Complications and Rates of Subsequent Lumbar Surgery Following Lumbar Total Disc Arthroplasty and Lumbar Fusion

Presentation and management of infection in total disc replacement: A review

Background

Total disc replacement (TDR) is widely used in the treatment of cervical and lumbar spine pathologies. Although TDR infection, particularly delayed infection, is uncommon, the results can be devastating, and consensus on clinical management remains elusive. In this review of the literature, we asked: (1) What are the reported rates of TDR infection; (2) What are the clinical characteristics of TDR infection; and (3) How has infection been managed for TDR patients?

Methods

We performed a search of the literature using PubMed and Embase to identify studies that reported TDR infection rates, the identification and management of TDR infection, or TDR failures with positive cultures. Twenty database studies (17 focusing on the cervical spine and 3 on the lumbar spine) and 10 case reports representing 15 patients were reviewed along with device Summary of Safety and Effectiveness Data reports.

Results

We found a lack of clarity regarding how infection was diagnosed, indicating a variation in clinical approach and highlighting the need for a standard definition of TDR infection. Furthermore, while reported infection rates were low, the absence of a clear definition prevented robust data analysis and may contribute to underreporting in the literature. We found that treatment strategy and success rely on several factors including patient symptoms and time to onset, microorganism type, and implant positioning/stability.

Conclusions

Although treatment strategies varied throughout the extant literature, common practices in eliminating infection and reconstructing the spine emerged. The results will inform future work on the creation of a more robust definition of TDR infection and as well as recommendations for management.

Outcomes of patients undergoing single-level arthroplasty versus anterior lumbar interbody fusion

BACKGROUND

Compared to vertebral body fusion, artificial discs are thought to lessen the risks of adjacent segment disease and the need for additional surgery by maintaining spinal mobility as they mimic the intervertebral disc structure. No studies have compared the rates of postoperative complications and the requirement for secondary surgery at adjacent segments among patients who have undergone anterior lumbar interbody fusions (ALIF) versus those undergoing lumbar arthroplasty.

METHODS

An all-payer claims database identified 11,367 individuals who underwent single-level ALIF and lumbar arthroplasty for degenerative disc disease (DDD) between January 2010 and October 2020. Rates of complications following surgery, the need for additional lumbar surgeries, length of stay (LOS), and postoperative opioid utilization were assessed in matched cohorts based on logistic regression models. Kaplan-Meyer plots were created to model the probability of additional surgery.

RESULTS

Following 1:1 exact matching, 846 records of patients who had undergone ALIF or lumbar arthroplasty were analyzed. All-cause readmission within 30-30 days following surgery was significantly higher in patients undergoing ALIF versus arthroplasty (2.6% vs. 0.71%, p = 0.02). LOS was significantly lower among the patients who had undergone ALIF (1.043 ± 0.21 vs. 2.17 ± 1.7, p < .001).

CONCLUSIONS

ALIF and lumbar arthroplasty procedures are equally safe and effective in treating DDD. Our findings do not support that single-level fusions may biomechanically necessitate revisional surgeries.

Single-Level Total Disc Replacement: Index-Level and Adjacent-Level Revision Surgery Incidence, Characteristics, and Outcomes

BACKGROUND

The literature reports that index level (IL) revision spine surgery (RSS) and adjacent level (AL) RSS are diminished in lumbar TDR compared with fusion procedures. There is a paucity of PROMs reported after RSS.

OBJECTIVE

To present the incidence of RSS at the IL and AL following single-level lumbar total disc replacement (TDR) and to document patient-related outcome measures (PROMs) associated with RSS.

METHODS

PROMs and timelines were analyzed for 32 RSS patients from a prospective cohort study of 401 patients treated with TDR for single-level degenerative disc disease. The data collected prospectively are analyzed from baseline (prior to index surgery) to latest follow-up following RSS. PROMs, including visual analog scales for back and leg, Oswestry Disability Index, and Roland-Morris Disability Questionnaire, were collected preoperatively; postoperatively at 3, 6, and 12 months; and annually thereafter until RSS. The time to RSS was recorded, and PROMs for RSS (IL, AL, or both) were documented, analyzed, and compared.

