Orthopaedics & Traumatology: Surgery & Research 100 (2014) S1–S14

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Review article

Total disc replacement

J.-M. Vital ∗ , L. Boissière
Unité Rachis 1, hôpital Tripode, CHU de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France

a r t i c l e i n f o a b s t r a c t

Article history: Total disc replacement (TDR) (partial disc replacement will not be described) has been used in the lumbar
Accepted 7 June 2013 spine since the 1980s, and more recently in the cervical spine. Although the biomechanical concepts are
the same and both are inserted through an anterior approach, lumbar TDR is conventionally indicated
Keywords: for chronic low back pain, whereas cervical TDR is used for soft discal hernia resulting in cervicobrachial
Cervical total disc replacement (CTDR) neuralgia. The insertion technique must be rigorous, with precise centering in the disc space, taking
Lumbar total disc replacement (LTDR) account of vascular anatomy, which is more complex in the lumbar region, particularly proximally to
Cervical herniation
L5–S1. All of the numerous studies, including prospective randomized comparative trials, have demon-
Cervicobrachial neuralgia
Low back pain
strated non-inferiority to fusion, or even short-term superiority regarding speed of improvement. The
main implant-related complication is bridging heterotopic ossification with resulting loss of range of
motion and increased rates of adjacent segment degeneration, although with an incidence lower than
after arthrodesis. A sufficiently long follow-up, which has not yet been reached, will be necessary to
establish definitively an advantage for TDR, particularly in the cervical spine.
© 2014 Elsevier Masson SAS. All rights reserved.

The present article is restricted to total disc replacement (TDR)
after complete intervertebral disc ablation at cervical (CTDR) or
lumbar (LTDR) level. This involves mechanical prostheses for which
we now have a certain follow-up, especially as regards to LTDR,
which has been regularly implemented since the 1980s. We shall
not deal with nucleus replacement, which is less widely practiced
and has a very limited literature.
The biomechanics of CTDR and LTDR is the same, but the indi-
cations differ. CTDR may be indicated after ablation of a hernia
causing cervicobrachial neuralgia (CBN), while LTDR is indicated
after ablation of a degenerative disc implicated in chronic low back
pain.
Both procedures use an anterior approach, although the techni-
cal problems are specific, as the vascular obstacles to lumbar disc
access, especially above L5–S1, have no equivalent at the cervical
level.
Theoretically, the interest of TDR lies in implanting a mobile
and, if possible, shock-absorbing component with sufficient height
to replace the disc that has either been crossed so as to remove
the cervical compressive discal hernia or totally removed in order
to treat lumbar pain. The alternative, and inevitable comparator, is
arthrodesis. The advantage of TDR is not immediately obvious, as
CBN and low back pain are alleviated by both procedures if the indi-
cations were correct; the expected benefit of implantation is more
long-term, with a lower rate of degeneration of adjacent segments,
which cannot be properly assessed on less than 10 or even 15 years’
follow-up.
As detailed below, most studies comparing arthrodesis and TDR
demonstrated the non-inferiority of the latter in terms of immedi-
ate results; lack of sufficient follow-up, however, means that any
long-term advantage remains to be proven.
1. History
1.1. LTDR
Historically, LTDR preceded CTDR.
The first LTDR, which had the form of a steel ball, was implanted
by Fernstrom, using an anterior approach, in 1960. Initial results
seemed encouraging, but proved disappointing in the long-term as
the ball subsided into the subchondral bone.
In the early 1980s, Schellnack and Buttner implanted the SB
Charité® prosthesis, which comprised two chromium-cobalt plates
and a mobile polyethylene core. In France, David and Lemaire reg-
ularly used the three successive models [1–3] of this prosthesis.
In 1989, Marnay described the ProDisc-L® , which has plates with
a central titanium stem.
Since then, many different LTDR designs have come onto the
market (Fig. 1).
1.2. CTDR

∗ Corresponding author. In 1962, Fernstrom encountered the same problems in CTDR as

E-mail address: jean-marc.vital@chu-bordeaux.fr (J.-M. Vital). in LTDR with his prosthesis.

