Lumbar Disc Arthroplasty

Primary Operative Indications

Discogenic low back pain with ALL of the following:
Pain arising from 1 or 2-level disc disruption involving L3-4, L4-5, and/or L5-S1 segments
Presence of symptoms 6 months or greater
Failed nonoperative management, including but not limited to:
- >6 weeks of PT
- injections, pain medications…etc.
Primary complaint of axial back pain, with a possible secondary complaint of lower extremity pain
Age 18-60

Presence of symptomatic degenerative disc disease at more than 2 levels
Facet joint arthropathy, with signs that primary source of pain is facet mediated
- Possible to perform in patients with asymptomatic facets with Pathria Grade 1-3, not Grade 4
Instability with spondylolisthesis greater than Grade 1
Presence of any pars defect
Leg pain predominance, chronic radiculopathy (unremitting pain with predominance of leg pain greater than back pain, extending over at least one year)
Osteopenia, DEXA T-score < or equal to -1.0
- Possible for patients >~1.5 T-Score on Dexa scan
  - Hounsfield units as measured on CT, not as reliable
Poorly managed psychiatric disorder
Age >60 years or <18 years
Presence of infection or tumor
Moderate to severe scoliosis or major deformity
More than 40-50% loss of endplates surface area due to cysts or other severe endplate abnormality
Facet ankylosis
Metal allergy or history of implant rejection
AP length of vertebral body smaller than implant size
- <27mm for the Prodisc-L
High risk anterior approach
- Vascular calcification
- Previous vascular surgery in area of anterior spine
- Retroperitoneal radiation
- Abarrant vascular anatomy
- Obesity (varied based on surgeon experience)

3-level disease
Age >60 years possible with adequate bone quality without circumferential stenosis (Bertagnoli, 2006)
Osteopenia, DEXA T-score < or equal to -1.0
- Possible for patients >~1.5 T-Score on Dexa scan
Instability with spondylolisthesis greater than Grade 1
- (Some surgeons would say that you should avoid lumbar ADR with any amount of anterolisthesis)
- Retrolisthesis acceptable if Grade 1 or less
Facet joint arthropathy
- Possible to perform in patients with relatively asymptomatic facets with Pathria Grade 1-3, not Grade 4
Prior laminectomy at lumbar ADR level
Scoliosis, >15degrees
- Some surgeons tolerate scoliosis if no lateral listhesis at target disc, not at apex and <~15 degrees.
High sacral slope >~80 degrees, though some research says higher SS is not a contraindication (Arunakul, 2017)

No difference in outcomes with previous discectomy or laminectomy (Leahy, 2008, Bertagnoli, 2006)

Xray L-spine
- AP view, used to match intraop AP rotation
- Lateral, measure alignment for target sagittal balance
- Flexion/Extension view, identify instability
- EOS, consider full spine alignment
CT L-spine
- Look for sclerotic endplates, may require sharper enplate cutter due to difficulty cutting through endplates
- Some consider Spec-CT as an option to help identify painful level as it may correlate with active disc inflammation (not yet literature based)
MRI without contrast, L-Spine
- Review disc degeneration
- Review for stenosis or disc hernations
- Review foraminal stenosis
- Review health of the facets