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Early Complications
Late Complications
Subsidence
Facet Arthrosis
Heterotopic Ossication
Conclusion
Early Complications
Subsidence
Subsidence of the prosthesis is one of the common complications of TDR. It is generally regarded as a late complication of
disk arthroplasty and Cinotti et al4 stated that subsidence
occurred in patients who had an undersized prosthesis. In
our series, however, subsidence occurred in the early postoperative period in relation to a fracture of the vertebral body
(Fig. 291) or in patients with osteoporosis (Fig. 292).
Marked subsidence and the resultant change in the conguration of the prosthesis could make the polyethylene core
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228
Section III Restoration of Lumbar Motion Segment: B Lumbar Total Disk Replacement
229
C
Figure 292 (A) Sixty-two-year-old female. The immediate postoperative anteroposterior plain radiograph showed unparallel plates of
L4L5 prosthesis. (B) The radiograph taken on postoperative
day 4 showed the subsidence of the upper plate of the L4L5 prosthesis
into the L4 vertebral body. (C) Reinforcement of the vertebral body with
polymethyl methacrylate was done to prevent further sinking of the
prosthesis. (Courtesy of Dr. Won-Cheol Choi.)
230
Section III Restoration of Lumbar Motion Segment: B Lumbar Total Disk Replacement
Figure 293 Thirty-two-year-old female. (A) Postoperative computed tomographic (CT) scan showed posterior lip of L5 upper end
plate fracture. The patient had weakness of right big toe in dorsiexion.
The fractured fragment compressing the neural tissue was removed via
a posterior approach. (B) CT scan taken after revision surgery showed
removal of offending bony fragment. (Courtesy of Dr. Gun Choi.)
Vertical split fracture of the vertebral body after arthroplasty with the ProDisc has been reported (Fig. 294).26
Because the ProDisc has a large keel on the plates, chiseling
is needed to make grooves on the vertebral bodies for the
insertion of the prosthesis. This step of the procedure
can cause a vertical split fracture of the vertebral body.
Therefore, care should be exercised during the chiseling of
the bodies and insertion of the ProDisc, especially when it
is implanted in a patient with small dimensions of the
vertebral body, or when replacement is planned at multiple
levels.
Postoperative Radiculopathy
Some patients experience postoperative radicular pain that
was not present before the surgery. In most cases, the cause
Figure 294 (A) Vertical split fracture of the vertebral body after ProDisc replacement. Plain radiograph showed vertical split fracture lines at L4 and
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L5 vertebral bodies. (B) Coronal reformation of computed tomographic image showed the fracture lines.
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Figure 295 (A) Preoperative and (B) postoperative plain lateral radiographs of 44-year-old female. Note the marked postoperative increment of
disk height of the operated level. The patient complained of severe postoperative back and right leg pain.
distraction of the disk space when it is distracted. The manuals of the surgical technique for both prostheses recommend choosing a device as big as possible to prevent the
problems of device migration or extrusion of the polyethylene core. Therefore, there is a tendency to choose a prosthesis with maximal distraction of the disk space. We feel this
tendency causes the problems of postoperative radicular
pain or back pain caused by traction of the nerve root or distraction of the facet joints. Another problem is that devices
currently available are too big for certain patients who are
short in stature and have small vertebral body dimensions. It
is inevitable that disk arthroplasty in those patients would
cause overdistraction of the disk space.
Another type of persistent postoperative back pain is one
caused by poor patient selection. TDR is not appropriate in a
patient who already has signicant facet arthropathy, and in
fact may cause facet pain by distraction and mobilization of
the already degenerated, hypertrophied, and immobile joint.
In that case, disk arthroplasty should be withheld and spinal
arthrodesis should be considered.
232
Section III Restoration of Lumbar Motion Segment: B Lumbar Total Disk Replacement
during the removal of a concomitant foraminal disk herniation in a patient with degenerative disk disease, resulting in
footdrop after the surgery. The patient eventually recovered
from the footdrop, but the experience was painful. Care
should be exercised not to damage an exiting nerve root
when the neural foraminal area is decompressed from an
anterior approach.
Infection
Infection after TDR is rare. There were no reported case of
infection after TDR in the literature, and there was only one
case of infection in our series. The patient underwent a
hybrid type of disk replacement at L5S1 in combination
with posterior fusion at the above levels. The dorsal wound
became infected and later the infection was disseminated
into the L5S1 space making the prosthesis loosen and subside. The revision was done via a transperitoneal route,
removing the prosthesis and grafting an iliac bone strut after
careful debridement.
If infection around the prosthesis occurs, conservative care
with antibiotics is generally not recommended because the
bulk of the implant hinders the antibiotics ability to eradicate the infection.28 Surgical treatment is indicated, but a
concern arises about this revision surgery because removal
of the implant can be life-threatening given the extensive
scarring around the great vessels. As Santos et al29 pointed
out, although infection after disk arthroplasty per se has not
been reported in the literature, a protocol to handle it needs
to be put in place.
Another issue is prophylactic use of antibiotics in a medical
procedure that can cause bacteremia after disk arthroplasty.
After joint arthroplasty, medical procedures that cause
bacteremia, such as dental work, require prophylactic antibiotics.30 Although it is generally not recommended in spinal
fusion, this will need consideration in spinal arthroplasty
because once the prosthesis is infected via the hematogenous route the consequence can be disastrous.
Late Complications
Facet Arthrosis
Van Ooij et al22 reported 11 patients with facet arthrosis after
TDR with the SB Charit prosthesis in a series of 500 patients operated on at a single institution near their hospital.
They performed posterior fusion on eight of the patients and
found that facet joint hypertrophy reached huge dimensions.
They postulated that the cause of the facet arthrosis was
abnormal movement patterns of the segment containing the
disk prosthesis. In the ProDisc series, there is no report
addressing the issue of facet arthrosis. This is because the
history of the ProDisc is shorter than that of the SB Charit,
and facet arthrosis is a long-term complication. Link31 described the biomechanics of disk prostheses and differences
in impingement and stress on the facet joint in relation to
movement of the core of the prosthesis. He theorized that
the sliding core of the SB Charit prosthesis was biomechanically superior to the xed core of the ProDisc in unloading
the facet joint in exion and extension of the lumbar motion
Heterotopic Ossication
Heterotopic ossication in articial disk replacement has
been described by several authors.4,5,7,24 McAfee et al34 developed a classication of heterotopic ossication based on the
classication of heterotopic ossication of the hip following
total hip replacement. Heterotopic ossication after disk
arthroplasty did not affect clinical outcome, however. There
have been reports of spontaneous fusion after disk arthroplasty.4 In our series, there are several cases in which the
implanted segment showed no movement at all, although
spontaneous fusion around the prosthesis has not been
observed. Regardless of the clinical outcomes, those
cases should be regarded as surgical failures because the
preservation of motion is one of the major purposes of disk
arthroplasty.
Conclusion
Several complications in lumbar disk arthroplasty exist.
Encouraged by the favorable early clinical outcomes and potential advantage of prevention of accelerated degeneration
of the adjacent segment, TDR will be widely used in spinal
practice. However, it is obvious that TDR will face more
frequent complications when it is used widely by less experienced hands. Additionally, there is room for improvement
of the device design and instruments. To reduce the complications of TDR in which treatment can sometimes be life
233
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[DE1]
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Au: Is this the correct manufacturer and location for the ProDisc
mentioned here?
[DE2]
Au: First author is incorrect per Medline. Please check.
[CR3]
Au: Please provide rst three authors with et al if more than six
authors. If six or fewer, please provide all author names. See also
other references citing et al.
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[DE6]