1877-0568/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.otsr.2013.06.018
S2 J.-M. Vital, L. Boissière / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S1–S14
Fig. 1. Four types of LTDR mentioned in the article.
The Prestige® prosthesis was not developed until 1989–1991. It
was a metal-metal design, screwed into the vertebral bodies with
a stabilization crest.
Only in 1995 did Bryan begin to use the CTDR named for him on
a regular basis.
In Europe, the first implantation in 2000 was followed by numer-
ous multicenter studies, mainly under the supervision of Goffin and
Pointillart.
A large range of CTDR designs have subsequently been marketed
(Fig. 2).
2. Biomechanics
TDRs are made up of bearing surfaces designed to accommodate
load without breaking, to reduce friction and wear and to conserve
range of motion as long as possible.
Assessment is in terms of wear and motion tests under varying
loads and movements. Implementation of 30 to 50 million cycles is
taken as equivalent to a lifetime of 30 to 50 years.
The materials used are the following:
• metals and alloys such as:
◦ stainless steel alloys,
◦ titanium and titanium alloys,
◦ cobalt alloys;
• ceramics, more resistant to wear but more fragile due to their low
ductility;
• high molecular weight polyethylene, such as UHMWPE (ultra-
high molecular weight polyethylene), for the nucleus between
the metal plates.
TDR models are classified by anchorage, surface and friction cou-
ple, constrained or unconstrained design, location of the center of
movement and, finally, compatibility with MRI.
Anchorage (or contact between the implant and the vertebral
plates (Fig. 2)) may be by stem, screw or macro-texture. The surface
coating facilitates osseointegration; it may be in hydroxyapatite,
tricalcium phosphate, porous titanium or chromium-cobalt.
Constrained TDRs require stronger anchorage, as greater forces
are transmitted to the vertebral plates. The plates of the Bryan CTDR
are therefore highly mobile to protect them against the risks of
mechanical stress.
2.1.1. Friction couples
The 4 types of friction couple are:
• metal/polyethylene;
• metal/metal;
• ceramic/polyethylen;
• ceramic/ceramic.
Metal/polyethylene is the oldest friction bearing used in arthro-
plasty, notably of the hip, and is a reference; the polyethylene debris
particles generated are large sized.
Metal/metal and, even more so, ceramic/ceramic couples gen-
erate very little and smaller sized debris, thus reducing the risk of
inflammation.
2.1.2. Constrained or non-constrained design
A normal disc has 6 degrees of freedom (df): 3 in translation and
3 in rotation. Three types of TDR can thus be distinguished:
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Fig. 2. Five types of CTDR mentioned in the article.
• non-constrained 6-df: the Bryan CTDR, the ESP® (Elastic Spine
Pad) LTDR;
• semi-constrained 5-df with free nucleus: SB Charité® , Mobidisc®
and Mobi-C ® ;
• constrained 3-df with fixed nucleus: the Discocerv® and ProDisc-
C® CTDRs and ProDisc-L® and Maverick® LTDRs.
Non-constrained designs do not require perfect centering but
impose greater stress on the posterior joints.
Constrained designs require excellent stability and thus perfect
anchorage.
Semi-constrained designs are stable, since translation is exerted
within the nucleus, increasing with the nuclear radius.
There are some CTDRs with a center located, anatomically, under
the replaced disc. Other TDRs, in contrast, have a center of rotation
above the disc as their nucleus has a convex lower face.
Ceramic/ceramic or ceramic/polyethylene models are best
adapted to MRI (Fig. 3).
3. Indications
Unlike hip implants, CTDRs and LTDRs may be indicated in
young subjects, with a variety of clinical signs.
LTDRs are usually indicated for disabling low back pain; selec-
tion should be rigorous, as results in low back pain surgery are
generally less than excellent.
CTDRs are associated to decompression surgery, usually for CBN
or occasionally for incipient myelopathy.
Both cervical and lumbar procedures may be hybrid, associating
TDR and fusion of adjacent levels, with the implant usually above
the arthrodesis.
3.1. Lumbar indications
The essential indication for LTDR is chronic low back pain resis-
tant to conservative management, with little or no associated
radiculalgia.
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Clinical assessment must be precise, comprising:
• VAS (visual analog scale) lumbar and radicular assessment;
• Oswestry score for lumboradicular pathology and especially the
Quebec score, for optimal assessment of the functional impair-
ment induced by the low back pain;
• SF12 score to assess perceived physical and psychological health,
associated, in some cases, to more strictly psychological scales
such as the Hospital Anxiety and Depression scale (HAD),
assessing emotional impact, or the Coping Strategy Questionnaire
(CSQ), assessing coping as defense strategy.
Mannion et Elfering [1] reported the following factors of poor
prognosis: prolonged symptom evolution, severity of the pathol-
ogy being treated, poor health status and comorbidity, anxiety and
depression, “familial reinforcement” of pain, smoking, occupational
dissatisfaction, and prolonged sick leave and sickness benefit.
There are few physical signs specific to low back pain of discal
origin that can be taken as indications for LTDR. Roughly, lumbar
disc pain, increasing under flexion, may be contrasted with poste-
rior joint pain, increasing in extension.
Paraclinically, plain and especially EOS whole-spine radiographs
determine overall sagittal balance.
Standardized dynamic radiographs may reveal very excep-
tional hypermobility. CT is best suited to the posterior joints,
which should be as normal as possible. In MRI, MC (modic
change) 1 (inflammation) or mixed one-half MC enhanced on fat-
sat sequences are major indications, validated by Blondel et al. [2]
(Figs. 4–6). MRI also assesses the degree of fatty degeneration in
the paravertebral muscles.
Vascular exploration on MRI or CT angiography is recom-
mended, to locate the large vessels (Fig. 7). Discography by pain
reproduction may help in case of discordant imaging findings, and
is increasingly discussed in the literature.
Previous discal surgery is, surprisingly, a frequent indication in
case of postoperative MC-1. Any malalignment such as scoliosis
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Fig. 3. Ceramic/ceramic TDR: non-artifacted control MRI.

