Many people with chronic low back pain caused by a damaged spinal disc choose to undergo lumbar artificial disc replacement. This spine surgery involves removing the damaged disc and replacing it with an artificial device that preserves the motion of the spine at that level.
As with all surgeries, there is a lot for patients to consider beforehand. SpineNation spoke with a number of surgeons who routinely perform that procedure, along with a physical therapist, to find out their answers to some of the most commonly asked questions about this procedure.
We spoke with Dr. Robert S. Bray, Jr., a neurological spine surgeon and founder of DISC Sports & Spine Center
in Newport Beach, California; Dr. Colin Haines, a spine surgeon at Virginia Spine Institute
in Reston Virginia; Dr. Grant D. Shifflett, an orthopedic spine surgeon at DISC Sports & Spine Center
in Newport Beach, California; Dr. Khawar Siddique, a neurosurgeon at DOCS Spine + Orthopedics
in Los Angeles, California; and Dan Neal, a physical therapist at The CORE Institute
in Phoenix, Arizona.
Some answers have been edited for brevity and clarity.
Lumbar ADR Surgery
SpineNation: How do surgeons prepare for a lumbar ADR surgery?
Dr. Shifflet: Lumbar disc replacement is a surgery that surgeons shouldn't take lightly. You really want to move slowly and thoughtfully through the process.
When I see a patient who is interested in having a lumbar disc replacement, I want to find out exactly where their pain is, what exacerbates their pain, and what got them to this point. I also find out whether they have tried non-operative modalities such as physical therapy, acupuncture, and spinal injections. We can even use spinal injections to tease out if someone really is a good candidate for lumbar ADR and where their pain is coming from.
A surgeon should arrive on the day of the disc replacement surgery as confident as possible that that the disc is the source of a patient's pain and not some other cause. While it seems like “where’s the pain coming from?” is an obvious question, it’s our most challenging one. So as a surgeion, you have to do a deep dive to make sure a patient is a good candidate.
SpineNation: How does a surgeon decide which implant to use?
Dr. Shifflet: When choosing an implant, surgeons have to keep in mind the structure of a patient's spine, but patients don’t need to worry about those kinds of details.
In the United States, there are only two artificial disc devices approved by the Food and Drug Administration for the lumbar spine — the activL and the Prodisc-L. Based on a patient’s anatomy and a surgeon’s comfort with the device, surgeons and patients can select one or the other. But as a patient, you can be comfortable with either of the approved discs.
As far as the disc size, both approved discs come with a lot of options and sizes. I’ve never had a patient where we didn’t have the right size. I’ve even done disc replacement on people who are thin and short in stature, and I have still been able to find an appropriately sized disc.
SpineNation: How does a surgeon prepare the spine for the implant?
Dr. Shifflet: Preparation of the spine really involves cleaning out, opening up, and releasing the damaged disc. We use a little blade to cut the disc, and then we use a series of small instruments to scrape the cartilage off the bone, so there’s a nice bone surface for the artificial disc device to fit onto and adhere to.
This is what we call the endplate preparation. The disc has metal on the top and bottom, and plastic in between. The metal is what has to integrate with the bone. If you do a poor job of cleaning off the cartilage, the disk can slip, slide, or fail.
The other part of preparing the spine has to do with a structure on the back of the vertebral body called the posterior longitudinal ligament, which is a big ligament that runs up and down the spine. With disc replacement, you have to release that ligament so you’re able to fit the disc in the space and restore motion at that level. This is especially critical in cases where the disc is really collapsed.
SpineNation: What is a lumbar ADR surgery like?
Dr. Bray: A lumbar ADR can be done as an outpatient procedure. Critical to its success, however, is having an experienced team, which includes a vascular surgeon who can take a minimally invasive approach. In general, patients are up and walking within hours of the procedure.
The operating room has a complex set-up that includes an operating microscope and neuromonitoring [to monitor a patient's nervous system during the procedure]. In addition, if there is any bleeding, which is a very rare event, a cell saver is used [to collect and clean the patient's blood so it can be returned to them].
Who is in the operating room during the surgery and what are their roles?
