Indications For Total Disc Replacement Research Articles

P64. In which cases do surgeons specializing in total disc replacement perform fusion in patients with symptomatic lumbar disc degeneration?

BACKGROUND CONTEXT Results of lumbar total disc replacement (TDR) have consistently been reported to be similar or superior to lumbar interbody fusion in appropriately selected patients. However, the indications for TDR are less broad than for fusion. PURPOSE The purpose of this study was to investigate the reasons and their frequency for why TDR specialty surgeons performed lumbar fusion rather than TDR. STUDY DESIGN/SETTING The study was based on a retrospective review of a consecutive case series at a spine specialty clinic. PATIENT SAMPLE The study was based on the consecutive series of 515 patients undergoing lumbar TDR or fusion during a 5-year period by three surgeons specializing in TDR. OUTCOME MEASURES The primary outcome measures for the study were: the type of surgery performed (TDR vs fusion), and the reason why fusion was performed rather than TDR. METHODS For each fusion, the reason for not performing TDR was recorded. The primary reason for not performing TDR were classified into categories such as significant facet changes, insurance noncoverage/denial, significant spondylolisthesis, combined pathologies, etc. The “combined” category was used for patients with multiple related problems such as severe stenosis, disc space collapsed, spondylolisthesis and/or segmental instability. RESULTS During the study period, 65.4% (n=337) of patients underwent TDR and the remaining 34.6% (n=178) underwent lumbar interbody fusion (stand-alone ALIF or ALIF combined with posterior instrumentation +/- fusion). Of the 178 fusion patients, the most common reason for fusion vs TDR was combined factors which occurred in 59 patients (11.5%). The second most common reason was greater than Grade 1 spondylolisthesis (n=32, 6.2%), followed by insurance noncoverage (n=24, 4.7%) and 13 did not receive TDR due to osteopenia/osteoporosis (2.5%). There were pars defects in 11 patients (2.1%), degenerative deformity in 9 patients (1.7%) and pseudarthrosis repair led to fusion in 6 patients (1.2%). Other reasons for fusion included significant facet joint degeneration and/or painful facets (n=4, 0.8%), bridging osteophytes (0.4%), and significant scarring from prior discectomy (n=2, 0.4%). There was one case (0.2%) each of: possible metal allergy, pedicle fracture, apophyseal ring defect, intraspinal extradural mass, annular cyst, TDR removal, TLIF cage removal, ankylosing spondylitis, rheumatoid arthritis, high sacral slope, possible post-stem cell injection discitis (performed remote), and one patient opted for fusion instead of TDR. In 4 patients (0.8%) the reason for fusion vs TDR could not be clearly determined from the chart review. Fusion patients’ mean age was significantly greater than TDR patients (52.5 vs 41.6 years; p CONCLUSIONS The most common reason for not performing lumbar TDR was related to factors that may compromise the stability of the operated segment and/or functionality of the TDR. The older age may be related to these factors as well as segmental degenerative deformity leading to fusion. The results of this study found that many patients are good candidates for lumbar TDR. However, even among TDR specialists, fusion may be preferred in some patients where it is prudent to not take undue risks. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The Kellgren and Lawrence Score as a helpful tool for the indication for total disc replacement at the cervical spine.

Several studies showed encouraging results after total disc replacement (TDR) in patients with cervical-brachial syndrome (CBS). The aim of this study was to supplement the existing documentation of results after total disc replacement and to underline the importance of the correct indication. The clinical and radiological outcome of 34 patients was evaluated in a 2-year follow-up by several parameters as the Visual Analogue Scale (VAS) for pain, the Neck Disability Index (NDI) and the Kellgren and Lawrence Score. The median values for NDI changed from 65% (20-90) before surgery to 20% (0-86) 2 years after surgery (p< 0.0001). Pain intensity had an average rate of reduction from 8.4 ± 2 cm (VAS scale 0-10 cm) to 2.9 ± 2 cm (p< 0.0001). A median of 1 (0-3) was calculated for the Kellgren and Lawrence Score in the affected segment preoperatively. Due to loosening in five cases the TDR was removed and changed into anterior cervical decompression and fusion (ACDF). In all of these five cases a preoperative Kellgren and Lawrence Score of 2 or 3 was calculated and five of five patients (100%) were smokers. The use of TDR in nonsmoking patients with a low preoperative Kellgren and Lawrence Score of 0-1 lead to a clinically and radiologically successful outcome.

Spinal motion preservation surgery: indications and applications.

