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Multiple-Level Lumbar Total Disk Replacement

A Prospective Clinical and Radiographic Analysis of Motion Preservation at 24–72 Months

Rasouli, Alexandre, MD; Cuellar, Jason M., MD, PhD; Kanim, Lea, MS; Delamarter, Rick, MD

doi: 10.1097/BSD.0000000000000704

Background: Recent studies demonstrate the efficacy of lumbar arthroplasty using the ProDisc-L. Patients frequently present with multilevel pathology and may be candidates for multilevel disk replacement.

Purpose: To evaluate clinical outcomes and sagittal range of motion of operated levels and adjacent lumbar motion segments in multiple-level ProDisc-L constructs after 2–6 years follow-up.

Patient Sample: A total of 159 patients underwent adjacent 2-level (n=114), 3-level (n=41), or 4-level (n=4) lumbar total disk replacement (TDR).

Study-Design: This is a prospective cohort.

Outcome Measures: Clinical measures: Oswestry Disability Index and Visual Analog Score of patient satisfaction (VAS-S) and pain (VAS-P) data were collected. Radiographic measures: sagittal motion on preoperative and postoperative lumbar radiographs at each operative segment and adjacent segment.

Methods: Patients were evaluated with radiographic and clinical outcomes measures preoperatively, at 6 weeks, 3 months, 6 months, and annually for 24–72 months postoperatively.

Results: Radiographic: at the motion segment adjacent to the TDR, mean preoperative range of motion (ROM) was 8.20±2.88 degrees, compared with 8.40±2.4 degrees postoperatively at last follow-up (P>0.05). Between the 3 TDR groups, there were no significant differences in ROM at any time point except at L5–S1. Across both groups for TDR motion segments, the mean preoperative ROM was 10.15±2.71 versus 12.30±2.25 degrees postoperatively (P=0.011) at last follow-up. At L5–S1 mean preoperative motion was 7.60±3.90 versus 5.81±3.1 degrees postoperatively (P=0.60). Clinical: at 24–72 months postoperatively, all patients had significant reductions in Oswestry Disability Index, VAS-P, and VAS-S scores (P<0.05). At up to 72 months of follow-up, no patient underwent adjacent-level surgery but there were 3 cases of index-level revision surgery.

Conclusions: Multilevel TDR preserves ROM at the individual TDR levels. Most significantly, the nonoperative adjacent level maintains its preoperative ROM at 2–6 years postoperatively. At up to 6 years of follow-up, there has been no need for revision or adjacent-segment surgery. Patients also demonstrate significant improvement in pain and disability at latest follow-up.

Cedars-Sinai Spine Center, Los Angeles, CA

The authors declare no conflict of interest.

Reprints: Jason M. Cuellar, MD, PhD, 450 N Roxbury Drive, 3rd Floor, Beverly Hills, CA 90210 (e-mail:

Received April 7, 2017

Accepted May 8, 2018

© 2019 by Lippincott Williams & Wilkins, Inc.