At 20, this University of Nevada Reno student clearly had a promising career ahead of her as a competitive swimmer. Until, that is, a mishap in the pool one day sunk her athletic aspirations and plunged her lower back into the deep end of pain. Fortunately, the injury – which occurred during a swim meet in 2004 – produced no paralysis or other neurologic impairments. Still, the resultant pain greatly degraded the quality of her life, preventing enjoyment of even so much as a leisurely dip in the water.
The physicians who saw her over the course of the next year attempted to treat her with conservative care and chronic-pain management strategies that included physical therapy, epidural injections, anti-inflammatory medications, muscle relaxants and prescription narcotics – all to no avail. A last-resort intervention held out to the patient was spine fusion surgery. This was problematic, though: Owing to the patient’s young age, the outcome of arthrodesis was likely to be far less than optimal.
Case description
The patient was referred to Tahoe Fracture & Orthopedic Medical Clinic (now Swift Orthopedics), where a then-relatively new, FDA-approved alternative to spine fusion surgery was being offered. During her first visit to the clinic, a detailed medical history was taken. Disc herniation at L5-S1 was suspected – a suspicion confirmed by plain X-ray, MRI and discography studies.
Treatment plan
The patient was found to be an appropriate candidate for disc arthroplasty, the alternative to conventional arthrodesis. The procedure began with a small incision in the lower portion of her abdomen. An anterior approach was used; fluoroscopy provided real-time imaging guidance throughout the two-hour procedure. The damaged disc was completely removed and replaced with a cobalt-polyethylene implant. The device was a mobile bearing segment, similar to those employed in knee and hip replacements.
Outcome
No complications developed, either during or after the procedure. The patient was released 48 hours later and sent home wearing a corset-type lumbar brace to promote comfort and provide wound site protection in the first week after hospital discharge. As expected, a very early return to function was observed. Approximately six weeks postoperatively, the patient was able to participate in recreational swimming – and to do so pain-free.
Discussion
According to the literature, arthrodesis – which continues to be a standard of care – is typically most appropriate for patients over the age of 40. Disc arthroplasty (or, total disc replacement) is an arthrodesis alternative appropriate for patients younger than 40. The goals of disc arthroplasty are to provide long-term pain relief, protect neural elements and prevent posterior facet arthropathy as well as adjacent segment disease by preserving spinal motion.
Following fusion surgery, return to normal function typically takes three months. By contrast, following total disc replacement surgery, return to function occurs as early as six weeks. Incision site and affected muscle heal in about two to four weeks, at which point it is usually appropriate to begin physical therapy for purposes of strengthening the abdominal and core muscles plus increasing range of motion.
