Total Disc Replacement Complications
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Overview
Cervical arthroplasty, a surgical intervention for cervical spine issues, can be associated with complications stemming from patient selection and surgical technique. Certain patients with specific conditions may not be appropriate candidates for the procedure and may experience complications.
Errors during surgery can lead to problems such as implant sinking, implant dislodgement, nerve-related symptoms, spinal curvature, and abnormal bone growth. This article focuses on the unique complications of cervical arthroplasty and provides a comparison of these complications between cervical total disc replacement (cTDR) and anterior cervical discectomy and fusion (ACDF) procedures.
Implant Sinking, Dislodgment, Displacement, And Bone Loss
Possible complications of cervical arthroplasty include implant sinking (subsidence), implant movement or dislocation, persistent nerve root symptoms (residual radiculopathy), and rare cases of osteolysis.
Subsidence can lead to neck pain and nerve compression, and its occurrence rates vary in the available literature. Patients with osteopenia or osteoporosis have a higher risk. Suboptimal surgical techniques like violating the end plates or using undersized implants can contribute to subsidence.
Insufficient decompression during the procedure can result in ongoing radicular symptoms. Osteolysis, although uncommon, can arise from wear debris or an immune response, especially when metal-on-metal devices are used.
Addressing complications such as subsidence, expulsion, dislocation, and osteolysis usually involves undergoing revision surgery with anterior approaches, where the device is removed and converted to fusion, either through ACDF or anterior corpectomy.
On the other hand, recurrent radiculopathy caused by recurrent or residual foraminal stenosis can typically be treated with a posterior minimally invasive laminoforaminotomy. This procedure is also minimally invasive and preserves motion.
Heterotopic Ossification
Heterotopic ossification (HO) is characterized by the abnormal formation of bone outside the skeletal system, which can arise as a complication after arthroplasty procedures.
This condition can lead to restricted joint movement and, in some cases, fusion of the affected joint. Various risk factors have been identified, including advanced spondylosis, osteophytic disease, male gender, and older age. To minimize the occurrence of HO, it is crucial to undertake careful patient selection, employ precise surgical techniques, and ensure the use of appropriately sized implants.
When selecting patients for arthroplasty, it is important to consider the presence of risk factors that may predispose individuals to develop HO. Surgeons should follow meticulous surgical techniques, which involve thorough irrigation during drilling and the use of bone wax when necessary to prevent exposure of cancellous bone.
Optimal implant sizing is also important, as choosing implants that adequately cover the end plates can help reduce the risk of HO. It is noteworthy that HO typically does not produce noticeable symptoms, thereby rendering revision surgery unnecessary in most cases. Instead, the focus lies on implementing preventive measures and closely monitoring patients for any potential complications associated with HO.
Adjacent Segment Disease
Adjacent segment disease is characterized by degenerative changes in spinal segments adjacent to a previously fused spinal level. It can cause symptoms like radiculopathy, myelopathy, or mechanical instability.
The introduction of motion-preserving devices aimed to reduce stress on adjacent segments, potentially decreasing the occurrence of adjacent segment disease compared to fusion. However, the development of this condition is influenced by various factors, including the underlying degenerative process, patient selection, surgical technique, and the number of levels treated.
While arthroplasty may show promise in reducing adjacent-level degeneration and disease compared to fusion, further research is necessary to gain a comprehensive understanding of its effectiveness.
Research conducted on cadavers has shown that artificial disc placement decreases stress on neighboring segments in comparison to simulated fusion. Initial findings from studies examining adjacent segment degeneration after artificial disc replacement revealed no signs of degeneration during a 5-year follow-up.
A meta-analysis involving FDA Investigational Device Exemption (IDE) studies, which encompassed three randomized multicenter trials, exhibited a notably reduced incidence of adjacent-level surgery favoring arthroplasty.
Supporting evidence from a thorough meta-analysis further confirmed the lower occurrence of adjacent segment degeneration and reoperation in favor of arthroplasty. Long-term studies with follow-up durations of up to 84 months have demonstrated the potential for reduced rates of adjacent-level degeneration and reoperation with arthroplasty.
