Artificial Disc Replacement

Degenerative disease of the spine is one of the leading causes of disability in the adult population. Most of these patients are treated non-surgically with analgesia, physiotherapy and injections. The majority will get better without surgery. However, a group of patients will continue to experience pain. The chronic nature of spinal pain can be disabling and interferes with the ability to work and participate in regular daily activities. For these patients, surgical treatment becomes necessary.

Surgical treatment for degenerative spine disease has traditionally been spinal fusion. Unfortunately, there are a number of drawbacks to spinal fusion. Firstly, the bone may not be able to heal or fuse. The average success rate of fusion is approximately 80%. Failure of the bone to fuse may be associated with continued symptoms. Secondly, fusion will cause stiffness

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and decreased motion of the spine. Thirdly, spinal fusion will cause more stress to be transferred to adjacent levels. This increased stress at the adjacent level may cause further degeneration at the adjacent levels which may lead to additional spine surgery.
Artificial disc replacement is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial devices in the lumbar (lower) or cervical (upper) spine. The procedure is used to treat chronic, severe low back pain and cervical pain resulting from degenerative disc disease.

Artificial disc replacement has been developed as an alternative to spine fusion. The introduction of the total disc replacement aims to relieve patient symptoms while preserving motion at the operative spinal level. The advantage of preserving motion is to minimize the stress at adjacent levels and thereby decrease the risk of degeneration of the adjacent segment.
Currently artificial disc replacement can be used for the lumbar or the cervical spine. Many different models have been developed. The majority consists of two metal plates that have teeth to anchor the implant onto the bone of the vertebral bodies. Between the two plates is a metal core or a plastic core made up of polyethylene that allows for motion. Figure 1 shows a lumbar artificial disc replacement. Figure 2 shows a cervical artificial disc replacement.

Figure 1. Lumbar artificial disc

Figure 1. Lumbar artificial disc

Figure 2. Cervical artificial disc

Figure 2. Cervical artificial disc

 

 

 

 

 

 

 

 

 

 

The clinical diagnoses for lumbar artificial disc replacement include symptomatic degenerative disc disease and post-discectomy syndrome. Post-discectomy syndrome is persistent back pain following previous surgery to remove a

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herniated disc. For cervical artificial disc replacement, the diagnoses include cervical radiculopathy (where the nerve root is compressed) and cervical myelopathy (where the spinal cord is compressed).

The technique to insert an artificial disc (whether in the neck or low back) is routine and safe. For the cervical spine it involves going from the front of the neck. For the lumbar spine, it involves going through the abdomen. The procedure begins by removing the gelatinous disc between the vertebrae. Once the disc is removed, two metal plates are pressed into the bony endplates above and below the space now vacated by the disc. Metal spikes hold these plates in place on the bone. Eventually bone will grow over and around the metal plates. In between the metal plates is a metal or plastic core made of a polyethylene. Figure 3 shows the artificial disc placed in the spine.

Figure 3. Artificial disc placed in spine

Figure 3. Artificial disc placed in spine

Careful selection of patients for artificial disc replacement is critical. There are several conditions that may prevent patients from receiving a disc replacement. These include spondylolisthesis (the slipping of one vertebral body across a lower one), osteoporosis, vertebral body fracture, allergy to the materials in the device, spinal tumor, spinal infection, morbid obesity, significant changes of the facet joints (joints in the back portion of the spine), pregnancy, chronic steroid use or autoimmune problems. Also, total disc replacements are designed to be implanted from an anterior approach (through the abdomen for lumbar). Patients may be excluded from receiving an artificial disc if they previously had abdominal surgery or if the condition of the blood vessels in front of the spine increases the risk of significant injury during this type of spinal surgery.
In addition to the potential complications associated with general anesthesia, the complications associated with artificial disc replacement may include breakage of the metal plate, dislocation of the implant, infection, nerve injury and injury to blood vessels and urological structures. To help minimize complications associated with the implant itself, proper selection of patients and size of implant is very important. Also, artificial implants may fail over time due to wear of the materials and loosening of the implants.