Dr. Shifflet: Staff in the operating room vary a little bit depending on whether you’re at an academic location versus a private practice. Generally speaking, you have an anesthesiologist, a surgeon who’s doing the spine work, and a vascular surgeon. The vascular surgeon gets us access to the spine, usually through a two- or three-inch incision below the belly button.
There’s also a scrub tech who is very experienced with the equipment and instruments that are used during the operation. Basically, the scrub tech helps with our workflow. They don’t do the surgery, but they hand us instruments and keep the surgery moving forward.
Then there's a circulating nurse who helps with anything that the anesthesiologist needs, or any materials or equipment surgeons might need once they're scrubbed in and their hands are sterile.
There's also usually a person who represents the artificial disc device company. This person has a very detailed understanding of all the specific things about the implant — sizes, shapes, angles, insertion devices, and removal devices. Their job is to know everything about the implant that’s going in.
These surgeries are done with X-ray guidance, so there’s an X-ray tech who is there to take pictures for us. We use these images to make sure everything’s in a good position.
Academic centers might also have medical residents, fellows, or medical students.
SpineNation: How long does a lumbar ADR surgery take?
Dr. Shifflet: It varies somewhat. I tell patients that there is no race here, and there is no gold medal for being the fastest in putting these discs in. But you also don’t want to be taking too long to do the procedure, since blood vessels need to be retracted in order to gain access to the spine and the patient needs anesthesia.
So you want to move efficiently and expeditiously. Generally, around 45 minutes to an hour is a reasonable amount of time to do a lumbar disc replacement. Some surgeons may go a little faster, and some a little slower. But it shouldn’t be a 3- or 4-hour operation.
SpineNation: Where does a lumbar ADR surgery happen?
Dr. Shifflet: We do both hospital cases and surgery center cases. There are, of course, complex cases that have to be done in a hospital. However, we do most of these procedures in an outpatient surgery setting.
SpineNation: What happens if a person is nervous about anesthesia or the surgery?
Dr. Shifflet: One thing we’ll often do is have a person talk to one of our previous patients about their own experience with the surgery. This way, prospective patients can picture what the procedure might look like for them.
I also like to reassure people that spine surgeries are all that we do at our center. So everything is optimized to getting patients through the surgery safely, with not too much anesthesia and not too little pain medication.
Our anesthesiologists also meet with patients pre-operatively. The anesthesiologist at our center actually had a lumbar disc replacement. So he’s not only an anesthesiologist, he’s also had the surgery. I think this helps patients feel better about things.
Recovery from Lumbar ADR
SpineNation: What does home recovery look like?
Dr. Bray: As far as home recovery goes, the patient is fully self-sufficient, able to move around, and provide their own care after the surgery. Support from family or friends is a nice comfort, but not a necessity.
The most important part of recovery is the first week of full rest — in a bed, couch, or easy chair — with frequently shifting positions. Patients should sit up to eat, and take five-minute walks, but really it’s about resting most of the time.
Pain medications and the surgery itself often slow the gastrointestinal tract, so patients should pay careful attention to resuming normal bowel function, which is often the limiting factor. Patients can usually resume normal bowel function within a week, with stool softeners and laxatives, as needed.
Dr. Haines: During recovery, patients should expect some abdominal soreness, back pain, and constipation for approximately one to two weeks after surgery.
SpineNation: Are there any restrictions on activities during recovery?
Dr. Siddique: For the first two weeks after surgery, the patient should not partake in any physical activity other than walking. During physical therapy (2 to 10 weeks), they should do the exercises advised by their physical therapist. After physical therapy ends, they can start light- to moderate-impact exercises.
Throughout their lifetime, patients should continue to do core exercises two to three times per week. The ultimate goal is for patients to resume their normal activities (running, lifting, skiing, golfing, etc.).
Dr. Bray: We restrict patients from impact sports or heavy lifting for three months. But after the first week they can resume driving, as tolerated, with breaks. They can also resume light exercise, such as walking or riding a stationary bike, as tolerated. With periods of rest in between, most people can be up and around almost normally within one month after their surgery.
Dr. Haines: It takes 4 to 6 weeks for the implant to settle into the bones above and below, and it takes 6 to 8 weeks for patients to feel ready to begin returning to impact activities. Right after the surgery, though, they are able to walk, bend, sleep in their bed, and carry out simple tasks like showering and dressing.
