Abstract
Introduction: Prosthetic devices have been developed to partially or totally replace symptomatic discs. Potential postoperative complications include infection, mechanical failure, loss of fixation, and neurological irritation or deficit. In the event of a complication, a sound surgical salvage strategy can result in a satisfactory outcome for the patient.
Methods: The study is a retrospective review of five revision cases in patients implanted with the third-generation Charité artificial disc prosthesis. The study involves a series of 182 patients since 1997, performed by a single surgeon. Of the 182 cases, 5 (2.7%) required surgical revision. The outcome measures used included back and leg VAS, Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (R-MD), and patient self-assessment of outcome.
Results: Patient #1 had total disc replacement (TDR) at L3-4 and L4-5 and developed an early anterior sub-luxation at L3-4. The original device was removed and a new prosthesis inserted. Patient #2 had TDR at L4-5 and L5-S1 and experienced a core dislocation at L5-S1 resulting in a left iliac vein obstruction. This patient had an inferior vena cava umbrella with removal of the prosthesis and conversion to ALIF. Patient #3 had TDR at L4-5 and L5-S1 and experienced increased L5 radicular pain due to over distraction at L5-S1. This patient underwent removal of the prosthesis and conversion to instrumented circumferential fusion. Patient #4 had TDR at L5-S1 and experienced a core dislocation. The prosthesis was removed and an ALIF was performed. Patient #5 had TDR at L5-S1 and developed a spondylolisthesis secondary to progression of facet arthropathy. The prosthesis remained in situ and was supplemented with an instrumented posterolateral fusion. Mean back VAS was 4.2 (0–7). Mean leg VAS was 2.1 (0–7). Mean ODI was 32.4 (0–58). Mean R-MD was 11.4 (1–18). Patients were asked to rate their satisfaction with their revision outcome with choices of excellent, good, satisfactory, or poor. Four rated their outcome as excellent and one as good. Two patients suffer from the significant co-morbidity of rheumatoid arthritis and one is in early postoperative phase.
Discussion: Considerable scepticism exists about the advantages of total disc replacement and significant attention has been given to revision procedures and complications. A surgical revision rate of 2.7% from a single surgeon’s experience was reported. This rate is well below the rate suggested in the literature in relation to lumbar fusion. Careful patient selection and pre-operative planning remain paramount in avoiding the need for revision. As with other types of spinal surgery, a reliable and predictable surgical revision strategy is necessary to manage complications.
The abstracts were prepared by I. B. McPhee. Correspondence should be addressed to the Spine Society of Australia Secretariat, The Adelaide Centre for Spinal Research, Institute of Medical and Veterinary Science, PO Box 14, Rundle Mall, Adelaide SA 5000, Australia.
