Category Archives: Degenerative Disc Disease

Inserting A ‘Mini Cushion’ and/or Other Implants in the Spine to Reduce Back Pain

Feature Image sourced from:

http://www.vanniveronesi.com/2/minimally_invasive_surgery_mis_interspinous_process_decompression_devices_6893927.html

Dear Pain Matters readers,

Introduction

Degenerative Cervical Myelopathy

The most common cause of spinal cord dysfunction and pain in adults is degenerative cervical myelopathy.  Myelopathy is spinal cord damage caused by disc degeneration (disc bulges), bone spurs (osteophytes) and other inflammatory triggers.

If not effectively treated, back pain, limb sensory loss and abnormal sensations (paraesthesia)* may result.  Gait and hand dexterity may be compromised.

See Anne’s story (below) that highlights degenerative cervical myelopathy including the importance of timely diagnosis and effective treatment

Degenerative Disc Disease   

Countless people suffer from severe back pain due to degenerative disc disease.  

Damaged discs in the spine may lead to reduced shock absorption while walking, jogging or pursuing other activities.  Shortened discs due to injury, disease or prior surgery may cause vertebrae to come into direct contact with one another.  This may result in bone-on-bone pain, sciatica and other complications.

Tingling and/or numbness in the buttocks or legs may occur due to herniated (i.e. bulging, collapsed or slipped) discs.  This may render walking difficult for some patients.

Once injured or arthritic, discs are usually unable to heal due to their avascular nature.  

Sadly, back pain may become a constant companion.

Novel Treatment for Back Pain Resulting from Damaged Discs: An Implant Called a Device for Intervertebral Assisted Motion (DIAM Implant)

Traditionally, the only surgical option for back pain caused by degenerated discs involved fusing the spinal bones together (aka spinal fusion).

A new implant called a Device for Intervertebral Assisted Motion (DIAM implant) is now available that may offer relief from back pain due to diseased or injured discs.

The DIAM implant is as a polyester-covered silicone interspinous shock absorber that works like a ‘bumper’.  Being small and H-shaped, this implant is designed to shift the weight away from the anterior column.  This helps restore the functional integrity of the posterior column of the spine.

Like a small cushion inserted between injured or diseased vertebrae in the spine, this implant may prevent vertebrae from coming into contact, hence preventing further damage to the vertebrae.  By acting as a shock absorber by reducing stress on damaged vertebrae, a DIAM implant may lead to reduced or eliminated back pain.

During surgery, a small surgical incision is made along the spine and a low amount of bone, interspinous ligament, muscle and/or other soft tissue is removed.  The DIAM implant is then inserted into the space between the spinous processes.**  This implant is subsequently attached to nearby vertebrae.

Other Interspinous Spacers Including Aperius Devices

Degenerative spinal disease may also be treated via alternative interspinous spacers including Aperius PercLID system (Fabrizi et al, 2011).

Risks

Wear and tear and/or rejection by the immune system of DIAM implants and other interspinous spacers may occur in some patients.  This may lead to pain and inflammation as well as the removal of affected implants (Seo et al, 2016).

‘Anne’, a 62-Year Old Woman, has Discectomy and Implants for Severe and Painful Cervical Myelopathy

‘Anne’ (not her real name) (62) suffered from severe degenerative cervical myelopathy since she was 59 (although this diagnosis was not confirmed until 3 years later).  As a result, Anne was hospitalised 11 times in the emergency room (ER) in 3 years.

Anne endured pain and abnormal sensations (paraesthesia) from her neck down including in her hands, groins, trunk and legs.  She had a ongoing feeling of water retention throughout her body.

Anne had many strange sensations including:

  • ‘A wet gel-like substance’ had invaded the skin of her face, limbs and trunk; and
  • ‘Something [was] stuck on her skin’ and ‘her hair was stuck down’.

Anne thought that these odd feelings were caused by her olive oil moisturising cream.  (This was because her severe degenerative cervical myelopathy was not diagnosed until 3 years later.)  

During her 11 visits to ER, doctors dismissed Anne ‘for being delusional’ (despite her not taking any psychiatric medication).

While doctors urged her to undergo a psychiatric assessment and a mental health review, Anne resisted.

Anne had back and neck pain as well as numbness and tingling in her arms.  Her legs were stiff and she had difficulty walking.  Anne’s right leg often gave way resulting in numerous falls.   Her coordination and manual dexterity were severely compromised.  Anne had difficulty urinating as well as urinary and faecal incontinence.