RESULTS

The median time to RSS in the IL cohort was 35 months (interquartile range [IQR] = 9-51 months). The median time to RSS cohort was 70 months (IQR = 41.3-105.3 months). Timepoints facilitate PROM discussion for RSS. Patients in both groups achieved thresholds for the minimum clinically important difference for pain and disability scores. The small sample size in each group contributed to the variability demonstrated by the 95% CIs, thereby cautioning definitive conclusions.

CONCLUSIONS

This study reveals that statistically significant and modest clinical improvements in PROMs can be achieved in RSS for lumbar TDR at IL and AL. The surgical approach and technique are reflective of the pathology and suggest that anterior RSS for AL degeneration and posterior RSS for IL pathology yield similar results.

CLINICAL RELEVANCE

Statistical and clinical improvements can be achieved in IL-RSS and AL-RSS following single level TDR. It is essential for clinicians to understand and verify the underlying IL and/or AL pathology to select an appropriate management strategy and to facilitate balanced informed discussions with patients.

LEVEL OF EVIDENCE: 4

New Hope for Treating Intervertebral Disc Degeneration: Microsphere-Based Delivery System

Intervertebral disc (IVD) degeneration (IVDD) has been considered the dominant factor in low back pain (LBP), and its etiological mechanisms are complex and not yet fully elucidated. To date, the treatment of IVDD has mainly focused on relieving clinical symptoms and cannot fundamentally solve the problem. Recently, a novel microsphere-based therapeutic strategy has held promise for IVD regeneration and has yielded encouraging results with in vitro experiments and animal models. With excellent injectability, biocompatibility, and biodegradability, this microsphere carrier allows for targeted delivery and controlled release of drugs, gene regulatory sequences, and other bioactive substances and supports cell implantation and directed differentiation, aiming to improve the disease state of IVD at the source. This review discusses the possible mechanisms of IVDD and the limitations of current therapies, focusing on the application of microsphere delivery systems in IVDD, including targeted delivery of active substances and drugs, cellular therapy, and gene therapy, and attempts to provide a new understanding for the treatment of IVDD.

Advances and Prospects in Biomaterials for Intervertebral Disk Regeneration

Low-back and neck-shoulder pains caused by intervertebral disk degeneration are highly prevalent among middle-aged and elderly people globally. The main therapy method for intervertebral disk degeneration is surgical intervention, including interbody fusion, disk replacement, and diskectomy. However, the stress changes caused by traditional fusion surgery are prone to degeneration of adjacent segments, while non-fusion surgery has problems, such as ossification of artificial intervertebral disks. To overcome these drawbacks, biomaterials that could endogenously regenerate the intervertebral disk and restore the biomechanical function of the intervertebral disk is imperative. Intervertebral disk is a fibrocartilaginous tissue, primarily comprising nucleus pulposus and annulus fibrosus. Nucleus pulposus (NP) contains high water and proteoglycan, and its main function is absorbing compressive forces and dispersing loads from physical activities to other body parts. Annulus fibrosus (AF) is a multilamellar structure that encloses the NP, comprises water and collagen, and supports compressive and shear stress during complex motion. Therefore, different biomaterials and tissue engineering strategies are required for the functional recovery of NP and AF based on their structures and function. Recently, great progress has been achieved on biomaterials for NP and AF made of functional polymers, such as chitosan, collagen, polylactic acid, and polycaprolactone. However, scaffolds regenerating intervertebral disk remain unexplored. Hence, several tissue engineering strategies based on cell transplantation and growth factors have been extensively researched. In this review, we summarized the functional polymers and tissue engineering strategies of NP and AF to endogenously regenerate degenerative intervertebral disk. The perspective and challenges of tissue engineering strategies using functional polymers, cell transplantation, and growth factor for generating degenerative intervertebral disks were also discussed.

