Wednesday, November 22, 2006

Prosthetic disc replacement it for you ?

There is a lot of talk nowadays about prosthetic disc replacement (PDR) for low back pain. Should all patients with back pain get their discs replaced ? Is it the new ultimate therapy for back pain ?

PDR is another wonderful advance in the treatment of low back pain. Here the patient's diseased disc is replaced by a prosthetic one, much like a total knee replacement. Chronic low back pain is a big and difficult problem, frustrating for both, the doctor and the patient. In this depressing scenario, the results of PDR look promising. Unfortunately only a few patients would qualify for disc replacement. This is because there are multiple causes for low back pain. Pain could arise from the discs, the facet joints, the ligamentum flavum, etc. Obviously a disc replacement is useless for pain arising from facet arthropathy.

What, then are the indications for disc replacement ?
Disc replacement is advocated in ...
  1. Patients with severe & disabling pain with degenerative disc disease who have failed at least 6 months of non operative treatment. (anti-inflammatory and analgesic medication, physiotherapy, injections, acupuncture, bed-rest, back school training) with
  2. Objective evidence of disc disease in the form of x rays and MRI with
  3. A positive provocative discography as confirmation (preferable)
  4. In patients between 18 to 60 years of age.
Disc replacement is not for ...
  1. Patients with facet arthropathy.
  2. Patients with osteoporosis.
  3. Patients with spinal deformities and instabilities (spondylolisthesis, post op instability)
  4. Patients with morbid obesity.
  5. Patients with disc bulges that significantly compress the spinal cord & nerve roots causing leg pain and weakness.
  6. Patients with infection.
  7. Patients with failed back syndrome and epidural fibrosis.
As is obvious, PDR is useful for a limited population of patients. In fact only 5% of of patients qualifying for lumbar spine surgery meet the criteria for disc replacement.

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