Lumbar artificial disc replacement has changed the way that spine surgeons treat patients with chronic low back pain caused by a damaged spinal disk.
While the technology has come a long since the very first artificial discs were developed, this treatment continues to improve. SpineNation spoke with a number of surgeons about their approach to this motion-preserving surgery.
We spoke with Dr. Robert S. Bray, Jr., a neurological spine surgeon and founder of DISC Sports & Spine Center
in Newport Beach, California; Dr. Georgiy Brusovanik, a spine surgeon with Miami Back & Neck Specialists
in Miami, Florida; 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; and Dr. Khawar Siddique, a neurosurgeon at DOCS Spine + Orthopedics
in Los Angeles, California.
Some of the responses have been edited for brevity and clarity.
Why is lumbar artificial disc replacement (ADR) a good option for people with a disease or damaged disc in the low back?
Dr. Shifflett: With every type of musculoskeletal medicine, we're trying to restore motion, recreate a person’s natural anatomy, and get the body back to the way it used to be. That's based on a desire to alleviate pain, fix structural problems, and give people the best functional outcome.
So a disc replacement in the right patient and under the right circumstances can go a long way toward increasing your mobility and allowing you to get back to the activities that you like, earlier and more aggressively.
Ultimately, you're kind of paying it forward to yourself, because with certain interventions like spinal fusions, we worry about the adjacent disks wearing out or breaking down. Disc replacements hopefully give greater longevity to the other disks, so that you need less surgery in the future and are able to continue doing what you want to.
Are there certain people who are better suited for lumbar ADR?
Dr. Shifflett: Compared to disc replacements in the cervical spine (neck), lumbar disc replacements fit a more narrow set of patients because the biomechanical stresses on your low back are significantly different than on your neck.
The people who tend to be good candidates for lumbar ADR are typically younger patients who are active or want to remain active. If you're 50 or younger, it's more likely that you'll have the spinal anatomy and health that would allow you to be a candidate for disc replacement.
Many people are candidates for lumbar disc replacements. But where we get into the finer details is on the work-up and evaluation, whether it’s by X-ray, MRI, or CAT scan.
With imaging, you’re looking for people who have isolated disc disease at one, and in some cases two, levels, and a pretty good spine at every other level. Also, the facet joints — the little joints on the back of the spine — are not replaced in a disc replacement surgery, so those really have to be in great shape.
Dr. Brusovanik: I prefer total disc replacement for patients suffering from back pain and associated sciatica. Younger patients, same as older patients, can suffer from debilitating pain due to disc problems.
The degree of disk degeneration varies. If the disk is not so bad and the patient is suffering, disk replacement allows me to avoid the main issues associated with fusion, e.g. adjacent-level disk degeneration.
In addition, if the facet joints between the vertebrae are okay and the disk has maintained at least seven millimeters of height, disk replacement is the best solution.
How important is patient selection to the success of lumbar ADR?
Dr. Bray: Lumbar ADR is not for every patient. Caution is needed in selection as a bad outcome will result in the need for further surgery. The lumbar ADR motion device should be restricted to injury or degeneration that is isolated to the disc alone.
Many low back problems involve multiple areas of the joint, with additional problems of arthritic changes in the posterior facet joints, stenosis, tilt or scoliosis of the segments — or, in general, multiple degenerative segments. These patients do not do well with lumbar ADR and the likelihood of retained pain is much higher.
Careful selection of the patient and a workup with MRI, CT, and X-rays to rule out instability are critical. When the appropriate patient and reason for the surgery are considered carefully, the outcome can be excellent, with a full return to normal. Also, second opinions should be encouraged, in order for the patient to hear all sides of this developing field.
Dr. Shifflett: Surgeons have to not get greedy with lumbar disc replacements, meaning not overly stretch the indications. If you put a disc replacement in someone who should not have gotten one, and this replacement fails — which thankfully is a very rare phenomenon, mainly because we're indicating people really well—it really is a nightmare scenario to take a disc replacement out. So the bulk of the work comes at the beginning by making sure a patient is a good candidate.
What kinds of things do you talk with potential patients about?
Dr. Siddique: We take time to educate each prospective patient so they can make an informed decision on how to proceed. This education includes showing the patient a model of the ADR device, explaining how it works, and showing how it differs from fusion surgery.
Dr. Haines: Patients often come to me with knowledge about this motion-preserving procedure and are hopeful this will be an option for them.
While it’s true that not every patient will be a candidate for ADR, my approach is to consider all surgical options and educate patients about why they are or are not a candidate, especially if it’s a procedure they desire.
It is also important to counsel patients on the immediate postoperative restrictions on heavy lifting and aggressive activities like sports, in order to avoid device failure.
If a lumbar ADR isn’t successful, can it be corrected?
Dr. Bray: While a revision and removal of the lumbar ADR device can be done, the risks associated with re-exposure through the same area are higher for vascular or other organ injuries. Simply fusing over from the back of the spine can be done, but again with a significant failure rate.
Updated: June 5, 2021