Recovery from artificial disc replacement and care afterwards are much like that for other anterior approaches to the spine. In some cases, recovery is faster than for a traditional fusion surgery. There is less pain from the

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procedure and fewer complications in general. Another potential advantage of disc replacement is a more rapid

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return to activities than occurs after fusion surgery. Fusion patients have limited activities during the time required for the bone graft to grow into a solid mass. Because one of the goals of artificial discs is motion, patients are encouraged to return to motion early, although at a gradual progression. The length and type of activity restrictions following surgery are also much less with disc replacement.

Contributing Specialist:

(Spine Surgery)

Island Orthopaedic Consultants
Gleneagles Med Ctr,#02-16,
Tel:(65) 6474 5488, 6479 8998
Mt Elizabeth Med Ctr, #06-03,
Tel:(65) 6737 5683
Website: www.iog.com.sg

 

Minimally Invasive Spine Surgery

Introduction

Traditional spine surgery usually requires long incisions. Muscles are cut and moved away from the spine to expose the surgical area. This causes increased pain, long recovery time and impaired spinal function.

With minimally invasive (keyhole) techniques, surgery on the spine can be performed with a wound of only 2-3cm and many of these can be performed as day surgery. Prolapsed intervertebral disc, spinal stenosis and spondylolisthesis are some of the conditions that can be performed with minimally invasive surgery.

Technique

In minimally invasive surgery a tubular retractor is used to dilate the muscles and create a tunnel to expose the spine (Fig 1a,b). Using the tubular retractor, procedures to relieve pressure on the spinal cord and to remove the slipped disc can be performed.

In patients who require spinal fusion to stabilize the spine, the metal screws and rods can be inserted through small wounds (Fig. 2).

Advantages

1. Smaller scars

2. Less tissue trauma

3. Less blood loss

4. Less postoperative pain

5. Shorter hospital stay

6. Faster rehabilitation

7. Quicker return to work and normal activities

Clinical example

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patient with back pain and both leg pain which is worse with walking. Patient underwent minimally invasive surgery to relieve the pressure on the spinal nerves. He had rapid recovery with a small wound.

References

  1. Benedict Peng. Clinical and Radiological Outcomes of Minimally Invasive versus Open Transforaminal Lumbar Interbody FusionSpine 2009 Jun 1;34(13):1385-9.

Contributing Specialist:

(Spine Surgery)

Island Orthopaedic Consultants
Gleneagles Med Ctr,#02-16,
Tel:(65) 6474 5488, 6479 8998
Mt Elizabeth Med Ctr, #06-03,
Tel:(65) 6737 5683
Website: www.iog.com.sg

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What Can You Do To Help Your Back and/or Neck?

In our fast-paced society, we often look for “quick fix” solutions to quickly remove the pain. We need to understand that in many instances, back or neck pain become obvious as a result of years of “neglect” of the spine. Patients with back or neck pain can become sedentary, or become out of shape, gaining weight that places more strain on the low back. Our goal at the Centre for Spine and Scoliosis Surgery (CSS) is to make your back or neck stronger, more flexible, and thus reducing the chance of further injury. Many of these can be achieved by educating you on the structure and function of the spine, and the lifestyle modifications that may accompany.

While a spinal injection or surgery can help relieve symptoms, not maintaining spinal muscle strength and flexibility, or use of good body mechanics can increase your likelihood of future problems. You have to remember that as you get older,

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If you have difficulty standing without shifting weight, try standing with one leg on a footrest, periodically switching feet. It is also important to do back stretches now and

then in order to reduce stiffness of the back.

Lifting is a common activity in our daily life. When lifting, maneuver the object close to your body, and use the strength in your legs to get the object off the ground, rather than your low back. Whenever possible, your back should not bend forward when lifting something, however light it may appear.
Contributing Specialist:

Dr Hee Hwan Tak
MBBS, FRCS (Ed), FRCS (Glas), FAMS (Ortho)
Medical Director and Senior Consultant, Pinnacle Spine & Scoliosis Centre
Mobile: 65-98283132
Tel: 65-67370680
Fax: 65-67370522
Emergency: 65-97718964
Website: http://www.p-ortho.com
3 Mount Elizabeth, Mount Elizabeth Medical Centre, #04-07, Singapore 228510
Adjunct Associate Professor, Nanyang Technological University, Singapore
Panel of Medical Experts, The Subordinate Courts of Singapore

Associate Editorial Board Member, The Spine Journal (USA)

 

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