Current Reviews in Musculoskeletal Medicine

, Volume 10, Issue 2, pp 153–159 | Cite as

Lumbar disc replacement surgery—successes and obstacles to widespread adoption

  • Stephan N. Salzmann
  • Nicolas Plais
  • Jennifer Shue
  • Federico P. GirardiEmail author
Motion Preserving Spine Surgery (C Kepler, section editor)
Part of the following topical collections:
  1. Topical Collection on Motion Preserving Spine Surgery


Purpose of review

Lumbar disc replacement has been a surgical alternative to fusion surgery for the treatment of lumbar degenerative disc disease (DDD) for many years. Despite enthusiasm after the approval of the first devices, implantation rates have remained low, especially in the USA. The goal of this review is to provide a general overview of lumbar disc replacement in order to comprehend the successes and obstacles to widespread adoption.

Recent findings

Although a large amount of evidence-based data including satisfactory long-term results is available, implantation rates in the USA have not increased in the last decade. Possible explanations for this include strict indications for use, challenging surgical techniques, lack of device selection, fear of late complications or revision surgeries, and reimbursement issues.


Recent publications can address some of the past concerns, but there still remain obstacles to widespread adoption. Upcoming data on long-term outcome, implant durability and possible very late complications will determine the future of lumbar disc replacement surgery.


Degenerative disc disease Lumbar spine Fusion Total disc replacement Widespread adoption 


