J Neurol Surg A Cent Eur Neurosurg 2015; 76(02): 133-138
DOI: 10.1055/s-0034-1394187
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Controlled Motion with the XL-TDR Lateral-Approach Lumbar Total Disk Replacement: In Vitro Kinematic Investigation

Luiz Pimenta
1   Department of Minimally Invasive Surgery, Instituto de Patologia de Coluna, São Paulo, Brazil
2   Department of Neurosurgery, UCSD San Diego, San Diego, California, United States
Alex Turner
3   Department of Research and Testing, NuVasive, San Diego, California, United States
Leonardo Oliveira
1   Department of Minimally Invasive Surgery, Instituto de Patologia de Coluna, São Paulo, Brazil
Luis Marchi
1   Department of Minimally Invasive Surgery, Instituto de Patologia de Coluna, São Paulo, Brazil
Bryan Cornwall
4   Department of Clinical Operations, NuVasive, San Diego, California, United States
› Author Affiliations
Further Information

Publication History

29 May 2014

14 July 2014

Publication Date:
29 December 2014 (online)


Objective Anterior-approach total disk replacement (TDR) devices are thought to retain close to so-called normal range of motion (ROM); however, they are also inherently unstable due to resection of the anterior longitudinal ligament and annulus. This instability/laxity is manifested as increased neutral zone (NZ) motion. The XL-TDR device (NuVasive, Inc., San Diego, California, United States) is implanted through a lateral approach that preserves the anterior ligamentous and annular structures. This potentially makes the XL-TDR device more stable than those delivered anteriorly. This study investigates XL-TDR biomechanical features in a cadaveric model.

Methods Biomechanical evaluation consisting of nondestructive multidirectional testing was performed with the hybrid protocol on six fresh-frozen cadaveric specimens (L2–S1). Motion segment kinematics were obtained using an optoelectronic system. Test conditions were (1) intact spine, (2) XL-TDR at L4–L5, and (3) XL-TDR at L4–L5 with anterior annulus/ligament resected. ROM and NZ were calculated for each condition in each loading direction (flexion-extension total, flexion alone, extension alone, lateral bending, and axial rotation).

Results Insertion of the XL-TDR device decreased ROM with respect to intact in all directions. NZ in all directions was not statistically different from intact (p < 0.05), although there was a trend toward decreased NZ in flexion (p = 0.078). Removing the anterior ligament/annulus increased ROM significantly with respect to the XL-TDR condition in all directions (p < 0.003). NZ also increased, with the most significant changes in extension, lateral bending, and axial rotation (p < 0.002).

Conclusions The kinematics of XL-TDR have demonstrated that the retention of the anterior ligament/annulus has a significant stabilizing effect, diminishing ROM to less than intact, with a more controlled motion (more natural NZ). Removing the anterior ligament/annulus illustrated its stabilizing role, with ROM and NZ increasing significantly. Future studies will investigate the potential benefit of controlled XL-TDR motion on facet kinematics that may have clinical implications related to limiting facet degeneration.

