Technique of insertion of total lumbar disc prostheses: preoperative assessment, insertion technique and significance of navigation

Abstract

Total disc arthroplasty for lumbar spine is a new solution for low back pain treatment after adequate patient selection. The surgical technique starts with a morphological and anatomical analysis to eliminate surgical exposure problems. The surgical approach is retroperitoneal from the left or the right side after horizontal skin incision. Video-assistance improves vision and allows minimal invasive exposure. At level L5-S1, the exposure is performed in the vessels bifurcation (aorta and vena cava), at level L4–L5 the ligature of the lumbar ascending vein is the key point to allow appropriate retraction of the vessels. In some difficult cases the use of dedicated implants allows prosthesis insertion without extensive exposure by the use of an oblique implant. The disc preparation is crucial with a good posterior release. Insertion of the prosthesis is guided with instruments according to the type of fixation (keel or pikes). To optimise the implant positioning, navigation guidance is a useful tool as any offset of the prosthesis can induce a bad mechanical load transmission. Patient selection remains the key for good clinical outcomes.