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Artificial Lumbar Disc Surgery | American Association of Neurological Surgeons

Low back pain is one of the leading causes of disability worldwide. More than 2/3 of the population will have an episode of low back pain in their lifetime. This can affect one’s work and limit activity. There are many causes of low back pain, including arthritis of the joints in the spine, disc herniation, instability and degenerated discs, also known as . It is important to identify the primary cause of the pain to determine the appropriate treatment. Disk replacement surgery in the low back, also known as , is an option designed to remove and replace a worn or damaged disc that has become painful and debilitating.

A doctor does a thorough evaluation to try and determine the primary cause of back pain. This includes a detailed history and physical exam, which may focus on which body positions cause or reproduce pain.

Other tests doctors order include x-rays, magnetic resonance imaging (MRI) and computed tomography (CT). Most often, prior to recommending surgery, the doctor will assess the patient’s bones and discs with at least two of these imaging techniques.

Doctors may also order a provocative discogram to help decide if the worn or damaged disc seen on imaging is the cause of the pain.

Non-surgical treatment options for discogenic back pain include medications to relieve pain, physical therapy (including traction therapy), spinal injections, bracing, alternative therapies (such as acupuncture) and lifestyle modifications.

Indications for Surgery

Artificial disc surgery is an alternative to spinal fusion surgery, a common operation performed for low back pain from a symptomatic degenerated disc. Pitfalls to fusion surgery include improper healing, also known as pseudarthrosis, and stress on the spinal levels above and below the fusion. Artificial discs, which gained FDA approval in the early 2000s, were created to avoid these potential consequences of fusion surgery. If there is a single painful degenerated disc for more than six months and it has not responded to physical therapy or other conservative measures, like anti-inflammatories, the patient may be a candidate for artificial disc surgery.

Goals of Surgery

The goals of artificial lumbar disc surgery are to: 1) remove the diseased disc; 2) restore normal disc height; 3) decrease discogenic back pain; 4) preserve motion in the affected vertebral segment; and 5) improve patient function. In comparison to spinal fusion surgery, potential benefits of artificial disc technology may include quicker recovery time, more spine mobility after surgery, less stress on adjacent discs and no need to harvest and use a bone graft.

Surgical Procedure

During surgery, the patient is under general anesthesia and an incision is made in the abdomen. Through this opening, the affected disc is removed and replaced. The average postoperative hospital stay is about three to four days.

• Need for additional surgery to remove or replace the implant
• Allergic reaction to the implant materials
• Bleeding or blood vessel problems
• Implants that bend, break, loosen or move
• Incision problems, including infection
• Male sexual dysfunction
• Pain or discomfort
• Side effects from anesthesia
• Slow intestinal movement
• Spinal cord or nerve damage
• Spinal fluid leakage/tears of the dura (a layer of tissue covering the spinal cord)

There is still debate among the medical community about the efficacy of artificial lumbar disc surgery. In many of the pivotal trials, patients who had artificial discs implanted saw improvements in their back pain and a lowering of their disability after surgery, but the difference in improvement between the artificial disc and a standard fusion surgery was not considered meaningful.

There is also concern over the durability of these implants. In several documented cases, the artificial disc slipped out of place for undetermined reasons, which is a significant cause for concern. In addition to dislocation or migration, there is also concern about the long-term wear of the metal. Load-bearing implants that allow motion have been shown to potentially generate wear debris over time and the long-term effects of wear debris on the spine are currently unknown. Long-term patient monitoring is essential to properly assess how effective and safe artificial disc surgery is in comparison to spinal fusion surgery.

• Nie, H., Chen, G., Wang, X., & Zeng, J. (2015). Comparison of Total Disc Replacement with lumbar fusion: a meta-analysis of randomized controlled trials. J Coll Physicians Surg Pak. 25(1), 60-7.
• Yajun, W., Yue, Z., Xiuxin, H., & Cui, C. (2010). A meta-analysis of artificial total disc replacement versus fusion for lumbar degenerative disc disease. European Spine Journal, 19(8), 1250-1261.
• Ding, F., Jia, Z., Zhao, Z., Xie, L., Gao, X., Ma, D., & Liu, M. (2016). Total disc replacement versus fusion for lumbar degenerative disc disease: A systematic review of overlapping meta-analyses. European Spine Journal, 26(3), 806-815.
• Formica, M., Divano, S., Cavagnaro, L., Basso, M., Zanirato, A., Formica, C., & Felli, L. (2017). Lumbar total disc arthroplasty: Outdated surgery or here to stay procedure? A systematic review of current literature. Journal of Orthopaedics and Traumatology, 18(3), 197-215.

• Yale Medicine. (2017). For a Cross-Country Skier, Disk Replacement Surgery Ends a Battle with Back Pain.
• BMJ. (2019). Discogenic low back pain.