Lumbar ADR: a triumph of technology over reason?

The many unanswered questions surrounding ADR beget the question of whether patients would ultimately be better managed with lumbar fusion surgery or even no surgery at all. Lumbar fusion technology has made advances in recent years with the advent of transforaminal lumbar interbody fusion (TLIF) and the use of bone morphogenetic proteins. With a TLIF procedure, spine surgeons are able to obtain a 360-degree fusion through a single posterior incision with more predictable long-term results, especially when patients have confounding issues. Although early clinical results show ADR to be a promising alternative to current surgical options, long-term results are needed to adequately assess the procedure's efficacy. There will always be a demand for new technology. Cost, quality, and access are performance benchmarks for hospital survival in the current health care industry. Today's health care environment forces surgeons to be fiscally responsible while still providing the best quality care possible. Therefore, the cost of ADR compared to a traditional pedicle screw instrumentation (about $12,000 per segment vs $3,500 per segment) must be taken into consideration. Is the additional cost of ADR justified when studies so far fail to show a statistically significant difference in long-term outcomes? How do we justify the added cost when conventional lumbar fusion, the gold standard for intractable cases, has more predictable outcomes? Ultimately, ADR may be a more promising alternative to spinal fusion for patients with multilevel DDD (ie, a three-segment lumbar disk replacement) because it can spare disk decompensation of the adjacent segments.