Three years later, Anne was finally referred for MRI imaging of her spine.

Following MRI imaging, Anne was diagnosed with severe cervical myelopathy due to degenerative changes in her cervical spine NOT delusions!  Specifically, there was 2 bone spur protusions, one that compressed her spinal cord at C3/4 and another one that led to a narrowing near C5/6.

Surgery for decompression via anterior cervical discectomy at C3/4 was expedited as well as spinal implants.

Following recovery from spinal surgery, Anne’s pain levels decreased while her other symptoms improved.

In summary, despite having been seen by many doctors during 11 visits to ER, Anne was not diagnosed with severe cervical myelopathy until 3 years later.  As a consequence, Anne suffered from intense neck and back pain, abnormal sensations and other symptoms of severe cervical myelopathy for 3 long years.

The good news is that once a correct diagnosis was finally made, and successful spinal surgery was done, many of Anne’s symptoms either decreased or disappeared (Mowforth et al, 2019; Berres, 2019).

A Back Pain Patient Named Rebecca Who Had DIAM Implant Surgery

Having suffered severe low back pain for several years that worsened after becoming a mom of two, Rebecca Morgan of Bristol, UK, said:

‘I started to find everyday activities difficult — even sitting down for any length of time was painful.  The thought of having to lift my son in and out of the bath would sometimes drive me to tears.’

An X-Ray and MRI revealed a collapsed disc as well as changes in the adjacent joints.  Due to the disc’s shortened height, (quoting Rebecca) ‘the nearby joints were inflamed and rubbing together.’ 

In her spinal surgeon’s words:

‘A standing X-Ray showed that one of [her joints in her back] slipped backwards every time she moved or stood up.’

A DIAM implant was inserted between the inflamed joints via minimally invasive surgery.

Rebecca continued with her story (quoting):

‘… my disc was so unsupported and unstable that [the specialist] could move it every which way during the operation.’

No wonder Rebecca had severe back pain prior to her DIAM implant!!

Following successful surgery involving DIAM implant, Rebecca stated (quoting):

‘I was up and walking within a couple of hours after the operation, and within a few weeks I was back to normal. I went on a long-haul flight to Australia, to take the children to visit relatives, just seven weeks after the operation. Now, I’m looking forward to starting pilates classes.’

‘[The DIAM implant] has changed my life … As a result, I have finally said goodbye to all the prescription drugs I used to take, and gone back to the gym.’

In her surgeon’s words:

‘[The DIAM implant] acts as a firm cushion and a stabiliser, and is unique in that it is not made out of metal and isn’t stiff. Rebecca had instant relief and needed only a short stay in hospital’

(Dobson, 2010).

What a heart-warming and inspiring story!

Four Studies Involving Interspinous Spacers (e.g. DIAM Implants, Aperius Devices) for Degenerative Spinal Disease

1. A DIAM Implant Study

A study involving back pain patients (N=68; aged 23 to 75) showed that all patients enjoyed benefits including 92% who had good to excellent improvements, post-DIAM implant.  

Best of all, implant patients enjoyed pain reductions of 71% and enhanced movements by 64% (on average) (Dobson, 2010).

2. A Taiwanese DIAM Implant Study

Back pain patients (N=34) who underwent DIAM implant surgery were followed up for a minimum of 3 years.

All 34 patients enjoyed relief from symptoms.

Specifically, 31 patients (91%) remained symptom free and enjoyed excellent/good results throughout the study, post-DIAM implant. 

However, back pain not due to DIAM surgery nor degenerated discs returned in 3 patients (9%) (Lu et al, 2016).

3. An Italian Review Involving Interspinous Spacers (i.e. DIAM and Aperius Devices) for Degenerative Lumbar Spinal Disease

An Italian review was done of low back pain patients (N=1575) who underwent interspinous device (DIAM or Aperius) insertion for the treatment of degenerative spinal disease.  This included patients with degenerative disc disease (N=478), canal and/or foraminal stenosis (N=347), disc herniation (N=283), black disc and facet syndrome (N=143) and topping-off (N=64).

The average operating time for a DIAM implant was 35 minutes and for an Aperius device was 7 minutes.

Complications arose due to infections (N=10) and fractures of the posterior spinous processes (N=10).  Forty patients required spinal fusion (N=30) or total disc replacement (N=10).