Fusion is one of the most commonly performed spinal procedures, indicated for a wide range of spinal problems. Elimination of motion though results in accelerated degeneration of the adjacent level, known as adjacent level disease. Motion preservation surgical methods were developed in order to overcome this complication. These methods include total disc replacement, laminoplasty, interspinous implants and dynamic posterior stabilization systems. The initial enthusiasm about these methods was followed by certain concerns about their clinical usefulness and their results. The main indications for total disc replacement are degenerative disc disease, but the numerous contraindications for this method make it difficult to find the right candidate. Application of interspinous implants has shown good results in patients with spinal stenosis, but a more precise definition is needed regarding the severity of spinal stenosis up to which these implants can be used. Laminoplasty has several advantages and less complications compared to fusion and laminectomy in patients with cervical myelopathy/radiculopathy. Dynamic posterior stabilization could replace conventional fusion in certain cases, but also in this case the results are successful only in mild to moderate cases.

Bandscheibenendoprothesen – Ein kritisches Update

Die zervikale und lumbale Bandscheibenendoprothetik kann gute klinische Ergebnisse erzielen, wenn eine sehr sorgfältige präoperative Abklärung zur richtigen Patientenselektion führt. Der folgende Artikel soll als Hilfestellung dienen, die Indikation zur Versorgung mit einer Bandscheibenprothese zu stellen, die Implantationstechnik zu erläutern sowie Hilfestellungen geben, um Komplikationen zu vermeiden. Die derzeit vorliegenden Studien werden hinsichtlich der klinischen Ergebnisse der Bandscheibenendoprothetik kritisch hinterfragt.

Charité lumbar artificial disc retrieval: use of a lateral minimally invasive technique

Indications for total disc replacement (TDR) may include implant loosening, malposition, displacement, early wear, and infection. Each indication is likely to require different preoperative planning, testing, and strategies. Preoperative planning is the first and most important step in performing a TDR revision. An organized approach reduces operative time, minimizes risks, decreases stress, and increases the success rate. Primary revision of a failed total disc arthroplasty can be planned as a posterior fusion, leaving the TDR device in place, but an unstable anterior column may require retrieval and revision of the interbody device. An anterior revision approach is associated with significant risk due to scarring and adhesions resulting from the primary procedure, making mobilization of the vessels very difficult, especially at the L4-5 bifurcation. The authors describe a new alternative for retrieval and revision of a TDR device. They present the details of two cases of TDR device revision in which they performed a minimally invasive extreme-lateral interbody fusion to effect a safer access route that avoids vascular structures and the creation of scar tissue.

Charité total disc replacement—clinical and radiographical results after an average follow-up of 17 years

A retrospective clinical-radiological study to evaluate the long-term outcome after artificial disc replacement was performed. The objective is to investigate long-term results after implantation of a modular type artificial disc prosthesis in patients with degenerative disc disease (DDD). Total disc replacement (TDR) is a surgical procedure intended to save segmental spinal function, and thus replace spondylodesis. Short-term results are promising, whereas long-term results are scarce. The Charité TDR is the oldest existing implant, therefore, the longest possible follow-up is presented here. Seventy-one patients were treated with 84 Charité TDRs types I-III. Indication for TDR was moderate to severe DDD. Fifty-three patients (63 TDRs) were available for long-term follow-up of 17 years. Evaluation included Oswestry disability index, visual analog scale, overall outcome score, plain and extension/flexion radiographs. Implantation of Charité TDR resulted in a 60% rate of spontaneous ankylosis after 17 years. No significant difference between the three types of prostheses was found concerning clinical outcome. Reoperation was necessary in 11% of patients. Although no adjacent segment degeneration was observed in the functional implants (17%), these patients were significantly less satisfied than those with spontaneous ankylosis. TDR, nowadays, is an approved procedure. Proof that long-term results of TDR implantation in DDD are at least as good as fusion results is still missing.

A new classification system for degenerative disc disease of the lumbar spine based on magnetic resonance imaging, provocative discography, plain radiographs and anatomic considerations

Prior attempts to classify degenerative disc disease (DDD) of the lumbar spine have been based on magnetic resonance imaging (MRI) signal intensity. Internal disruption of the disc is not reliably diagnosed by MRI alone. No attempt has been made to include provocative discography and plain radiographs. The intervertebral joint is a three-joint complex consisting not only of the end plate–disc–end plate joint of the anterior column, but also the two facet joints of the posterior column. To date, no classification system for lumbar DDD has taken into account the state of degeneration of the facet joints. In the past this may not have been important with regard to arthrodesis. But as early experience indicates, the degree of degeneration of the facet joints is paramount to the clinical success of an artificial disc replacement. As we transition from intervertebral joint fusion to intervertebral joint replacement, it is imperative that the state of degeneration of the three-joint complex be classified in such a way that all can evaluate lumbar DDD using the same terminology. A new classification system for lumbar DDD is presented. The intervertebral segment is graded in two parts: the anterior column and the posterior column, based on MRI, discography and plain radiographs. The system will be validated through a blinded study of 100 patients requiring stand-alone anterior lumbar interbody fusion or circumferential fusion. Although the debate over which discs are best treated surgically with indication for total disc replacement, or with indication for fusion will continue for some time, the basic understanding of intervertebral disc and posterior facet joint pathology, classified and validated in a simple forthright manner, is essential as we move forward with artificial disc technology.