Orthopedics-Online

Intervertebral disc prosthesis

Synonyms

Artificial disc, disc replacement, artificial disc replacement, disc arthroplasty, cervical disc prosthesis, lumbar disc prosthesis, disc prosthesis implantation

definition

A Intervertebral disc prosthesis is an artificial disc replacement made of metal and plastic. A artificial disc is used as a replacement for a worn (degenerated), natural Intervertebral disc used. The aim is to reduce the disc-related (discogenic) Back pain to eliminate while maintaining the natural mobility of the spine. An alternative to this was the stiffening of the spine (Spinal fusion) the surgical method of choice in the relevant spinal column in the last few decades.

Figure prosthetic disc

The picture shows a lateral x-ray of the cervical spine after a successful implantation of a disc prosthesis. The reason for the operation was a herniated disc of the cervical spine that could not be adequately treated conservatively.

The intervertebral disc prosthesis is not always the best therapeutic solution. Particularly when changes in the spine due to wear and tear, the stiffening of the affected segment (medically known as a spinal fusion) is often the therapeutic agent of choice.

During the operation of the intervertebral disc prosthesis, the degenerated intervertebral disc is completely removed and the intervertebral disc prosthesis is placed between the vertebral bodies instead. There it is anchored according to its prosthesis design with metal extensions. Due to its special structure, the intervertebral disc prosthesis can follow the movements of the spine. Intervertebral disc prostheses are available for the cervical and lumbar spine. Both times the operation is done from the front, not from the back.

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The spine is difficult to treat. On the one hand it is exposed to high mechanical loads, on the other hand it has great mobility.

The treatment of the spine (e.g. herniated disc, facet syndrome, foramen stenosis, etc.) therefore requires a lot of experience.
I focus on a wide variety of diseases of the spine.
The aim of any treatment is treatment without surgery.

Which therapy achieves the best results in the long term can only be determined after looking at all of the information (Examination, X-ray, ultrasound, MRI, etc.) be assessed.

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introduction

The possibility of installing a Intervertebral disc prosthesis represents a major step forward in spinal surgery.

Intervertebral disc prostheses have only been implanted in large numbers for a few years. There are currently approx. 11,000 disc prostheses implanted, the trend is clearly increasing. In comparison, there are around 180,000 in Germany alone Knee prostheses and Hip prostheses implanted annually. The experience with intervertebral disc prostheses is therefore still relatively recent. Much of the long-term prognosis of a disc prosthesis is still unknown. Nevertheless, the first short to medium-term results after disc prosthesis implantation are very encouraging, which is why a significant increase in the number of implantations is expected in the future.

Structure of a disc prosthesis

A disc prosthesis consists of two Cobalt-chromium-molybdenum Metal plates. The metal surface is coated with titanium or hydroxyapatite. The rough surface structure and the coating of the metal plates allow the prosthesis to grow well into the adjacent vertebral bodies. To ensure immediate stability after implantation, an intervertebral disc prosthesis has type-dependent metal extensions, whereby the intervertebral disc prosthesis is attached to the adjacent vertebral bodies (Primary stability) and a displacement is prevented until the final bony growth.

To the movements of the Spine To be able to participate, an intervertebral disc prosthesis has a plastic core between the metal plates (Polyethylene) or metal. When bending to the side and bending back and forth, the spinal column movements take place via the axes of this core of the disc.

Indication for intervertebral disc prosthesis

Before any operational measure, unless it is an emergency, the full range of conservative therapy of the herniated disc be exploited.

The optimal time for a disc prosthesis implantation can also be missed if, due to disc degeneration (Decrease in height, loss of water in the intervertebral disc) has developed greater spinal instability and subsequent degeneration of other vertebral body structures (e.g. the small vertebral joints).

A distinction must be made between the indications for the implantation of a disc prosthesis in the cervical and lumbar spine.

The classic indication for the implantation of a disc prosthesis is disc-related, monosegmental back pain as a result of disc wear (Discopathy). Monosegmental means that only one intervertebral disc is diseased and needs to be replaced.Due to the intervertebral disc means that the intervertebral disc itself is the cause of the back pain and not a cause disc prolapse or other spinal changes caused by wear and tear are the cause.

In the meantime, 2-3 intervertebral disc segments are being replaced at the same time if neighboring intervertebral discs are also diseased and their share of the Back pain to have. A good diagnosis is important in this regard, because not every wear and tear of the intervertebral discs requires treatment. Only those intervertebral discs that are disease worthy are replaced.

That too Post-nucleotomy syndrome, In the sense of persistent, intervertebral disc-related back pain, after prior removal of a herniated disc, this can be an indication for the implantation of a disc prosthesis.

While the acute herniated disc in the lumbar spine is a contraindication for the implantation of a disc prosthesis and is removed microsurgically in the classic way (Microdiscectomy), The herniated disc in the cervical spine is increasingly being treated with a disc prosthesis. Removing the herniated disc alone is not possible in the cervical spine area because the Herniated disc from behind, as is common with the lumbar spine, is technically very difficult and dangerous due to anatomical conditions. Until now, herniated discs in the cervical spine were operated on from the front, the affected disc and the herniated disc removed and the adjacent vertebral bodies fused, i.e. the spine was stiffened in this section.

Contraindications

The implantation of a disc prosthesis is not a panacea for the elimination of back pain.
On the contrary, Most degenerative spinal diseases are a contraindication to implanting a disc prosthesis.

