At Home with Dr Christian Jessen - 112

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Say goodbye
to back pain
Disc replacement surgery can change your life. Here, two consultant
spinal surgeons outline the various procedures available and the
likely outcomes you can expect if you undergo treatment

T

he ﬁrst
widely
used
lumbar
total disc
total
replacement
was the Charite
device, designed in
the Charite Hospital
in East Berlin in the 1980s, explains
spinal surgeon Mr David Harrison.
MB.BS BSc FRCS AKC. 'Over the
subsequent 30 years, there has been
a steady evolution of these devices
aiming to reproduce, as closely as
possible, the normal motion and
resilience of the vertebral disc.'

Assessing the damage

'Disc replacement in the lumbar spine is not
a substitute for fusion but rather a means to
sustain useful movement in a damaged and
painful segment of the spine. That is provided
that the muscles, ligaments and supportive
joints that operate within the painful area are
still functioning appropriately.
'There is no distinct upper or lower age limit
to the use of lumbar disc replacement. On
rare occasions I've used it in teenagers and in
adults over the age of 60, but in all these cases
the biology of the spine has to be essentially
similar to that of a young- to middle-aged adult.
'The most important aspect of the use of
artiﬁcial disc replacement is in selecting the
individual who is most likely to beneﬁt. This is
a demanding clinical process as one has to
prove, as far as is possible, that it is a single
(or occasionally two adjacent discs) that is
causing the problem in the ﬁrst place.'

Achieving the best results

'Fundamentally, lumbar TDR is used for severe
mechanical low back pain that has failed
to respond to conservative care including
normalising patient's body mass index and
maximising core trunk muscle control.

'Where well-motivated patients
have failed to respond to a
well-planned physical therapy
schedule, consideration can be
given to a total disc repair
(TDR) if there is an isolated
pain source within a single
low lumbar disc. Selection
requires careful discussion
with the patient based upon
good quality MRI and CT
scans of the lumbar spine. MRI
shows the biology of the disc,
the neurological contents of the
spinal canal and the quality of the
muscle that controls the lower back.
CT shows the ﬁne anatomy of the
bone and can be used to assess the
local bone strength.
'Only those individuals who have
sufﬁcient bone strength to support the
additional stress the artiﬁcial disc will place
on adjacent vertebrae can be considered.
Those patients who have degenerative changes
in the facet joints, a narrow spinal canal with
lumbar stenosis or disc protrusions that are not
accessible for removal from an anterior approach
should not be considered, because collapse of
the prosthesis into the bone, ongoing symptoms
from spinal stenosis or neural compression from
disc material are likely to lead to a poor result.'

Speciﬁc selection

'With this careful assessment process, in spite
of seeing thousands of patients with back pain
in the past 24 years, I have implanted fewer
than 300 devices. In other words, only 2-5% of
patients presenting with persistent mechanical
low back pain are suitable candidates.
'The upside of this careful selection process
is that, during this time, there have only been
12 to 15 patients who have returned requiring
conversion of a disc replacement to a fusion,
or who have experienced mechanical
failure of the device as a result of subsidence
into the surrounding vertebral body.'
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At Home with Dr Christian Jessen

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