Fig. 4. Indication for LTDR for inflammatory L5–S1 discopathy.

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Fig. 5. Indication for LTDR for L5–S1 “discal insufficiency”.

Fig. 6. More limited indication for LTDR for severe discal impingement under arthrodesis for scoliosis.

or spondylolisthesis and proven osteoporosis, on the other hand,
contra-indicates LTDR.
3.2. Cervical indications
CTDR is mainly indicated for:
• soft hernia inducing CBN resistant to 6 weeks’ classical medical
treatment or causing radicular motor deficit;
• stenosing soft hernia inducing myelopathy.
The patient is assessed by cervical VAS and especially upper-
limb VAS, NDI (Neck Disability Index) and possibly a cervical
myelopathy score such as the EMS (European Myelopathy Score).
Soft hernia surgery may consist in simple discectomy, inducing
kyphosis, or in arthrodesis, which was long the gold standard but
involves risk of non-union and adjacent level syndrome (Fig. 8).
Osteophytic hard discal hernia is a more debatable indication,
as the intervertebral segment is less mobile. CTDR is considered
indicated in case of < 4◦ range of motion in flexion-extension on
preoperative dynamic X-ray. Broad uncal release may, however,
be performed to restore range of motion after implantation in the
stiffer segments.
Myelopathy caused by cervical osteoarthritis with local com-
pression is an even more debatable indication: CTDR would
enhance range of motion, but motion caused the circumferential
stenosis compressing the spinal cord. Sekhon [3] reported 11 cases
of CTDR for myelopathy, with good clinical results in all but 1 case
where there was kyphosis after Bryan CTDR. These positive findings
suggest that the risk of post-surgical soft tissue hypertrophy is low
if all the compressive tissue is removed, and the implant prevents
discal subsidence aggravating the medullary compression.
Contra-indications to CTDR are previous anterior cervical
surgery, posterior joint osteoarthritis (which is always difficult to
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Fig. 9. “French position” for LTDR.