Neal: Patients can do a lot of activity when recovering from home, but they need to listen to their body and limit how much twisting, bending, and lifting heavy objects they do.
SpineNation: Do patients need any special equipment during recovery?
Neal: Patients don’t normally require any special equipment to aid in their recovery at home, but each situation is different. At The CORE Institute, we urge our patients to listen to their body and consult their physical therapist about the treatment that is right for them.
SpineNation: How important is physical therapy for recovery?
Dr. Bray: Physical therapy is more important for preventing future injury to other segments of the back or correcting underlying weaknesses, than it is needed for recovery from lumbar ADR. However, a good flexibility and core program is critical to maximizing outcomes after surgery.
Dr. Haines: Physical therapy should start once the incision heals. A patient’s return to work is based on their occupation, pain level, and comfort with driving once they are off the pain medications.
Neal: We recommend that patients see a physical therapist after their surgery in order to understand which exercises will help them heal faster and which can hinder their recovery.
SpineNation: What does physical therapy after lumbar ADR involve?
Dr. Siddique: Rehab is mandatory after any spine surgery. The patient will start physical therapy two weeks after surgery. Physical therapy consists of core strengthening and non-impact exercises for two months.
Dr. Haines: I prefer that my patients begin with aquatic therapy, if possible, which is a reduced-gravity setting that puts less stress on the implant while it heals into the bones.
Our in-house physical therapy center has an aquatic treadmill, which I strongly encourage my patients to utilize. After a few weeks, patients transition from aquatic therapy to physical therapy out of the water, focusing on achieving proper motion.
Neal: After lumbar ADR surgery, patients go through outpatient orthopedic physical therapy. We focus on core stabilization training, cardiovascular conditioning, and building overall conditioning — within appropriate physical restrictions. The goal is to protect the tissues that are healing and to stabilize the implants.
At our center, our physical therapists use exercises, hands-on assessments, movement analysis, lifting education, and other treatments to improve the mobility and independence of patients recovering from lumbar ADR surgery.
Our physical therapists also work closely with a patient’s surgeon to deliver a comprehensive and tailored plan specific to their recovery and to their individual physical, recreational, and work needs.
SpineNation: How long is a rehabilitation program?
Neal: As a healthy patient reaches the 6- to 8-week recovery timeframe, and there is evidence that all healing is going to plan, physical therapy shifts toward focusing on restoring normal movement routines, including training for them to return to heavier lifting or playing sports.
In most cases, through physical therapy, it takes about 3 months to return to normal activities, and patients are considered fully healed after 6 months.
Quality of Life After Lumbar ADR
SpineNation: Is it possible for the lumbar ADR device to fail?
Dr. Bray: In general, any implant has a device failure rate, but the lumbar ADR failure rate has been low. A small number of the devices have shown delayed settling or migration, but this is rare.
The most likely occurrence is migration of the device before it bonds to the bone. So during the first few months after surgery, it's important to limit activities that involve bending or lifting.
Dr. Siddique: Anything manufactured can fail at some point. Device migration is very rare. If the ADR fails in the long-term, it’s typically because it stops moving. But that may not cause symptoms. Patients can also develop progressive facet arthropathy [degenerative arthritis which affects the facet joints on the back of the spine], which becomes painful at the level of the ADR surgery.
Degeneration of other segments in the spine happens in everyone over time, regardless of whether they have had surgery. It will take many years to figure out how much the lumbar ADR protects the adjacent segments. Having said that, given the success of the cervical ADR, my money is on the lumbar ADR being far superior than a spinal fusion.
Dr. Haines: Device failure is always a concern. However, preserving motion at the level of surgery with ADR may not add additional stress to the adjacent levels. This is something that can occur with fusion surgery due to eliminating motion at the level of the damaged disc.
Still, ADR does not reverse the aging effects already in place at the adjacent levels. There are times when the adjacent level or levels are already degenerating. It is important to educate patients about this ahead of time, because the degenerative process is likely to continue even without additional stress from their ADR surgery.
Updated: June 17, 2021