gms | German Medical Science

In lumbar DDD the surgical procedures are discectomy, fusion or arthroplasty. Especially the decision between fusion and arthroplasty is difficult. Therefore an algorithm was developed to facilitate the surgeon's choice.

This algorithm is based on patient's history, the clinical presentation of the symptoms, the findings in plain x-rays, CT-scan and MRI and the result of facet analgesia and provocative discography. Furthermore an additional DXA scan to exclude osteoporosis may be necessary.

Contraindications for arthroplasty are tumors, infections, spondylolisthesis, spinal stenosis or previous disc surgery detected with imaging procedures.

In disc degeneration or herniation and a predominance of discogenic pain or an equal distribution of radicular- and discogenic pain a step-diagnostic with MRI (Modic-signs), facet-joint analgesia and provocative discography should be performed to confirm the painful disc degeneration and consideration for disc replacement. In women above 40 years or patients suspect for osteoporosis a DXA scan should be done.

The presented algorithm is used at the author's institution since 18 month now.

In about 200 patients with DDD in different clinical settings and the need for surgical treatment only 10% (20 patients) could be considered for arthroplasty with satisfactory short term results. In another 10% a microdiscectomy was performed. In 80% a fusion was still the procedure of the first choice.

From this experience the author think that a strict patient selection using the described step-diagnostic for lumbar arthroplasty is mandatory to achieve satisfactory results and avoid complications, pitfalls and failures of disc replacement surgery.