4. Surgical techniques

LTDR and CTDR both use an anterior approach, but with differing
techniques.
Cervicotomy is performed for any anterior cervical discal pro-
cedure, inclining the trachea-bronchial axis sideward.
In LTDR, the approach is complicated by the relations of the aorta
and the vena cava and its bifurcation branches, especially at L4–L5
and L3–L4.

Fig. 7. Preoperative angio-MRI.

4.1. LTDR

assess, although CT is more effective than MRI), longitudinal dorsal The patient is usually positioned with the legs apart (“French
ligament ossification, hyperostosis, myelopathy due to retrocor- position”), with a bladder catheter (Fig. 9).
poreal compression, traumatic discal and ligamentary instability, The disc in question is located under AP and lateral radiography.
osteoporosis and infectious or neoplastic pathology. An oximeter on the left hallux monitors blood pressure.

Fig. 8. Indication for double C5–C6 and C6–C7 CTDR for double left soft discal hernia: a and b: preoperative views in flexion-extension; c, d and e: postoperative MRI; f:
postoperative lateral view; g: postoperative AP view; h and i: postoperative views in flexion-extension
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Fig. 10. LTDR (a) and CTDR (b) approaches, axial slices.
The surgical field is wide, from the xyphoid region to the pubis,
with the iliac crests visible.
The approach is retroperitoneal, with a lower risk to the superior
hypogastric plexus and thus of retrograde ejaculation in men or
vaginal dryness in women than on a transperitoneal approach (0.8%
versus 10%) (Fig. 10).
In L5–S1, the median sacral vessels should be controlled and the
disc freed with a width of 4 cm, taking care on the side of the left
iliac vein.
In L4–L5, the aorta and vena cava are inclined from right to left
after, if necessary, ligating any ascending lumbar or iliolumbar vein
(Fig. 11).
The disc is ablated completely up to the dorsal longitudinal
ligament, which according to some authors should also be system-
atically resected, which incurs a risk of epidural bleeding. Stem or
macro-texture anchorage is performed after thorough freshening
of the vertebral plates, without going beyond the subchondral bone.
Centering may be navigation-assisted (Le Huec [4]), and should be
very strict, both frontally and sagittally, as it determines mechanical
functioning.
LTDR height averages 11–13 mm, obviously varying with level
and with the size of the patients (Fig. 12).
Some authors, such as Marnay, recommend oblique prostheses
in L4–L5, to avoid undue vessel traction.
Vessel exposure can be complicated, with risk of vascular
wounding, and the orthopedic surgeon needs to have skilled backup
in vascular surgery (“access surgeon”) available, following the very
clear recommendations of Brau et al. [5], especially in revision pro-
cedures.
A lateral transpsoas approach avoids the need for vessel dissec-
tion, but has not been validated.
4.2. CTDR
The CTDR technique is much the same as for implanting an
intersomatic cage, as is also the case for LTDR.
Preoperative planning should take account of the dimensions of
the intervertebral disc and vertebral bodies, using tracing, as in the
Bryan technique.
S7
The patient is positioned in dorsal decubitus, slightly forward to
reduce epidural bleeding, under fluoroscopy throughout (Fig. 13).
It is essential to locate the level to be operated on; cervicotomy
may be horizontal for 1-level CTDR or vertical for 2 or more levels
(Fig. 10).
The two longus colli muscles are carefully pulled aside and
discectomy is almost always completed by sectioning the dorsal
longitudinal ligament, soft hernia very frequently being intraliga-
mentary.
The intersomatic distractor, with its tips planted in the adja-
cent bodies, reveals the posterior part of the discal space. The tips
are placed precisely in the middle of the vertebral bodies by ancil-
laries which locate the center of the disc by contacting the two
unci (Fig. 14). This technique provides better centering than frontal
fluoroscopy [6].
For soft hernia, resection uses disc forceps or, for hard hernia, a
high speed burr and a rongeur. The transverse and anteroposterior
