Total joint replacement of the lumbar spine: surgical technique and procedural details

Surgical arthrodesis of the degenerative lumbar spine eliminates natural mobility across the motion segment and permanently alters the stress distribution resulting in accelerated degeneration at adjacent levels. This article and accompanying video describe the surgical details of an alternative motion preservation procedure: total joint replacement (TJR) of the lumbar spine. This procedure is indicated for patients who exhibit radiographic evidence of severe degeneration of the three-joint complex (intervertebral disc and facet joints). The TJR procedure involves a bilateral transforaminal lumbar interbody approach with complete laminectomy, bilateral facet removal, and discectomy to achieve neural decompression followed by device implantation to accomplish a lumbar motion segment reconstruction. A three-column pedicle vertebral body osteotomy (PVBO) is undertaken of the superior portion of the vertebral body and pedicle of the lower level as additional surgical preparation as well as keel cuts, soft tissue tensioning of the collapsed disc space, and height and length trialing. The treated segment receives bilateral implants inserted along the axis of the pedicles, fixated with a retention screw into the vertebral body of the caudal level. The implant replaces the biomechanical function of the resected disc and facets, serving as a new articulation with the flexion/extension motion of the three joint complex of the lumbar motion segment reproduced by the device.