Publication: Incidence of Contraindications to Total Disc Arthroplasty (Facets)

[Justin]

The Spine Journal
Volume 7, Issue 1 , January-February 2007, Pages 5-11

Copyright © 2007 Elsevier Inc. All rights reserved.

Clinical Study

Incidence of contraindications to total disc arthroplasty: a retrospective review of 100 consecutive fusion patients with a specific analysis of facet arthrosis


David A. Wong MD, MSc, FRCS(C)a, , , Betsy Annesser DPtb, Tim Birney MDc, Roderick Lamond MD, FRCS(C)d, Anant Kumar MDe, Stephen Johnson MDd, Sanjay Jatana MDe and Gary Ghiselli MDe

aDirector, Advanced Center for Spinal Microsurgery at Presbyterian St. Luke's Medical Center, Denver, CO
bDirector, Spinal Research, Presbyterian St. Luke's Medical Center, Denver, CO
cWestern Orthopedics, Denver, CO
dWestern Neurological, Denver, CO
eDenver Spine, Denver, CO

Received 10 December 2005; accepted 5 April 2006. Available online 29 December 2006.



Abstract

Background context

The role of total disc arthroplasty (TDA) in the treatment of spinal pathology is unclear. TDA has been touted as an alternative to fusion. However, not all back pain is purely discogenic in origin. Contraindications to TDA exist. At Spine Week in Porto, Portugal, Cammisa's group from the Hospital for Special Surgery in New York presented a series of 56 fusions where 100% of patients had one or more of 10 contraindications to TDA. En face, this appears to be an extremely large number.

Purpose

The purpose of the study was to repeat the Hospital for Special Surgery study in another cohort of fusion patients.

Study design/setting

This study was an independent, retrospective record review of 100 consecutive lumbar spinal fusions performed at a tertiary care private medical center.

Patient sample

All adult patients having primary1–3 level lumbar spinal fusions from January 2003 to May 2004 were assessed.

Outcome measures

Physiologic measures included imaging, range of motion, and response to facet blocks.

Methods

A retrospective chart review was performed of 100 consecutive patients having primary 1–3 level lumbar fusion by all five active staff spinal surgeons (3 orthopedic and 2 neurosurgeons). The review was performed independently by the doctorate level physiotherapist who serves as the medical center's research coordinator, reporting to the chairman of the Hospital institutional review board. The same 10 contraindications from Cammisa's study were noted. Additional facet arthrosis data were collected, including mention on imaging reports or operating room notes. Clinical notes were reviewed for documentation of range of lumbar motion (ROM) and whether there was restricted or painful extension ROM. Note was made if patients had facet blocks as another clinical indicator of facet arthrosis.

Results

All 100 patients had at least one contraindication to TDA. The average was 3.69 (range 1–7). Only one patient had facet arthrosis as their only contraindication. Facet arthrosis was documented on imaging reports or operating room notes in 97/100. Reduced extension was present in 71/75 charts that documented ROM. Facet blocks were performed in 12/100 and gave greater than 50% relief in nine.

Conclusions

Both our study and Cammisa's indicate that all lumbar fusion patients in our two institutions have at least one contraindication to TDA. The average fusion patient does not appear to have isolated discogenic pain. A large proportion of the patients appeared to have facet arthritis. The point where facet arthrosis definitely constitutes a contradiction to TDA will require analysis during long-term arthroplasty follow-up studies. Suitable patients for TDA may not represent a significant cohort presently undergoing lumbar fusion.

Keywords: Lumbar disc arthroplasty; Lumbar fusion; Facet arthritis; Arthroplasty contraindications

[ZorroSF]

this is not a surprise finding. I think they are going to start revising procedures to determine those who should really get a disc replacement and those who should get fusion. Of course, the 2nd and 3rd generation of discs hopefully will alleviate facet degeneration. Leaving the possibility of otherwise failed TDR's a newfound success.