For instance, a study involving the SECURE-C device revealed a significantly lower incidence of adjacent segment reoperation in the arthroplasty group compared to the anterior cervical discectomy and fusion (ACDF) group.
Likewise, investigations involving the Prestige ST Disc and Mobi-C device have shown decreased incidences of adjacent segment degeneration and subsequent surgeries in the arthroplasty groups compared to ACDF.
These results provide further evidence supporting the idea that arthroplasty may be linked to a decreased risk of adjacent segment degeneration and the requirement for additional surgical interventions, both at the treated level and neighboring segments.
Dysphagia
Dysphagia, characterized by difficulty swallowing, is a frequent complication that can arise after anterior cervical surgery. While the precise causes remain unclear, they are likely influenced by multiple factors.
Age, duration of degenerative disease, operative time, blood loss, multilevel surgery, diabetes, and smoking have been identified as predictors of dysphagia. Immediately after surgery, dysphagia rates are typically high, with no significant disparity observed between cervical arthroplasty and anterior cervical discectomy and fusion (ACDF) in most studies.
However, some studies indicate a potentially lower occurrence of dysphagia with arthroplasty. A meta-analysis concluded that ACDF does not demonstrate superiority over arthroplasty across various outcome measures.
To minimize the likelihood of dysphagia during anterior cervical exposure, it is advised to utilize well-established techniques. These strategies involve ensuring careful control of bleeding, positioning retractors in the longus colli muscles and periodically releasing them every 15 to 20 minutes, conducting thorough release of muscles and soft tissues during dissection (including potential removal of the omohyoid muscle), deflating the endotracheal cuff after retractor placement, maintaining adequate blood flow in the superficial temporal artery following retraction, and administering corticosteroids perioperatively.
Complications Related to Blood Vessels and Risk of Infection
Adverse vascular events and surgical site infections are infrequent in anterior cervical surgery. Comparisons between arthroplasty and anterior cervical discectomy and fusion (ACDF) have shown minimal blood loss with no substantial disparity between the two procedures.
Although isolated cases of intraoperative vascular injuries have been reported, the overall incidence of surgical site infections remains minimal. Consistent findings across various studies comparing arthroplasty and ACDF have highlighted low rates of vascular events and infections.
Dysphagia, the most common complication, is not associated with a higher risk in arthroplasty compared to anterior cervical discectomy and fusion (ACDF). Complications related to the anterior cervical approach are infrequent and display similar occurrence rates in both ACDF and cervical total disc replacement (cTDR). Rates of vascular complications and infection are low, with no significant differences observed between ACDF and arthroplasty.
Precise patient selection and surgical technique can help mitigate complications associated with cervical artificial disc placement, such as subsidence, displacement, osteolysis, and heterotopic ossification (HO), although these occurrences are rare. Cervical arthroplasty is most suitable for patients with 1- to 2-level cervical soft disc disease, mild spondylosis, and no significant facet disease or osteoporosis.
Surgical techniques may vary depending on the chosen implant, but they typically involve accurate midline verification, symmetrical decompression with resection of the proximal uncovertebral joint, minimal drilling, preservation of the bony end plates, appropriate implant sizing, and placement close to the disc’s natural center of rotation. In the event of failed cervical disc arthroplasty, revision surgery is typically straightforward and tailored to address the specific cause of failure.
The development of adjacent segment disease can be observed after arthroplasty or arthrodesis surgeries, and it is influenced by various factors. Biomechanical research has demonstrated that artificial disc placement decreases the stress on neighboring levels in comparison to fusion.
The clinical significance of these reduced stresses is still a matter of discussion. Nevertheless, several meta-analyses and long-term studies indicate that cervical arthroplasty might be associated with a lower occurrence of adjacent segment degeneration and disease.
Do you have more questions?Â
What are the most common complications associated with total disc replacement (TDR)?
The most common complications include infection, implant migration or subsidence, nerve damage, adjacent segment disease, and issues related to the wear of the artificial disc materials. These complications can arise due to various factors, including surgical technique and patient-specific issues
Can TDR cause adjacent segment disease?
