Myth Buster

We hear a lot of myths and bad advice tossed about on the Internet, especially posted on artificial disc replacement discussion forums (and yes these "non-profit", supposedly "neutral" organizations have contacted the professor asking for support and the professor has turned them down for the obvious conflict of interest it would be). We would expect this from people new to spine surgery and marketers for certain medical devices. We are disappointed that untrained representatives of want-to-be (wannabe) competitors use these tactics to recruit patients. These myths are often based on old information (which is no longer true), partial information, misinterpretations of scientific data, conjecture, creativity and sometimes things that are flatly contrary to common sense.

Because it can be quite difficult for patients unfamiliar to medicine, medical science, the business of medicine and spine surgery, the professor believes these unpleasant issues and myths should be addressed. So before we get into the actual medical myths, let's enumerate some of these other issues.

1. We have seen people copy pages on this website and reverse a few words to support their claims.

2. We see people diagnose themselves based a few things they read on the Internet or on their own imagination. For example, a patient might say, my c4 nerve root hurts. Unfortunately, the human nervous system is not that discriminating and no procedure could be planned on that report. Or they may say my nerve root is damaged, I saw it an X-ray. It is a fact that x-rays cannot see a nerve root. While, we do not question their claims of pain, only their diagnoses. The body and medicine are complicated and the true knowledge of a patient's condition takes work, time and money to discover. Such self-diagnosis can be dangerous to the patient and mislead others..

3. We have had people demanding money not to post or to remove negative postings about the professor. This appears to be a common practice using the website. For further information about this practice click this article about the website.

4. We see that a few doctors and clinics promote themselves as motion-preservation of ADR specialist, but really only do the traditional fusions. These "bait and switch" advertisers get people heavily invested in a consultation and then offer reasons not to do the motion preservation surgery. The patient's only defense against this is to have the evaluation with Prof. Dr. Bertagnoli.

5. We have the Internet trolls, who uses distortion and lies to insert themselves into the middle of an exciting new field of medicine. While this may serve their ego needs, it unfortunately confuses patients.

6. Prof. Dr. Bertagnoli pays commissions to no one for soliciting or bringing patients. This is against German law and is questionable ethically, however that does not stop people from imaging it is so.

For all these reasons and more, we have posted on this page some of the things that have come to our attention, cautioning patients to investigate their individual cases with Prof. Dr. Bertagnoli to make certain that they base their decisions on current and accurate information. Ask us questions. We want the patient to be completely informed. Knowledge is power for the patient making these important decisions about care.

We encourage readers to send in statements they hear or read, which don't exactly sound right. Perhaps we can post and respond to the suspect ideas here. Here are listed some of myths and then the reality. They are in the order they are received and seem to get a bit more outrageous as time goes by.

M1 Some would-be competitors have tried to impugn Prof. Dr. Bertagnoli's character by saying that Prof. Dr. Bertagnoli uses only the Prodisc ADR, because he gets a royalty from it.
R. Prof Dr. Bertagnoli has implanted many different types of discs. In fact, manufacturers often seek him out in clinical trials to implant new discs and today he still uses different types of discs. He did help to develop some of the Prodisc models with other doctors and engineers and he developed the surgical instrumentation for implantation. However, it is against German law, medical ethics and the contract with manufacturer for Prof. Dr. Bertagnoli to receive any royalty for a Prodisc device that he uses in any of his patients. However, this is not the case with some competitors who often are trained on only one type of ADR. Please report to us anyone who says or writes anything contrary to this fact.

M2. Heard from a patient of a prominent ivy league university spine surgeon, who does ADR occasionally, that ADR cannot be performed on a patient with six lumbar vertebrae.
R. While about 10% of the population have six lumbar vertebrae (five percent of the population have four lumbar vertebrae), neither is a contraindication for ADR. This sufficiently scared the patient from pursuing other options and the surgeon did a fusion. Simply astounding what some doctors will say and how is the patient to know, except for having an evaluation with Prof. Dr. Bertagnoli? If there had been a true contraindication such as a pars defect, we could easily accept the option for fusion, but unfortunately it appears the patient received less than optimal treatment based on the doctor's limitations.

