Viscoelastic Disc Arthroplasty Provides Superior Back and Leg Pain Relief in Patients with Lumbar Disc Degeneration Compared to Anterior Lumbar Interbody Fusion

Lumbar and cervical viscoelastic disc replacement: Concepts and current experience

The ideal lumbar and cervical discs should provide six degrees of freedom and tri-planar (three-dimensional) motion. Although all artificial discs are intended to achieve the same goals, there is considerable heterogeneity in the design of lumbar and cervical implants. The “second generation total disc replacements” are non-articulating viscoelastic implants aiming at the reconstruction of physiologic levels of shock absorption and flexural stiffness. This review aims to give an overview of the available implants detailing the concepts and the functional results experimentally and clinically. These monobloc prostheses raise new challenges concerning the choice of materials for the constitution of the viscoelastic cushion, the connection between the components of the internal structure and the metal endplates and even the bone anchoring mode. New objectives concerning the quality of movement and mobility control must be defined.

Lumbar Arthroplasty: Past, Present, and Future

Lumbar degenerative disc disease is a pathologic process that affects a large portion of our aging population. In the recent past, surgical treatment has involved fusion procedures. However, lumbar disc arthroplasty and replacement provides an alternative for carefully selected patients. It provides the major advantage of motion preservation and thus keeps adjacent segments from significantly progressive degeneration. The history of lumbar disc replacement has roots that start in the 1960s with the implantation of stainless-steel balls. Decades later, multiple implants with different material design and biomechanical properties were introduced to the market. New third-generation implants have made great strides in improved biomechanics and clinical outcomes. Although there is room for further advancement and studies are warranted to assess the long-term durability and sustainability of lumbar disc arthroplasty, it has certainly proven to be a very acceptable alternative within the surgical armamentarium that should be offered to patients who meet indications. In this review we present an overview of lumbar disc arthroplasty including its history, indications, biomechanics, challenges, and future directions.

Five-year follow-up of clinical and radiological outcomes of LP-ESP elastomeric lumbar total disc replacement in active patients

BACKGROUND CONTEXT

The surgical treatment of degenerative disc disease at the lumbar spine may involve fusion. Total disc replacement (TDR) is an alternative treatment to avoid fusion-related adverse events, specifically adjacent segment disease. New generation of elastomeric non-articulating devices has been developed to more effectively replicate the shock absorption and flexural stiffness of native disc.

PURPOSE

To report 5 years clinical and radiographic outcomes, range of motion (ROM), and position of the center of rotation after a viscoelastic lumbar TDR.

STUDY DESIGN

Prospective observational cohort study PATIENT SAMPLE: Sixty-one patients OUTCOME MEASURES: The clinical evaluation was based on visual analog scale (VAS) for pain, Oswestry disability index (ODI) score, short form-36 (SF-36) including the physical component summary (PCS) and the mental component summary (MCS), and general health questionnaire-28 (GHQ28). The radiological outcomes were ROM and position of the center of rotation at the index and the adjacent levels and the adjacent disc height changes.

METHODS

Our study group included 61 consecutive patients with monosegmental disc replacement. We selected patients who could provide a global lumbar spine mobility analysis (intermediate functional activity according to the Baecke score). Hybrid constructs had been excluded. Only the cases with complete clinical and radiological follow-up at 3, 6, 12, 24, and 60 months were included.

RESULTS

There was a significant improvement in VAS (3.3±2.5 vs. 6.6±1.7, p<.001), in ODI (20±17.9 vs. 51.2±14.6, p<.001), GHQ28 (52.6±15.5 vs. 64.2±15.6, p<.001), SF-36 PCS (58.8±4.8 vs. 32.4±3.4, p<.001), and SF-36 MCS (60.7±6 vs. 42.3±3.4, p<.001). The mean location centers of the index level and adjacent discs were comparable to those previously published in asymptomatic patients. According to the definition of Zigler and Delamarter, all of our cases remained grade 0 for adjacent level disc height (within 25% of normal).

CONCLUSIONS

This series reports significant improvement in midterm follow-up after TDR, which is consistent with previously published studies but with a lower rate of revision surgery and no adjacent level disease pathologies. The radiographic assessment of the patients demonstrated the quality of functional reconstruction of the lumbar spine after LP-ESP viscoelastic disc replacement.

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.

Cervical disc replacement surgery: indications, technique, and technical pearls

PURPOSE OF REVIEW

Cervical disc replacement (CDR) is a surgical option for appropriately indicated patients, and high success rates have been reported in the literature. Complications and failures are often associated with patient indications or technical variables, and the goal of this review is to assist surgeons in understanding these factors.

RECENT FINDINGS

Several investigations have been published in the last 5 years supporting the use of CDR in specific patient populations. CDR has been shown to be comparable or favorable to anterior cervical discectomy and fusion in several meta-analyses and mid-term follow-up studies. CDR was developed as a technique to preserve motion following a decompression procedure while minimizing several of the complications associated with fusion and posterior cervical spine procedures. Though success with cervical fusion and posterior foraminotomy has been well documented in the literature, high rates of mid- and long-term complications have been clearly established. CDR has also been associated with several complications and challenges with regard to surgical technique, though improvements in implant design have lead to an increase in utilization. Several devices currently exist and vary in terms of material, design, and outcomes. This review paper discusses indications, surgical technique, and technical pearls and reviews the CDR devices currently available.