Indications

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  Lumbar disk arthroplasty (LDA) is indicated as a treatment of chronic, incapacitating low back pain that is diskogenic in origin at the L4-5 or L5-S1 level and not accompanied by neural element compression resulting in claudication or radiculopathy. Diagnosis should be documented with magnetic resonance imaging (MRI), plain lumbar spine x-rays, and positive results of provocative diskography of the pathologic level.

• •

  To be considered for surgery, patients should have failed at least 6 months of conservative nonsurgical therapies and ideally be 18 to 50 years old. Patients who have previously undergone posterior disk interventions, such as diskectomy or nucleolysis, may be candidates for LDA as long as no acute neural compression is present, and the remaining facet anatomy is sufficient to prevent distraction of the disk space and provide stability of the segment to be operated.

Contraindications

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  Assuming a patient’s general medical condition is adequate to undergo elective spine surgery, contraindications to this procedure are active diskitis, previous (failed) fusion surgery at the pathologic level, malignancy, fracture or spondylolysis of the adjacent vertebrae, spondylolisthesis of the pathologic segment, osteopenia insufficient to support the disk prosthesis, and advanced facet arthrosis.

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  As with other anterior lumbar spine procedures, relative contraindications to this approach include the presence of an infrarenal aortic aneurysm, congenital or iatrogenic genitourinary anatomic abnormalities such as an ipsilateral single ureter or kidney, or a history of previous retroperitoneal surgery.

Planning and positioning

The patient is positioned supine on the operating table. The lumbar spine is placed in extension; the patient’s legs are abducted if a lithotomy position is used. The surgeon performs the procedure standing between the legs of the patient if the lithotomy position is used. This position gives the surgeon a slightly more centered approach during prosthesis placement, which can be crucial to the success of the device.

Before incision, the correct disk space is localized using anteroposterior and lateral fluoroscopy, and the skin is marked appropriately. The incision for this approach corridor is centered at this location and marked.

Procedure

Transperitoneal or retroperitoneal approaches may be used to access the L4-5 and L5-1 disk spaces. Both approaches may be performed via various incisions, including midline, paramedian, and Pfannenstiel incisions. An approach from the left side is generally performed because gentle manual retraction of the aorta is more safely performed than retraction of the inferior vena cava. Most surgeons prefer to use the retroperitoneal mini-open approach because of lower rates of hollow viscus injury, retrograde ejaculation, and postoperative ileus. Final fluoroscopic confirmation of the correct disk level is mandatory when the anterior spine is visualized intraoperatively. The anatomic midline is determined with anteroposterior fluoroscopy and marked with a screw above the disk to be removed.

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