A curious researcher from Croatia has dug into 80 studies to uncover some of the reasons spine and neuro surgeons are occasionally reluctant to perform a total disc replacement (TDR). The study, “Failure of lumbar disc surgery: management by fusion or arthroplasty?” appears in the November 13, 2018 edition of International Orthopaedics.
Re: TDR, It’s Objective Reality vs. Subjective Opinion
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Dr. Vladimir Kovač, with the Arithera Hospital for Special Diseases in Zagreb and author of the study, explained his research to OTW, “I am a spine surgeon, and besides other pathologies I perform disc arthroplasties. I am satisfied with my results. However, there are a lot of controversies in this procedure, and numerous colleagues are against this procedure. My personal interest was to find out what is objective in these pro- and con- arguments.”
Dr. Kovačfound that issueswith anterior surgery, reimbursement policy, and potential problems with salvage surgery are major reasons for the decline in TDRs.
Dr. Kovačcommented to OTW, “For me the most important information was that we avoid objectively better surgery, because of subjective reasons (for example insufficient competence in anterior surgery).”
“Nobody thinks about turning back to hip fusions, because there are complications and problems in hip arthroplasty. So hip arthroplasty is improving on and on. For me, spine fusions have reached the top of further improvement (there are no further significant improvements possible).”
“Disc arthroplasty is still at the beginning. It is a demanding surgery, but I am convinced that a lot of surgical and constructional improvements can be done. I believe there is no way to go backwards. Despite that it can be difficult, it seems to me that the only way is to solve the problems and move forward.”
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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