Analysis of post-operative pain patterns following total lumbar disc replacement: results from fluoroscopically guided spine infiltrations

Abstract

Although a variety of biomechanical laboratory investigations and radiological studies have highlighted the potential problems associated with total lumbar disc replacement (TDR), no previous study has performed a systematic clinical failure analysis. The aim of this study was to identify the post-operative pain sources, establish the incidence of post-operative pain patterns and investigate the effect on post-operative outcome with the help of fluoroscopically guided spine infiltrations in patients from an ongoing prospective study with ProDisc II. Patients who reported unsatisfactory results at any of the FU-examinations received fluoroscopically guided spine infiltrations as part of a semi-invasive diagnostic and conservative treatment program. Pain sources were identified in patients with reproducible (C29) significant (50-75%) or highly significant (75-100%) pain relief. Results were correlated with outcome parameters visual analogue scale (VAS), Oswestry disability index (ODI) and the subjective patient satisfaction rate. From a total of 175 operated patients with a mean follow-up (FU) of 29.3 months (range 12.2-74.9 months), n = 342 infiltrations were performed in n = 58 patients (33.1%) overall. Facet joint pain, predominantly at the index level (86.4%), was identified in n = 22 patients (12.6%). The sacroiliac joint was a similarly frequent cause of post-operative pain (n = 21, 12.0%). Pain from both structures influenced all outcome parameters negatively (P \ 0.05). Patients with an early onset of pain (B6 months) were 2-59 higher at risk of developing persisting complaints and unsatisfactory outcome at later FU-stages in comparison to the entire study cohort (P \ 0.05). The level of TDR significantly influenced postoperative outcome. Best results were achieved for the TDRs above the lumbosacral junction at L4/5 (incidence of posterior joint pain 14.8%). Inferior outcome and a significantly higher incidence of posterior joint pain were observed for TDR at L5/S1 (21.6%) and bisegmental TDR at L4/5/S1 (33.3%), respectively. Lumbar facet and/or ISJpain are a frequent and currently underestimated source of post-operative pain and the most common reasons for unsatisfactory results following TDR. Further failureanalysis studies are required and adequate salvage treatment options need to be established with respect to the underlying pathology of post-operative pain. The question as to whether or not TDR will reduce the incidence of posterior joint pain, which has been previously attributed to lumbar fusion procedures, remains unanswered. Additional studies will have to investigate whether TDR compromises the index-segment in an attempt to avoid adjacent segment degeneration.

Parameters influencing the outcome after total disc replacement at the lumbosacral junction. Part 2: distraction and posterior translation lead to clinical failure after a mean follow-up of 5 years

“…Similar to the results of Siepe et al [22,23], the patients with clinical failure reported pain during the early postoperative stage without apparent FJD at this time. The early and final clinical scores correlated with each other.…”

“…Our probabilistic FEM study identified that sagittal misalignment can cause both, increased facet joint capsule tensile forces in the case of iatrogenic posterior translation and increased compressive forces when iatrogenically shifting the superior vertebra anteriorly [27]. Although both situations would theoretically explain the development of FJD in patients with TDR [19][20][21][22][23], we have proven that especially a posterior translation of the superior vertebra leads to clinical failure. As discussed, posterior translation leads to higher capsule tensile or shear forces.…”

“…A preoperatively existent high-grade facet joint degeneration (FJD) can especially lead to inferior clinical results; therefore, FJD was suggested as a contraindication for this procedure [18]. However, facet joint forces may increase after TDR followed by a de novo development or the progression of preoperatively existing initial FJD in a relevant percentage of patients (20-36 %) with a resulting inferior clinical outcome [19][20][21][22][23]. In a prospective study, Siepe et al [23] found that FJD appeared more frequently at the index level compared with the adjacent levels and significantly more frequently at the lumbosacral junction compared with the levels above it.…”

Resect or not to resect: the role of posterior longitudinal ligament in lumbar total disc replacement

“…This hypothesis seems to be partially proven when looking at the results of Punt et al [14], who stated facet joint arthrosis as possible cause of failure after TDR. Recently, Siepe et al [17] also reported of a substantial percentage of patients (33.1%) with significant pain after TDR. In 12.6% of their patients, the lumbar facet joints were diagnosed as the source of pain, mostly located at the index level.…”

The Michel Benoist and Robert Mulholland yearly European Spine Journal Review

“…If indeed the pregnancy-related pelvic pain is from the sacra-iliac joint, it is curious that the clinical features of so-called sacroiliac pain after fusion or indeed after lumbar disc replacement are so different. Siepe in 2008 [47] investigated 175 patients with back ache after disc replacement, by using local anaesthetic injections, and found that in 12 % the pain was from the sacroiliac joint. However, the pattern described was quite unlike the pelvic pain of pregnancy.…”