dimensions are measured using a trial component.
The height of the CTDR is that of the neighbouring discs in the
case of soft hernia. If all the discs are damaged, the implant is placed
not too high, to avoid postoperative neck pain by tension to the
posterior joints, and not too low, to conserve range of motion and
avoid the risk of early postoperative heterotopic ossification. Mean
CTDR height is 5 mm.
Postoperative course is simple in both cases:
• after LTDR, the patient can leave bed the following day with a
simple lumbar belt;
• after CTDR, no cervical collar is needed.
5. Results
Assessment is founded:
• clinically, on the evolution of CBN and neck pain or of low back
pain;
• radiologically, on range of motion and sagittal balance.
Follow-up for assessment is:
S8 J.-M. Vital, L. Boissière / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S1–S14
Fig. 11. Anterior vasculo-neural relations (a: overall view) of L4L5 (b) and L5–S1 (c) discs.
• short-term (< 2 years);
• medium-term (2 < – < 10 years);
• long-term (> 10 years), which is more frequent for LTDR, which
is the older technique.
A large number of publications have reported series, often
designer series; the most interesting results come from random-
ized comparative studies, required in the USA for FDA marketing
approval.
One issue in the comparative studies is the type of arthrodesis
compared with TDR. In CTDR, it was mainly allograft associated
to a screwed plate, which in Europe is not the gold standard for
arthrodesis. In LTDR, arthrodesis was either purely anterior or else
circumferential.
Finally, in both CTDR and LTDR, multilevel procedures gave bet-
ter results and, above all, fewer cases of adjacent level syndrome;
this is understandable, as adjacent levels liable to become symp-
tomatic over time were replaced.
TDR range of motion diminished progressively over time, like a
normal disc that stiffens with age.
Sagittal balance was slightly affected by TDR, which improved
discal lordosis, whereas underlying discs lost lordosis.
5.1. LTDR results
In the short-term (2 years’ follow-up), Hellum et al. [7] reported
better results in 154 LTDR recipients when the back pain had been
of short evolution and the patients presented MC-1 or 2.
Blondel et al. [2] reported better results in case of MC-1.
Over the medium-term (8.6 years’ follow-up), Huang et al.
[8] reported better results when the implant remained mobile,
whereas Ross et al. [9], at 78 months’ follow-up, found only a
14% improvement in Oswestry score and decided to abandon
LTDR.
Over the long-term, Lemaire [10] reported 100 LTDRs at a mean
11.3 years’ follow-up, with only 10% bad clinical results (i.e., con-
dition worsened). David [11], reporting 106 LTDRs at 13 years’
follow-up, found only 10% of implants that had ceased to show
motion.
Finally, the results of these retrospective series, which are
always open to criticism, appear to be discordant.
In the USA there have been numerous prospective randomized
studies comparing LTDR and fusion.
The SB Charité® LTDR was compared to anterior arthrodesis by
Blumenthal et al. [12] and by MacAfee et al. [13]. Their clinical suc-
cess criterion was ≥ 25% improvement in Oswestry score, found in
75% of LTDRs versus 57% of arthrodeses. The radiological success
criterion was conserved range of motion, found in two-thirds of
LTDRs at 2 years’ follow-up. The authors thus concluded that LTDR
was not inferior to anterior arthrodesis.
Another series of randomized studies compared the ProDisc-
L® to circumferential arthrodesis, with Ziegler et al. [14] treating
1-level and Delamarter et al. [15] 2 levels. Their clinical success cri-
terion was 15% improvement in Oswestry score, found in 63% of
LTDRs versus 45% of arthrodeses. The radiological success criterion
was conserved implant motion, found in 94% of LTDRs at 2 years’
follow-up.
These randomized studies found little difference in terms of
clinical results or complications between LTDR and arthrodesis
 J.-M. Vital, L. Boissière / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S1–S14 S9

Fig. 12. L5–S1 LTDR for MC-1 inflammatory discopathy (Fatsat MRI (a), in flexion (b) and in extension (c)).