Compliance with ethical standards

Conflict of interest

Stephan N. Salzmann, Nicolas Plais and Jennifer Shue declare that they have no conflict of interest. Federico P. Girardi reports grants from MiMedx, personal fees from Paradigm Spine, LLC, personal fees from HealthPoint Capital, LP, personal fees from Spineart USA, personal fees and other from Centinel Spine, grants from Spinal Kinetics, personal fees from Scient'x USA, personal fees from Pharmawrite, LLC, personal fees from DePuy Spine, personal fees from OrthoDevelopment Corp, personal fees from Gerson Lehrman Group, Inc., personal fees from Lanx, Inc., grants from Aesculap Implant Systems, other from Paradigm Spine, other from LifeSpine, other from Pioneer Surgical Technology, Inc., and other from Small Bone Innovations, outside the submitted work.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, Woolf A, Vos T, Buchbinder R. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64:2028–37.CrossRefPubMedGoogle Scholar
  2. 2.
    Katz J. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Jt Surg. 2006;88:21–4.Google Scholar
  3. 3.
    • Garcia R, Yue JJ, Blumenthal S, et al. Lumbar total disc replacement for discogenic low back pain. Spine (Phila Pa 1976). 2015;40:1873–81. Recent RCT evaluating the safety and effectiveness of activL CrossRefGoogle Scholar
  4. 4.
    Lee YC, Zotti MGT, Osti OL. operative management of lumbar degenerative disc disease. Asian Spine J. 2016;10:801–19.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Are lumbar spine reoperation rates falling with greater use of fusion surgery and new surgical technology? Spine (Phila Pa 1976). 2007;32:2119–26.CrossRefGoogle Scholar
  6. 6.
    Yoshihara H, Yoneoka D. National trends in the surgical treatment for lumbar degenerative disc disease: United States, 2000 to 2009. Spine J. 2015;15:265–71.CrossRefPubMedGoogle Scholar
  7. 7.
    Harrop JS, Youssef JA, Maltenfort M, Vorwald P, Jabbour P, Bono CM, Goldfarb N, Vaccaro AR, Hilibrand AS. Lumbar adjacent segment degeneration and disease after arthrodesis and total disc arthroplasty. Spine (Phila Pa 1976). 2008;33:1701–7.CrossRefGoogle Scholar
  8. 8.
    Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery—the case for restraint. N Engl J Med. 2004;350:722–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Eliasberg CD, Kelly MP, Ajiboye RM, SooHoo NF. Complications and rates of subsequent lumbar surgery following lumbar total disc arthroplasty and lumbar fusion. Spine (Phila Pa 1976). 2016;41:173–81.CrossRefGoogle Scholar
  10. 10.
    Ghiselli G, Wang JC, Bhatia NN, Hsu WK, Dawson EG. Adjacent segment degeneration in the lumbar spine. J Bone Joint Surg Am. 2004;86–A:1497–503.CrossRefPubMedGoogle Scholar
  11. 11.
    Xia X-P, Chen H-L, Cheng H-B. Prevalence of adjacent segment degeneration after spine surgery: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2013;38:597–608.CrossRefGoogle Scholar
  12. 12.
    Park CK, Ph D. Total disc replacement in lumbar degenerative disc diseases. J Korean Neurosurg. 2015;58:401–11.CrossRefGoogle Scholar
  13. 13.
    Bono CM, Garfin SR. History and evolution of disc replacement. Spine J. 2004;4:145S–50S.CrossRefPubMedGoogle Scholar
  14. 14.
    Van Den Eerenbeemt KD, Ostelo RW, Van Royen BJ, Peul WC, Van Tulder MW. Total disc replacement surgery for symptomatic degenerative lumbar disc disease: a systematic review of the literature. Eur Spine J. 2010;19:1262–80.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Vital J-M, Boissière L. Total disc replacement. Orthop Traumatol Surg Res. 2014;100:S1–14.CrossRefPubMedGoogle Scholar
  16. 16.
    Szpalski M, Gunzburg R, Mayer M. Spine arthroplasty: a historical review. Eur Spine J. 2002;11(Suppl 2):S65–84.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Uschold TD, Fusco D, Germain R, Tumialan LM, Chang SW. Cervical and lumbar spinal arthroplasty: clinical review. AJNR Am J Neuroradiol. 2012;33:1631–41.CrossRefPubMedGoogle Scholar
  18. 18.
    Mayer HM. Total lumbar disc replacement. J Bone Joint Surg Br. 2005;87:1029–37.CrossRefPubMedGoogle Scholar
  19. 19.
    Baxter RM, Macdonald DW, Kurtz SM, Steinbeck MJ. Severe impingement of lumbar disc replacements increases the functional biological activity of polyethylene wear debris. J Bone Joint Surg Am. 2013;95:e751–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Phillips FM, Garfin SR. Cervical disc replacement. Spine (Phila Pa 1976). 2005;30:S27–33.CrossRefGoogle Scholar
  21. 21.
    • Guyer RD, Pettine K, Roh JS, Dimmig TA, Coric D, McAfee PC, Ohnmeiss DD. Five-year follow-up of a prospective, randomized trial comparing two lumbar total disc replacements. Spine (Phila Pa 1976). 2016;41:3–8. Recent RCT comparing outcomes of TDR with Kineflex-L and CHARITE. CrossRefGoogle Scholar
  22. 22.
    Wilke HJ, Schmidt R, Richter M, Schmoelz W, Reichel H, Cakir B. The role of prosthesis design on segmental biomechanics semi-constrained versus unconstrained prostheses and anterior versus posterior centre of rotation. Eur Spine J. 2012; doi: 10.1007/s00586-010-1552-1.Google Scholar
  23. 23.
    Galbusera F, Bellini CM, Zweig T, Ferguson S, Raimondi MT, Lamartina C, Brayda-Bruno M, Fornari M. Design concepts in lumbar total disc arthroplasty. Eur Spine J. 2008;17:1635–50.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Meir AR, Freeman BJC, Fraser RD, Fowler SM. Ten-year survival and clinical outcome of the AcroFlex lumbar disc replacement for the treatment of symptomatic disc degeneration. Spine J. 2013;13:13–21.CrossRefPubMedGoogle Scholar
  25. 25.
    Gamradt SC, Wang JC. Lumbar disc arthroplasty. Spine J. 2005;5:95–103.CrossRefPubMedGoogle Scholar
  26. 26.
    Büttner-Janz K, Guyer RD, Ohnmeiss DD. Indications for lumbar total disc replacement: selecting the right patient with the right indication for the right total disc. Int J spine Surg. 2014; doi: 10.14444/1012.PubMedGoogle Scholar
  27. 27.
    Tropiano P, Huang RC, Girardi FP, Cammisa FP, Marnay T. Lumbar total disc replacement. Surgical technique. J Bone Joint Surg Am. 2006;88(Suppl 1):50–64.CrossRefPubMedGoogle Scholar
  28. 28.
    Brau SA, Delamarter RB, Kropf MA, Watkins RG, Williams LA, Schiffman ML, Bae HW. Access strategies for revision in anterior lumbar surgery. Spine (Phila Pa 1976). 2008;33:1662–7.CrossRefGoogle Scholar
  29. 29.
