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About cervical disc replacement. These cages may have lower subsidence rates and, in addition, their usage allows easier assessment of fusion rates on radiographs.
However, some debate exists on the enhancement by titanium implants for bone incorporation into the implant as opposed to PEEK, which is thought to stimulate fibrous, non-mineralised tissue. Iliac crest graft has been long been considered the gold standard for spinal fusion, but it has several disadvantages compared to currently available alternatives.
These include associated donor site morbidity, increased blood loss, prolonged hospital stay and often limited graft volume in older patients. Bone graft substitutes can be broadly classified into two categories: 1 There are osteoinductive agents that induce formation of bone, and these include agents such as recombinant human bone morphogenetic protein, bone marrow aspirate etc.
Allograft yields comparable fusion rates to autograft without donor site morbidity [ 81 ], but with an increased cost and a potential for infectious disease transmission.
Demineralised bone matrix DBM , while still on-going investigation regarding its efficacy, has had early positive reports with high fusion rates [ 82 ]. Currently DBM is used as mass extender, combined with local autologous bone graft, rather than used in isolation.
Bone morphogenetic proteins BMPs are reported to be at least as effective as autologous bone graft substitutes or extenders [ 83 ]; however, there are concerns regarding their safety. With BMPs, extensive osteolysis resulting in graft subsidence and cage migration has been reported [ 84 ]. Higher rates of retrograde ejaculation have also been reported when used in ALIF, thought to be due to the inflammatory response associated with release of cytokines due to BMP in closed vicinity of the parasympathetic plexus [ 85 ].
However, Scott-Young [ 86 ] reported the incidence of the above to be only 0. Although not proven, there are theoretical concerns for a cancer when applying exogenous transforming growth factors such as BMPs [ 88 ]. A multitude of other graft substitutes and biological mediators are being introduced into clinical practice, but are beyond the scope of this review. Lumbar disc arthroplasty LDA has been increasingly adopted into routine spinal practice since its introduction in [ 89 ].
There is no current conclusive evidence of LDA superiority in the long-term in level I studies and the surgery is technically more challenging. However, mid-term studies of LDA have reported satisfactory clinical results and implant survival and comparable complication profiles to fusion [ 93 , 94 ] with proponents of LDA supporting its use for several theoretical and clinical advantages. The major driver for development of this technique has been the motion preserving philosophy as an alternative to fusion with theoretically lower risk for ASD.
However, it may be unfair to compare ASD to fusion procedures indiscriminately as the anterior approach itself has been reported as being associated with lower rates of ASD [ 96 , 97 ].
Other advantages cited for LDA include having no need either for grafting or screw based fixation [ 98 ] and having a lower reoperation rate with at least equivalent rates of return to work and clinical outcomes to fusion at mid-term [ 99 ]. In one study, David [ ] concluded that the "rate of reoperation secondary to adjacent segment disease is ten times lower than the rates reported in the literature for fusion. Studies of modern LDAs have also reported faster patient recovery, higher satisfaction in the short-term compared to the fusion techniques [ 95 ].
High rates of return to work and lower long-term unemployment have also been reported as other benefits for the LDAs [ 90 ]. These results may also be further improved with focused physiotherapy [ ]. Disadvantages cited in the literature are the disappointing outcomes from some of the earlier designs perhaps confounded also by patient selection , the lack of long-term outcomes of modern designs, the lower versatility in indications compared to fusion and the difficulty in acquiring adequate surgical expertise in performing this procedure.
Many of the cited complications such as implant extrusion and vascular injury can be linked to inadequate training, improper sizing and lack of confirmation of satisfactory placement on imaging [ ] with implant impingement linked to the aforementioned factors [ ]. Design variables relating to constraint and core mobility have also been shown to alter wear and force transmission in in vitro studies [ , ].
Earlier, some of the initial LDA designs led to inconsistent outcomes [ ]. For example, the cumulative survival for the Acroflex LDA was only Etiology of the implant failure reported by authors [ ] included failure of osteointergration, midsubstance elastomeric tears and osteolysis.