  • References

  • 1 Wilson-MacDonald J, Boeree N. Controversial topics in surgery: degenerative disc disease: disc replacement. For. Ann R Coll Surg Engl 2007; 89 (1) 6-11
  • 2 Frelinghuysen P, Huang RC, Girardi FP, Cammisa Jr FP. Lumbar total disc replacement part I: rationale, biomechanics, and implant types. Orthop Clin North Am 2005; 36 (3) 293-299
  • 3 Galbusera F, Bellini CM, Zweig T , et al. Design concepts in lumbar total disc arthroplasty. Eur Spine J 2008; 17 (12) 1635-1650
  • 4 Awe OO, Maltenfort MG, Prasad S, Harrop JS, Ratliff JK. Impact of total disc arthroplasty on the surgical management of lumbar degenerative disc disease: analysis of the Nationwide Inpatient Sample from 2000 to 2008. Surg Neurol Int 2011; 2: 139
  • 5 Berg S, Tullberg T, Branth B, Olerud C, Tropp H. Total disc replacement compared to lumbar fusion: a randomised controlled trial with 2-year follow-up. Eur Spine J 2009; 18 (10) 1512-1519
  • 6 Park C-K, Ryu K-S, Lee K-Y, Lee H-J. Clinical outcome of lumbar total disc replacement using ProDisc-L in degenerative disc disease: minimum 5-year follow-up results at a single institute. Spine 2012; 37 (8) 672-677
  • 7 Guyer RD, Thongtrangan I, Ohnmeiss DD. Outcomes of CHARITE lumbar artificial disk versus fusion: 5-year data. Semin Spine Surg 2012; 24 (1) 32-36
  • 8 Punt IM, Visser VM, van Rhijn LW , et al. Complications and reoperations of the SB Charité lumbar disc prosthesis: experience in 75 patients. Eur Spine J 2008; 17 (1) 36-43
  • 9 Leary SP, Regan JJ, Lanman TH, Wagner WH. Revision and explantation strategies involving the CHARITE lumbar artificial disc replacement. Spine 2007; 32 (9) 1001-1011
  • 10 van den Eerenbeemt KD, Ostelo RW, van Royen BJ, Peul WC, van Tulder MW. Total disc replacement surgery for symptomatic degenerative lumbar disc disease: a systematic review of the literature. Eur Spine J 2010; 19 (8) 1262-1280
  • 11 Gaffey JL, Ghanayem AJ, Voronov ML , et al. Effect of increasing implant height on lumbar spine kinematics and foraminal size using the ProDisc-L prosthesis. Spine 2010; 35 (19) 1777-1782
  • 12 Pimenta L, Oliveira L, Schaffa T, Coutinho E, Marchi L. Lumbar total disc replacement from an extreme lateral approach: clinical experience with a minimum of 2 years' follow-up. J Neurosurg Spine 2011; 14 (1) 38-45
  • 13 Marchi L, Oliveira L, Coutinho E, Pimenta L. The importance of the anterior longitudinal ligament in lumbar disc arthroplasty: 36-month follow-up experience in extreme lateral total disc replacement. Int J Spine Surg 2012; 6 (1) 18-23
  • 14 Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic assessment of the ability of the extreme lateral interbody fusion procedure to indirectly decompress the neural elements. Spine 2010; 35 (26, Suppl): S331-S337
  • 15 Marchi L, Oliveira L, Amaral R , et al. Anterior elongation as a minimally invasive alternative for sagittal imbalance-a case series. HSS J 2012; 8 (2) 122-127
  • 16 Marchi L, Oliveira L, Amaral R , et al. Lateral interbody fusion for treatment of discogenic low back pain: minimally invasive surgical techniques. Adv Orthop 2012; 2012: 282068
  • 17 Amaral R, Marchi L, Oliveira L. Minimally invasive lateral alternative for thoracolumbar interbody fusion. Coluna 2011; 10: 239-243
  • 18 Oliveira L, Marchi L, Coutinho E, Abdala N, Pimenta L. The use of rh-BMP2 in standalone eXtreme Lateral Interbody Fusion (XLIF®): clinical and radiological results after 24 months follow-up. World Spinal Column J 2010; 1 (1) 19-25
  • 19 Marchi L, Abdala N, Oliveira L, Amaral R, Coutinho E, Pimenta L. Radiographic and clinical evaluation of cage subsidence after stand-alone lateral interbody fusion. J Neurosurg Spine 2013; 19 (1) 110-118
  • 20 Dooley Z, Turner A, Cornwall G. Multiaxial spine testing apparatus: system characterization by evaluation of analog and cadaveric lumbar spines. Int J ExpComputational Biomech 2013; 2 (2) 189-203
