The Combined Use of a Posterior Dynamic Transpedicular Stabilization System and a Prosthetic Disc Nucleus Device in Treating Lumbar Degenerative Disc Disease With Disc Herniations

Mehdi Sasani; Ahmet Levent Aydin; Tunc Oktenoglu; Murat Cosar; Yaprak Ataker; Tuncay Kaner; Ali Fahir Ozer

doi:10.1016/SASJ-2008-0008-NT

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Figure 1
A schematic calculation: (A) A ratio of disc height and segmental lordosis angle (α angle) for the upper adjacent segment was calculated pre- and postoperatively. (B) Measurement of lordosis of the lumbar spine L1 to S1 was calculated.
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Figure 2
(A) Prosthetic disc nucleus (PDN-Solo, Raymedica, LLC) devices. (B) Titanium alloy Cosmic (Ulrich Gmbh & Co. KG, Ulm, Germany) dynamic pedicle screw.
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Figure 3
A postoperative lumbar CT scan showing the central position of the PDN device and proper position of the implanted pedicle screws.
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Figure 4
Postoperative complications: (A) A plain X-ray shows the device has migrated to lateral interspace vertebra (patient #13). (B) A T1-weighted sagittal MRI demonstrates that the PDN-Solo device has become embedded in the adjacent vertebra with massive degeneration at both endplate vertebral bones (patient #10). (C) A sagittal CT shows the PDN-Solo device has become embedded in the adjacent vertebra in a patient with discitis (patient #3).

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Table 1

Patients’ Demographic Data

Patient No.	Gender	Age	Preoperative Neurological Findings	Radiologic Findings (X-Ray, CT, MRI)	Operation	New/Recurrent Disc Herniation	Complication	Outcome (12 months)
1	F	26	− Right radiating pain − Right SLR: 30º + − Right S1 nerve root DH	− L4-5: black disc − L5-S1: central and right disc extrusion	− Right L5-S1 discectomy + PDN placement − L4-L5-S1 PDTS	New disc	None	Improved

2	F	40	− Left radiating pain − Left SLR: 10º + − Left gastrocnemius 2/5 MW	− L5-S1 disc sequestrated − Both endplate hyperintense	− Left L5-S1 discectomy + PDN placement − L5-S1 PDTS	New disc	None	Improved

3	M	57	− Right radiating pain − Right SLR: 45º +	− L5-S1 right disc extrusion, − Right L5 hemilaminotomy defect	− Right L5-S1 discectomy+ PDN placement − L5-S1 PDTS	Recurrent disc	− Discitis, − PDN device embedded into the L5 corpus	− Treatment: antibiotic administration, PDN was removed − LBP to 3 months − Late improved

4	M	34	− Right radiating pain − Right SLR: 45º +	− L4-5: bulging and annulus fibrosis rupture − L5-S1: Right disc protrusion	− Right L5-S1 discectomy + PDN placement − L4-L5-S1 PDTS	New disc	None	Improved

5	M	38	− LBP − Right radiating pain	− L5-S1 right disc protrusion − Both endplates hyperintense − Right L5 hemilaminotomy defect	− Right L5-S1 discectomy + PDN placement − L5-S1 PDTS	Recurrent disc	None	Improved

6	M	42	− LBP, left radiating pain − Left SLR: 30º + − Left L5 nerve root DH	− L4-5: left protrusion − Both endplates hyperintense − Left L4 hemilaminotomy defect	− Left L4-L5 discectomy + PDN placement − L4-L5 PDTS	Recurrent disc	None	Improved

7	M	44	− Left radiating pain − Left SLR: 45º + − Left L5 nerve root DH	− L4-5 left protrusion	− Left L4-L5 microdiscectomy +PDN placement − L4-L5 PDTS	New disc	None	Improved

8	M	45	− Right radiating pain − Right SLR: 30º +	− L3-L4: annulus fibrosis rupture − L4-L5: right L4 hemilaminotomy defect+ right disc extrusion	− Right L4-L5 discectomy + PDN placement − L3-L4-L5 PDTS	Recurrent disc	None	Improved

9	F	40	− Left leg radiating pain − Left SLR: 45º +	− L4-5 left disc extrusion. − Left L5 hemilaminotomy defect	− Left L4-L5 discectomy + PDN placement − L4-L5 PDTS	Recurrent disc	None	Improved

10	M	42	− Left leg radiating pain − Left SLR: 45º +	− L4-5 left disc extrusion	− Left L4-L5 discectomy +PDN placement − L4-L5 PDTS	Recurrent disc	PDN embedded into the L4 corpus and massive endplate degeneration in both endplates	− PTR+ conservative treatment to 3 months − LBP to 3 months − Late improved

11	M	39	− Right leg radiating pain − Right SLR: 45º + − Right gastrocnemius 2/5 MW	− L5-S1 foraminal disc protrusion	− Right L5-S1 discectomy +PDN placement − L5-S1 PDTS	New disc	None	Improved

12	M	45	− Left leg radiating pain − Left SLR: 45º +	− L4-5 left disc extrusion	− Left L4-L5 discectomy +PDN placement − L4-L5 PDTS	New disc	None	Improved

