the MRI. If legpain is diagnosed as atypical and in the same proportion or less as backpain, then the scar tissue usually is not relevant at all, even if you can see it on the MRI at all, because it is not causing the legpain. In all probability overloading of the dorsal annulus is mostly the source of that pain in back and legs. But… legpain should not be attended with a typical radicular pain-pattern or the only and predominating problem. In that case, usually the nerves are still compromised particularly by pressure and displacement: then decompression with or without fusion could be the better choice. Scraping off the scar tissue will not have a positive effect, but can be dangerous in damaging the underlying nerve root.
Q: If the pain is 60% in the back and 40% down the leg, is there an expectation that the surgery will relieve both pain elements, or only the backpain?
A:
Hopefully and mostly both pain elements will be resolved, because of 1) restoring normal load on the dorsal lumbar segment and 2) restoration of the height of the intervertebral space around the nerve root. Rarely a secondary dorsal release, widening of a nerve root canal at the back side, will be necessary. This is only performed after a period of evaluation of the leg complaints at least 3-6 months after the Artificial Disc implantation.
Q: If on the MRI it appears that there may be scar tissue attached to the nerve root, is there concern that the distraction of the vertebrae will entail more risk than usual due to the constraint of scar tissue on the nerve?
A:
Mostly the scar tissue is not important, but … permanent impingement can sometimes cause remnant pain. After normal implantation mostly it will not be painful anymore. Sometimes a secondary dorsal release, widening of a nerve root canal at the back side, will be necessary. This is only performed after a period of evaluation of the leg complaints at least 3-6 months after the Artificial Disc implantation.
Q: If one has had a collapsed disc for over 10 years, does this increase the possibility that re-obtaining normal disc height would increase the distraction factor?
A:
With the new techniques and new implants, there is almost no increase of overdistraction risk.
Q: Can one accomplish everything in one trip to Germany?
A:
Yes, if one wants to do this in one trip, the following schedule is most comfortable: arrival in or near Munich at Monday, overnight stay in a hotel or at home with relatives. Calm down and get rid of your jetlag. Wednesday or Thursday, complete intake at dr Zeegers office, with X-ray, MRI, and discussion of all options, perhaps discography, laboratory tests and anaesthesist preview. It is mandatory to complete all pre-surgery anesthesiologist examinations and tests in Munich. Discography if necessary, has to be performed by docter Zeegers himself. During the day before surgery patients should reduce their diet to a very light meal. At the night before surgery you have to take an enema or bowel cleansing solution and have only a very light meal as well. Overnight stay at a nearby hotel. Artificial Disc surgery on Friday. Walking two hours after surgery. Stationary in the Alpha Klinic for three days. Discharge from the hospital on Monday or Tuesday. Stay in Munich at a hotel for 10-14 days while initiating rehabilitation at the Gyrotronics department in the Alpha Klinik building. Final postoperative X-ray and wound control on Thursday 1 week after the surgery. Overseas flights are admissible from the fourteenth day on after surgery.
Q: When will the discography be performed ?
A:
Usually on the day before surgery, sometimes just ahead of the surgery. Right away after the discography the definitive diagnosis and treatment options will be discussed. At the evening before surgery you will get an enema.
Q: Is there a need for blood transfusion ?
A:
Sometimes diffuse bleeding from the epidural space is inevitable. Vascular damage is rare, but possible. Therefore we always keep two packed cells of blood units in the background for safety reasons. During surgery with a so called cell-saver your loss of blood is collected, filtered and re-infused.
Q: What about braces?
A:
A special soft brace is prescribed and is obligatory during the first 6 weeks postoperative period. It is supplied by Backshop, a brace specialist located at the Alpha Klinik. If the brace feels uncomfortable because of the wound during the hospitalisation, one is free to omit that until discharge. The brace is necessary only during mobilisation at daytime, not at night.
Q: How about the pre-operative check up?
A:
If you have questions about your medication in relation to your surgery, please contact our
General physician
Dr Gregor Blome
Phone +49 89 20 4000 255
Fax +49 89 20 4000 297
Email: blome@alphaklinik.de Q: When can one start more strenuous exercise after a disc implant?
A:
Generally from the 6th week after surgery if the check-up is ok
Q: What type of restrictions should one follow from the 6th week on after a discprosthesis implantation?
A:
If the X-ray check-up showed a good position of the prosthesis at 6 weeks, there are no restrictions anymore.
Q: Is it possible to repair more than one disc?
