Study design:

This was a retrospective clinical review.

Objective:

The objective of this study was to analyze failure mechanisms after total lumbar disk replacement (TDR) and surgical revision strategies in patients with recurrent low back pain (LBP).

Summary and background data:

Several reports indicate that TDR revision surgery carries a major risk and that it should not be recommended. The clinical results of posterior instrumented fusion using the prosthesis like an interbody cage have not been well analyzed.

Materials and methods:

From 2003 to 2018, 48 patients with recurrent LBP after TDR underwent revision surgery. The average age was 39 years (24-61 y). The mean follow-up was 100.4 months (24.6-207.7 mo). Clinical data, self-assessment of patient satisfaction, and Oswestry Disability Index collected at each clinical control or by phone call for the older files and radiologic assessments were reviewed. The surgical revision strategy included posterior fusion in 41 patients (group A) and TDR removal and anterior fusion in 7 patients (group B), of which 6 patients had an additional posterior fixation.

Results:

Facet joint osteoarthritis was associated with TDR failure in 85%. In 68% the position of the prosthesis was suboptimal. Range of motion was preserved in 25%, limited in extension in 65%, and limited in flexion in 40%. Limited range of motion and facet joint osteoarthritis were significantly related (P=0.0008). The complication rate in group B was 43% including iliac vein laceration. Preoperative and 2-year follow-up Oswestry Disability Index were 25.5 and 22.0, respectively, in group A versus 27.9 and 21.3 in group B.

Conclusions:

Posterior osteoarthritis was the principal cause of recurrent LBP in failed TDR. The anterior approach for revision carried a major vascular risk, whereas a simple posterior instrumented fusion leads to the same clinical results.

Level of evidence:

Level IV.