Lumbar disc arthroplasty

Abstract

Lumbar total disc replacement (L-TDR) is a motion-preserving surgical treatment for patients with degenerative disc disease (DDD) and debilitating mechanical low back pain (LBP) refractory to nonsurgical management. It represents an alternative surgical intervention to lumbar arthrodesis with theoretical advantages including the preservation of physiologic motion, which may lead to less axial back pain as well as to decreased rates of adjacent segment disease and reoperation. Secondary advantages include potential shorter recovery times. The ideal candidate for the L-TDR is a relatively young patient with normal neurologic exam suffering mechanical LBP that has failed at least 6 months of nonoperative management with imaging revealing focal DDD with little or no facet disease. Two multicenter, randomized, controlled investigational device exemption (IDE) trials in the United States comparing the Charite and ProDisc-L artificial discs versus lumbar fusion have demonstrated non-inferiority for safety and efficacy in relief of back pain up to 2 years following surgery. A third lumbar TDR device, Activ-L, received FDA approval after completing an IDE study comparing that artificial disc to both the Charite and ProDisc-L discs. Given the controversy surrounding the surgical treatment of DDD in general, many insurance carriers do not provide coverage for fusion or L-TDR which continues to affect the utilization of lumbar arthroplasty devices. A representative case of L-TDR is presented, as well as general patient selection, contraindications, and surgical technique including technical pearls with potential complications and avoidance strategies.