Significance of angular mismatch between vertebral endplate and prosthetic endplate in lumbar total disc replacement

A retrospective study.

To determine whether angular mismatch between the vertebral endplate and prosthetic endplate during lumbar total disc replacement (L-TDR) affects the radiological and clinical outcomes.

A prosthesis anchored to the vertebral body by using a large central keel carries an inherent risk of angular mismatch between the vertebral endplate and prosthetic endplate at a segment with a greater degree of lordosis, such as L5-S1. Theoretically, this angular mismatch can cause several problems, such as segmental hyperlordosis, anterior positioning of the upper prosthesis, posterior prosthetic edge subsidence, decreased range of motion (ROM), and a poor clinical outcome.

This study evaluated 64 prosthetic levels of 56 patients who were implanted with L-TDR between June 2002 and February 2006. There were 38 and 26 prosthetic levels at the L4-5 and L5-S1, respectively. The mean follow-up period was 25.6 (12 to 49) months. The angle of mismatch between the lower endplate of the upper vertebral body and the upper prosthetic plate, segmental flexion/extension ROM, segmental lordosis angle at extension, distance from the posterior wall of the vertebral body to the posterior prosthetic edge were measured by obtaining radiographs. Clinically, the Visual Analogue Scale and Oswestry Disability Index were also evaluated.

The angular mismatches between the upper vertebra and prosthesis at L4-5 and L5-S1 were 1.6 degree and 5.6 degree, respectively (P <0.001), at the final follow-up; these angles were not significantly different from those measured on radiographs obtained postoperatively (2.3 degree and 4.9 degree in L4-5 and L5-S1, respectively, P=0.324 in L4-5 and P=0.620 in L5-S1). The mean segmental ROM of the operated levels was 10.6 degree (4 to 22) and 6.1 degree (2 to 13) in the L4-5 and L5-S1, respectively (P <0.001). The mean segmental ROM, mean segmental lordosis angle, and mean distance from the posterior margin of the vertebral body to the posterior edge of the prosthesis in L5-S1 were 6.8 degree (4 to 13), 12.8 degree (8 to 17), and 3.8 mm (1 to 6 mm) in patients with an angular mismatch of <10 degree, and were 4.6 degree (2 to 7), 21.3 degree (19 to 25), and 6.0 mm (2 to 8 mm) in patients with an angular mismatch of more than 10 degree (P=0.024, <0.001, and 0.039), respectively. In L4-5, there were only 2 cases with an angular mismatch of more than 5 degree, which had no statistical significance. There were no significant differences in the clinical outcomes, Visual Analogue Scale, and Oswestry Disability Index between patients with an angular mismatch of <10 degree and those with an angular mismatch of more than 10 degree (P >0.05).

Angular mismatch was more common in L5-S1 than in L4-5. L-TDR at the most lordotic level, L5-S1, and implantation of an upper prosthesis with a mismatched angle seem to be the causes of a reduced segmental ROM, increased segmental lordosis, and anterior malpositioning of the prosthesis. However, these changes do not affect the clinical outcomes of patients.