A:
Yes absolutely. Mostly the discography can distinguish between the painful and painless discs, even if they show some degeneration on the MRI. Results in double level are equal to one level implantations but the implantation technique is more demanding. We have many very succesful double level and even 3 level implantations.
Q: Are you doing 2-level prosthetic disc implants?
A:
Yes, with the same success rate as single level
Q: How many 2-level implants have you done in the last years?
A:
About 50% of the surgeries are multilevel.
Q: Can you perform a 2 disc surgery at once?
A:
Double level Artificial Disc replacement should be done in one session, which is the best way to do it.
Q: Have you ever done 2 levels at separate times?
A:
Yes, but that is a really poor alternative: using the same approach again can be demanding with extra risks
Q: Is it possible to have a second implant on another level a few years down the road?
A:
Yes that is possible, but performed very very rarely. Degeneration of a neighbouring level is mostly not a problem, even not in the long run, if the discography was without typical memorypain on that segment.
Q: Is the recovery much more different for a 2-level implant?
A:
There is almost no difference.
Q: What about postoperative pain medication?
A:
If needed you will get as much pain medication as possible. Patients with a high painkiller tolerance will get their own pain medication directly after surgery. We have a lot of experience with patients who are taking high dose of painkillers.
Q: Is there a possibility that after undergoing disc replacement surgery my condition might worsen.
A:
Worsening of your condition is very unlikely. Very rarely some legpain persists. Since we use nerve root monitoring persistent legpain is even less.? > Read more
Q: Can you give me an idea of your success rates for both types of operation? I know that how one person rates success can be very different from someone elses rating, but any indications you can give me would be helpful.
A:
If the preoperative tests are all concordant and the diagnosis is perfect, the success rate is over 85% positive in the Artificial Disc implantation, either one or two levels.
Q: What is the mortality rate (dead rate) for this type of disk replacement operation?
A:
Mortality rate is 0% zero since 1989 in my hands
Q: What is the bone density "T score" cut-off point in bone densitometry after which you believe it is no longer safe to implant a device?
A:
There is no definitive cut-off point, every below normal value means a risk factor, but .... we have experience in women with a normal bone density finding and poor bone quality during surgery. We had some patients with a poor bone quality on the bone scan but with good bone quality during surgery. If there is bad quality of bone during surgery we perform a STALIF instead of ADR, but that is very exceptional. But T-scores lower than -1,5 or -2,0 are out of safe range.
Q: What could be done in the case of subsidence?
A:
In case of subsidence, which is very rare (if so mostly in the first week after surgery), we perform a percutaneous vertebroplasty with Calcibone or Cortoss to restore the endplate height with or without repositioning of the implant plate.
Q: Is there any contraindication to taking a bisphosphonate (such as Fosomax) immediately pre/post surgery?
A:
No
Q: Can you predict the working life span for an Artificial Disc?
A:
I have only experience of 17 year now, but if implanted in the optimal way the working life span for the Artificial Disc is longer than a lifetime. Docter Zeegers uses the Active L discprosthesis for the lumbar spine. This disc prosthesis exists of two metal support plates with plasmapore coating with an extra calcium phosphate layer for optimal stability. The mobile core (of high molecular polyethylene) is embedded in the metal plates and all round optimal protected. In this way, the current design of the new generation Active L discprosthesis guarantees optimal protection of the polyethylene core. The metal support plates of the prosthesis cannot wear.
Because of the very small range of motion of one spinal unit (=disc + vertebra), in comparison with for instance a hip or knee, abrasion of the plastic core is very unlikely. The more or less anatomical shape of the Active L implant assures a symmetrical positioning in the lumbar spine. This guarantees that the plastic core is not overloaded. Due to the continuous pressure in the spine, the prosthesis remains in place for ever. This is extra guaranteed by the ` teeth` and the bioactive surfaces.
Q: Is a 'painful disc' caused by defects in the annulus? If we leave the greater part of the annulus intact, aren't we leaving the pain generator?
A:
No, the pain generator is the imbalance and abnormal pressure because of disc failure. The pain receptors in the dorsal annulus are only the messengers and that part of the annulus will be removed for let's say 75%.
Q: How long must I remain in Germany, post-op?