Predictors of Extended Hospitalization and Early Reoperation After Elective Lumbar Disc Arthroplasty

BACKGROUND

Lumbar disc arthroplasty (LDA) has emerged as a motion-sparing alternative to lumbar fusion. Although LDA may be amenable to the ambulatory surgical setting, to date no study has identified the factors predisposing patients to extended hospital stay.

METHODS

A national surgical quality improvement database was queried from 2011 to 2019 for patients undergoing elective, single-level, primary LDA. Univariate and multivariate logistic regression analyses were performed to elucidate predictors of length of stay (LOS) at or above the 90th percentile of the study population (3 days). Secondary study endpoints included rates of complications, as well as predictors and reasons for unplanned reoperation within 30 days.

RESULTS

A total of 630 patients met eligibility criteria for the study, of whom 517 (82.1%) had LOS <3 days and 113 (17.9%) had LOS ≥3 days. Multivariate logistic regression revealed associations between prolonged hospitalization and postoperative diagnosis of degenerative disk disease, obesity, Hispanic identity, and operation length >120 minutes. Before discharge, patients with LOS ≥3 days were more likely to have venous thromboembolisms, pneumonia, surgical site infections, and reoperations. Independent predictors of reoperation were wound infections, diabetes, and smoking.

CONCLUSIONS

Complications following elective single-level LDA are relatively rare, with few extended hospitalizations being attributable to any specific complication. Risk factors for prolonged LOS appear to be related to diagnosis and surgical time rather than to modifiable preoperative comorbidities. Conversely, unplanned reoperations within 30 days are associated with optimizable perioperative factors such as smoking, diabetes, and surgical site infection.

Risk factors for reoperation after lumbar total disc replacement at short-, mid-, and long-term follow-up

BACKGROUND CONTEXT

The reoperation rate following TDR (Total Disc replacement) has been established at short- and mid-term time points through the Food and Drug Administration Investigational Device Exemption (FDA IDE) trials. However, these trials include highly selected centers and surgeons with strict governance of indications. The utilization of TDR throughout the community needs further analysis.

PURPOSE

To identify the risk factors for lumbar spine reoperation in patients undergoing lumbar total disc replacement (TDR) at short-, mid-, and long-term follow-up.

STUDY DESIGN/SETTING

This study is a multi-center retrospective cohort study utilizing the New York Statewide Planning and Research Cooperative System database.

PATIENT SAMPLE

We identified 1,368 patients who underwent an elective primary lumbar TDR in New York State between January 1, 2005 and September 30, 2013.

OUTCOME MEASURES

The primary functional outcome of interest was lumbar reoperation, specifically the evaluation of independent risk factors for lumbar reoperation at a minimum of 2 years, with sub-analyses performed at 5 and ten years.

METHODS

International Classification of Diseases, Ninth revision codes were utilized to identify patients undergoing a primary lumbar TDR. We excluded patients with primary/revision lumbar fusion procedures and revision disc replacement procedures. Hospital academic status was determined by the Accreditation Council for Graduate Medical Education. Unique encrypted patient identifiers allowed for longitudinal follow-up for reoperation. Logistic regression models compared reoperation and no-reoperation cohorts, and were performed on sub-analyses for significant univariate predictors of reoperation.

RESULTS

Between January 2005 and September 2013, 1368 patients underwent a primary lumbar TDR. Reoperation occurred in 8.8% by 2 years, 15.8% by 5 years, and 19.5% by ten years. Diabetics were more likely to have reoperations (7.5% vs 3.8%, p=.013). Teaching hospitals experienced a decreased reoperation rate compared to nonteaching hospitals at 2-year (5.0% vs 10.5%, p=.002), 5-year (10.7% vs 17.9%, p=.002) and 10-year (11.7% vs 21.9%, p=.045) follow-up. Lumbar fusion was the most common reoperation (14.2%).

CONCLUSION

We identified an 8.8% reoperation rate after inpatient lumbar TDR at 2-years, 15.8% at 5-years, and 19.5% at 10-years. When stratifying by teaching status, reoperation rates at teaching centers align with those reported in FDA IDE studies. Diabetes was the only patient factor influencing reoperation rate. There is a growing consensus that lumbar TDR is a durable and appropriate surgical option for lumbar degenerative disc disease. Proper indications are crucial to obtaining good outcomes with lumbar TDR.

