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Lumbar Total Disc ReplacementSeven to Eleven-Year Follow-Up
Patrick Tropiano, MD1; Russel C. Huang, MD2; Federico P. Girardi, MD2; Frank P. CammisaJr., MD2; Thierry Marnay, MD3
1 Department of Orthopaedic Surgery, Hôpital CHU Nord, Chemin des Bourrelly, 13915 Marseille CEDEX 20, France
2 The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for R.C. Huang: russelhuang@yahoo.com
3 Department of Orthopaedic Surgery, Clinique du Parc, 50 Rue Emile-Combes, Boite Postal 20, 34171 Castelnau-le-Lez, France
View Disclosures and Other Information
A video supplement to this article is available from the Video Journal of Orthopaedics. A video clip is available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Spine Solutions. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Spine Solutions). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Clinique du Parc, Castelnau-le-Lez, France

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Mar 01;87(3):490-496. doi: 10.2106/JBJS.C.01345
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Background: Symptomatic lumbar degenerative disc disease is a challenging entity to treat. The results of arthrodesis may be compromised in the short term by pseudarthrosis and in the long term by pain at the iliac-crest donor site and by junctional degeneration. Total disc replacement has the potential to provide long-lasting relief to these patients. The purpose of this study was to present the clinical and radiographic results assessed seven to eleven years following a Prodisc total lumbar disc replacement.

Methods: Sixty-four patients had single or multiple-level implantation of a total lumbar disc replacement between 1990 and 1993. The mean duration of follow-up was 8.7 years. Clinical results were evaluated by assessing preoperative and postoperative lumbar pain, radiculopathy, disability, and modified Stauffer-Coventry scores. Preoperative and postoperative radiographs were evaluated as well. Subgroup analysis was performed to determine if gender, an age of less than forty-five years, previous surgery, or multilevel surgery had an effect on outcome.

Results: At an average of 8.7 years postoperatively, there were significant improvements in the back-pain, radiculopathy, disability, and modified Stauffer-Coventry scores. Thirty-three of the fifty-five patients with sufficient follow-up had an excellent result, eight had a good result, and fourteen had a poor result. Neither gender nor multilevel surgery affected outcome. An age of less than forty-five years and prior lumbar surgery had small but significant negative effects on outcome. Radiographs did not demonstrate loosening, migration, or mechanical failure in any patient. Five patients had approach-related complications.

Conclusions: The Prodisc lumbar total disc replacement appears to be effective and safe for the treatment of symptomatic degenerative disc disease. Gender and multilevel surgery did not affect the outcomes, whereas prior lumbar surgery or an age of less than forty-five years was associated with slightly worse outcomes. Longer follow-up of this cohort of patients and randomized trials comparing disc replacement with arthrodesis are needed.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Russel C. Huang
    Posted on April 21, 2005
    Dr Huang and Colleagues respond to Dr. Theruvil, et al
    Hospital for Special Surgery

    To the Editor:

    We thank Dr.Mundlur and colleagues for their interest in our article. It does indeed appear that maintenance of segmental motion is critical to prevent adjacent segment degeneration (ASD). The radiographic outcomes of the patients in our study were reported separately[1]. The mean prosthetic flexion- extension range of motion (ROM) was 3.8 degrees at mean 8.7 years. The incidence of radiographic (not symptomatic) ASD was 24%. Mean TDR motion in patients without ASD was 4.7 degrees versus 1.6 degrees in patients with ASD (p <_0.035. statistical="statistical" analysis="analysis" with="with" the="the" small="small" numbers="numbers" available="available" failed="failed" to="to" show="show" a="a" significant="significant" correlation="correlation" between="between" radiographic="radiographic" asd="asd" and="and" clinical="clinical" outcome.2="outcome.2" p="p" /> Deeper investigation into radiographic ASD after TDR showed that in this cohort of patients, those with TDR ROM greater than or equal to 5 degrees had a 0% prevalence of ASD at 8.7 years [3], well below the rate of ASD seen after fusion. These data suggest that motion preservation has the ability to reduce the incidence of ASD. While we are disappointed in the relatively low ROM achieved by this first-generation Prodisc implant, the fact that maintenance of ROM seems to prevent ASD points to the need for further optimization of implant designs to maximize motion.

    Difficulty implanting the SB Charite device in multilevel cases was not directly observed in this study of the first-generation Prodisc implant, but was reported separately by Cinnotti et al.[4]


    Patrick Tropiano, Russel C.Huang, Federico P Girardi, Frank P. Cammisa, Jr., Thierry Marnay


    1. Huang RC, Girardi FP, Cammisa Jr FP, Tropiano P, Marnay T. Long- term flexion-extension range of motion of the prodisc total disc replacement. J Spinal Disord Tech 2003;16:435-40.

    2. Huang RC, Girardi FP, Cammisa Jr FP, Lim MR, Tropiano P, Marnay T. The relationship between range of motion and outcome in lumbar total disc replacement at 9-year follow-up. North American Spine Society 19th Annual Meeting. Chicago, IL, 2004.

    3. Huang RC, Girardi FP, Lim MR, Cammisa Jr FP, Tropiano P, Marnay T. Range of motion and adjacent level degeneration after lumbar total disc replacement. Scoliosis Research Society 39th Annual Meeting. Buenos Aires, Argentina, 2004.

    4. Cinotti G, David T, Postacchini F. Results of disc prosthesis after a minimum follow-up period of 2 years. Spine 1996;21:995-1000.

    Bipin Theruvil, FRCS
    Posted on April 18, 2005
    Lumbar Total Disc Replacement
    St Mary's Hospital, Isle of Wight, UK

    To the Editor:

    We read the article “Lumbar Total Disc Replacement. Seven to Eleven-Year Follow-up” (1) with great interest and congratulate Marnay, et al, on their excellent study. We are quite reassured to find that there was no incidence of polyethylene wear in any of their cases.

    The authors mention that one of the main advantages of disc arthroplasty, as compared to fusion, is the ability to prevent adjacent segment degeneration (ASD). Preservation of segmental motion is essential to prevent ASD. We would be very interested to know if the range of movement of the replaced discs was maintained in the long term in the 64 patients and if so how was this evaluated. We would be keen to know if the authors observed any ASD in their group of patients.

    This study incidentally has the longest follow up (8.7years) among the articles on disc arthoplasty reported so far. In another recent article, 27.4% patients developed ASD and underwent decompression or arthrodesis, at an average follow up of 6.7 years following lumbar spine fusion (2).

    In our hospital, the SB Charité Disc is our implant of choice. We have experience with this prosthesis in 39 patients of which 9 cases were 2 level disc replacements. In contrast to the opinion of the authors we have not encountered problems in obtaining distraction at the second level with this particular prosthesis.

    Yours sincerely,

    P. Mundlur

    B. Theruvil

    C. Dare

    E. Rahall


    (1)Patrick Tropiano, Russel C. Huang, Federico P. Girardi, Frank P. Cammisa, Jr., and Thierry Marnay Lumbar Total Disc Replacement. Seven to Eleven-Year Follow-Up J Bone Joint Surg Am 2005; 87: 490-496

    (2) Ghiselli G, Wang JC, Bhatia NN, Hsu WK, Dawson EG, Adjacent segment degeneration in the lumbar spine.J Bone Joint Surg Am. 2004 Jul;86 -A(7):1497-503.

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