29

Complications of Lumbar Disk Arthroplasty

Sang-Ho Lee and Chan Shik Shim

Early Complications

Late Complications

Subsidence

Facet Arthrosis

Migration of Polyethylene Core

Polyethylene Wear and Osteolysis

Device Migration, Dislocation, or Subluxation

Heterotopic Ossication

Fracture of the Vertebral Body

Postoperative Radiculopathy

Conclusion

Persistent Back Pain

Cerebrospinal Fluid Leakage and Root Injury
Infection
Recent successful clinical results of lumbar disk arthroplasty
have provoked widespread enthusiasm. The early- and
intermediate-term clinical results of total disk replacement
(TDR) were promising.115 Early results of prospective randomized studies comparing TDR with spinal arthrodesis have
shown that TDR is doing as well or better than fusion.1620 But
the complications of TDR reported so far are neither rare nor
minor in their potential severity. The incidence of complications even with experienced surgeons are not negligible and
it is expected that the incidence will increase if TDR is widespread and done by less experienced surgeons.21 Furthermore, some of the reported complications are signicantly
dangerous and difcult to deal with.22 Therefore, it is worth
appreciating all of the reported complications in this early
period of enthusiasm to be aware of the real advantages and
disadvantages of lumbar TDR and to avoid complications, if
possible, when it is adopted in ones own practice.
This chapter discusses the complications of lumbar disk
arthroplasty that are not related to surgical approach.

Early Complications
Subsidence
Subsidence of the prosthesis is one of the common complications of TDR. It is generally regarded as a late complication of
disk arthroplasty and Cinotti et al4 stated that subsidence
occurred in patients who had an undersized prosthesis. In
our series, however, subsidence occurred in the early postoperative period in relation to a fracture of the vertebral body
(Fig. 291) or in patients with osteoporosis (Fig. 292).
Marked subsidence and the resultant change in the conguration of the prosthesis could make the polyethylene core

extrude. Because the extruded core may damage the great

vessels that lie in front of the vertebral column, the prosthesis should be removed when the subsidence is identied in
the immediate postoperative period or the conguration of
the prosthesis is distorted signicantly. However, in cases
where the subsidence is not signicant, reinforcement of the
vertebral body with polymethyl methacrylate (PMMA) can
prevent further sinking of the prosthesis (Fig. 292C).
Technical error may be one cause of the subsidence. End
plate preparation should be carefully done to make the
plates of the prosthesis parallel because obliquity in the
coronal plane may cause subsidence (Fig. 292A). The prosthesis should be positioned in the center of the coronal plane
of the disk space to maintain the coronal balance of the
spinal motion segment. Advanced segmental scoliosis preoperatively should be regarded as a relative contraindication
of TDR because it is difcult to restore the scoliotic segment
with an articial disk. A patient with signicant osteoporosis
also should be excluded from TDR. In patients who have osteoporosis and refuse to accept fusion, augmentation of the
vertebral body with PMMA may be a possible solution. There
has been a successful report of concomitant augmentation of
the vertebral body with PMMA in a patient with osteoporosis
who underwent TDR,23 but long-term data are needed to
prove its long-term efcacy.
Delayed subsidence several years after the successful
implantation of the prosthesis is another concern. When the
vertebral body becomes osteoporotic as the patient ages,
because of the discrepancy of the strength between bone and
prosthesis, the prosthesis could subside. Although some
investigators presumed that the porous-coated end plates
(titanium and hydroxyapatite) would improve biological
xation of the metal plates to the vertebral bodies,24 it is uncertain that it could prevent late subsidence of the prosthesis.

227

228

Section III Restoration of Lumbar Motion Segment: B Lumbar Total Disk Replacement

Figure 291 (A) Fifty-eight-year-old female. Lateral radiograph taken

postoperative day 1 showed proper positioning of the implant. (B) On
postoperative day 6, she felt severe back pain and radiography revealed

subsidence of the implant with a transverse fracture of the L5 vertebral

body. The prosthesis was removed and anterior lumbar interbody
fusion was done. (Courtesy of Dr. Byung-Joon Kong.)

Migration of Polyethylene Core

subluxation has decreased.4,5 With the ProDisc, though,

there is no reported device migration or subluxation in the
literature,8,11,12 we experienced a case of device subluxation
in our ProDisc series. One reason that the ProDisc showed
no incidence of device migration or subluxation may be that
it has a high keel on the plates that gives more solid xation
in the immediate postoperative period than does the SB
Charit.

