European Spine Journal

, Volume 26, Issue 3, pp 794–798 | Cite as

Rotation effect and anatomic landmark accuracy for midline placement of lumbar artificial disc under fluoroscopy

  • Mark Mikhael
  • Jaysson T. Brooks
  • Yusuf T. Akpolat
  • Wayne K. Cheng
Original Article



Total disc arthroplasty can be a viable alternative to fusion for degenerative disc disease of the lumbar spine. The correct placement of the prosthesis within 3 mm from midline is critical for optimal function. Intra-operative radiographic error could lead to malposition of the prosthesis. The objective of this study was first to measure the effect of fluoroscopy angle on the placement of prosthesis under fluoroscopy. Secondly, determine the visual accuracy of the placement of artificial discs using different anatomical landmarks (pedicle, waist, endplate, spinous process) under fluoroscopy.


Artificial discs were implanted into three cadaver specimens at L2-3, L3-4, and L4-L5. Fluoroscopic images were obtained at 0°, 2.5°, 5°, 7.5°, 10°, and 15° from the mid axis. Computerized tomography (CT) scans were obtained after the procedure. Distances were measured from each of the anatomic landmarks to the center of the implant on both fluoroscopy and CT. The difference between fluoroscopy and CT scans was compared to evaluate the position of prosthesis to each anatomic landmark at different angles.


The differences between the fluoroscopy to CT measurements from the implant to pedicle was 1.31 mm, p < 0.01; implant to waist was 1.72 mm, p < 0.01; implant to endplate was 1.99 mm, p < 0.01; implant to spinous process was 3.14 mm, p < 0.01. When the fluoroscopy angle was greater than 7.5°, the difference between fluoroscopy and CT measurements was greater than 3 mm for all landmarks.


A fluoroscopy angle of 7.5° or more can lead to implant malposition greater than 3 mm. The pedicle is the most accurate of the anatomic landmarks studied for placement of total artificial discs in the lumbar spine.


Artificial disc Total disc replacement Malposition Fluoroscopic guidance Accuracy 


Conflict of interest

The authors declare no conflict of interest.


  1. 1.
    McAfee PC et al (2005) A prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part II: evaluation of radiographic outcomes and correlation of surgical technique accuracy with clinical outcomes. Spine (Phila Pa 1976) 30(14):576–583 (discussion E388-90) CrossRefGoogle Scholar
  2. 2.
    Strube P et al (2013) Parameters influencing the outcome after total disc replacement at the lumbosacral junction. Part 2: distraction and posterior translation lead to clinical failure after a mean follow-up of 5 years. Eur Spine J 22(10):2279–2287CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Rohlmann A et al (2013) Parameters influencing the outcome after total disc replacement at the lumbosacral junction. Part 1: misalignment of the vertebrae adjacent to a total disc replacement affects the facet joint and facet capsule forces in a probabilistic finite element analysis. Eur Spine J 22(10):2271–2278CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Han KS et al (2013) Effect of centers of rotation on spinal loads and muscle forces in total disk replacement of lumbar spine. Proc Inst Mech Eng H 227(5):543–550CrossRefPubMedGoogle Scholar
  5. 5.
    Zigler JE, Delamarter RB (2012) Five-year results of the prospective, randomized, multicenter, Food and Drug Administration investigational device exemption study of the ProDisc-L total disc replacement versus circumferential arthrodesis for the treatment of single-level degenerative disc disease. J Neurosurg Spine 17(6):493–501CrossRefPubMedGoogle Scholar
  6. 6.
    Boss OL et al (2013) Lumbar total disc replacement: correlation of clinical outcome and radiological parameters. Acta Neurochir (Wien) 155(10):1923–1930CrossRefGoogle Scholar
  7. 7.
    Rohlmann A et al (2008) Effect of position and height of a mobile core type artificial disc on the biomechanical behaviour of the lumbar spine. Proc Inst Mech Eng H 222(2):229–239CrossRefPubMedGoogle Scholar
  8. 8.
    Mistry DN, Robertson PA (2006) Radiologic landmark accuracy for optimum coronal placement of total disc arthroplasty in the lumbar spine. J Spinal Disord Tech 19(4):231–236CrossRefPubMedGoogle Scholar
  9. 9.
    van Ooij A, Oner FC, Verbout AJ (2003) Complications of artificial disc replacement: a report of 27 patients with the SB Charite disc. J Spinal Disord Tech 16(4):369–383CrossRefPubMedGoogle Scholar
  10. 10.
    David T (2007) Long-term results of one-level lumbar arthroplasty: minimum 10-year follow-up of the CHARITE artificial disc in 106 patients. Spine (Phila Pa 1976) 32(6):661–666CrossRefGoogle Scholar
  11. 11.
    Guyer RD et al (2009) Prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: five-year follow-up. Spine J 9(5):374–386CrossRefPubMedGoogle Scholar
  12. 12.
    Kafchitsas K, Rauschmann M (2009) Navigation of artificial disc replacement: evaluation in a cadaver study. Comput Aided Surg 14(1–3):28–36CrossRefPubMedGoogle Scholar
  13. 13.
    Mathews H, Eisermann L, LeHuec J, Friesem T (2005) Total disc arthroplasty using maverick total disc replacement. In: Guyer R, Zigler J (eds) Spinal arthroplasty: a new era in spine care, Chap 13. Quality Medical Publishing, St. Louis, MissouriGoogle Scholar
  14. 14.
    Rauschmann MA et al (2009) Insertion of the artificial disc replacement: a cadaver study comparing the conventional surgical technique and the use of a navigation system. Spine (Phila Pa 1976) 34(10):1110–1115CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Mark Mikhael
    • 1
  • Jaysson T. Brooks
    • 2
  • Yusuf T. Akpolat
    • 1
  • Wayne K. Cheng
    • 1
  1. 1.Department of Orthopaedic Surgery, School of MedicineLoma Linda UniversityLoma LindaUSA
  2. 2.Department of Orthopedic SurgeryJohns Hopkins HospitalBaltimoreUSA

Personalised recommendations