Comparative Analysis of 30-Day Readmission, Reoperation, and Morbidity Between Lumbar Disc Arthroplasty Performed in the Inpatient and Outpatient Settings Utilizing the ACS-NSQIP Dataset

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Spine surgery has been increasingly performed in the outpatient setting, providing greater control over cost, efficiency, and resource utilization. However, research evaluating the safety of this trend is limited. The objective of this study is to compare 30-day readmission, reoperation, and morbidity for patients undergoing lumbar disc arthroplasty (LDA) in the inpatient versus outpatient settings.

METHODS

Patients who underwent LDA from 2005 to 2018 were identified using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database. Regression was utilized to compare readmission, reoperation, and morbidity between surgical settings, and to evaluate for predictors thereof.

RESULTS

We identified 751 patients. There were no significant differences between inpatient and outpatient LDA in rates of readmission, reoperation, or morbidity on univariate or multivariate analyses. There were also no significant differences in rates of specific complications. Inpatient operative time (138 ± 75 minutes) was significantly (P < .001) longer than outpatient operative time (106 ± 43 minutes). In multivariate analysis, diabetes (P < .001, OR = 7.365), baseline dyspnea (P = .039, OR = 6.447), and increased platelet count (P = .048, OR = 1.007) predicted readmission. Diabetes (P = .016, OR = 6.533) and baseline dyspnea (P = .046, OR = 13.814) predicted reoperation. Baseline dyspnea (P = .021, OR = 8.188) and ASA (American Society of Anesthesiologists) class ≥3 (P = .014, OR = 3.515) predicted morbidity. Decreased hematocrit (P = .008) and increased operative time (P = .003) were associated with morbidity in univariate analysis, but not in multivariate analysis.

CONCLUSIONS

Readmission, reoperation, and morbidity were statistically similar between surgical setting, indicating that LDA can be safely performed in the outpatient setting. Higher ASA class and specific comorbidities predicted poorer 30-day outcomes. These findings can guide choice of surgical setting given specific patient factors.

Association Between Social Determinants of Health and Postoperative Outcomes in Patients Undergoing Single-Level Lumbar Fusions: A Matched Analysis

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The aim of this study was to analyze association between social determinants of health (SDH) disparity on postoperative complication rates, and 30-day and 90-day all-cause readmission in patients undergoing single-level lumbar fusions.

SUMMARY OF BACKGROUND DATA

Decreasing postoperative complication rates is of great interest to surgeons and healthcare systems. Postoperative complications are associated with poor convalescence, inferior patient reported outcomes measures, and increased health care resource utilization. Better understanding of the association between Social Determinants of Health (SDH) on postoperative outcomes maybe helpful to decrease postoperative complication rates.

METHODS

MARINER 2020, an all-payer claims database, was utilized to identify patients undergoing single-level lumbar fusions between 2010 and 2018. The primary outcomes were the rates of any postoperative complication, symptomatic pseudarthrosis, need for revision surgery, or 30-day and 90-day all-cause readmission.

RESULTS

The exact matched population analyzed in this study contained 16,560 patients (8280 [50.0%] patients undergoing single-level lumbar fusion with an SDH disparity; 8280 [50.0%] patients undergoing single-level lumbar fusion without a disparity). Both patient groups were balanced at baseline. The rate of symptomatic pseudarthrosis (1.0% vs. 0.6%, P < 0.05) or any postoperative complication (16.3% vs. 10.4%, P < 0.05) in the matched analysis was higher in the disparity group. The presence of a disparity was associated with 70% increased odds of developing any complication (OR 1.7, 95% CI 1.53-1.84) or symptomatic pseudarthrosis (OR 1.7, 95% CI 1.17-2.37). Unadjusted and adjusted sensitivity analyses yielded similar results as the primary analysis.

CONCLUSION

Social Determinants of Health affect outcomes in spine surgery patients and are associated with an increased risk of developing postoperative complications following lumbar spine fusion.Level of Evidence: 3.