There was a case of migration of the polyethylene core

reported in the ProDisc series and it was attributed to technical fault.19 With the SB Charit (DePuy Spine, Raynham,
MA) it occurred at the L5S1 level where there was a large
lumbosacral angle and hyperlordosis with a large distance
between the two vertebral end plates anteriorly and a narrow posterior disk space. In such a case, David24 proposed to
use the prosthesis with a more acute angle and place it more
posteriorly. In our experience of 620 TDR cases, we have
encountered one case of extrusion of the polyethylene core
with resultant subluxation of the upper plate of the ProDisc
[DE1] (Synthes, Inc., West Chester, PA). In our opinion, the extrusion of the core is closely related to surgical technique. It
is important to see that the core is securely positioned after
the insertion. With the ProDisc, it is easy to see if the core is
properly placed because the anterior margin of the core is at
the same level of the device plates and it should not protrude
over the edges of the plates of the prosthesis. With the SB
Charit, it is better to conrm the position of the core with
uoroscopy because there is a metallic marker around the
polyethylene core.

Device Migration, Dislocation, or Subluxation

Device migration or dislocations were reported in the study of
previous models of the SB Charit (Charit I and Charit II)7,25
but with the SB Charit III, the incidence of migration or

Fracture of the Vertebral Body

Fracture of the posterior corner of the vertebral body is a
well-known complication of the SB Charit replacement
(Fig. 293). The SB Charit has spikes on the anterior and
posterior margin of the plates and these spikes can cause
fracture of the posterior lips of the vertebral body during insertion of the prosthesis. It is better to prepare the posterior
portion of the vertebral end plates adequately for smooth
insertion of the prosthesis with a high-speed drill or a
curette. It was also recommended that once the polyethylene
core has been inserted, the prosthesis should not be hammered to be placed posteriorly.24 If the fracture of the posterior lip of the vertebral end plate is identied immediately
after the surgery and the patient has symptoms of neural
compression, the bony fragment should be removed by
either an anterior or a posterior approach. We prefer the
posterior approach because it can allow removal of the bony
fragment compressing the thecal sac and root without the
need to manipulate the prosthesis.

29 Complications of Lumbar Disk Arthroplasty

229

C
Figure 292 (A) Sixty-two-year-old female. The immediate postoperative anteroposterior plain radiograph showed unparallel plates of
L4L5 prosthesis. (B) The radiograph taken on postoperative
day 4 showed the subsidence of the upper plate of the L4L5 prosthesis

into the L4 vertebral body. (C) Reinforcement of the vertebral body with
polymethyl methacrylate was done to prevent further sinking of the
prosthesis. (Courtesy of Dr. Won-Cheol Choi.)

230

Section III Restoration of Lumbar Motion Segment: B Lumbar Total Disk Replacement

Figure 293 Thirty-two-year-old female. (A) Postoperative computed tomographic (CT) scan showed posterior lip of L5 upper end
plate fracture. The patient had weakness of right big toe in dorsiexion.

The fractured fragment compressing the neural tissue was removed via
a posterior approach. (B) CT scan taken after revision surgery showed
removal of offending bony fragment. (Courtesy of Dr. Gun Choi.)

Vertical split fracture of the vertebral body after arthroplasty with the ProDisc has been reported (Fig. 294).26
Because the ProDisc has a large keel on the plates, chiseling
is needed to make grooves on the vertebral bodies for the
insertion of the prosthesis. This step of the procedure
can cause a vertical split fracture of the vertebral body.
Therefore, care should be exercised during the chiseling of
the bodies and insertion of the ProDisc, especially when it
is implanted in a patient with small dimensions of the
vertebral body, or when replacement is planned at multiple
levels.

There were two cases of facet fracture after articial disk

replacement in patients who underwent previous laminectomy for disk herniation.27 It was recommended that in a
patient with a history of laminectomy, the extent of laminectomy and amount of facet remaining should be checked
before the articial disk replacement is planned.

Postoperative Radiculopathy
Some patients experience postoperative radicular pain that
was not present before the surgery. In most cases, the cause

Figure 294 (A) Vertical split fracture of the vertebral body after ProDisc replacement. Plain radiograph showed vertical split fracture lines at L4 and
[DE6]
L5 vertebral bodies. (B) Coronal reformation of computed tomographic image showed the fracture lines.

