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In which cases do surgeons specializing in total disc replacement perform fusion in patients with symptomatic lumbar disc degeneration?



The purpose of this study was to investigate reasons and their frequency for why spine surgeons subspecializing in total disc replacement (TDR) performed lumbar fusion rather than TDR.


The study was based on a consecutive series of 515 patients undergoing lumbar TDR or fusion during a 5-year period by three surgeons specializing in TDR. For each fusion patient, the reason for not performing TDR was recorded.


TDR was performed in 65.4% (n = 337) of patients and the remaining 34.6% (n = 178) underwent anterior lumbar interbody fusion (ALIF ± posterior instrumentation). Of the 178 fusion patients, the most common reason for fusion was combined factors related to severe degenerative changes (n = 59, 11.5% of the study population). The second most common reason was > Grade 1 spondylolisthesis (n = 32, 6.2%), followed by insurance non-coverage (n = 24, 4.7%), and osteopenia/osteoporosis (n = 13, 2.5%). Fusion patients were significantly older than TDR patients (52.5 vs. 41.6 years; p < 0.01). There was no significant difference with respect to gender (41.2% female vs. 43.8% female, p > 0.05) or the percentage of patients with single-level surgery (61.2% vs. 56.7%, p > 0.05).


The most common reason for not performing lumbar TDR was related to anatomic factors that may compromise stability of the operated segment and/or TDR functionality. The older age of fusion patients may be related to these factors. This study found that many patients are appropriate candidates for lumbar TDR. However, even among TDR subspecialists, fusion is preferred when there are factors that cannot be addressed with TDR and/or may compromise implant functionality.

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Correspondence to Jack E. Zigler.

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This study was reviewed and cleared by at IRB. In relation to lumbar disc replacement, Zigler is a consultant to Aesculap and Centinel Spine; Guyer is a consultant to Aesculap; Blumenthal is a consultant and does speaking/teaching for Aesculap and owns stock in Centinel Spine (< 1%); Shellock is a consultant for Centinel Spine; Satin and Ohnmeiss have nothing to disclose.

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Zigler, J.E., Guyer, R.D., Blumenthal, S.L. et al. In which cases do surgeons specializing in total disc replacement perform fusion in patients with symptomatic lumbar disc degeneration?. Eur Spine J (2022).

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  • Total disc replacement
  • Lumbar spine; indications
  • Anterior lumbar interbody fusion