Morphologic analysis of Chinese lumbar endplate by three-dimensional computed tomography reconstructions for helping design lumbar disc prosthesis

Lumbar disc prostheses have been used increasingly in recent years. The successful design of lumbar disc prostheses depends on accurate morphometric parameters. However, the morphologic dimensions of lumbar endplate area have not been investigated in Chinese population.A total of 1800 lumbar endplates were retrospectively accessed in 150 Chinese adults. Eighteen parameters of each lumbar segment were measured by three-dimensional computed tomography reconstructions from T12/L1 to L5/S1. These obtained parameters were compared between genders, bilateral sides, vertebral segments, and different populations.Endplate length and width increased in general, and there was a significant decrease for length/width ratio from T12 to S1 (P = .03). The average concavity depth of the lower lumbar endplate (2.09 ± 0.93 mm) was usually larger than that of the upper lumbar endplate (1.61 ± 0.74 mm) (P = .02). The percentage of the most concave point of the upper and lower lumbar endplate was 50.01 ± 10.76% and 56.41 ± 9.93%, respectively. Anterior, medium, or posterior intervertebral endplate height was severally 10.01 ± 1.98 mm, 10.46 ± 2.03 mm, and 6.41 ± 1.74 mm, and increased among vertebral segments (P = .01).The intervertebral endplate angle significantly increased from T12-L1 to L5-S1 (P = .01). Parameters displayed significant difference between genders. The morphometric parameters of different populations also showed differences.In conclusion, there is a morphologic discrepancy in dimensions of lumbar endplate regarding genders, vertebral segments, and different populations. It is essential to design the lumbar disc prosthesis suited for Chinese patients specially, for which the morphometric parameters in our study can be utilized.

Evaluation of a rabbit model of adjacent intervertebral disc degeneration after fixation and fusion and maintenance in an upright feeding cage

Purpose: To establish an animal model of adjacent intervertebral disc degeneration by performing spinal fixation and fusion after percutaneous needle puncture and removal of the intervertebral disc or percutaneous needling of the vertebral body without removal of the intervertebral disc. Methods: We established a model of adjacent intervertebral disc degeneration after spinal fixation and fusion of rabbits maintained in upright feeding cages. Twenty-five healthy New Zealand rabbits were used. In the experimental group, the L3-4 intervertebral disc was percutaneously punctured with an 18-G needle under fluoroscopic guidance. Once degeneration occurred, the L3-4 disc was excised, and interbody fusion was performed. The changes in the adjacent intervertebral discs were observed periodically via X-ray and MRI. In the control group, the L3 vertebral body was percutaneously needled with an 18-G needle under fluoroscopic guidance. The changes in the adjacent intervertebral discs were observed on X-ray and MRI at 4, 8, and 12 weeks after puncture in both groups. At 12 weeks postoperatively, the animals were euthanized, and the histopathologic changes of the adjacent intervertebral discs were assessed using hematoxylin-eosin and TdT-mediated dUTP nick end labeling (TUNEL) staining. The mRNA and protein expressions of aggrecanase-1 were measured by real-time quantitative PCR and Western blot analysis. The product of aggrecan degradation, Aggrecan ARGxx, was measured by Western blot analysis. Results: The degeneration of the intervertebral discs in the adjacent segments in the experimental group increased over time. The mRNA and protein expressions of aggrecanase-1 and the expression of Aggrecan ARGxx in the experimental group were significantly increased after puncture, fixation, and fusion (P<0.05). The adjacent intervertebral disc sections had a significantly lower cell density and significantly higher TUNEL-positive cell rate in the experimental group than the control group (P<0.05). Conclusion: The results suggest that the occurrence of intervertebral disc degeneration in adjacent segments may begin with the degeneration of the punctured intervertebral disc.