29 Complications of Lumbar Disk Arthroplasty

231

Figure 295 (A) Preoperative and (B) postoperative plain lateral radiographs of 44-year-old female. Note the marked postoperative increment of
disk height of the operated level. The patient complained of severe postoperative back and right leg pain.

is unknown.24 We consider the cause to be traction of the

nerve root due to the overdistraction of the disk space in
patients who already have decreased disk height due to
degenerative disk disease for a prolonged period of time. The
majority of the radiculopathy has been transitory, resolving
within 3 months. But in cases with severe radicular pain, the
device should be removed and replaced with a device of
smaller height or a conversion to anterior lumbar interbody
fusion.

Persistent Back Pain

Some patients complain of severe back pain in the immediate postoperative period, most of which is caused by the
overdistraction of the disk space (Fig. 295). We encountered one patient with severe intolerable back pain in the
recovery room. The patient was revised immediately,
replacing the polyethylene core with a smaller one. If the
postoperative back pain is signicant immediately after surgery, the prosthesis should be removed or changed to a
smaller one. But, because most of the patients who have had
a disk replaced with an articial disk prosthesis experience
some kind of transitory, vague, and dull back pain in the
immediate postoperative period, the revision surgery
should be decided based on the severity of the pain and the
patients disability.
In the case of overdistraction there is no quantitative
method with which to measure the distraction of the disk
space. The proper size of the prosthesis is determined
empirically by the surgeon according to the extent of

distraction of the disk space when it is distracted. The manuals of the surgical technique for both prostheses recommend choosing a device as big as possible to prevent the
problems of device migration or extrusion of the polyethylene core. Therefore, there is a tendency to choose a prosthesis with maximal distraction of the disk space. We feel this
tendency causes the problems of postoperative radicular
pain or back pain caused by traction of the nerve root or distraction of the facet joints. Another problem is that devices
currently available are too big for certain patients who are
short in stature and have small vertebral body dimensions. It
is inevitable that disk arthroplasty in those patients would
cause overdistraction of the disk space.
Another type of persistent postoperative back pain is one
caused by poor patient selection. TDR is not appropriate in a
patient who already has signicant facet arthropathy, and in
fact may cause facet pain by distraction and mobilization of
the already degenerated, hypertrophied, and immobile joint.
In that case, disk arthroplasty should be withheld and spinal
arthrodesis should be considered.

Cerebrospinal Fluid Leakage and Root Injury

Cerebrospinal uid (CSF) leakage due to a dural tear can
occur in patients who have undergone previous posterior
surgery.24 The tear of the dura in such a circumstance is difcult to repair. Usually, it can be managed with hemostatic
sponges and brin glue. Root injury can occur when aggressive decompression of the neural foramen is attempted. We
experienced a case of a partial avulsion injury of the L5 root

232

Section III Restoration of Lumbar Motion Segment: B Lumbar Total Disk Replacement

during the removal of a concomitant foraminal disk herniation in a patient with degenerative disk disease, resulting in
footdrop after the surgery. The patient eventually recovered
from the footdrop, but the experience was painful. Care
should be exercised not to damage an exiting nerve root
when the neural foraminal area is decompressed from an
anterior approach.

Infection
Infection after TDR is rare. There were no reported case of
infection after TDR in the literature, and there was only one
case of infection in our series. The patient underwent a
hybrid type of disk replacement at L5S1 in combination
with posterior fusion at the above levels. The dorsal wound
became infected and later the infection was disseminated
into the L5S1 space making the prosthesis loosen and subside. The revision was done via a transperitoneal route,
removing the prosthesis and grafting an iliac bone strut after
careful debridement.
If infection around the prosthesis occurs, conservative care
with antibiotics is generally not recommended because the
bulk of the implant hinders the antibiotics ability to eradicate the infection.28 Surgical treatment is indicated, but a
concern arises about this revision surgery because removal
of the implant can be life-threatening given the extensive
scarring around the great vessels. As Santos et al29 pointed
out, although infection after disk arthroplasty per se has not
been reported in the literature, a protocol to handle it needs
to be put in place.
Another issue is prophylactic use of antibiotics in a medical
procedure that can cause bacteremia after disk arthroplasty.
After joint arthroplasty, medical procedures that cause
bacteremia, such as dental work, require prophylactic antibiotics.30 Although it is generally not recommended in spinal
fusion, this will need consideration in spinal arthroplasty
because once the prosthesis is infected via the hematogenous route the consequence can be disastrous.