These can be broadly separated into those related to the anterior surgical approach e. Device failures necessitating repeat operations have been reported at 5. Salvage procedures involving conversion to spinal fusion are technically demanding; however, they appear to improve outcomes modestly in failed LDA [ ].
Metal ion and polyethylene wear particle release from the articulation interface also add to the disadvantages [ ]. Limited versatility exists compared to fusion techniques as there are relative contraindications for three or more lumbar levels, high lumbar disease above L3 , spondylolisthesis, severe ligamentous instability, facet degeneration, adjacent prior fusion and conditions affecting bony healing e.
Despite good results for single-level LDA, there is evidence to suggest that the two-level arthroplasty constructs have comparatively poorer outcomes and have an increase in the rate of complications compared to the two-level fusions [ 94 , , ]. However, conflicting data exists with some authors reporting good outcomes with two-level LDA [ ] and outcomes comparable to single-level LDA [ , , ], and thus calling into question the role of design and constraint of the implant itself [ , ].
The poorer outcomes were in fact thought to be due to increased segmental instability and postoperative facet and sacroiliac pain from increased loading [ 94 ]. However, there are currently limited published results in this area. This approach currently has only been reportedly used for two-level disease in the literature, with ALIF performed on the more severe usually inferior level and LDA on the less severely affected or hypermobile level.
Hoff et al. For the same group of patients, however, symptoms derived from parasympathetic changes were noted in only 9. Kasis et al. Long-term studies are required in this area to assess viability of this technique in addressing multiple-level LDDD and, specifically, to assess whether these techniques are superior clinically to multiple-level fusion. This would need assessing not just the clinical outcomes but also the complication profiles, ASD, revision rates and economic costs.
Stem cell therapy combined with tissue engineering approaches for effective delivery into the degenerative disc has been proposed as a minimally invasive alternative to manage LBP. This therapy focuses on the restoration of extracellular matrix of the "damaged" disc where autologous nucleus pulposus cells or bone marrow derived mesenchymal stem cells are harvested, expanded in vitro and delivered into the nucleus pulposus, with the hope of stabilizing or reversing LDDD pathology.
In a recent systematic review evaluating the effectiveness of a tissue engineered approach in the treatment of DDD in controlled animal studies, the technique has shown promising results in improvement in disc height and MRI signal intensity but none of the studies showed restoration to the properties of a healthy disc [ ]. Human trials on the use of mesenchymal stem cells from autologous bone marrow in patients with LDDD are currently on-going in multiple centres.
Finally, short term results of intradiscal pulsed radiofrequency have been promising and have shown not to be significantly different from intradiscal electrothermal therapy at 6 months [ ]. While LDDD is extremely common, the role of operative treatment and the choices of which operative treatments to select for which patients remain controversial. There is scientific evidence to support surgery in carefully selected patients who have failed to respond to appropriate non-operative treatments over a minimum of six months and do not exhibit any substantial psychosocial overlay.
Confirming a clinical diagnosis of discogenic back pain with supportive imaging is, however, crucial for targeted treatment of the condition with either disc clearance and fusion or LDA.
As revision procedures for LDA can be complex with expenses considerable, long-term studies demonstrating superiority over fusion are required before this technique may be recommended to replace fusion as the gold standard. While early evidence suggests comparable results between single-level LDA and fusion, the role of multilevel LDA has not yet been fully scrutinized in comparison to multiple-level fusion.
There is no current long-term evidence that motion-sparing LDA reduces symptomatic adjacent segment disease or robust long-term evidence for hybrid techniques combining arthroplasty and fusion.
Should multiple-level LDA or hybrid constructs demonstrate long-term evidence in line with their promising short- to mid-term outcomes, they may surpass fusion surgery as the treatment of choice for patients with multilevel LDDD who meet indications for either fusion or LDA. Novel and minimally invasive fusion techniques continue to be developed in expectation of improving clinical outcomes through minimizing soft-tissue damage.
