Dear Mark,

My recovery has progressed much as we had hoped it would. Hopefully the next 6 months will continue to show improvement.

I want to thank you for the role you have played in my return to a life. I was following the suggestion of another German spine surgeon when I first contacted you, and I did so because my pain level and the limiting condition of my spine prevented me from doing that what was necessary to obtain information needed to determine if I should proceed with ADR. Medication and constant high level of pain had severely restricted my ability to gather and analyze. I could not sit long enough to review websites.

And yet, when I spoke with you I began to sense that you were acutely aware of the difficulties I was encountering. Your answers were clear and conveyed with compassion and patience,and without judgement. Thereby, you made apparent that your ability to understand, and appreciatively respond, was the gift of having shared the same experiences. Having yourself undergone ADR, and assisting so many others, you understood the questions I was struggling to formulate.

Mark, as my condition rapidly deteriorated Jennifer and I began to ask you to become involved in travel arrangements, scheduling, and communications with the doctor's office. I appreciated that you did not "sugar-coat" the details of what we were going to do (recovery, testing,etc). When things were going to be very painful and challenging you stated so, yet...you never forgot what it was like when you were making similar decisions and you remembered to remind me that good results were possible.

Eventually, Jennifer and I made the decision that as ADR was our only chance of having an acceptable quality of life, it was critical to do everything possible to stack the odds in our favor. We decided that would include the services of Global Patient Network, and meeting you in Germany.

Also, I knew that I would not be able to help Jennifer on the last leg of the trip from Munich to Bogen. The concern was very great that Jennifer would be expended on getting me there, and that assistance from GPN was important to enable her to be at her best when she was most needed.

The first time we met, when you got us through customsand secured our baggage, I was confident I had made the correct decision.Your personal experience, and insight gained from having helped so many others had a positive impact on the success of my ADR.

Mark here... I have to say a few things about Ken's case. First, the surgery was one of the most amazing things I've ever seen. Ken had a substantial curve that

was destroying his spinal balance and was likely a huge factor in how bad his spine had become. The origin of the curve was probably due to a wedge shaped L3 vertebral body. Since his spine was VERY crooked to start with, as Dr. Bertagnoli put in the three artificial discs that surround the fusion, every thing was all misaligned. Keels were pointing in every direction and nothing seemed to be aligned. I kept quiet, but I was very concerned about what the final configuration was going to look like. After all three ProDiscs were installed, he cut a wedge shaped piece of bone away from the misshapen vertebral body. He then put carbon fiber cage filled with morselized bone on the right side of the L3-4 disc space. I'd never seen these cages put in oriented this way. He put another cage in on the left side of the disc space. Dr. Bertagnoli was using 2 cages where there would normally be one. They were turned 90 degrees to normal orientation. Then I could see what Dr. Bertagnoli intended. Because removing the wedge of bone compromised the endplate, he required much greater than normal coverage of the vertebral body. Even with augmenting the bone strength with vertebroplasty, he was concerned about subsidence and the best way to avoid that was by getting as close to 100% coverage as possible. Things started to look a little better, but all the keels were still all off-kilter. The disc space was still very wedge shaped. The cage on the right seemed to be pretty tight, but the cage on the left was very loose. I was worried.

Dr. Bertagnoli then made a hole in Ken's left side and created access to the spine from an extreme lateral angle. This is the ALPA approach that he pioneered and is still state of the art and used today with Nuvasive's XLIF and MAXCESS systems. After placing the screws in L3 and L4, Dr. Bertagnoli joined them with a threaded rod. As he tightened the system, the threaded rod functioned as a jackscrew and changed the wedge shaped disc space that had left one of the cage all loose and floppy, into a very tight system. When the endplates were parallel, both cages were beautifully aligned and clamped firmly around BOTH cages. It was the most amazing thing to watch as all of the keels that were pointing in different directions were magically pulled into alignment as he pulled the endplates parallel. This was not the first time that I saw Dr. Bertagnoli's engineering background allow him to perform wonders in the OR!

The second thing I have to tell you is about the time I spoke to Ken at about 5 months post op. As we spoke, he was describing pain levels and medication levels that really gave me pause. I was worried about his outcome. Here is what our conversation was like:

What constitutes surgical success may be different for all of us. Pain free, medication free may not be a reasonable expectation, especially in such an extreme case. It's great to know that at 5 months, even with such pain and continued medication use, Ken's life was so much better. At 1 year post-op, when Ken's email was written, he had continued to improve. I look forward to more positive updates!

All the best,

Mark