J Korean Soc Spine Surg.  2008 Jun;15(2):115-131. 10.4184/jkss.2008.15.2.115.

Current Status of Lumbar Total Disc Replacement (TDR)

• Lee CS

• KMID: 2097842
• DOI: http://doi.org/10.4184/jkss.2008.15.2.115

Abstract

Fusion surgery remains the gold standard for surgical treatment of lumbar degenerative disc disease (DDD). However, fusion surgery has many intrinsic problems related to altered biomechanics and balance. Total disc replacement (TDR) has received increasing attention over the last several years because of its capacity for both functional and symptomatic improvement and its avoidance of problems intrinsic to fusion surgery. Artificial disc replacement is not a new concept, the first attempts having been undertaken in the early 1950s. However, during the past 15 years, considerable advances have been made, with clinical success noted in several prospective randomized studies and mid-long term retrospective studies. Proper patient selection and surgical technique are key factors in achieving a successful outcome. TDR plays a limited role and has limited indications for replacing fusion surgery in patients with lumbar DDD. The main goal of TDR is restoration of normal intervertebral disc function. Varying degrees of motion can be restored through TDR; however, the pattern of motion and center of rotation are not physiologic. In spite of some favorable reports, many TDR-related problems remain to be solved. Successful disc function is measured not only in terms of quantity of motion, but also in terms of quality of motion and shock energy absorption capacity. For successful repair to be declared, facet unloading should be achieved, and fatigue strength should be improved. New procedures should be characterized by a reduction in the technical problems of implantation and retrieval. We expect that the next generation of TDR will overcome the limitations of first generation TDR. This therapeutic modality shows much promise for the treatment of lumbar DDD.

Keyword

Lumbar spine; Total disc replacement

MeSH Terms

Absorption
Biomechanics
Dichlorodiphenyldichloroethane
Fatigue
Humans
Intervertebral Disc
Patient Selection
Shock
Total Disc Replacement
Dichlorodiphenyldichloroethane

Figure

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  Fig. 1. IAR according to the design of TDR. In Prodisc, av. IAR parameters were not significantly modified by disc replacement. IAR path (centrode) had a vertically oriented centrode. In Charite, IAR centrode had a vertical distribution in flexion/extension moving up into flexion (cited from ref.16)

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  Fig. 2. Patterns of load-displacement curve after Charite TDR. The pattern of intervertebral load-displacement curves for implanted segments was different from the intact case in 8 of 10 TDRs; instead of a gradually changing motion pattern of a normal lumbar segment, the TDR displayed regions of both relatively small and relatively large changes in angle with gradual moment application. (cited from ref. 17)

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  Fig. 3. Endplate geometry for the implantation of TDR. (A) is the best type, however, it has collapsed disc space and is difficult to distract. It is sometimes difficult to insert the implant deeply in Type (B). Biconcave shaped endplate shows mismatching with implant.

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  Fig. 4. Typical DDD which shows vertical instability. This is the best indication for TDR.

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  Fig. 5. Angular mismatching between vertebral and prosthetic endplate

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  Fig. 6. Heterotopic ossification after lumbar TDR. Grade 3 HO in front of the implant which limits ROM.

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