Lumbar Total Disc Replacement

What is Lumbar Total Disc Replacement? 

Lumbar Total Disc Replacement (LTDR) is a type of surgical procedure that involves removing a damaged or diseased disc in the lower part of the spine (lumbar region) and replacing it with an artificial disc. This procedure aims to alleviate back and/or leg pain while maintaining or restoring the natural motion of the spine.


Who is Suitable for Lumbar Total Disc Replacement?

Various factors can make someone suitable for a Lumbar Total Disc Replacement. They include:

  • Persistent pain: This procedure is often considered for individuals with persistent, debilitating lower back pain affecting their social, vocational and recreational activities that haven't responded to conservative treatments like physiotherapy, medication, and injections.
  • Discogenic pain: The pain must be determined to come from the disc itself, usually identified through targeted history, examination, imaging studies, as well as discography or other diagnostic tests.
  • No significant facet joint disease: Lumbar Total Disc Replacement is unsuitable for individuals with significant arthritis in the facet joints of the spine, as this can also cause lower back pain and isn't addressed by disc replacement. These patients will be better treated with fusion surgery.
  • No previous major spinal surgery: This procedure is generally not recommended for people with major surgery on their spine.
  • No spinal deformity: People with a significant spinal deformity, like scoliosis, are generally not considered good candidates for this procedure.
  • No osteoporosis: The procedure isn't typically recommended for individuals with osteoporosis, as the weak bones may not be able to support the artificial disc properly.


Benefits of Lumbar Total Disc Replacement

  • Pain Relief: The main benefit of LTDR is that it can significantly relieve chronic, debilitating lower back pain.
  • Restoration of Spine Mobility: Unlike spinal fusion, which fuses the vertebral bones and can restrict movement, LTDR aims to maintain or restore the spine's natural range of motion.
  • Reduced Risk of Adjacent Segment Disease: In fusion surgeries, the segment above or below the fusion site may experience increased stress, potentially leading to additional degeneration and subsequent surgeries. By preserving spinal mobility, LTDR can reduce this risk.
  • Quick Recovery: Patients typically recover quicker and return to normal activities after LTDR, unlike more traditional procedures like spinal fusion.


Types of Lumbar Total Disc Replacement

Various artificial discs have been developed with different designs and materials. Two main types are:

  • Metal-on-polymer includes the Prodisc or Activ-L. This artificial disc consists of metal end plates that attach to the adjacent vertebrae and a polymer (plastic) core that cushions and facilitates motion.
  • Metal-on-Metal Discs include the CHARITÉ artificial disc and the Maverick artificial disc. They have two metal end plates attached to the vertebrae and a r metal core in between.
  • Elastomeric Discs: These, like the ProDisc-L and Activ-L discs, have two metal endplates and a flexible, plastic-like core. This design aims to mimic a natural disc's movement and function closely.


Alternative Options to Lumbar Total Disc Replacement

  • Conservative Treatments: This would be the first step in treating back pain, involving physical therapy, medications, and epidural steroid injections.
  • Spinal Fusion: A traditional surgical alternative to LTDR is spinal fusion, which involves fusing the vertebrae to eliminate movement and thus alleviate pain.
  • Minimally Invasive Spine Surgery: Depending on the cause of the pain, minimally invasive procedures such as discectomy or laminectomy might be options.
  • Interventional Procedures: Some patients might benefit from nerve blocks, radiofrequency ablation, or spinal cord stimulation.


Preparation for a Lumbar Total Disc Replacement 

  • Medical Evaluation: Your surgeon will thoroughly evaluate your medical history, conduct physical examinations, and order imaging tests to confirm your pain's source and suitability for the procedure.
  • Lifestyle Adjustments: You may be asked to stop smoking, as it can impair bone healing and increase the risk of complications. If you're overweight, you may be advised to lose weight to reduce the strain on your spine and improve surgical outcomes.
  • Medication Review: Certain medications, such as blood thinners, may need to be stopped before surgery to reduce the risk of excessive bleeding. Always discuss this with your surgeon.
  • Preoperative Testing: This can include blood tests, electrocardiograms (ECG), and chest X-rays to ensure you're healthy enough for surgery and anaesthesia.
  • Pre-surgical Physiotherapy: Some surgeons recommend a course of physiotherapy to strengthen the back muscles and improve recovery outcomes.
  • Fasting: You will likely need to fast (no food or drink) for a certain period before surgery, typically from midnight the night before.