However, the only long-term evidence for predictably successful clinical outcomes currently exists in carefully selected patients undergoing open fusions and employing correct grafting and stabilization techniques. As such, the best approach for fusion remains debatable. In addition, the more complex, technically demanding and higher risk interbody fusion techniques, such as ALIF or TLIF, might be advocated for younger, active patients or patients with a higher risk of non-union.
We would like to thank Ass. Matthew Scott-Young Gold Coast Spine, Queensland, Australia for enlightening perspectives on anterior approach surgery and lumbar disc arthroplasty.
Conflict of Interest: No potential conflict of interest relevant to this article was reported. National Center for Biotechnology Information , U. Journal List Asian Spine J v. Asian Spine J. Published online Aug Find articles by Yu Chao Lee. Find articles by Mario Giuseppe Tedesco Zotti. Find articles by Orso Lorenzo Osti. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding author: Mario Giuseppe Tedesco Zotti. Received Feb 9; Accepted Mar This article has been cited by other articles in PMC.
Abstract Lumbar degenerative disc disease is extremely common. Keywords: Low back pain, Disc degeneration, Lumbar fusion, Disc replacement, outcome. Open in a separate window. A schematic demonstrating nerve ingrowth of sinuvertebral nerves into the outer annulus, a process that is increased and upregulated in the case of degenerative disc disease. Clinical Presentation Low back pain lumbago generally manifests itself as prevalent axial lumbar back pain with radiation to the buttock region.
Imaging Plain radiographs in patients with LDDD may demonstrate reduced disc height and in later stages, end plate sclerosis, osteophyte formation and foraminal stenosis. Sagittal T2-weighted magnetic resonance imaging demonstrating Modic hyperintense end plate changes with increased signal in annulus of a lumbar disc seen in degenerative disc disease.
There is dye extravasation and evidence of internal disruption of the disc D. Operative Treatment Operative treatment for lumbar back pain has long been a topic of debate with regards to its merits over non-surgical treatments. Fusion for LDDD The rationale behind arthrodesis of a selected lumbar spinal segment is to reduce the nociceptive load by wide removal of the disrupted disc material and the stabilization of the affected motion segment s that are thought to be causing pain due to continued motion of the involved sensitized levels.
Posterolateral fusion Posterolateral fusion PLF targets only the posterior elements. Interbody fusion Interbody fusion can be performed with either a posterior or anterior approach. Lateral and anteroposterior lumbar plain radiographs demonstrating transforaminal lumbar interbody fusion with titanium cage and posterior instrumentation for lumbar degenerative disc disease.
Minimally invasive surgery fusion The minimally invasive surgery MIS fusion techniques have been developed that allow access while limiting soft tissue dissection and muscle damage. Comparison of fusion techniques Over the past few decades, there has been an explosion of different instrumentation types, fusion methods and bone graft sources developed to improve fusion rates and improve functional outcomes.
Preoperative magnetic resonance imaging of a year-old male who had recurrent disc prolapse with radiculopathy following an initial discectomy A, B. Postoperative radiographs of anterior lumbar interbody fusion performed for the same patient demonstrating progression of fusion at 6-month follow-up C, D.
Interbody and graft options Previously, tricortical blocks of autologous iliac crest bone graft were used in surgery. Lumbar disc arthroplasty Lumbar disc arthroplasty LDA has been increasingly adopted into routine spinal practice since its introduction in [ 89 ].
Preoperative magnetic resonance imaging MRI of a year-old woman with chronic axial low back pain with evidence of degenerative disc disease on MRI A and concordant reproduction of symptoms of provocative discography B.
Postoperative radiographs demonstrating lumbar disc arthroplasty with flexion and extension C, D as well as anteroposterior views E. Novel technologies Stem cell therapy combined with tissue engineering approaches for effective delivery into the degenerative disc has been proposed as a minimally invasive alternative to manage LBP.
Conclusions While LDDD is extremely common, the role of operative treatment and the choices of which operative treatments to select for which patients remain controversial. Acknowledgments We would like to thank Ass. Footnotes Conflict of Interest: No potential conflict of interest relevant to this article was reported. References 1. Spine Phila Pa ; 26 — Cost-effectiveness of lumbar fusion and nonsurgical treatment for chronic low back pain in the Swedish Lumbar Spine Study: a multicenter, randomized, controlled trial from the Swedish Lumbar Spine Study Group.
