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 More about treatment |
Why choose for an artificial disc replacement?Fusion/spondylodesis (with or without screws, with or without cages, but was always combined with bone-transplantation) seems still the golden standard for patients with painful Degenerative Disc Disease (DDD). However, since more then 20 years there is an alternative replacement of the painful `damaged' disc by an artificial disc.
Removing only the disc doesn't help against lower back pain. It is known that hernia operations (where only the bulging disc tissue is removed) can especially reduce leg complaints, but the back pain continues to exist or becomes even worse. With a fusion/spondylodesis operation (via the abdomen or the back), after removal of parts of the disc, the further movement of the former painful disc is blocked. The disc is replaced by bone grafts from the pelvis, with or without cage. Generally those vertebra are immediately fixed afterwards, but sound fusion needs a lot of time because of the time consuming ingrowth of bone graft. This "stiffen" situation have also disadvantages: because the articulation-function has disappeared, the strain of the spine movements is put on the other discs. Very often the adjacent level will deteriorate because of overloading. Because of this overload these discs are more at risk then before the operation. Apart from that, it can take a while until the "fusion" actually takes place. About the same process takes place with a dorsal spondylodesis with screws done via the back.
With a total artificial disc replacement however the mobility is preserved. There are several reasons why an Artificial Disc Prosthesis (ADR) has our preference above fusion:- The disc prosthesis should keep the spinal segment mobile
- The natural alignement and disc height is repaired
- Good surgery results in > 85%
- Patient satisfaction perfect in 50% after artificial disc replacement (patient satisfaction only perfect in 5% of the patients after fusion)
- Degeneration of adjacent elements is hopefully prevented
- Walking without support is possible directly after the artificial discimplantation surgery
- Fast recovery and fast pain reduction
- Fast rehabilitation with return to work within 2-6 weeks
- Every back operation has the risk of ongoing pain, but the risk of re-operation after a disc prothesis operation is 50% less than with a fusion operation
- Much more perfect patients with ADR going back to heavy labour and heavy sports activities (this is seldom the case in fusion). source: Round Tables In Spine Surgery, Volume 1 o Number 4 o 2006, B. Conix, R. Hes, Middelheim, Antwerpen
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Tell me more about artificial total disc replacementAfter Artificial Disc implantation the mobility of the spine is saved. We do not have wait for ingrowing fusion. A disc prosthesis contains generally two metal support plates, with a mobile core. The constant pressure in between the vertebra garantees that the prosthesis is immediately fixed. Glue, cement or screws are not necessary. The prosthesis works the best when adjacent vertebra’s are not damaged and if the implant is well centred. The motion of the adjacent vertebra’s remains possible and the natural disc height between the collapsed vertebra’s is restored. The adjacent levels of the back should be less overloaded than after a fusion operation (McAfee et.al.). At laboratory research the disc prosthesis level has nearly the same movability as the disc segment of a ' normal ' human disc. Artificial total disc replacement prosthesis is possible at more levels. Statistically, a prosthesis at one level has almost the same positive result as two levels. Doctor Zeegers has good experiences with even three prostheses above each other. Thus a real attempt is being made to keep the spine mobile.
Artificial Disc Replacement has a high succes rate with overall healthy people, with a chronic back-leg problem because of "painful damaged disc". This procedure can also be very succesfull after failed hernia operations, with continuing back pain. For patients with returning back complaints after a fusion operation, a prosthesis below or above the fusioned area can be succesful. Even when a fusion operation seems the only solution, one should first of all consider a disc prosthesis. Most clinics still prefer fusion-operations for chronic back pain syndromes. In our opinion a fusion should only be considered, when artificial disc is contra indicated.
Rarely remnant motion of the disc prosthesis can however also be a disadvantage: 1) an irritated nerve can remain irritated. Nowadays we have intra operative nerve root monitoring to prevent post surgical irritation. 2) In some cases facet arthritis can become worse. But it has still not been determined if this is due to the disc prosthesis or an independent disease. |
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Intra operative nerve root monitoringThe so called EMG NeuroVision allows monitoring of the activity spinal nerves during spine surgery, in real time and throughout the entire operation. When introducing the artificial disc implant an alarm tone rings if the implant is too close to one of the nerve roots. The position of the artificial disc implant easily (because docter Zeegers is not using keel-shaped implants) can be adjusted until monitor shows that the surgeon is in the limits of the safe area. |
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DiscographyMost of the patients will get a pre-operative discography in advance, to confirm that a dehydrated or bad disc is really the cause of the pain.
A discography is a new diagnostic technique, performed under local anaesthesia. A contrast-agent (mixed with antibiotics) is inserted into the disc through a delicate spinal-needle. A pathological, degenerated disc can be determined when memory pain is evoked (pain-recognition) and after studying the images of the disc, made during the examination. |
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When is ADR not indicated?Sometimes it is so obvious that a discography is not necessary. When there is any doubt concerning the exact cause of the back pain, surgery should not be performed. In case of severe degeneration of the facet joints (backside), scar tissue around an old hernia, infection and poor bone quality a disc prosthesis is no solution. For women above 40 the quality of the vertebra must be tested with a bone density test (DEXA). After ADR most patients can return to their work within six weeks. Younger people under 45 seem to profit more than the elderly. The "ideal candidate" is the younger patient (age ‹ 45), without former back surgery, without too much wear and tear of the spine and with good bone quality. But elderly people can also still have a high success rate with artificial disc replacement. |
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