    Frelinghuysen P, Huang RC, Girardi FP, Cammisa FP. Lumbar total disc replacement part I: rationale, biomechanics, and implant types. Orthop Clin North Am. 2005;36:293–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Dehn T. Degenerative disc disease: disc replacement. Ann R Coll Surg Engl. 2007;89:6–11.CrossRefPubMedCentralGoogle Scholar
  31. 31.
    Zigler J, Garcia R. ISASS policy statement—lumbar artificial disc. Int J spine Surg. 2015;9:7.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Siepe CJ, Heider F, Wiechert K, Hitzl W, Ishak B, Mayer MH. Mid- to long-term results of total lumbar disc replacement: a prospective analysis with 5- to 10-year follow-up. Spine J. 2014;14:1417–31.CrossRefPubMedGoogle Scholar
  33. 33.
    Yue JJ, Garcia R, Miller LE. The activL(®) artificial disc: a next-generation motion-preserving implant for chronic lumbar discogenic pain. Med Devices (Auckl). 2016;9:75–84.Google Scholar
  34. 34.
    • LS Bao, Hai Y, Kong C, Wang QYI, Su Q, Zang L, Kang N, MX Long, Wang Y. An 11-year minimum follow-up of the Charite III lumbar disc replacement for the treatment of symptomatic degenerative disc disease. Eur Spine J 2015: 24:2056–2064. Recently published study presenting results of TDR with the Charite III with a mean follow-up of 11.8 years. Google Scholar
  35. 35.
    • Park S-J, Lee C-S, Chung S-S, Lee K-H, Kim W-S, Lee J-Y. Long-term outcomes following lumbar total disc replacement using ProDisc-II average 10-year follow-up at a single institute. Spine (Phila Pa 1976). 2016;4(1):971–7. Recently published article highlighting the importance of patient selection for successful outcomes. CrossRefGoogle Scholar
  36. 36.
    Aghayev E, Etter C, Bärlocher C, et al. Five-year results of lumbar disc prostheses in the SWISSspine registry. Eur Spine J. 2014;23:2114–26.CrossRefPubMedGoogle Scholar
  37. 37.
    Nie H, Chen G, Wang X, Zeng J. Comparison of total disc replacement with lumbar fusion: a meta-analysis of randomized controlled trials. J Coll Physicians Surg Pak. 2015;25:60–7.PubMedGoogle Scholar
  38. 38.
    Jacobs W, Van der Gaag NA, Tuschel A, de Kleuver M, Peul W, Verbout AJ, Oner FC. Total disc replacement for chronic back pain in the presence of disc degeneration. Cochrane database Syst Rev 2012:CD008326.Google Scholar
  39. 39.
    Wei J, Song Y, Sun L, Lv C. Comparison of artificial total disc replacement versus fusion for lumbar degenerative disc disease: a meta-analysis of randomized controlled trials. Int Orthop. 2013;37:1315–25.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Rao M-J, Cao S-S. Artificial total disc replacement versus fusion for lumbar degenerative disc disease: a meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg. 2014;134:149–58.CrossRefPubMedGoogle Scholar
  41. 41.
    Yajun W, Yue Z, Xiuxin H, Cui C. A meta-analysis of artificial total disc replacement versus fusion for lumbar degenerative disc disease. Eur Spine J. 2010;19:1250–61.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    • Ding F, Jia Z, Zhao Z, Xie L, Gao X, Ma D, Liu M. Total disc replacement versus fusion for lumbar degenerative disc disease: a systematic review of overlapping meta-analyses. Eur Spine J 2016: 1–10. This article evaluates the published meta-analyses of RCTs comparing lumbar TDR with fusion. Google Scholar
  43. 43.
    Zigler J, Delamarter R, Spivak JM, et al. Results of the prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of the ProDisc-L total disc replacement versus circumferential fusion for the treatment of 1-level degenerative disc disease. Spine (Phila Pa 1976). 2007;32:1155–62. discussion 1163Google Scholar
  44. 44.
    Blumenthal S, McAfee PC, Guyer RD, Hochschuler SH, Geisler FH, Holt RT, Garcia R, Regan JJ, Ohnmeiss DD. A prospective, randomized, multicenter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes. Spine (Phila Pa 1976). 2005;30(1565–75):–91.Google Scholar
  45. 45.
    Sasso RC, Foulk DM, Hahn M. Prospective, randomized trial of metal-on-metal artificial lumbar disc replacement: initial results for treatment of discogenic pain. Spine (Phila Pa 1976). 2008;33:123–31.CrossRefGoogle Scholar
  46. 46.
    Gornet MF, Burkus JK, Dryer RF, Peloza JH. Lumbar disc arthroplasty with MAVERICK disc versus stand-alone Interbody fusion. Spine (Phila Pa 1976). 2011;36:E1600–11.CrossRefGoogle Scholar
  47. 47.
    Hellum C, Johnsen LG, Storheim K, Nygaard OP, Brox JI, Rossvoll I, Rø M, Sandvik L, Grundnes O. Surgery with disc prosthesis versus rehabilitation in patients with low back pain and degenerative disc: two year follow-up of randomised study. BMJ. 2011;342:d2786.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Berg S, Tullberg T, Branth B, Olerud C, Tropp H. Total disc replacement compared to lumbar fusion: a randomised controlled trial with 2-year follow-up. Eur Spine J. 2009;18:1512–9.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Moreno P, Boulot J. Comparative study of short-term results between total artificial disc prosthesis and anterior lumbar interbody fusion. Rev Chir Orthop Reparatrice Appar Mot. 2008;94:282–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Alahmadi H, Deutsch H. Outcome of salvage lumbar fusion after lumbar arthroplasty. Asian Spine J. 2014;8:13–8.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    David T. 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). 2007;32:661–6.CrossRefGoogle Scholar
  52. 52.
    Lemaire JP, Carrier H, Ali. EHS clinical and radiological outcomes with the CHARITÉ™ artificial disc: a 10-year minimum follow-up. J Spinal Disord Tech 2005: 18:353–359Google Scholar
  53. 53.
    Zigler J, Delamarter R. 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. 2012;17:493–501.CrossRefPubMedGoogle Scholar
  54. 54.
    Zigler J, Glenn J, Delamarter R. Five-year adjacent-level degenerative changes in patients with single-level disease treated using lumbar total disc replacement with ProDisc-L versus circumferential fusion. J Neurosurg Spine. 2012;17:504–11.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Stephan N. Salzmann
    • 1
  • Nicolas Plais
    • 1
  • Jennifer Shue
    • 1
  • Federico P. Girardi
    • 1
    Email author
  1. 1.Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special SurgeryWeill Cornell Medical CollegeNew YorkUSA

Personalised recommendations