In silico feasibility assessment of extracorporeal delivery of low-intensity pulsed ultrasound to intervertebral discs within the lumbar spine

Low intensity pulsed ultrasound (LIPUS) may have utility for non-invasive treatment of discogenic lower back pain through stimulating, remodeling and accelerating healing of injured or degenerated intervertebral disc (IVD) tissues. This study investigates the feasibility of delivering LIPUS to lumbar IVDs between L2 and S1 spine vertebra using a planar extracorporeal phased array (8 × 8 cm, 1024 elements, 500 kHz). Three 3D anatomical models with heterogenous tissues were generated from patient CT image sets and used in the simulation-based analysis. Time-reversal acoustic modeling techniques were applied to optimize posterior-lateral placement of the array with respect to the body to facilitate energy deposition in discrete target regions spanning the annulus fibrosus and central nucleus of each IVD. Forward acoustic and biothermal simulations were performed with time-reversal optimized array placements and driving amplitude/phase settings to predict LIPUS intensity distributions at target sites and to investigate off-target energy deposition and heating potential. Simulation results demonstrate focal intensity gain of 5-168 across all IVD targets and anatomical models, with greater average intensity gain (>50) and energy localization in posterior, posterolateral, and lateral target sites of IVDs. Localized LIPUS delivery was enhanced in thinner patient anatomies and in the high lumbar levels (L2-L3 and L3-L4). Multiple amplitude/phasing illumination patterns could be sequenced at a fixed array position for larger regional energy coverage in the IVD. Biothermal simulations demonstrated that LIPUS-appropriate exposures of 100 mW cm^-2 I_SPTA to the target disc region would result in <1 °C global peak temperature elevation for all cases. Hence, simulations suggest that spatially-precise extracorporeal delivery of therapeutically relevant LIPUS doses to discrete regions of lumbar IVDs is feasible and may be useful in clinical management of discogenic back pain.

ICR in human cadaveric specimens: An essential parameter to consider in a new lumbar disc prosthesis design

STUDY DESIGN

Biomechanical study in cadaveric specimens.

BACKGROUND

The commercially available lumbar disc prostheses do not reproduce the intact disc's Instantaneous centre of Rotation (ICR), thus inducing an overload on adjacent anatomical structures, promoting secondary degeneration.

AIM

To examine biomechanical testing of cadaveric lumbar spine specimens in order to evaluate and define the ICR of intact lumbar discs.

MATERIAL AND METHODS

Twelve cold preserved fresh human cadaveric lumbosacral spine specimens were subjected to computerized tomography (CT), magnetic resonance imaging (MRI) and biomechanical testing. Kinematic studies were performed to analyse range of movements in order to determine ICR.

RESULTS

Flexoextension and lateral bending tests showed a positive linear correlation between the angle rotated and the displacement of the ICR in different axes.

DISCUSSION

ICR has not been taken into account in any of the available literature regarding lumbar disc prosthesis. Considering our results, neither the actual ball-and-socket nor the withdrawn elastomeric nucleus models fit the biomechanics of the lumbar spine, which could at least in part explain the failure rates of the implants in terms of postoperative failed back syndrome (low back pain). It is reasonable to consider then that an implant should also adapt the equations of the movement of the intact ICR of the joint to the post-surgical ICR.

CONCLUSIONS

This is the first cadaveric study on the ICR of the human lumbar spine. We have shown that it is feasible to calculate and consider this parameter in order to design future prosthesis with improved clinical and biomechanical characteristics.

Five-year Results of a Randomized Controlled Trial for Lumbar Artificial Discs in Single-level Degenerative Disc Disease

STUDY DESIGN

A prospective, multicenter, randomized, controlled, investigational device exemption (IDE) noninferiority trial.

OBJECTIVE

The aim of this study was to compare the 5-year safety and effectiveness of the activL Artificial Disc with Control Total Disc Replacement (TDR) systems (ProDisc-L or Charité) in the treatment of patients with symptomatic single-level lumbar degenerative disc disease (DDD).

SUMMARY OF BACKGROUND DATA

The activL Artificial Disc received Food and Drug Administration approval in 2015 based on 2-year follow-up data.