While TDR is designed to reduce the risk of adjacent segment disease compared to spinal fusion, it is still possible. This condition occurs when the segments above or below the treated disc experience increased stress, potentially leading to degeneration over time
What are the signs of infection after TDR surgery?
Signs of infection include increased pain, redness, swelling at the surgical site, fever, and drainage from the incision. Early detection and treatment with antibiotics are crucial to prevent serious complications​
How is implant subsidence treated?
Treatment for implant subsidence can vary. Mild cases might be monitored closely, while severe cases may require revision surgery to reposition or replace the implant to ensure stability and function​
What are the risks of spinal cord injury during TDR?
Spinal cord injury is a rare but serious risk of TDR. The risk can be minimized by using advanced imaging techniques during surgery and ensuring the surgeon has extensive experience with the procedure
How can dislocation of the artificial disc be prevented?
Proper surgical technique and patient selection are crucial in preventing dislocation. Ensuring the implant is correctly sized and positioned, and avoiding activities that place undue stress on the spine during recovery, are important preventive measures​
What are the long-term complications of TDR?
Long-term complications can include implant wear, development of adjacent segment disease, chronic pain, and, in rare cases, the need for revision surgery. Ongoing monitoring and follow-up with your surgeon are essential to address any issues early
Can TDR implants wear out over time?
Yes, TDR implants can wear out over time, particularly the polyethylene components. Wear and tear can lead to mechanical failure or the generation of wear particles, which might cause inflammation or other issues​
How is implant migration detected?
Implant migration is typically detected through imaging studies such as X-rays, CT scans, or MRIs. Symptoms might include new or worsening pain, changes in mobility, or nerve-related symptoms​
Can smoking affect the outcome of TDR?
Yes, smoking can negatively impact the outcome of TDR by impairing bone healing and increasing the risk of complications such as infection and poor implant integration
What factors increase the risk of complications after TDR?
Factors that increase the risk include poor bone quality, obesity, smoking, diabetes, and having multiple levels of the spine treated. Patient-specific factors such as age and overall health also play a role​
How is infection treated after TDR?
Infection is treated with antibiotics, and in severe cases, surgical debridement may be necessary. Early detection and treatment are crucial to prevent implant failure or other serious complications​
What are the symptoms of implant subsidence?
Symptoms of implant subsidence may include increased or new onset pain, a sensation of instability in the neck, and possibly nerve-related symptoms like numbness or weakness if nerve compression occurs
What are the risks of allergic reactions to TDR implants?
Allergic reactions to the materials used in TDR implants are rare but possible. Patients with known metal allergies should discuss this with their surgeon, who may choose alternative materials or conduct preoperative testing​
Can TDR be reversed if complications arise?
In some cases, TDR can be revised or converted to a spinal fusion if complications arise. This decision is based on the specific issue and the patient’s overall health and condition
How are chronic pain complications managed after TDR?
Chronic pain after TDR may be managed with physical therapy, medications, pain management techniques, and in some cases, additional surgical intervention if a specific cause is identified​
Can improper surgical technique lead to TDR complications?
Yes, improper surgical technique can lead to complications such as poor implant positioning, nerve damage, and increased risk of infection. Choosing an experienced surgeon is crucial to minimize these risks
Are certain patients more likely to experience complications with TDR?
Patients with poor bone quality, severe degenerative disc disease, or other underlying health conditions may be at higher risk for complications. A thorough preoperative assessment helps identify and mitigate these risks​
How is nerve compression treated after TDR?
Nerve compression after TDR may be treated with medications, physical therapy, and in severe cases, surgical intervention to relieve the pressure on the affected nerves
Can TDR implants fracture?
Implant fracture is rare but can occur, typically due to severe trauma or poor implant positioning. If a fracture occurs, revision surgery is often necessary to replace the damaged implant
What follow-up care is necessary to monitor for TDR complications?
Regular follow-up visits with your surgeon are crucial. These visits typically include physical exams and imaging studies to monitor the condition of the implant and detect any potential issues early
Can lifestyle factors influence the risk of TDR complications?
Yes, lifestyle factors such as maintaining a healthy weight, avoiding smoking, and engaging in regular physical activity can positively influence the outcome and reduce the risk of complications after TDR​
Dr. Vedant Vaksha
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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