M3. Another ADR can revise an M-6 implant, but not Prodisc C Nova implant (patient reports February 23, 2014).
R This is false on the face of it. Either disc could be replaced with another ADR, the only difference is that with the M-6 the surgeon must chisel out the one-piece modular M6 disc, if the inner core fails and we have seen this. If the inner core of the Prodisc C- Nova should fail, only the core needs to be replaced, because it is a three-piece device (two endplates and inner core). We do not know of a case, where the core of the Prodisc C Nova has failed, but we must always be ready for every scenario. The manufacturer has supplied a kit for this. (The endplates of either device are made of titanium and failure of the plates is never seen.) If the inner core of the M-6 should fail, replacing the entire M-6 device would require chiseling the endplates of the M-6 out of the vertebral bone, given it is seated in the bone. Prof. Dr. Bertagnoli has revised M-6s (poorly placed and sized, not failed devices) with Prodisc C Novas. It is also possible in some revision cases that either ADR cannot be replaced with another ADR and fusion must be used for the revision. (This is almost always due to poor surgeries or further degeneration of the patient's spine.) In those cases, the revision could be accomplished by fusing over the ADR or replacing the ADR with a fusion cage, regardless of which device was used. Of course, we must remember we are talking in generalities here and that revisions are rare. Talking about specific cases is more productive.

M4. Minimally-invasive artificial disc replacement?
R. Minimally-invasive artificial disc replacement is more of a marketing technique than a reality in spine surgery. Promoters of this idea are usually referring to transperotineal approach to the spine. This technique is fraught with the risk of infection and thromboses. These risks are more than a theory, as we have seen patients from other surgeons employing this technique with these complications. The notion of minimally-invasive surgeries originated and still has a close association with laparoscopic surgeries. There is no laparoscopic ADR surgery.

M5. Once I have had a fusion surgery, I cannot have an artificial disc replacement.
R. This is patently false in the last decade, but is a holdover from the early days of ADR surgery. The combination of ADR and fusion is known as a hybrid construct. Prof. Dr. Bertagnoli pioneered hybrid constructs, published research papers on the subject and he routinely performs this surgery.

M6. My cervical artificial disc replacement will autofuse as a result of heterotopic ossification?
R. In cervical ADR this was a concern in some of the early cases. This mostly occurred because of poor surgeries/undersized discs. Heterotopic Ossification (HO) is classified into four levels and is not problematic until it reaches level three or four. Currently, problematic heterotopic ossification rarely occurs. Click for a greater understanding of 360 motion preservation or the comment below for severe cases of facet hypertrophy.)Although there was concern about facet arthrosis or facet hypertrophy in the early years of ADR surgery, it has been proven with many success stories of ADR surgery, that this is not the case in mild to moderate facet arthrosis. Indeed, ADR relieves the pressure on the facets, by restoring the height of the intervertebral disc space. Also in severe cases sometimes the facets can be removed and a type of ADR surgery known as 360 Motion Preservation can be done.

M11. ADR surgery causes facet degeneration.
R. Properly placed ADRs relieve the pressure on the facet joints. If the ADR is improperly placed, problems can result. We have seen many cases where surgeons have improperly placed the ADR and subsequent facet pain has occurred. There are many inadequately trained surgeons doing this procedure. There is one observational paper claiming that ADR surgery leads to facet pain, but the paper is only reporting patient responses and makes no judgment about the placement of the ADRs and views many old ADR designs, hence it suggests a false conclusion about ADR surgery, which is ADR surgery causes facet pain.

M12. Cushioning ADRs, known as "third generation artificial discs" are automatically a better device than traditional discs.
R. Cushioning is a prima facia desirable property for an ADR, but it is not the whole picture. Stability is often more important in the restoration of a spinal segment, especially, if the patient is having a multi-level surgery. If the cushioning ADR is unconstrained, it offers no protection to overloading the facet joints, as a result of the spine assuming a less than natural shape due to the existing pathology. Also, simplicity of the device's construction and its reliability of its chemistry is part of an elegant and durable design of an ADR. There are many such elastomer and semi-constrained devices in Europe.

M13. Cushioning ADRs, known as "third generation artificial discs" restore the natural center of rotation.
R. This is rarely true, because of the existing pathology in the patient. For a better understanding of this issue please see Artificial Disc - Center of Rotation.