Lumbar Total Disc Replacement Procedure

  • Anaesthesia: The procedure is performed under general anaesthesia, so you'll be asleep and not feel anything.
  • Indwelling Catheter (IDC): A bladder tube will be placed to allow emptying your bladder before and during surgery. This will be removed on the first day post-operation.
  • Incision: A surgical incision is made in the lower abdomen, in the midline, typically on one side, allowing access between the rectus abdominus muscles, the retroperitoneal space and the front of the spine.
  • Blood vessel management: The large vessels at the front of the spine (aorta and inferior vena cava) are accessed between or to the side. 
  • Disc removal and preparation: The damaged intervertebral disc between the affected vertebrae is carefully removed. The endplates of the adjacent vertebrae are prepared for inserting the artificial disc.
  • Closure: The incision is closed with sutures, a pain catheter is placed and sterile dressings are applied.
  • Recovery: After the surgery, you will be moved to a recovery area, where you will be monitored until the anaesthesia wears off. You will then be transferred to a hospital room before being discharged home between 1-3 days later.


Lumbar Total Disc Replacement Recovery Plan

  • Immediate Postoperative Period: You'll likely stay in the hospital for a few days post-surgery. Pain management will be a priority, and physiotherapists will help you with early mobilisation.
  • Home Care: Keeping the surgical site clean and dry is important after discharge. Pain medication should be used as prescribed.
  • Physiotherapy: Usually starts within a few weeks after surgery, focusing on gradually strengthening your back and abdominal muscles to stabilise and support your spine.
  • Activity Moderation: You'll be encouraged to increase your activity levels gradually. However, heavy lifting or intense physical activity may be restricted for several months.
  • Regular Follow-ups: Scheduled visits with your surgeon and physiotherapist will be needed to monitor your progress and healing.


Lumbar Total Disc Replacement Prognosis

Many patients experience significant relief from back pain after an LTDR and can return to normal activities. Studies have shown that artificial disc replacement can maintain or improve spine mobility and may result in a lower likelihood of needing future spine surgeries compared to traditional spinal fusion. However, as with any surgery, outcomes can vary based on patient characteristics and surgical factors.


Lumbar Total Disc Replacement Risks

While LTDR is generally considered safe, it carries some risks, including:

  • Complications related to anaesthesia: General anaesthesia carries risks, including allergic reactions, respiratory issues, or adverse medication reactions.
  • Bleeding: Excessive bleeding during or after surgery is possible and may necessitate blood transfusion or further surgical intervention.
  • Nerve or vascular injury: There is a small risk of damaging nearby nerves or blood vessels during the procedure, which may result in neurological deficits or vascular complications.
  • Implant-related complications: The artificial disc used during LTDR may have complications such as instability, polyethylene wear or subsidence (sinking into the bone), which can cause recurrence of symptoms.
  • Infection: There is a risk of developing a surgical site infection, which may be superficial or deep and require antibiotic treatment or additional procedures.
  • Retrograde ejaculation (Men only): Rarely, the sympathetic nerves may be damaged, leading to an inability to ejaculate properly. This can lead to infertility, and if this may concern you for future family planning, it may be appropriate to take measures to have your sperm collected and frozen before the procedure. 
  • Adjacent segment disease: Instrumentation at one level of the spine can lead to increased stress placed on adjacent levels, although this is reduced compared with traditional fusion. This may lead to further symptoms and surgery being required in the future. 
  • Other general surgical risks include blood clots, pneumonia, or reactions to anaesthesia, medications or dressings.


What if Lumbar Total Disc Replacement is Delayed?

If LTDR is delayed, it might result in prolonged discomfort and activity limitation due to chronic back pain. The degenerative process may continue and possibly worsen. However, delaying this surgery doesn't generally cause additional harm to the spine, assuming conservative measures are used to manage symptoms. As always, any decision related to the timing of surgery should be discussed with your qualified spinal surgeon, considering your specific condition and circumstances.

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