A:
Flying in to Europe on Monday because of jet lag problems, visiting docter Zeegers on Wednesday or Thursday, surgery on Friday, clinical stay at the hospital until Monday or Tuesday (3 days) (Friday-nigth until Tuesday morning) Tuesday moving to your hotel, followed by outpatient rehab at the Gyrotronics department. Outpatient checkout at drs. Zeegers office on Thursday 2 weeks after surgery. Plan staying in Germany for around 2,5 weeks. Don´t make your schedule too tight!
Q: What airport could I fly into?
A:
Munich International http://www.munich-airport.de/EN/Areas/Consumer/Flugplan/index.jsp
Q: How do I get from the airport to the clinic?
A:
Best and most convenient would be to take a taxi. Taxis are widely available at the Munich airport and are safe and clean.
A one way trip lasts about 30 minutes and costs approximately 50 Euro. Second – however not quite as convenient- option would be the fast and affordable Airport shuttle train (S1), it travels from Munich Airport to Munich main station, where you can take the subway U4 in direction “Arabellapark”.
The clinic shuttle will take you back to the airport when you depart after your surgery/stay in Munich.
Q: What are the most comfortble hotels near the clinic?
A:
Arabella Sheraton Grand, Arabella Sheraton Bogenhausen or Holiday Inn (all approximately 5 minutes walking distance from our clinic), make arrangements with Nicole. For your partner or any other buddy, the Hotel Arabella Sheraton Bogenhausen is the most convenient and offers reasonable rates. |
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Q: What to send or bring?
A:
Bring every report and film on your spine. Please save a new MRI test for your visit here, because we have most modern special equipment for discopathy research.
Q: How to decide for a single or multi level surgery
A:
The decision making of a single or two level procedure can be done only by drs. Zeegers after personal examination, completed by a new MRI and new discographic test. Sometimes we need a neurologist examination too.
Q: What paperwork do you require in order to put me on the schedule?
A:
Ask for Nicole, but bring all hard copies of reports and films if possible
Q: Where are you performing the intake, imaging procedures, surgery and after treatment?
A:
At the Alpha Klinik in Munich only. All preoperative check-ups and discography are mostly scheduled on Thursdays. Surgeries are mostly scheduled on Fridays. Artificial Disc implantations, cage implantations and dorsal fusion procedures need a 3 to 5 days hospitalization at the Alpha Klinik.
Q: On average, how soon are your patients able to return to work?
A:
That is one of the successful advantages of the Artificial Disc: white collar worker in 2 weeks, blue collar worker in 6 weeks.
Q: What about the anti thrombotic stockings?
A:
The anti thrombotic stockings are to be worn during the hospitalization only and then once more during the flight home.
Q: What is the waiting time for treatment?
A:
Waiting time for surgery nowadays is normally 2-3 weeks
Q: Is the Artificial Disc procedure possible in the cervical areas?
A:
Yes, one or multilevel. Drs. Zeegers uses the Mobi C, a very elegant and successful mobile cervical implant. |
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Q: Is MRI possible after Artificial Disc surgery?
A: Yes and no: MRI is possible but not the first choice after Artificial Disc surgery, because MRI only shows a black shadow around the prosthesis in the sagittal view and in the transverse view most details near the prosthesis are not clear anymore. Some of the most recent MRI machines give better results already, but that is not common. In case of diagnostic pain-problems after Artificial Disc surgery CT (sometimes with contrast) is the best choice.
Q: How about the post operative check-up?
A: For overseas patients an in-between check-up at drs. Zeegers office 10-14 days after surgery is advisable, just some days before taking off.
First regular check-up has to be done at the sixth week postoperative: X-ray control of the standing lumbar spine can be provided by your physician at home. Pictures and comments should be sent by mail or email to drs. Zeegers personal assistant mrs. Nicole Haesen (secretaresse@alphaklinik.demon.nl) or to drs. Zeegers office at the Alpha Klinik in Munich (zeegers@alphaklinik.de).
Drs. Willem Zeegers
Alpha Klinik
Effnerstrasse 38
81925 Münich
Germany Europe
zeegers@alphaklinik.de
Q: How much will ADR surgery cost?
A: First things first: exact costs information only possible after making up the indication and surgical possibilities. The costs depending on intake, hospital stay and type of operation. All in costs round about 20.000 - 24.000 Euro, but please ask Nicole about exact prices and arrangements. For information about global and exact costs:
Dutch secretary Mrs. Nicole Haesen
P.O. Box 4916
6202 TC Maastricht Netherlands
Tel: +31 43- 356 04 45
Fax: +31 43- 356 04 40
secretaresse@alphaklinik.demon.nl
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