(especially in case of anterior arthrodesis using bone morpho-
genetic protein, avoiding the harmful effects of graft harvesting).
Follow-up, however was too short for assessment of possible
impact on adjacent levels.
5.2. CTDR results
In the USA, numerous randomized studies have compared clin-
ical efficacy in CTDR and anterior arthrodesis by allograft and
screwed plate (Murray et al. [16], McAffee et al. [17]).
At a mean 2 years’ follow-up, there was no difference in clinical
results.
In Beaurain’s multicenter retrospective study [18] of the MOBI-
C® implant, the VAS neck pain score fell from 46 preoperatively
to 21 postoperatively, upper-limb VAS score from 64 to 23, and
NDI score from 50% to 26%. 91% of the patients would agree to re-
operation.
Recently, Grob et al. [19] stressed the difficulty of interpre-
ting the results of randomized studies comparing implantation and
fusion: the better results associated with the former may be due to
more rigorous patient selection.
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6. Complications

The most frequent complications are: adjacent segment degen-

eration (expected to be less than with arthrodesis) and heterotopic
ossifications, reducing the implant’s range of motion in CTDR.
Complications related to the surgical approach, prosthesis
subsidence into the plates (axial migration) or very occasional
anteroposterior migration are less specific to CTDR.
Anteroposterior migration, by displacement of plates or nucleus,
is exceptional but may have severe consequences: backward neuro-
logical compression (Fig. 15), forward oesophageal compression in
CTDR, and forward vascular compression in LTDR (Figs. 16 and 17).
Anterior revision surgery is complicated, especially in the lumbar
region [5].

6.1. Axial subsidence of the implant into the plates, and kyphosis

In LTDR, subsidence is due to osteoporosis, and significantly

Fig. 13. Patient positioning for CTDR (horizontal incision after location of stern-
ocleidomastoid, with fluoroscope).
impairs implant functioning (Fig. 18). In CTDR, there is a risk of
kyphosis, notably with the Bryan model, due either to poor indica-
tion (excessive anterior disc narrowing) or to defective technique.
Metal ion release with inflammatory reaction was reported by
Cavanaug et al. [20], who discovered fibrous and inflammatory tis-
sue following ProDisc-C® CTDR.

Fig. 14. Transverse CTDR centering (a: AP view; b, c, d: superior views of 3 different ancillaries).
 J.-M. Vital, L. Boissière / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S1–S14 S11

Fig. 15. Posterior displacement of C5C6 CTDR, stable in flexion-extension.

Fig. 16. Anterior displacement of inferior plate of L5–S1 LTDR, revised by circumferential arthrodesis.

Anterior, posterior or circumferential heterotopic ossification
(Figs. 19 and 20) induces fusion that is more rapid than the natu-
ral evolution. MacAfee et al. [21] provided a classification for the
lumbar and Mehren et al. [22] for the cervical region.
Mehren et al. reported 42% class-11 heterotopic ossification
(complete bone bridges but conserved motion) and 8% class IV
(complete fusion, not systematically associated with poor results).
Goffin et al. [23] reported 12% fusion at 4 years after Bryan TDR.
Quang and Pointillart [24], reporting a series of Bryan TDR at
8 years’ follow-up, found 48% heterotopic ossification, with only 9
of the 27 patients (one-third) having a completely immobile CTDR.
It is to be borne in mind that secondary fusion with kyphosis is
associated with more severe risk of adjacent syndrome than is
arthrodesis.
Prevention of heterotopic ossification is founded on:
• indication of soft hernia, with sufficient preoperative motion on
a disc showing little degeneration;
• minimal longus colli dissection, with painstaking wax hemostasis
of the bone;
• using an implant of sufficient but not excessive height, so as not
to block the posterior joint system;
• iterative lavage with physiological saline, to eliminate bone pow-
der caused by decompression using a high speed burr;
• for some authors, 2–3 weeks’ postoperative anti-inflammatory
drugs, as in hip replacement.
Chen et al. [25], in a recent meta-analysis, found ossification
in 44.6% of cases at 1 year and in 58.2% at 2 years, without correla-
tion with functional results or any clear effect of anti-inflammatory
medication.
6.2. Impact on adjacent segments (adjacent syndrome)
The reduced rate of adjacent syndrome is the real theoretic
advantage of TDR over fusion.
As in all spinal surgery, the distinction must be made between:
• radiologic adjacent syndrome (40–90%), with a frequency
increasing over follow-up, approximating natural evolution; this
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Fig. 17. Expulsion of L5–S1LTDR nucleus.

