TOTAL DISC REPLACEMENT
Spinal surgery is presently undergoing radical changes. Surgical options for patients previously told to live with their pain may now provide relief and resumption of active and enjoyable lifestyles. This technology is predicated on the disc as a major source of pain generation. Patients suffering from disc related pain may have been given various diagnoses, such as degenerative disc disease, lumbar spondylosis, annular tears, central disc herniations, vacuum disc degeneration, disc protrusions, etc. The clinical symptoms are characterized by severe at times, excruciating low back pain with activity, particularly repetitive bending, sitting, driving in a car, or twisting.
The lumbar disc as a source of pain began with the now famous Mixter and Barr New England Journal of Medicine article that began the era of discectomy surgery. However, what initially was perceived as a panacea for back pain met with inconsistent results for back pain relief. Over time, patients with disc pathology were felt to be ideal surgical candidates, only if they experienced mostly buttock and leg pain in the face of correlative imaging studies. Patients experiencing mostly back pain were soon discovered not to be ideal surgical candidates, with many experiencing worse pain after surgical discectomy. This led many physicians away from regarding the disc of a primary pain generator. Shrouding the disc in more controversy were the occasional patients who benefited from posterolateral fusion surgery. Why had some patients benefited while others did not? Again, inconsistency led many physicians away from the disc and in many cases; back patients began being regarded as chronic complainers who never seemed to improve, despite technically well-performed surgeries. Why posterolateral stabilization with or without hardware could provide consistent back pain relief has been a major point of contention among spinal specialists.
Fortunately, interbody fusion devices, although flawed in design, focused attention back to the disc as a major pain generator. Physicians recognized the excellent early results with interbody cages and their application became immensely popular. Unfortunately, the interbody space required more preparation than drilling cylindrical cages into it to allow a solid interbody fusion, and late failure 6-8 months post op plagued many spinal surgeries. However, because of the metallic artifact of the interbody cages, especially if augmented with pedicle screw fixation, radiographic images became nearly impossible to interpret. Patients were frequently imaged and told everything looks as it did after implantation and therefore could not be implicated as the source of their recurrent pain. This gradually led to more conflict and confusion regarding surgical indications for fusions and the inconsistent results despite technically well-performed surgeries.
The advent of total disc replacement and nuclear replacement again properly focuses spinal specialists on the disc as a primary pain generator. This technology, if properly applied, may provide another valuable tool for some specialists to utilize. Patient selection as in most procedures will be critical, and an understanding of the source of the pain generator is critical before indicating any patient for a spinal procedure. For these reasons, the physicians at the New Jersey Spine Institute feel uniquely qualified to evaluate and educate patients in order to provide a diagnosis and treatment regimen specifically addressing the patient’s pain generator, rather than adopting technology as it appears in the tabloid in a haphazard fashion without the necessary understanding of its indications.
We have always felt that the importance of new technology and the procedures which this technology generates, should be rigorously tested against existing technologies. For example, interbody threaded cages were never adopted for more than a hand full of cases. In comparison to the interbody fusion done with threaded bone dowels, horizontally oriented titanium cages pale in comparison for clinical success. We have in fact revised many horizontally oriented titanium cages with clinical success
For more information on the New Jersey Spine Institute, please see our website at www.njspineinstitute.com.
Somerset Orthopedic Associates, PA