Late Complications
Facet Arthrosis
Van Ooij et al22 reported 11 patients with facet arthrosis after
TDR with the SB Charit prosthesis in a series of 500 patients operated on at a single institution near their hospital.
They performed posterior fusion on eight of the patients and
found that facet joint hypertrophy reached huge dimensions.
They postulated that the cause of the facet arthrosis was
abnormal movement patterns of the segment containing the
disk prosthesis. In the ProDisc series, there is no report
addressing the issue of facet arthrosis. This is because the
history of the ProDisc is shorter than that of the SB Charit,
and facet arthrosis is a long-term complication. Link31 described the biomechanics of disk prostheses and differences
in impingement and stress on the facet joint in relation to
movement of the core of the prosthesis. He theorized that
the sliding core of the SB Charit prosthesis was biomechanically superior to the xed core of the ProDisc in unloading
the facet joint in exion and extension of the lumbar motion

segment. Links theory may be true in some respects, but

long-term evidence is needed to conrm the superiority of
the sliding core over the xed core in preservation of the
facet joint because there is also a concern that too much unloading and mobilizing of the facet joint can cause laxity of
the facet capsule, which in turn causes hypertrophy of the
facet joint. David24 described bilateral symmetric facet
arthritis in a patient whose prosthesis had been placed too
far anteriorly. Anteriorly placed prostheses can cause
marked movement of the facet joint in exion and extension
because the center of rotation locates much more anteriorly
than the instantaneous axis of rotation of the normal motion
segment. This case reinforces the concern that too much
mobilization of the facet joint can cause late problems in
that joint.

Polyethylene Wear and Osteolysis

Polyethylene wear was reported by van Ooij et al22 in a
patient with a prosthesis in situ for more than 13 years.
However, there is no other report of polyethylene wear
thus far in both the SB Charit and ProDisc series. Although
the cobalt-chromium-molybdenum alloy was known to
make less polyethylene wear debris,32,33 the production of
wear particles has not been completely prevented and
many questions about wear debris from material other
than polyethylene remain unanswered. Although there has
been no other reported case of osteolysis or polyethylene
wear in either the SB Charit or the ProDisc series, longterm results are needed to answer the question of wear
debris.

Heterotopic Ossication
Heterotopic ossication in articial disk replacement has
been described by several authors.4,5,7,24 McAfee et al34 developed a classication of heterotopic ossication based on the
classication of heterotopic ossication of the hip following
total hip replacement. Heterotopic ossication after disk
arthroplasty did not affect clinical outcome, however. There
have been reports of spontaneous fusion after disk arthroplasty.4 In our series, there are several cases in which the
implanted segment showed no movement at all, although
spontaneous fusion around the prosthesis has not been
observed. Regardless of the clinical outcomes, those
cases should be regarded as surgical failures because the
preservation of motion is one of the major purposes of disk
arthroplasty.

Conclusion
Several complications in lumbar disk arthroplasty exist.
Encouraged by the favorable early clinical outcomes and potential advantage of prevention of accelerated degeneration
of the adjacent segment, TDR will be widely used in spinal
practice. However, it is obvious that TDR will face more
frequent complications when it is used widely by less experienced hands. Additionally, there is room for improvement
of the device design and instruments. To reduce the complications of TDR in which treatment can sometimes be life

29 Complications of Lumbar Disk Arthroplasty

threatening, the surgeon should be well informed about
detailed surgical techniques and the deciencies of each prosthesis and should stick to the most important principle for
successful surgeryproper patient selection. It should be kept

233

in mind that, with current technology, total disk replacement

cannot completely replace spinal arthrodesis like total joint
replacement has replaced joint arthrodesis in other elds of
joint surgery.

References

[DE2]
[CR3]

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7. Grifth SL, Shelokov AP, Buttner-Janz K, LeMaire JP, Zeegers WS. A
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9. Hochschuler SH, Ohnmeiss DD, Guyer RD, Blumenthal SL. Articial
disc: preliminary results of a prospective study in the United States.
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17. Guyer RD, McAfee PC, Hochschuler SH, et al. Prospective randomized
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18. McAfee PC, Fedder IL, Saiedy S, Shucosky EM, Cunningham BWSB.
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19. Zigler JE, Burd TA, Vialle EN, Sachs BL, Rashbaum RF, Ohnmeiss DD.
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J Spinal Disord Tech 2003;16:384389

[DE1]

[DE4]

Au: Is this the correct manufacturer and location for the ProDisc
mentioned here?
[DE2]
Au: First author is incorrect per Medline. Please check.
[CR3]
Au: Please provide rst three authors with et al if more than six
authors. If six or fewer, please provide all author names. See also
other references citing et al.

[DE5]
[DE6]

Au: Buttner, okay?

Au: Please provide supplement no.
Au: Please mention arrows in legends for (A) and (B).