The review reported that symptoms were resolved or improved in 1505 patients (95%) after interspinous device insertion.

This included 924 patients who enjoyed excellent results including nil back pain and complete restoration of mobility after implant surgery.  All 924 patients were able to return to normal work and pursue normal activities.

Another 483 patients had good results including relief of symptoms albeit with some nonradicular pain.  All 483 patients were able to return to modified work.

A further 98 patients had fair results with some improvement in function.  However, these patients could not return to work and/or remained disabled.

Sadly, the remaining 70 patients had a poor outcome following interspinous device insertion.  Their symptoms remained unchanged and they required further surgical intervention.

Having said that, interspinous implant is reversible in failed back syndrome.  More importantly, the vast majority of patients enjoyed partial or complete relief from back pain after interspinous device insertion (Fabrizi et al, 2011).

4. A French DIAM Implant Study

A French study involving back pain patients (N=104) showed that 88.5% enjoyed improvements, 9.6% had no change and 1.9% were indeterminable.

Pain medication intake was decreased in 63.1% of the patients, increased in 12.3% and unaltered in 24.6% (Taylor et al, 2007).

Summary

I hope that the stories about Rebecca and Anne as well as the 4 studies may offer hope to some patients with severe back pain due to degenerative spinal disease.

Sabina Walker, Blogger of Pain Matters (in WordPress).

Key

* Paraesthesia is abnormal sensation.  This may include tingling or pricking (i.e. pins and needles).  This may be due to pressure or damage to peripheral nerves.

** Spinous processes are the vertebrae that stick out in the back of your spine.  These can be felt as bumps on your back.   

Media

(1) Dobson, Roger. Tiny cushion that sits in your spine to cure back pain. Daily Mail Australia (

https://www.dailymail.co.uk/health/article-1240599/Tiny-cushion-sits-spine-cure-pain.html

Peer-Reviewed Paper

(2) Lu et al. Clinical outcome following DIAM implantation for symptomatic lumbar internal disk disruption: a 3-year retrospective analysis. J Pain Res (31 Oct 2016); 2016: 917—924.

https://doi.org/10.2147/JPR.S115847

https://www.dovepress.com/clinical-outcome-following-diam-implantation-for-symptomatic-lumbar-in-peer-reviewed-fulltext-article-JPR

(3) Taylor et al. Device for intervertebral assisted motion: technique and initial results. Neurosurg Focus (15 Jan 2007); 22(1): E6.

https://doi.org/10.3171/foc.2007.22.1.6

https://www.ncbi.nlm.nih.gov/pubmed/17608340

(4) Seo et al. Foreign Body Reaction after Implantation of a Device for Intervertebral Assisted Motion. J Korean Neurosurg Soc (Nov 2016); 59(6): 647–649.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5106367/

(5) Fabrizi et al. Interspinous spacers in the treatment of degenerative lumbar spinal disease: our experience with DIAM and aperius devices. Eur Spine J (2011); 20(Suppl 1): S20–S26.

doi: 10.1007/s00586-011-1753-2

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3087040/

(6) Mowforth et al. “I am not delusional!” Sensory dysaesthesia secondary to degenerative cervical myelopathy. 

https://casereports.bmj.com/content/bmjcr/12/4/e229033.full.pdf

Peer-Reviewed Papers Not Discussed Above

(7A) Pintauro et al. Interspinous implants: are the new implants better than the last generation? A review. Curr Rev Musculoskelet Med (2017); 10(2): 189–198.

doi:10.1007/s12178-017-9401-z

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435632/

(7B) Buric and Pulidori. Long-term reduction in pain and disability after surgery with the interspinous device for intervertebral assisted motion (DIAM) spinal stabilization system in patients with low back pain: 4-year follow-up from a longitudinal prospective case series. Eur Spine J (2011); 20(8): 1304–1311.

doi: 10.1007/s00586-011-1697-6

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3175853/

(7C) Gazzeri et al. Failure rates and complications of interspinous process decompression devices: a European multicenter study. Neurosurg Focus (2015); 39(4): E14.

doi: 10.3171/2015.7.FOCUS15244

https://www.ncbi.nlm.nih.gov/pubmed/26424338

Media (in German)

(8) Berres, Irene. Eine rätselhafte PatientinDie ist doch verrückt. Spiegel (5 May 2019).

https://www.spiegel.de/gesundheit/diagnose/ein-raetselhafter-patient-die-ist-doch-verrueckt-a-1264438.html

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