The reason is very simple: the implantation of a disc prosthesis only eliminates the back pain that is caused by the diseased disc itself. Because of this is a requirement for one Disc prosthesis implantation, that there must be no other wear-related diseases of the spine that are causal or contributory to the Back pain could be. In these cases, other surgical procedures are used. Otherwise the not exactly small and cheap operation may not be successful and the pain that existed before the operation will remain almost unchanged or even worsened afterwards.

To the Contraindications belong:

Acute Herniated disc of the lumbar spine (disproportionate operation)
Osteoporosis (risk of the intervertebral disc collapsing into the adjacent vertebral bodies)
Older age (usually additional wear and tear of other vertebral body structures, often poor bone quality)
Vertebral body sliding (spondylolisthesis (cause of pain is not treated))
Wear of the vertebral joints (spondylarthrosis (cause of pain is not treated))
Spinal canal narrowing (spinal canal stenosis (cause of pain is not treated))

Advantages of the intervertebral disc prosthesis

Classic surgical procedure for back pain caused by intervertebral discs (no herniated disc!), as well as the acute herniated disc Cervical spine, was until recently the stiffening operation of the spine with removal of the intervertebral disc and fusion of the vertebral bodies with one another. It is an established process with good operational results.

A major disadvantage of this surgical procedure, especially in the area of the lumbar spine, is that compared to the Disc prosthesis implantation major trauma as the operation is performed on the back through the muscles and ligaments of the spine. This results in a longer recovery time compared to disc prosthesis implantation (rehabilitation) for the patient.

As the biggest advantage of the Intervertebral disc prosthesis but will preserve the natural Spinal mobility seen. For the following reason: Due to a stiffening operation on the spine, the natural transmission of force to the spine is disturbed and the intervertebral discs that are adjacent to the stiffened spine section are overloaded. The consequence can be renewed back pain caused by the intervertebral disc due to premature wear (Follow-up degeneration). Studies on the cervical spine showed that intervertebral discs in the immediate vicinity of a Vertebral fusion are exposed to an average of 73% more than usual.

Due to the movement of the intervertebral disc prosthesis, all parts of the spinal column should naturally be stressed and subsequent degeneration of the neighboring segments should not occur. Long-term studies on this are still lacking.

Nevertheless, the mobility of the intervertebral disc prostheses is at least given and after at least 1 year averages 8 ° for the L5 / S1 segment and 10 ° for the L4 / 5 segment. The extent to which this flexibility can be maintained over the years is not yet certain.

Herniated disc of the cervical spine

Intervertebral disc
Vertebral bodies
Spinal cord
disc prolapse

Operational preparation

The most important thing in preparation for the operation of the disc prosthesis is correct Indication.
In addition to the physical examination, this primarily requires imaging examination procedures.

X-ray

Disc disease can be diagnosed on plain x-rays. The Intervertebral disc himself is on one X-ray Although not recognizable, a reduced intervertebral body distance between two neighboring vertebral bodies indicates a vertebral disc that is reduced in height and therefore diseased (Chondrosis). Irregularities in the top and base plates as well as bone compression in the neighboring vertebral bodies indicate that the vertebral bodies are involved in the disease process (Osteochondrosis).

The x-ray also provides indications of a decreased condition Bone density or for instability between the vertebral bodies. A vertebral body displacement can be seen in the latter on the lateral x-ray images. Sometimes, however, X-ray function recordings (X-ray recordings with maximum forward and backward flexion) are also necessary to prove a vertebral body displacement and thus the instability. A severe instability or osteoporosis is, as already mentioned, a contraindication for the implantation of a disc prosthesis.

MRI (magnetic resonance imaging) of the cervical and lumbar spine

The Magnetic resonance tomography of the cervical spine or the lumbar spine has become an indispensable part of the diagnosis of diseases of the spine. In contrast to x-rays, the intervertebral disc itself, but also all other important structures of the spine, can be assessed. A disease of the vertebral body joints (spondylarthrosis) is recognized as well as a narrowing of the vertebral canal (spinal canal stenosis). Both diseases are contraindications for the implantation of a disc prosthesis.

The MRI of the lumbar spine / cervical spine (Magnetic resonance imaging) is therefore the best imaging method for diagnosing spinal diseases. What MRI (magnetic resonance imaging) cannot do, however, is to establish a relationship between the image findings (e.g. a diseased intervertebral disc) and the patient's complaints.
This means that a diseased intervertebral disc can be the reason for back pain, but it doesn't have to be. On the contrary, most patients with changes in the intervertebral discs due to wear and tear are symptom-free.

Discography

A Discography is a small surgical procedure that is only performed under local anesthesia of the patient. It is a diagnostic procedure that requires the cooperation of the patient.
A contrast medium is injected into the intervertebral disc with a thin needle and an X-ray image is then taken. In this way, the intervertebral disc tissue can be precisely mapped and damage can be made visible. Above all, however, the injection serves to confirm the diagnosis in the case of suspected discogenic back pain.

The injection of the Contrast agent leads to a Pressure increase in the disc space, which leads to a pain provocation. During the injection, the patient should feel exactly the pain he is familiar with and express this to the doctor.
If this is the case one speaks of a positive distension test. If no pain is provoked, the distension test is negative and the cause of the Back pain remains unclear at first. A disc prosthesis implantation will then be omitted.