Disc replacement case example
The following profiles one patient’s experience
with the CHARITÉ Artificial Disc This patient
was a participant in the U.S. multi-center clinical
trial to study the effectiveness and safety of the
device.
History of back pain
The patient is a 33-year-old Caucasian
female who had 2 prior lumbar laminectomy surgeries
at L5-S1 (the bottom level of the spine). Her
leg pain improved after these two spinal operations,
but her low back pain increased due to progressive
collapse of the L5-S1 intervertebral disc.
She tried three years of conservative therapy, including
physical therapy, ultrasound, acupuncture, and epidural
steroid injections, all of which failed to relieve
her ongoing low back pain. A subsequent pregnancy increased
the stress on her lumbar spine and made the low back
pain significantly worse.
Prior to her disc replacement surgery, the patient’s
pain was preventing her from performing routine tasks,
such as getting dressed, getting in and out of the
car, and lifting groceries, and she had missed a lot
of work. The patient admitted that she was taking too
much pain medication in order to perform routine daily
activities. She could not perform any athletic activities
such as riding a bike, aerobic walking, or swimming.
She was otherwise healthy and did not smoke.
Physical exam
On physical exam, the patient primarily had mechanical
lower back pain (90% of pain in the back; 10% of pain
in back of the thigh).
The patient’s neurological exam was normal but
her spinal mobility was severely restricted. While
in the standing position and with her knees locked
in the straight position she could not even bend forwards
to touch her kneecaps (much less her toes). Spinal
extension (bending backwards) increased her low back
pain. She had very little endurance while working and
had increased pain while sitting or driving.
Diagnostic tests
An x-ray showed that the L5-S1 disc space was completely
narrowed, and an MRI scan confirmed that the L5-S1
disc was severely degenerated. There were also Modic
changes, which means that there was bone marrow edema
and inflammatory changes of the vertebral body bone
adjacent to the collapsed disc.
A discogram showed concordant pain with injection
of a very small amount of saline into the center of
the disk at L5-S1. This injection reproduced the distribution
and intensity of the patient’s major pain. After
characterizing the patient’s pain response, a
small amount of long acting anesthetic was injected
and this relieved her characteristic, activity limiting
pain. The discogram did not reproduce the patient’s
pain with injections at either the L3-L4 or at L4-L5
levels (normal discs) (see
Figure 4).
CHARITÉ Artificial Disc surgery
The patient decided to enroll in the clinical trial
for disc replacement surgery. The CHARITÉ prosthesis
was used in a disc replacement surgery that took approximately
90 minutes to perform. The first day following the
surgery, the patient was allowed out of bed to sit
in a chair. Aside from discomfort from the incision
in her lower abdomen, the patient reported that she
felt relatively comfortable after surgery.
Following CHARITÉ artificial disc replacement
surgery
The patient was discharged from the hospital three
days after surgery and started rehabilitation (physical
therapy) two days after surgery. She continued rehabilitation
for seven weeks following the surgery to build up her
abdominal and paraspinal muscle tone.
Initial follow-up
At her 6 week postoperative check up, the patient
was bending normally and able to pick up her baby.
She had returned to office work and was able to drive
back and forth to work, a less than one hour commute.
From an objective standpoint, the Oswestry scale
measurement of her pain improved from 55 (nearly
disabled) to 5 (the normal amount of back pain ranges
from 0 to 10).
Her postoperative radiographs showed good bending
motion at the L5-S1 level. The important thing is
that the disc space collapse had been corrected,
which increases the height of the neuroforamen, meaning
that there is the normal amount of room for the nerve
roots. The Modic changes or inflammatory reaction
adjacent to the disc had resolved. The position of
the components of the disc prosthesis was excellent
(see
Figure 5).
Longer term follow-up
Five years after CHARITÉ reconstruction
of the patient’s collapsed disk, her back pain
disability has resolved and she is doing fine. She
reports that she has taken her kids and walked throughout
Disneyworld, danced all night at weddings, and returned
to work full time running a busy dental practice.
The range of motion and flexibility of the patient’s
back has continually improved since the date of surgery.
By: Paul
C. McAfee, MD
Updated March 30, 2005
Original publication January 8, 2001
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