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Disc height and motion patterns in the lumbar spine in patients treated with total disc replacement or fusion for discogenic back pain: Results from a randomized controlled trial
Lowenstromska Hospital.
Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics and Sports Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Orthopaedic Centre, Department of Orthopaedics Linköping.
Institute Of Clinical Neuroscience,Norwegian University of Science and Technology, Trondheim, Norway.
2011 (English)In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 11, no 11, 991-998 p.Article in journal (Refereed) Published
Abstract [en]

Study Design. Comparison of X-ray measurements in a randomized controlled trial between instrumented posterior fusion (N=72) and total disc replacement (TDR) (N=80) for chronic low back pain assumed to be discogenic. Results were compared to clinical outcome.

Objective. To see if surgical goals for respective treatments had been reached, if clinical outcome was related to this, and if differences in disc height and adjacent segment motion patterns between groups occurred.

Summary of Background Data. Fusion is considered the “gold standard” in surgical treatment of degenerated disc disease, though the resulting stiffness may induce degeneration in adjacent segments. TDR aims to restore and maintain mobility by replacing a painful disc. Little is known about the degree and quality of mobility in artificial discs in vivo, and whether maintained mobility reduces stress on adjacent segments.

Methods. Flexion-extension X-rays were analyzed pre- and two years postoperatively using Distortion Compensated Roentgen Analysis (DCRA) at treated and adjacent levels, mobility following fusion and TDR was estimated. Changes in disc height and changes in mobility patterns in adjacent segments were compared. The results were compared with clinical outcome regarding back pain.

Results. 78% of fused patients had no mobility whereas 89% of TDR-patients were mobile, but with less than normal mobility. The fulfilment of surgical goals was not correlated to clinical outcome. Fused segments were lower and TDR-segments were higher than normal. There were minor differences, there being more translation or flexion-extension at adjacent levels in the fusion group than in the TDR group.

Conclusions. This very accurate X-ray method (DCRA) indicates that surgical goals were reached in most patients. This however, was not correlated to outcome. Differences between the groups in postoperative disc height and motion patterns at adjacent segments may lead to differences in outcome in the long-term perspective, but this was not detectable after two years.

Place, publisher, year, edition, pages
Elsevier, 2011. Vol. 11, no 11, 991-998 p.
Keyword [en]
RCT, Fusion, total disc replacement, mobility, disc height, clinical outcome, DCRA, adjacent segment
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-54288DOI: 10.1016/j.spinee.2011.08.434ISI: 000297864300001OAI: diva2:302553
Available from: 2010-03-08 Created: 2010-03-08 Last updated: 2012-01-02
In thesis
1. On Total Disc Replacement
Open this publication in new window or tab >>On Total Disc Replacement
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Low back pain consumes a large part of the community’s resources dedicated to health care and sick leave. Back disorders also negatively affect the individual leading to pain suffering, decreased quality-of-life and disability. Chronic low back pain (CLBP) due to degenerative disc disease (DDD) is today often treated with fusion when conservative treatment has failed and symptoms are severe. This treatment is as successful as arthroplasty is for hip arthritis in restoring the patient’s quality of life and reducing disability. Even so, there are some problems with this treatment, one of these being recurrent CLBP from an adjacent segment (ASD) after primarily successful surgery. This has led to the development of alternative surgical treatments and devices that maintain or restore mobility, in order to reduce the risk for ASD. Of these new devices, the most frequently used are the disc prostheses used in Total Disc Replacement (TDR).

This thesis is based on four studies comparing total disc replacement with posterior fusion. The studies are all based on a material of 152 patients with DDD in one or two segments, aged 20-55 years that were randomly treated with either posterior fusion or TDR.

The first study concerned clinical outcome and complications. Follow-up was 100% at both one and two years. It revealed that both treatment groups had a clear benefit from treatment and that patients with TDR were better in almost all outcome scores at one-year follow-up. Fusion patients continued to improve during the second year. At two-year follow-up there was a remaining difference in favour of TDR for back pain. 73% in the TDR group and 63% in the fusion group were much better or totally pain-free (n.s.), while twice as many patients in the TDR group were totally pain free (30%) compared to the fusion group (15%).

Time of surgery and total time in hospital were shorter in the TDR group.

There was no difference in complications and reoperations, except that seventeen of the patients in the fusion group were re-operated for removal of their implants.

The second study concerned sex life and sexual function. TDR is performed via an anterior approach, an approach that has been used for a long time for various procedures on the lumbar spine. A frequent complication reported in males when this approach is used is persistent retrograde ejaculation. The TDR group in this material was operated via an extra-peritoneal approach to the retroperitoneal space, and there were no cases of persistent retrograde ejaculation. There was a surprisingly high frequency of men in the fusion group reporting deterioration in ability to have an orgasm postoperatively.

Preoperative sex life was severely hampered in the majority of patients in the entire material, but sex life underwent a marked improvement in both treatment groups by the two-year follow-up that correlated with reduction in back pain.

The third study was on mobility in the lumbar spinal segments, where X-rays were taken in full extension and flexion prior to surgery and at two-year follow-up. Analysis of the films showed that 78% of the patients in the fusion group reached the surgical goal (non-mobility) and that 89% of the TDR patients maintained mobility.

Preoperative disc height was lower than in a normative database in both groups, and remained lower in the fusion group, while it became higher in the TDR group. Mobility in the operated segment increased in the TDR group postoperatively. Mobility at the rest of the lumbar spine increased in both treatment groups. Mobility in adjacent segments was within the norm postoperatively, but slightly larger in the fusion group.

In the fourth study the health economics of TDR vs Fusion was analysed. The hospital costs for the procedure were higher for patients in the fusion group compared to the TDR group, and the TDR patients were on sick-leave two months less.

In all, these studies showed that the results in the TDR group were as good as in the fusion group. Patients are more likely to be totally pain-free when treated with TDR compared to fusion. Treatment with this new procedure seems justified in selected patients at least in the short-term perspective. Long-term follow-up is underway and results will be published in due course.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2010. 70 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1168
National Category
Medical and Health Sciences
urn:nbn:se:liu:diva-54290 (URN)978-91-7393-439-8 (ISBN)
Public defence
2010-03-26, Aulan, Psykiatribyggnaden, Löwenströmska Sjukhuset, Upplands Väsby, 13:00 (English)
Available from: 2010-03-08 Created: 2010-03-08 Last updated: 2010-05-10Bibliographically approved

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Tropp, Hans
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Orthopaedics and Sports MedicineFaculty of Health SciencesDepartment of Orthopaedics Linköping
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