13	M	40	− LBP − Right radiating pain	− L5-S1 right disc protrusion	− Right L5-S1 discectomy +PDN placement − L5-S1 PDTS	Recurrent disc	PDN migrated to right side in the intervertebral space	Improved

SLR: Straight Leg Rising
LBP: Lower back pain
DH: Dermatome hypoesthesia
MW: Muscle Weakness
PTR: Physical Treatment and Rehabilitation
PDN: Prosthetic Disc Nucleus
PDTS: Posterior Dynamic Transpedicular Stabilization

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Table 2

Patients’ Outcomes and Radiological Evaluations Prior To and After Surgery

Patient No.		1	2	3	4	5	6	7	8	9	10	11	12	13
Preop	VAS	6	10	5	7	7	8	8	7	8	7	8	7	8
	ODI	24	82	38	72	64	56	72	56	76	60	60	72	62
	LLº aº	27 4	52 12	37 12	47 12	32 11	38 8	54 10	73 12	51 7	76 34	43 8	31 3	55 12
	α º	4	12	12	12	11	8	10	12	7	34	8	3	12
	DHu	0.271	0.261	0.275	0.297	0.187	0.333	0.285	0.19	0.287	0.273	0.197	0.148	0.25
	DHo	0.203	0.141	0.166	0.231	0.271	0.226	0.22	0.154	0.3	0.257	0.264	0.237	0.211

Early Postop(3rd Day)	LLº	26	48	30	52	31	29	45	64	55	65	48	45	40
	αº	1	7	7	10	8	6	8	4	13	12	12	1	11
	DHu	0.308	0.279	0.333	0.4	0.297	0.256	0.244	0.257	0.329	0.324	0.223	0.25	0.27
	DHo	0.3	0.227	0.198	0.297	0.324	0.288	0.255	0.155	0.38	0.261	0.269	0.297	0.244

3 Mos. Postop	VAS	2	2	3	1	2	3	2	3	1	2	2	3	3
	ODI	20	32	26	26	18	38	32	26	18	28	20	48	38
	LLº	37	61	26	58	33	41	49	52	65	68	47	43	51
	αº	4	26	10	12	8	8	12	2	14	12	18	4	8
	DHu	0.25	0.314	0.275	0.273	0.283	0.303	0.297	0.24	0.317	0.296	0.192	0.227	0.217
	DHo	0.267	0.189	0.169	0.319	0.291	0.352	0.237	0.2	0.295	0.12	0.185	0.228	0.267

6 Mos. Postop	VAS	2	1	1	1	1	2	2	1	2	1	3	2	2
	ODI	20	26	16	18	12	18	20	18	12	12	12	24	24
	LLº	35	63	31	58	21	32	49	49	57	64	45	41	45
	αº	4	26	9	14	7	7	9	2	12	14	12	4	11
	DHu	0.189	0.319	0.223	0.267	0.229	0.295	0.231	0.242	0.296	0.257	0.186	0.251	0.241
	DHo	0.291	0.192	0.177	0.32	0.314	0.276	0.261	0.271	0.311	0.2	0.191	0.215	0.261
12 Mos. Postop	VAS	2	1	1	0	0	0	2	1	1	1	3	2	2
	ODI	18	20	16	8	6	6	12	16	18	12	8	20	26
	LLº	34	67	30	58	20	35	47	54	52	52	47	43	50
	αº	3	28	10	11	10	9	9	2	11	12	11	3	18
	DHu	0.155	0.337	0.217	0.291	0.13	0.292	0.211	0.185	0.281	0.247	0.192	0.148	0.257
	DHo	0.32	0.202	0.167	0.317	0.312	0.268	0.257	0.196	0.297	0.298	0.188	0.197	0.125

VAS: Visual Analog Scale for Pain
ODI: Oswestry Disability Index
LL: Lumbar lordosis angle
α: Segmental lordosis angle
DHu: Disc height of the adjacent level
DHo: Disc height at the operated level

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Table 3

Averages of Preoperative and Postoperative Data Points

	VAS	ODI	LLº	αº	DHu	DHo
Preoperative	7.38	61.08	47.38	11.15	0.25	0.22

Early Postoperative (3rd day)	6.82	----	44.46	7.69	0.29	0.27

3 Month Follow-up	2.23	28.46	48.53	10.61	0.26	0.23

6 Month Follow-up	1.61	17.84	45.38	10.07	0.24	0.25

12 Month Follow-up	1.23	14.30	45.30	10.53	0.22	0.24

VAS: Visual analog scale for pain
ODI: Oswestry Disability Index
LL: Lumbar lordosis angle
α: Segmental lordosis angle
DHu: Disc height of the adjacent level
DHo: Disc height at the operated level

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Table 4

Preoperative And Postoperative 12-month Range of Motion Values

Patient	Preop Flexion	12-month Postop Flexion	Preop Extension	12-month Postop Extension
1	48	53	15	18
2	43	47	13	15
3	35	38	11	15
4	62	64	16	23
5	45	50	11	15
6	51	53	15	17
7	45	49	14	18
8	56	58	18	24
9	41	47	10	13
10	45	50	16	22
11	53	58	14	20
12	52	55	16	19
13	45	49	17	19
Mean:	47.76923	51.61538	14.30769	18.30769