Spine Phila Pa ; 29 — Disability resulting from occupational low back pain. Part I: What do we know about primary prevention?
A review of the scientific evidence on prevention before disability begins. Spine Phila Pa ; 21 — Choi YS. Pathophysiology of degenerative disc disease. The degenerated lumbar intervertebral disc is innervated primarily by peptide-containing sensory nerve fibers in humans.
Spine Phila Pa ; 31 — Innervation of the intervertebral disc. Neurocirugia Astur ; 24 — ISSLS prize winner: disc dynamic compression in rats produces long-lasting increases in inflammatory mediators in discs and induces long-lasting nerve injury and regeneration of the afferent fibers innervating discs: a pathomechanism for chronic discogenic low back pain.
Spine Phila Pa ; 37 — Resolving discogenic pain. Eur Spine J. The pathophysiology of degenerative disease of the lumbar spine. Orthop Clin North Am. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation.
J Bone Joint Surg Am. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects. Lumbar disc degeneration induces persistent groin pain. Multivariable analysis of the relationship between pain referral patterns and the source of chronic low back pain.
Pain Physician. Management of symptomatic lumbar degenerative disk disease. J Am Acad Orthop Surg. Incidence and course of low back pain episodes in the general population. Spine Phila Pa ; 30 — Exercise therapy for low back pain. Cochrane Database Syst Rev. Abnormal findings on magnetic resonance images of the cervical spines in asymptomatic subjects. Spine Phila Pa ; 40 — Magnetic resonance classification of lumbar intervertebral disc degeneration.
Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Vertebral endplate signal changes Modic change : a systematic literature review of prevalence and association with non-specific low back pain.
The expression of tumor necrosis factor-alpha and CD68 in high-intensity zone of lumbar intervertebral disc on magnetic resonance image in the patients with low back pain.
Spine Phila Pa ; 36 :E—E Zhou Y, Abdi S. Diagnosis and minimally invasive treatment of lumbar discogenic pain: a review of the literature. Clin J Pain. Gill K, Blumenthal SL. Functional results after anterior lumbar fusion at L5-S1 in patients with normal and abnormal MRI scans.
Spine Phila Pa ; 17 — Provocative discography screening improves surgical outcome. Wien Klin Wochenschr. Degenerative disc disease treated with combined anterior and posterior arthrodesis and posterior instrumentation. Once the disc space is exposed, the surgeon meticulously releases the deforming forces of the spine and prepares the bones for fusion.
The damaged disc is removed and the specialized cage is implanted. These far lateral techniques to access the spine may be combined with posterior approaches to obtain complete reconstruction of the spine. Alternatively, the anterior approach from a far lateral technique may be done as a stand-alone procedure for certain patients. One benefit of the lateral approach is that incisions made in this position can be significantly smaller than incisions of the traditional approaches.
In addition, approaching the spine from a lateral incision avoids many of the vital organs, muscles, and vessels that may be disrupted by the traditional approaches, decreasing the likelihood of post-operative abdominal muscle weakness and hernias. As a result, patients who undergo surgery using this far lateral approach to the lumbar spine commonly experience less blood loss and tissue trauma, improved mobilization, and faster recovery times.
Usually these symptoms are temporary and resolve within a few months after the surgery. Patients should discuss with their doctor which technique is right for them. Background The spine consists of 33 bones called vertebrae that provide body structure and protect the spinal cord Figure 1. Traditional Techniques There are several traditional approaches to access the spine for an interbody fusion. Lateral Approach A more recently developed lateral approach from the side may also be used and offers several advantages over the traditional approaches while maintaining the benefits of an anterior exposure of the spine.
Benefits and Complications of the Lateral Approach Benefits of Lateral Approach One benefit of the lateral approach is that incisions made in this position can be significantly smaller than incisions of the traditional approaches. In-person and virtual physician appointments. Book online.
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