M14. Cushioning ADRs protect the facets by limiting the rotation of the segment.
R. This is blatantly false. This is the natural function of the facets. In fact the internal resistance of this devices can contribute to complications. Please see Artificial Disc - Center of Rotation

M15. ADR revision surgery is life threatening.
R. This is somewhat true in 40% of the repeat lumbar surgical cases for both ADR and fusion, if the surgeon did not sew in a barrier between the spine and the major arteries. However, Prof. Dr. Bertagnoli does sew in this barrier and established this protocol in ADR surgery. In cases, where the barrier is not sewn in and where the surgeon is not as experienced as Prof. Dr. Bertagnoli in the approach to the spine, a vascular surgeon is sometimes called in, if spine surgery is needed again in the area of the previous operation. Patients should demand this adhesion barrier in their first lumbar surgery. The Prodics-O and Nuvasive extreme lateral approach were designed to avoid these vascular structures in such operations.

M16. All I need is a total discectomy to cure my disc problems. Once the discectomy is done the bones will fill in the intervertebral space. (We know of one spine surgeon saying this).
R. This is blatantly false for human beings. Vets do this with dogs, but dogs do not spend their lives in an upright position. Both ADR and fusion surgery were developed to restore the intervertebral space and decompress the radiating nerves from the spine and the facet joint and the nerves associated with the facet joint.

M17. AMP vertebroplasty should be done in every patient to prevent subsidence. (We know of one spine surgeon saying this).
R. AMP vertebroplasty has its risks, mostly the leaking of the ceramic material into the spinal canal through a defect in the bone. That would result in an emergency surgery to remove the ceramic material from the spinal canal. Statistics show, that if this were done on every patient, more patients would be harmed than helped. Only patients with weak bones should have AMP vertebroplasty.

M18. Subsidence only occurs in ADR surgery.
R. Subsidence also occurs in fusion surgery. Newer versions of most ADRs have broader endplates to further reduce the chance of subsidence.

M19. The high-density, cross-linked polyethylene core of the ProDisc is just a piece of plastic, which will easily break or deteriorate. (We know of one spine surgeon saying this to patients, but he probably got the idea from a medical device marketer)
R. High-density, cross-linked polyethylene has been in the human body for 40 years and is chemically inert. It is extremely durable and also used in hip and knee replacements, where much greater compression and shear forces applied to them, then we see in the spine.

M20. "Back surgery will make my back like was when I was 18 years old"
R. There is no substitute for a young healthy back and surgery can never restore a back to its optimal youthful condition, if the patient ever had such a back. However, surgery can greatly reduce the pain of a patient and restore function. In some cases like cervical myelopathy, surgery can be responsible for saving the patient's life.

M21. "One back surgery will cure all my back problems, now and in the future"
R. While this can be true for many patients, particularly trauma patients, most of our cases deal with spondolysis and its nephew degenerative disc disease. These degenerative conditions continue throughout the patient's life and it is impossible to predict the rate of progress for an individual patient.

M22. "Back surgery is 100% successful in every patient"
R. No surgical intervention is 100% successful in every patient. Also, the patient should be aware there are many definitions of "success".

M23. "The rods are not broken"
R. This was conclusion of a spine surgeon in the US who had placed two titanium rods in a patient's lumbar spine four years prior. The problem was they were clearly shown to be broken in an X-rays both the patient and surgeon were viewing. Such blatant denial of an obvious fact is sometimes called "gaslighting". It is not the first time we have seen it in doctor consultation.

M24. "The retroperitoneal approach makes an adhesion barrier unnecessary"

R. This comes from a German wannabe competitor, who after many patients finally switched to the retroperitoneal approach from the transperitoneal approach. His patient contacted us about his broken M6-L, which he received from this surgeon. This statement can only be a lie to cover poor surgical practices or a revelation of complete medical incompetence. The adhesion barrier used in ADR surgery and now in some fusion surgeries is to prevent adhesions between the spine and the vessels (veins) just in front of the spine. The adhesion barrier is a safety measure should the patient need surgery in the area again. If these veins are adhered to the spine, they are unlikely to be remobilized, thus blocking the surgeon from access to the spine. Attempts to remobilzed can lead to exsanguination (bleeding out). These adhesions occur in about 60% of revision cases, where the adhesion barrier is not used. In revision cases of high necessity, such as a broken M6-L, an oblique (quasi-lateral) approach can be used, but the surgery is difficult and should only be done by a very experienced surgeon.

Again we urge people to write us about their questions and the use of critical thinking and judgment when reading Artificial Disc Replacement Forums. Forums have unqualified responses. Get a qualified response.