METHODS

Eligible patients presented with symptomatic, single-level, lumbar DDD who failed ≥6 months of nonsurgical management. At entry, 324 patients were randomly allocated (2 : 1) to treatment with activL (n = 218) or Control (n = 106, including n = 65 ProDisc-L and n = 41 Charité) TDR. At 5-year follow up, a total of 261 patients (176 activL patients and 85 Control patients) were available for analysis.

RESULTS

The primary composite endpoint at 5 years for activL patients was noninferior to Control TDR. Relative to baseline, reductions in back pain severity and improvements in Oswestry Disability Index (ODI) were maintained for both the activL and Control TDR groups through 5 years. The activL group showed significantly better range of motion for flexion-extension rotation, flexion-extension translation, and disc angle, compared with Control TDR. Freedom from a serious adverse event through 5 years was 64% in activL patients, 47% in Control patients (log-rank P = 0.0068). Freedom from index-level and adjacent-level reoperation was high for TDR patients, ranging between 94% and 99%, respectively.

CONCLUSION

Long-term evidence supports lumbar total disc replacement as safe. The next-generation activL Artificial Disc is more effective at preserving range of motion than first-generation lumbar TDRs (ProDisc-L and Charité) and offers a higher safety profile. Other primary and secondary outcomes are similar between disc designs.

LEVEL OF EVIDENCE

2.

Disc herniation caused by a viscoelastic nucleus after total lumbar disc replacement-a case report

Degenerative disc disease (DDD) is highly prevalent. If conservative treatment fails, spinal fusion procedures are commonly performed. Total disc replacement (TDR) might be a surgical option for a distinct subset of patients with DDD. Several prostheses have been or are still available. Despite some promising initial clinical results, there is still limited experience with hardware-related adverse events. This report highlights an unreported complication after TDR with a viscoelastic device. Literature about long-term outcome and safety of this particular TDR is scarce. Hence, there exists limited experience with TDR-related complications with such a failure mode. We report a 34-year-old male presented to us with an acute S1 radiculopathy on the right. His past medical history was significant for prior TDR at the level L5/S1 at another hospital 2 years prior to this acute episode. Imaging studies revealed an intraspinal mass compromising the right S1 nerve root. This mass mimicked a disc herniation and sequestrectomy was performed. Intraoperatively, the prolapsed sequester turned out to be part of the viscoelastic nucleus of the disc prosthesis. Interbody fusion combined with posterior instrumentation was ultimately performed. The patient did well afterwards, but is currently (2 years later) developing adjacent segment disease with facet syndromes. Since TDR might be beneficial for certain patients, spine surgeons should be aware of potential device-related complications.

We Need to Talk about Lumbar Total Disc Replacement

BACKGROUND

Replacement of a diseased lumbar intervertebral disc with an artificial device, a procedure known as lumbar total disc replacement (LTDR), has been practiced since the 1980s.

METHODS

Comprehensive review of published literature germane to LTDR, but comment is restricted to high-quality evidence reporting implantation of lumbar artificial discs that have been commercially available for at least 15 years at the time of writing and which continue to be commercially available.

RESULTS

LTDR is shown to be a noninferior (and sometimes superior) alternative to lumbar fusion in patients with discogenic low back pain and/or radicular pain attributable to lumbar disc degenerative disease (LDDD). Further, LTDR is a motion-preserving procedure, and evidence is emerging that it may also result in risk reduction for subsequent development and/or progression of adjacent segment disease.

CONCLUSIONS

In spite of the substantial logistical challenges to the safe introduction of LTDR to a health care facility, the procedure continues to gain acceptance, albeit slowly.

CLINICAL RELEVANCE

Patients with LDDD who are considering an offer of spinal surgery can only provide valid and informed consent if they have been made aware of all reasonable surgical and nonsurgical options that may benefit them. Accordingly, and in those cases in which LTDR may have a role to play, patients under consideration for other forms of spinal surgery should be informed that this valid procedure exists.

Total Disc Arthroplasty Versus Anterior Interbody Fusion in the Lumbar Spine Have Relatively a Few Differences in Readmission and Short-term Adverse Events

STUDY DESIGN

Retrospective matched cohort study of prospectively collected data.

