Revision strategies in lumbar total disc arthroplasty

Study Design. Review of Literature. Objective. To review the published literature regarding revision lumbar total disc arthroplasty as well as potential options to avoid complications associated with the revision surgical approach. Summary of Background Data. The use of lumbar total disc arthroplasty in the United States has not achieved the same popularity as seen in Europe, where studies have reported favorable short- and intermediate- term results. In the United States, despite recognition that disc replacement may reduce the incidence of adjacent segment disease, the risk of potential complications associated with primary and revision total disc arthroplasty have diminished surgeon enthusiasm for the procedure. The use of adhesion barriers may address some of these concerns. Methods. A series of Ovid Medline and Pubmed- National Library of Medicine/ National Institutes of Health ( www. ncbi. nlm. nih. gov) searches were performed. Only articles written in English journals or published with English translations were included. Level of evidence of the selected articles was assessed. Results. The need for revision of lumbar total disc arthroplasty has been reported in a number of prospective, randomized trials ( level I or II evidence). Suboptimal patient selection and/ or surgical technique accounted for the majority of failed disc arthroplasties. Revision procedures have included posterior stabilization or anterior explantation with revision to arthroplasty or conversion to arthrodesis. The risk of injury to the great vessels and retroperitoneal structures is greater during revision than primary procedures. The use of a far lateral, or transpsoas approach to the anterior column may reduce these adverse events. The use of adhesion barriers has been shown to reduce adhesions in abdominal and pelvic surgery and may be of benefit in revision disc arthroplasty. Conclusion. Adherence to stringent indications and meticulous surgical technique may reduce the number of revision procedures. Further, the use of barriers to adhesion formation during the primary arthroplasty may also reduce risk to the retroperitoneal structures during revision approaches.