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How Does Total Disc Replacement Stack Up Against Spinal Fusion?

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Updated January 27, 2013

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

Question: How Does Total Disc Replacement Stack Up Against Spinal Fusion?

Recent studies suggest that total disc replacement is a promising alternative to spinal fusion.

Answer:

Total disc replacement was developed, at least in part, out of a concern for the effects that a spinal fusion may have on vertebral segments above and below the surgery site. Because two adjacent bones are fused together, the biomechanics of your spine may be altered after a fusion, which, in turn, may place pressure on the adjacent joints. Some believe the added pressure results in degeneration in those areas.

The thinking behind a total disc replacement is that it preserves your spine’s ability to move at the level(s) the procedure is done. In this way, a total disc replacement surgery may help reduce the incidence of joint stresses in neighboring joints, when compared with spinal fusion. (Degeneration in spinal joints above and below the site of a spinal fusion is commonly known as adjacent segment degeneration, or ASD.)

What We Know About the Safety and Effectiveness of Disc Replacement As Of April 2012

But motion preservation surgery (disc replacement is the most common type) is still new in the United States. Researchers are still collecting long-term data, and it’s certainly possible that techniques and strategies for performing disc replacement surgery have yet to be perfected. My opinion is, this could well play a role in the decision about which type of procedure to have for your first (often called “index”) surgery.

As of March 2012, a number of studies report 2-year data on the safety and outcome of total disc replacement surgeries. At the same time, 5-year data is beginning to emerge, with 10-year data next on the horizon.

So far, the disc replacement approach looks good, but this doesn’t mean it makes the best choice of treatment for you. A 2007 study published in Spine Journal reviewed records of 627 spine surgery patients, and found that based on the fact that an array of treatments (including conservative measures) exists from which patients might choose, and on the history of how new spine surgery technologies are introduced to the market, the risk for overuse of total disc replacement surgery is real.

A 2011 study published in The British Medical Journal evaluated 173 spine surgery patients (spinal fusion and disc replacement) to compare disc replacement surgery with conservative care (rehabilitation). The researchers wanted to know which of the two approaches was the most effective way to address chronic low back pain. The authors of the study found that those who initially had spinal fusion were twice as likely to have a revision surgery as those whose first surgery was a disc replacement. (Revision surgery rates for people with disc replacements ranged from 3.7 to 11.4% in this study.)

The study authors warned that while disc replacement surgery, when compared with a course of rehabilitation (i.e. physical therapy and non-invasive care), did result in improved ability to cope with one’s daily tasks and activities in a significant number of the 173 study participants, doctors and patients would do well to factor in the risks that accompany the surgery before committing to it.

By far and away, spinal fusions are performed more frequently than total disc replacements for common spinal conditions such as degenerative disc disease, scoliosis and more. (This is despite the persistence of concerns and unanswered questions about fusion.) An analysis comparing the ratio of lumbar spinal fusions to lumbar total disc replacements performed between years 2000 and 2008 found that disc replacements represented 2% of all spinal surgeries given.

Are You a Good Fit For Total Disc Replacement Surgery?

According to Dr. Joshua D. Auerbach, chief of spine surgery, Bronx-Lebanon Hospital Center, New York City, up to about 5% of patients who need a spine surgery are candidates for a total disc replacement. The limiting factors may include patient selection -- i.e. what are the odds you’ll experience a safe and successful outcome?

In his study, “The prevalence of contraindications to total disc replacement in a cohort of lumbar surgical patients,” Auerbach lists some of the contraindications to a total disc replacement surgery as:

A 2011 study published in Asian Spine Journal performed a retrospective review of lumbar spine surgery patient charts and also found that more than 2 level degenerative disc disease was a contraindication, as well.

Sources:

Auerbach, J., MD. Chief of Spine Surgery, Bronx-Lebanon Hospital Center, Assistant Professor of Surgery, Albert Einstein College of Medicine. Phone Interview. March 2012.

Awe OO. et. al. Impact of total disc arthroplasty on the surgical management of lumbar degenerative disc disease: Analysis of the Nationwide Inpatient Sample from 2000 to 2008. Surg Neurol Int. 2011;2:139. Epub 2011 Oct 12. http://www.ncbi.nlm.nih.gov/pubmed/22059134

Chin KR. Epidemiology of indications and contraindications to total disc replacement in an academic practice. Spine J. 2007 Jul-Aug;7(4):392-8. Epub 2007 Feb 12. http://www.ncbi.nlm.nih.gov/pubmed/17630136

Gerometta A, Rodriguez Olaverri JC, Bittan F. Infection and revision strategies in total disc arthroplasty. Int Orthop. 2012 Feb;36(2):471-4. Epub 2011 Dec 24. http://www.ncbi.nlm.nih.gov/pubmed/22198361

Hellum et al. Surgery with disc prosthesis versus rehabilitation in patients with low back pain and degenerative disc: two year follow-up of randomised study. BMJ. 2011; 342: d2786. Published online 2011 May 19.

Huang RC, Lim MR, Girardi FP, Cammisa FP Jr.The prevalence of contraindications to total disc replacement in a cohort of lumbar surgical patients. Spine (Phila Pa 1976). 2004 Nov 15;29(22):2538-41. http://www.ncbi.nlm.nih.gov/pubmed?term=The%20prevalence%20of%20contraindications%20to%20total%20disc%20replacement%20in%20a%20cohort%20of%20lumbar%20surgical%20patients

Quirno M, Goldstein JA, Bendo JA, Kim Y, Spivak JM. The Incidence of Potential Candidates for Total Disc Replacement among Lumbar and Cervical Fusion Patient Populations. Asian Spine J. 2011 Dec;5(4):213-9. Epub 2011 Nov 28. http://www.ncbi.nlm.nih.gov/pubmed?term=The%20Incidence%20of%20Potential%20Candidates%20for%20Total%20Disc%20Replacement%20among%20Lumbar%20and%20Cervical%20Fusion%20Patient%20Populations.

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