Background Context: One of the main postulated basic principles of total disc replacement (TDR) is the preservation of flexion/extension ability. In neutral position the ideal disc prosthesis should not stay in maximal possible extension which would imply an impingement of the prosthesis. An impingement would cause shear strains on the prosthesis endplates which probably accelerate loosening. Moreover an additional extension ability from the neutral position would indicate no impingement in the facet joints in neutral position and a physiological movement capability.

Purpose: The purpose of study was to evaluate a possible impingement of the prosthesis or facet joints after TDR in neutral position.

Study design: Prospective evaluation of radiological outcome measures after total disc replacement.

Patient sample: The patients (19 female, 10 male) ranged from 29 to 56 years of age (mean: 42.46.5 years). The mean follow up interval averaged 13.2 months (range: 6 – 35 months). The diagnosis of degenerative disc disease was confirmed by MRI (black disc) and discography (positive „Memory pain“). Pain relief after facet joint infiltration was an exlucsion criteria. All patients had a single-level disc replacement (Prodisc II, Spine Solutions) with the same angulation (6).

Outcome measures: Evaluation of a possible impingement of the prosthesis and impingement of facet joints in neutral position.

Methods: A computer based analysis of pre- and postoperative lateral X-rays in neutral position and dynamic x-rays. The angulation of prosthesis in neutral position and the extension ability in dynamic x-rays were measured.

Results: 15 patients showed no extension ability on dynamic x-rays and 10 of these 15 patients had an impingement with maximum extension of the prosthesis on x-rays in neutral position. In the remaining 14 patients the extension ability averaged pre-/postoperatively 2.3/1.3 (p=0.115). In 4 of the 14 patients the pros-thesis showed an impingement in maximum extension and in 10 patients the prosthesis was not in maximum possible extension.

Conclusion: Due to the constrained design of the Pro-Disc an impingement is possible and was recognized in nearly 30% of the cases. The imbalance of flexion vs extension bending moments with increase in extension bending moments due to resection of the anterior longitudinal ligament and anterior anulus seems to be a possible explanation. It still remains unclear if an impingement will result in facet joint protection or will trigger a loosening of the implant. A prosthesis design which preserves the anterior longitudinal ligament would be probably a possible solution.

Background Context: Total disc replacement (TDR) gained enormous popularity as a treatment option for symptomatic degenerative disc disease in the last few years. But the impact of the prosthesis design on the segmental biomechanics in most instances still remains unclear. As TDR results in a distraction of the capsuloligamentous structures, the disc height seems to be of crucial importance for the further biomechanical function of the operated level. Yet the biomechanical role of disc height after TDR still remains unclear.

Purpose: The purpose of study was to evaluate the influence of prosthesis height after total disc replacement on: 1) the sagittal balance and 2) the range of motion.

Study design: A radiological and an in-vitro biomechanical study.

Method: 6 human, lumbar spines L4–L5 were tested in vitro.The segmental lordosis of the specimen were measured on plain radiographs and the range of motion was measured for all six degrees of freedom with a previously described spine tester. The segmental lordosis and the range of motion at level L4–L5 was evaluated for following settings: 1) intact state 2) after implantation of a prosthesis with 5mm endplate 3) after implantation of a prosthesis with 7mm endplate.

The prosthesis used was a prototyp and had a constrained design with a ball and socket principle.

Results: Even the implantation of the lowest possible prosthesis height (5mm endplate) resulted in an increase of segmental lordosis (intact: 6.9; 5mm endplate: 8.8; p=0,027). Using a higher prosthesis (7mm endplate) further increased the segmental lordosis (10.5, p=0.041). The implantation of the lowest prosthesis resulted in significant increase of movement capability compared to the intact status for flexion-extension (8.6 vs 11.4; p=0.046) and axial rotation (2.9 vs 5.1; p=0.028). Lateral bending did not changed significantly (9.4 vs 8.6; p=0.345). The implantation of the higher prosthesis (7mm endplate) resulted in similar movement capability compared to intact status for flexion-extension (8.4 vs 8.6; p=0.116) and axial rotation (3.3 vs 2.9; p=0.600). Lateral bending decreased significantly compared to the intact status (5.1 vs 8.6; p=0.028).

Conclusion: Total disc replacement with the lowest prosthesis height inherently increases segmental lordosis. Further increase of disc height results in a significant enhancement of segmental lordosis by decreasing the range of motion for all three degrees of freedom. Yet, methods for scheduling the ideal disc height preoperatively, to provide a physiological lordosis thereby maintaining physiological range of motion postoperatively, seems not to be established already.