OBJECTIVE

To compare rates of adverse events and readmission between lumbar total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF) using the American College of Surgeons National Surgical Quality Improvement Program database.

SUMMARY OF BACKGROUND DATA

TDA and ALIF may be considered for similar degenerative indications. However, there have been a few large-cohort comparison studies of short-term clinical outcomes for these procedures.

METHODS

The 2011-2015 NSQIP databases were retrospectively queried to identify patients who underwent elective stand-alone ALIF and TDA. After propensity matching, the association of procedure type with adverse events and readmission was determined using McNemar's test. Operative time and postoperative length of stay (LOS) were compared using multivariate linear regression. Risk factors for adverse events were determined using multivariate Poisson regression.

RESULTS

In total, 1801 ALIF and 255 TDA patients were identified. After matching with propensity scores, there were no significant differences in the rates of any adverse event, serious adverse events, individual adverse events, or readmission other than blood transfusion, which occurred more frequently in the ALIF cohort (3.92% vs. 0.39%, P = 0.007). Operative time was not significantly different between the two cohorts, but postoperative LOS was significantly longer for ALIF cases (+0.28 days, P < 0.001). When evaluating 10 preoperative variables as potential risk factors for adverse events and readmission after TDA and ALIF, the majority of results were similar.

CONCLUSION

The only identified differences in perioperative outcomes between TDA and ALIF were a 3.53% higher incidence of blood transfusion and 0.28-day longer LOS for the ALIF group. These results suggest overall similar short-term general-health outcomes between the two groups, and that the choice between the two procedures, for the appropriately selected patient, should be based on longer-term functional outcomes.

LEVEL OF EVIDENCE

3.

Defining the Ideal Lumbar Total Disc Replacement Patient and Standard of Care

: Lumbar total disc replacement, now in use since 2004, was determined by the panel to be a standard of care for the treatment of symptomatic single-level lumbar degenerative disc disease in the active patient subpopulation as outlined by the investigational device exemption study criteria. The large body of evidence supporting this statement, including surgeons' experiences, was presented and discussed. Consensus statements focusing on decision-making criteria reflected that efficacy, long-term safety, clinical outcomes with validated measures, and cost-effectiveness should form the basis of decision-making by payers. Diagnostic challenges with lumbar degenerative disc disease patients were discussed among the panel, and it was concluded that although variably used among surgeons, reliable tools exist to appropriately diagnose discogenic back pain.

Challenges and Solutions for Lumbar Total Disc Replacement Implantation

: Long-term data are now available to support the safety and efficacy of lumbar total disc replacement (TDR). Five-year randomized and controlled trials, meta-analyses, and observational studies support a similar or lower risk of complications with lumbar TDR compared with fusion. The panel concluded that published data on commercially available lumbar TDR devices demonstrate minimal concerns with late-onset complications, and that the risk of adjacent segment degeneration and reoperations can be reduced with lumbar TDR versus fusion. Survey results of surgeon practice experiences supported the evidence, revealing a low rate of complications with TDR. Panelists acknowledged the importance of adhering to selection criteria to help minimize patient complications.

Lumbar disc replacement surgery-successes and obstacles to widespread adoption

PURPOSE OF REVIEW

Lumbar disc replacement has been a surgical alternative to fusion surgery for the treatment of lumbar degenerative disc disease (DDD) for many years. Despite enthusiasm after the approval of the first devices, implantation rates have remained low, especially in the USA. The goal of this review is to provide a general overview of lumbar disc replacement in order to comprehend the successes and obstacles to widespread adoption.

RECENT FINDINGS

Although a large amount of evidence-based data including satisfactory long-term results is available, implantation rates in the USA have not increased in the last decade. Possible explanations for this include strict indications for use, challenging surgical techniques, lack of device selection, fear of late complications or revision surgeries, and reimbursement issues. Recent publications can address some of the past concerns, but there still remain obstacles to widespread adoption. Upcoming data on long-term outcome, implant durability and possible very late complications will determine the future of lumbar disc replacement surgery.