Issues to Consider Before Having Artificial Disc Surgery

Issues to Consider Before Having Artificial Disc Surgery

As with any new surgical procedure, there are a number of factors that should be considered prior to undergoing an artificial disc surgery. A number of factors that may be helpful for patients to consider when considering whether or not to have artificial disc replacement surgery are outlined below.

  1. Surgeon training. Historically, the extent of training for spine surgeons to use a new technology has varied greatly. Some surgeons have pursued a level of training similar to that employed for the device's FDA trial, but unfortunately, this has not always been the case. There are currently no well defined, accepted standards for the training of surgeons wanting to employ the use of new technology.

    The manufacturer of the Charité artificial disc, DePuy Spine, has stated that prior to doing any surgery with the Charité disc surgeons must undergo extensive training sponsored by DePuy Spine. This mandatory training includes a combination of participating in artificial disc surgery procedures with other trained surgeons, consultation and visitation with spine surgeons, and lectures and educational materials.

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    In addition, the Spinal Arthroplasty Society has set a goal of establishing standardized training programs for physicians prior to their using any new artificial disc replacement technology. It is intended that the training be similar to that required for participation in the FDA clinical trials. While such training is expensive and time consuming for both the surgeons and faculty, there are many important benefits for patients, surgeons, hospitals, and manufacturers of the artificial disc.

  1. Surgeon skills. As with any type of spine surgery, the skill and experience of the surgeon performing the surgery is an important consideration. Unfortunately, this is usually difficult for patients to assess and there is no central source that reports on a surgeon’s outcomes. In general, it is a good idea to research a spine surgeon through some combination or asking a referring physician what their opinion is and asking other patients who have had the same procedure done with that surgeon.

    As a general rule in surgery, a surgeon's skills evolve and sharpen with more experience with a particular procedure. With the artificial disc procedure there is definitely a steep learning curve that includes learning how to use new instruments to implant the disc and to distract (open up) the disc space, and learning how to properly fit and place the disc in patients with different anatomical characteristics (e.g. a collapsed disc space, minor slippage of the vertebra that requires realignment, etc.). Many surgeons will also need to learn how to do back surgery by approaching the spine from the front (through the abdomen) instead of through the back. Many surgeons believe that having extensive experience with doing spine surgeries from the front (e.g. anterior lumbar interbody fusion surgery) is an important foundation for learning the artificial disc procedure. However, this is a debatable point as it has not been studied or proven.

  2. Patient selection. As with a spine fusion surgery, making sure that the individual patient is a good candidate for the procedure is essential to success. Here are a just couple of examples of how inappropriate patient selection can have serious consequences:
    • If a patient receives an artificial disc, but the disc that was replaced was not actually the cause of the patient's pain, then the patient will have undergone an extensive, invasive, and costly procedure but still have the same level of pain. This may seem like an incredibly obvious point, but with back pain it is often difficult to pinpoint the precise cause of a patient's pain. Accurate and careful diagnosis of the patient's pain generator is crucial and cannot be overemphasized.
    • If the patient does have a painful disc, but other factors (such as significant degenerative changes in the facet joint) are present, then the patient may have to undergo a revision surgery after the initial surgery to either correct the placement of the disc or fuse the spine - a situation that is definitely best avoided by correctly assessing all the risk factors prior to the first surgery.
  3. Reimbursement and expense. Typically, the total cost for an artificial disc replacement surgery ranges from about $35,000 to $45,000. Many insurance companies still consider the artificial disc an experimental or unproven procedure and therefore may not provide full coverage or any coverage at all. Currently, under Medicare and Medicaid only partial reimbursement is provided. While the reimbursement environment may improve over time, it is uncertain when and by how much it will improve.
  4. Potential long term issues. As a general precaution, it should be noted that in the US this is still a new technology and, as such, long term effects are not known. Any new medical technology carries with it a certain level of unknown risks. As an example, it is thought that most patients receiving a lumbar artificial disc will be about 30 to 40 years old at the time of the disc replacement, which means that to avoid the need for revision surgery, the disc prosthesis must last 40 to 50 years for most patients. At present, there are no indications that the disc will not last, but this is one example of an unknown risk that has yet to stand the test of time.
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