Elsevier

The Spine Journal

Volume 6, Issue 3, May–June 2006, Pages 242-247
The Spine Journal

Clinical Studies
Range of motion and adjacent level degeneration after lumbar total disc replacement

https://doi.org/10.1016/j.spinee.2005.04.013Get rights and content

Abstract

Background context

There are no published studies on the relationship between total disc replacement (TDR) motion and the development of adjacent level degeneration (ALD). Because prevention of ALD is the underlying justification for TDR, studies investigating the validity of this concept are essential.

Purpose

To examine the relationship between range of motion (ROM) and ALD 8.7 years after lumbar TDR.

Study design/setting

Retrospective radiographic and chart review.

Patient sample

Forty-two patients 8.7 years after lumbar TDR.

Outcome measures

Radiographic flexion-extension and ALD. Modified Stauffer-Coventry score. Oswestry Disability Questionnaire. Subjective patient ratings of back pain, leg pain, and disability.

Methods

We reviewed the flexion-extension radiographs of 42 patients 8.7 years after TDR. Cephalad adjacent levels were evaluated for degeneration: loss of disc space height, anterior osteophyte formation, or dynamic flexion-extension instability. Graphical analysis of motion and the prevalence of ALD was performed. A statistical relationship between ALD and clinical outcome was sought.

Results

Ten of 42 patients evaluated (24%) had radiographic ALD. The mean motion was 3.8°±2.0°. The patients with ALD had mean motion of 1.6°±1.3° whereas the patients without ALD had motion of 4.7°±4.5° (p=.035). A clear relationship between motion and the presence of ALD at 8.7-year follow-up was observed. Patients with motion 5° or greater (n=13) had a 0% prevalence of ALD. Patients with motion less than 5° (n=29) had a 34% prevalence of ALD (p=.021, odds ratio 13.5). ALD had no statistically significant effect on clinical outcome although the sample size was small.

Conclusions

At 8.7-year follow-up, the prevalence of ALD after TDR is higher in patients with motion less than 5°. The presence of ALD had no significant effect on clinical outcome, but the sample size was small. These data suggest that patients with significant ROM after lumbar TDR may have reduced risk for radiographic ALD.

Introduction

The fundamental rationale for performing total disc replacement (TDR) instead of fusion is preservation of motion. Theoretically, preservation of segmental motion may prevent the development of adjacent level degeneration (ALD) seen in long-term follow-up of fusions. No Class I or II data are currently available to support or refute this theory. It has been shown that some patients with lumbar TDR retain significant motion at short and midterm follow-up [1], [2], [3], [4], [5], [6]. Furthermore, low TDR range of motion (ROM) is statistically associated with the development of radiographic ALD [6]. However, we are not aware of any published data that quantify the relationship between motion preservation and the development of ALD.

Because new technologies bring with them new potential complications [7], the task of weighing the risk/benefit profile of TDR is difficult. Until long-term data from randomized controlled trials of TDR versus fusion are available, the theory that motion preservation reduces ALD will remain unproven. However, retrospective studies may provide important preliminary information to clinicians. The purpose of this study is to examine the relationship between ROM and the development of ALD 7 to 11 years after TDR. Finally, the clinical impact of radiographic ALD after TDR is examined.

Section snippets

Patients

From March 1990 to September 1993, 93 Prodisc (Aesculap AG & Co., Tuttlingen, Germany) total disc prostheses were implanted in 64 patients by a single surgeon (TM) at the Clinique du Parc (Castelnau-le-Lez, France). The indication for surgery was disc degeneration with discogenic back pain that had failed at least 6 months of nonsurgical management including anti-inflammatory medications, activity modification, and physical therapy. Diagnosis was based upon plain radiographs, magnetic resonance

Results

Of the 42 patients evaluated, 10 patients (24%) with radiographic ALD were identified. Four patients had loss of disc space height, three had anterior osteophyte formation, and three had both height loss and osteophyte formation. None had static or dynamic listhesis of greater than 3.5 mm. The mean ROM measured at all levels was 3.8°±2.0° (range 0–18). The patients with ALD had a ROM of 1.6°±1.3° (range 0–4) whereas the patients without ALD had ROM 4.7°±4.5° (range 0–18, p<.035).

A clear

Discussion

These data demonstrate that at mean 8.7-year follow-up, the prevalence of ALD after TDR is higher in patients with less ROM. The prevalence of ALD was statistically lower in patients with flexion-extension motion of at least 5°. In our patients, ROM less than 5° was necessary but not sufficient for the development of ALD because 59% of patients without ALD had ROM less than 5°. We are aware of no studies in the current literature that closely address the relationship between TDR ROM and

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