Fig. 18. Axial subsidence: a: of inferior plate of L3L4 LTDR; b: of superior plate of L5–S1 LTDR; c: of superior plate of L3L4 LTDR.

may consist of osteophytes, ante- or retro-listhesis or excessive
motion on dynamic X-ray;
• clinical adjacent syndrome (20–30%), with spinal and/or radicular
pain associated with one of the above images;
• surgical adjacent syndrome (5–15%), requiring revision in view
of clinical severity.
of motion and increased previous and late range of motion of seg-
ments adjacent to cages, without difference between upper and
lower discs. According to him, TDR provides more lordosis than
cages.
In 2008, Harrop et al. [29] reported reduced incidence of adja-
cent syndrome with LTDR.

Many retrospective studies reported rates of clinical and above
all surgical adjacent syndrome that were lower (although non-zero)
with TDR (Jawahar et al. [26]).
Roberston et al. [27], comparing 158 arthrodeses and 74 CTDRs,
found 17.5% and 3.4% rates of adjacent syndrome, respectively.
Ahn et al. [28], comparing 18 ProDisc-C® implants and 20 cages,
found impaired motion in the discs above and under the implant at
1 month post-surgery, followed by recovery of preoperative range
7. Costs and reimbursement
In a randomized study at 2 years’ follow-up, Fritzell [30] com-
pared 3 types of LTDR versus posterior arthrodesis. Clinical results
and costs were identical, but revision was more frequent with
arthrodesis.
Following a decree dated December 2, 2001, the French gov-
ernmental Journal Officiel included the Mobidisc® , Maverick® and
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Fig. 19. Heterotopic ossification on C6–C7 CTDR not restricting motion in flexion-extension.

Fig. 20. Heterotopic ossifications on C6–C7 CTDR blocking motion in flexion-extension.

ProDisc-L® implants in the list of products and procedures reim-
bursed under the national health insurance scheme.
Regulations have been drawn up for them to be implanted in
centers having expertise in spine pathology, with indications for-
mulated by a multidisciplinary team meeting; Indication is for a
single level and requires presence of a vascular surgeon in the cen-
ter. The procedure is coded as LFKA900.
A French national registry of LTDR is intended to be
the basis of a prospective multicenter observational study
including 600 patients with 5 years’ follow-up, assessing
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revision rates and satisfaction. Nothing is as yet planned for
CTDR.
8. Conclusion
TDR has demonstrated non-inferiority to fusion.
Indications for LTDR have diminished, as results are uncertain
in low back pain surgery, except for very specific indications such
as inflammatory lower lumbar single-discopathy.
CTDR is a reasonable option in cervical discal hernia with com-
pression of a root or of the spinal cord in young patients.
The required preoperative range of motion of the operated
intervertebral segment is conserved postoperatively, with clinical
results identical to those of intersomatic arthrodesis. Implantation
technique must be perfect, especially in terms of centering.
All comparative studies between TDR and arthrodesis, on the
other hand, have demonstrated reduced involvement of adjacent
segments with implantation.
The present limitation is lack of follow-up, currently less than
the 10 to 15 years needed to confirm definitively the advantage of
TDR over arthrodesis.
Disclosure of interest
LDR laboratory designer.
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