  • 21 Panjabi MM, Greenstein G, Duranceau J, Nolte LP. Three-dimensional quantitative morphology of lumbar spinal ligaments. J Spinal Disord 1991; 4 (1) 54-62
  • 22 Cunningham BW, Gordon JD, Dmitriev AE, Hu N, McAfee PC. Biomechanical evaluation of total disc replacement arthroplasty: an in vitro human cadaveric model. Spine 2003; 28 (20) S110-S117
  • 23 Battié MC, Videman T, Parent E. Lumbar disc degeneration: epidemiology and genetic influences. Spine 2004; 29 (23) 2679-2690
  • 24 Wilke HJ, Wenger K, Claes L. Testing criteria for spinal implants: recommendations for the standardization of in vitro stability testing of spinal implants. Eur Spine J 1998; 7 (2) 148-154
  • 25 Freeman BJC, Davenport J. Total disc replacement in the lumbar spine: a systematic review of the literature. Eur Spine J 2006; 15 (Suppl. 03) S439-S447
  • 26 Cunningham BW, Hu N, Beatson HJ, Serhan H, Sefter JC, McAfee PC. Revision strategies for single- and two-level total disc arthroplasty procedures: a biomechanical perspective. Spine J 2009; 9 (9) 735-743
  • 27 Patel AA, Brodke DS, Pimenta L , et al. Revision strategies in lumbar total disc arthroplasty. Spine 2008; 33 (11) 1276-1283
  • 28 Buttermann GR, Beaubien BP. Biomechanical characterization of an annulus-sparing spinal disc prosthesis. Spine J 2009; 9 (9) 744-753
  • 29 Kikkawa J, Cunningham BW, Shirado O, Hu N, McAfee PC, Oda H. Biomechanical evaluation of a posterolateral lumbar disc arthroplasty device: an in vitro human cadaveric model. Spine 2010; 35 (19) 1760-1768
  • 30 Rajaraman V, Vingan R, Roth P, Heary RF, Conklin L, Jacobs GB. Visceral and vascular complications resulting from anterior lumbar interbody fusion. J Neurosurg 1999; 91 (1, Suppl): 60-64
  • 31 Ahmadian A, Deukmedjian AR, Abel N, Dakwar E, Uribe JS. Analysis of lumbar plexopathies and nerve injury after lateral retroperitoneal transpsoas approach: diagnostic standardization. J Neurosurg Spine 2013; 18 (3) 289-297
  • 32 Bertagnoli R, Zigler J, Karg A, Voigt S. Complications and strategies for revision surgery in total disc replacement. Orthop Clin North Am 2005; 36 (3) 389-395
  • 33 Kostuik JP. Complications and surgical revision for failed disc arthroplasty. Spine J 2004; 4 (6, Suppl): 289S-291S
  • 34 Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord 1992; 5 (4) 390-396 ; discussion 397
  • 35 Bostelmann R, Steiger HJ, Tauber M, Leimert M. Width of the cervical intervertebral neuroforamina after total disc replacement with the Cerkinetic prosthesis: a three-dimensional simulation using a computer-aided design model. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (4) 205-208
  • 36 Cunningham B, Cappuccino A, Hu N, Kikkawa J, Klunk J, McAfee P. Biomechanical analysis of an anterior polyester patch to augment lumbar disc replacement - comparison of two lumbar arthroplasty devices using a cadaveric model. Paper presented at: 6th International Meeting on Advanced Spine Techniques; July 15–18, 2009 ; Vienna, Austria
  • 37 Park C-K, Ryu K-S, Jee W-H. Degenerative changes of discs and facet joints in lumbar total disc replacement using ProDisc II: minimum two-year follow-up. Spine 2008; 33 (16) 1755-1761
  • 38 Shim CS, Lee S-H, Shin H-D , et al. CHARITE versus ProDisc: a comparative study of a minimum 3-year follow-up. Spine 2007; 32 (9) 1012-1018
  • 39 Siepe CJ, Zelenkov P, Sauri-Barraza J-C , et al. The fate of facet joint and adjacent level disc degeneration following total lumbar disc replacement: a prospective clinical, X-ray, and magnetic resonance imaging investigation. Spine 2010; 35 (22) 1991-2003
  • 40 Guyer RD, Pettine K, Roh JS, Dimmig TA, Coric D, McAfee PC , et al. Comparison of 2 lumbar total disc replacements: results of a prospective, randomized, controlled, multicenter Food and Drug Administration trial with 24-month follow-up. Spine (Phila Pa 1976) 2014; 39 (12) 925-931