Motion preservation surgery in the spine refers to a group of surgeries which aim at preservation of the spine motion by replicating normal or near normal biomechanics. The fundamental to all these surgeries is the use of devices, that replicate these functions.
Decompression and fusion are classic procedures of spine surgery. Motion preservation surgeries are relatively newer concept. The intent of motion preservation surgeries is to provide a better treatment alternative that preserves the function of the spine well.
Motion preservation surgery of the spine is a complex, constantly evolving field and the research is ongoing.
Motion Preservation Surgeries for Cervical Spine
Cervical motion preservation surgery mainly consists of total disc replacement.
Cervical Total Disc Replacement
In cervical total disc replacement, there is the removal of the diseased disc and implantation of the arthroplasty device. The goal is neural decompression, restoration of near normal motion so as to minimize adjacent level disease.
Two devices for commercial use are the ProDisc-C (Synthes Spine USA) and Prestige ST (Medtronic, Memphis, TN).
Clinical trials are underway to determine clinical effectiveness versus anterior cervical compression and fusion
Complications of cervical total disc replacement include fracture, subsidence, migration of the implant, heterotopic ossification, and hardware failure or loosening. Subsidence, as in lumbar TDR, is a gradual process whereby the device settles into the adjacent vertebral body.
Motion Preservation Surgeries for Lumbar Spine
In the lumbar spine, motion preservation devices can be loosely grouped into anterior and posterior motion-preserving devices. anterior motion preservation devices
Anterior Motion Preservation Devices
These devices are intended to replicate the normal motion of the disc space.
Lumbar total disc replacement
Lumbar TDR devices vary widely in shape and composition. Following devices are in use
- Charite device (DePuy Spine)
- FlexiCore device (Stryker Spine)
- ProDisc-L device (Synthes Spine)
- NuVasive’s XL (Nuvasive)
Most of these devices require an invasive anterior approach. NuVasive’s XL is implanted indirectly through a far-lateral approach.
Image Credit: bnasurg
Complications associated with lumbar total disc replacement are hemorrhage, vascular injury, infection, peritoneal entry, vertebral fracture. Late complications of total disc replacement are subsidence of implant, implant migration, heterotopic ossification, adjacent-level degenerative disc disease
The clinical effectiveness has not been unequivocally determined.
Disc Nucleus Replacement
In partial disc replacement, the diseased nucleus pulposus is replaced or augmented with an injectable or preformed device. Annulus fibrosis is not replaced. The devices are in development
Posterior Motion Preservation Devices
These devices address pain originating from the posterior elements from the facet joints, ligaments, tendons, or muscles. Posterior motion preservation devices are also beneficial in spinal stenosis.
These devices can be put into three general categories:
Interspinous Process Spacers
These devices are designed to distract (open) the central canal and foramen[opening where the nerve roots come out of spinal canal]. These devices are designed to address pain and activity restrictions from spinal stenosis. Some of them may be used to treat degenerative disc disease.
The interspinous devices may be implanted as a day surgery procedure under sedation or under light anesthesia, thereby decreasing the risk of extensive open surgery in elderly.
Various interspinous spacer devices in use are X-STOP, Wallis interspinous device, and DIAM Spinal Stabilization System.
Posterior Dynamic Stabilization Devices
This acts as an internal brace for the spine. Posterior dynamic stabilization devices allow controlled motion in such as way as to achieve more normal movement of the spine. These devices are typically used to treat patients with spondylolisthesis and degenerative disc disease. As of now, these devices have been approved for use with fusion but not for independent use as dynamic stabilizers.
Facet Replacement or Total Element Replacement Devices
These are used in facet pain or lumbar spinal stenosis as in many patients, spinal stenosis is due to degeneration of the facet joints. Facet replacement devices replace the facet joints in the back of the spine to limit or control motion, and total element replacement devices replace all the elements in the back of the spine.
None of the devices have withstood the test of time, and most are still in various stages of investigation.
Kyphoplasty
Kyphoplasty is a minimally invasive treatment developed to treat vertebral compression fractures in the spine. Compression fractures cause back pain and make daily activities like walking and lifting difficult. The principle of the kyphoplasty is to strengthen the spine and possibly eliminate pain.
Read more about kyphoplasty
References
- J. Errico. Why a mechanical disc? Spine J, 4 (Suppl 6) (2004), pp. 151S–157S
- Yin, X. Yu, S. Zhou, et al. Is cervical disc arthroplasty superior to fusion for treatment of symptomatic cervical disc disease? A meta-analysis. Clin Orthop Relat Res, 471 (2013), pp. 1904–1919
- Wei, Y. Song, L. Sun, et al. Comparison of artificial total disc replacement versus fusion for lumbar degenerative disc disease: a meta-analysis of randomized controlled trials. Int Orthop, 37 (2013), pp. 1315–1325.
- Yajun, Z. Yue, H. Hiuxin. A meta-analysis of artificial total disc replacement versus fusion for lumbar degenerative disc disease. Eur Spine J, 19 (2010), pp. 1250–1261
- C. Wang, P.M. Arnold, J.T. Hermsmeyer, et al. Do lumbar motion preserving devices reduce the risk of adjacent segment pathology compared with fusion surgery? Spine, 37 (22S) (2012), pp. S133–S143
- E. Ziegler, J. Glenn, R.B. Delamarter. Five-year adjacent-level degenerative changes in patients with single-level disease treated using lumbar total disc replacement with ProDisc-L versus circumferential fusion. J Neurosurg Spine, 17 (6) (2012), pp. 504–511
Is this technique being used by big hospitals like AIIMS ?
These are newer methods and not all of them have been incorporated in clinical practice. However, few surgeons with special interest may be practising them. If you wish to know, you would need to ask the concerned surgeon rather than looking for hospital.
Take care.
Hi Doc I’m really scared as I’m due for surgery soon I had an mri done after I fell of a roller chair at work results were annular tear on l4 and l5 with dosc protrusio and disc dessication my surgeon had advised me that it needs to be removed as the disc is black due to all the fluid leaking out I have been in soo much pain for the past 12 months awaiting the procedure and the time is near.i was told here is not other natural options as If I don’t do the op I could end up paralysed because the div is now sitting on my spinal cord.is there any advice I’m really worried that after surgery I my not walk I don’t know how advanced South Africa is in terms of spine procedures.
Sorry if this reply does not get you in time.
Auri, what you need is a second opinion after taking a personal consultation with another doctor. Only after examination and evaluation it can be told whether you need surgical procedure or not.
Hi Doc how would I know if motion preservation surgery is available in South Africa I have a herniated disc on l4 and l5 and disc dessication so it’s black and has protruded into the spinal canal I suffer pain daily and medication is not so strong anymore
Auri,
Sorry! I am not aware of this in South Africa.