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The principle behind using artificial disc replacement surgery for treating spine pain and conditions is to enable a surgeon to treat a patient’s condition with the cervical or lumbar spine that usually arises as a result of aging or degenerating discs without using fusion, which alters a spine’s normal movement.
Artificial disc replacement aims to replace a bad disc that is causing pain with a mobile artificial disc, rather than removing the disc and fusing the vertebrae together, which is what takes place in a spinal fusion. The artificial disc allows the spine to maintain its natural mobility and theoretically prevents abnormal motion or stress on adjacent spinal segments. This abnormal motion or stress can result in the degeneration that is believed to be the cause of long-term spinal fusion failure.
Lateral ADR at lumbar spine
The development of the lateral approach allows today the possibility of offering TDR when the disc to be replaced is above L5-S1. The risks of the anterior approach are eliminated and neurophysiologic monitoring of the nerves decreases the risk of traction injuries of the lumbar plexus in its transpsoas trajectory. The XL procedure is what is termed a “minimally invasive” procedure. This means that instead of a traditional, larger single incision, the procedure is performed through one or more small incisions and an instrument known as a retractor is used to spread the tissues so that the surgeon can see the spine. This is made possible by the use of a dilator and retractor system, MaXcess®, developed by NuVasive®, Inc, in San Diego, CA. The system allows the surgeon to reach the spine via lateral access (from the side of the body).
Older lumbar total disc replacement (TDR) devices require an anterior approach for implantation. This approach has inherent limitations, including risks to abdominal structures and the need for resection of the anterior longitudinal ligament (ALL). Placement of a TDR device from a true lateral (extreme lateral [XL]) approach is thought to offer a less invasive option to access the disc space (reduced risk of interrupting blood circulation in the left leg, significantly reduced risk of arterial thromboembolism, reduced risk of plaque embolism with arteriosclerosis), preserving the stabilizing ligaments and avoiding scarring of anterior vasculature.
When L5-S1 has to be included in the surgical treatment, anterior TDR at this level or hybrid procedures (transforaminal lumbar interbody fusion [TLIF] or ALIF with cages and pedicles screws, versus Posterior Dynamic Stabilization with Dynesys at L5-S1 and XL-TDR at L4-5 or/and L3-4) could be performed.
A revision rate of 5.6% has been reported. Postoperative transient psoas weakness and anterior thigh numbness have been reported, both resolving within 2 weeks. 2.8% of cases demonstrated weakness of the leg ipsilateral to the approach side, which lasted through the 3-month visit but was resolved by the 6-month visit.
The benefits of this technique include minimal morbidity, avoiding mobilization of the great vessels, preserving the ALL, biomechanically stable orientation, and broader revision options than in anterior approach.
Minimally invasive spine surgery technology allows surgeons to reach the spine through several smaller incisions (as opposed to a single large incision). The majority of surgeons believe minimally invasive surgery is advantageous because it may allow for less tissue trauma, less scarring, shorter hospital stays and less postoperative discomfort, thereby affording a decreased need for post-operative pain medication.
Like all minimally invasive spine surgery techniques, the XL procedure was designed to treat disorders of the spine with the least amount of tissue (muscle, ligament, blood vessels and abdominal organs) disruption possible, so that there is minimal tissue-related damage from the surgery and the recovery time is therefore reduced.
There are a series of steps to complete an XL TDR:
- First, the patient will be positioned lying on his or her side. Then the surgeon will use x-rays to locate the disc that will be removed.
- Once the disc is located, the surgeon will mark the skin with a marker directly above the disc.
- Then the surgeon will make a small incision (cut) in the flank (low back region of the trunk) and use his or her finger to push away the peritoneum (sac covering the abdominal organs) from the abdominal wall.
- The surgeon will make a second incision directly on the side of the patient, or only this second incision.
- The surgeon will then insert a tube-like instrument known as a dilator into this incision.
- The surgeon will use x-rays to make sure that this dilator is in a good position above the disc.
- The surgeon will then insert a probe (blunt tool) through a muscle known as the psoas muscle. The psoas muscle is a large muscle that runs from the lower spine, wrapping around the pelvic area and attaches at the hip. A monitoring device allows detecting any retraction stress on the nerves allowing replacing the retractor in a position avoiding the nerve stretching a potential damage.
- A complete discectomy is performed
- The appropriate ADR prosthesis size is selected and inserted in the void disc space with a controlled distraction to recover the desired disc space height.
With an XL procedure, the following recovery facts are typical:
- Pain at the incision sites after surgery is normal and should be expected. This pain should eventually go away and should be easily controlled with oral pain medication that is prescribed upon discharge from the hospital.
- Because the XL surgery only splits muscles but does not cut muscles), many patients are able to get up and walk around the night after they have had surgery.
- The total time a patient spends in the hospital after the surgery depends on several factors, such as the number of vertebral levels that were treated, the severity of the problem and the patient’s overall health.
- Some patients who undergo an XL procedure are able to return home the same day as the surgery; others require a stay of a few days in the hospital.
- Most patients are able to return to their normal activities within a few weeks or months of surgery, depending of the patient’s type of work.
Previous lumbar Total Disc Replacement (TDR) devices require an anterior approach for implantation. This approach has inherent limitations, including risks to abdominal structures and the need for resection of the anterior longitudinal ligament (ALL). Placement of a TDR device from a true lateral (extreme lateral [XL]) approach is thought to offer a less invasive option to access the disc space (reduced risk of interrupting blood circulation in the left leg, significantly reduced risk of arterial thromboembolism, reduced risk of plaque embolism with arteriosclerosis), preserving the stabilizing ligaments and avoiding scarring of anterior vasculature.
When L5-S1 has to be included in the surgical treatment an anterior TDR procedure is performed. Some patients benefit from hybrid procedures; for example, a fusion performed anteriorly ALIF or transforaminal lumbar interbody fusion [TLIF] with cages and pedicles screws at L5-S1 and XL-ADR at the other lumbar levels or Posterior Dynamic Stabilization with Dynesys at L5-S1 and TDR at L4-5 or/and L3-4 could be performed.
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