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Total disc replacement for chronic back pain in the presence of disc degeneration


Jacobs, W., et al

Subject Keywords: The aim of this systematic review was to assess the effect of total disc replacement for chronic low-back pain in the presence of lumbar disc degeneration compared with other treatment options in terms of patient-centred improvement, motion preservation and adjacent segment degeneration
Type: Article
Region: International (other)

Artificial joints have had a remarkable impact in reducing pain and improving function in the knee and hip. But what about joint replacement in the spine? This systematic review set out to determine how total disc replacement compares with other treatments for chronic low-back pain in randomised controlled trials.

The disc is a strong but flexible structure that cushions and separates the bony vertebrae of the spine. Disc degeneration is a nearly universal feature of the aging process. Though there are many theories about the causes of low-back pain, chronic symptoms are often attributed to disc degeneration. So when patients do not improve after nonsurgical care, they sometimes consider surgery to remove a degenerated disc.

The traditional surgical approach in this area is spinal fusion, which involves removing all or part of a degenerated disc and joining the vertebrae above and below it. Previous reviews suggest that fusion surgery can lead to moderate pain relief and modest gains in function.  It appears to be superior to traditional physical therapy—but no better than an intensive rehabilitation program.

An alternative surgical approach is total disc replacement, which involves removing the disc and replacing it with an artificial implant made out of metal and plastic.

We identified seven randomised trials—involving a total of 1474 patients. Only one study compared total disc replacement with nonsurgical treatment, suggesting that surgery resulted in slightly better outcomes than intensive rehabilitation. But this did not translate into a clinically significant advantage that would make a major difference in patients’ lives.

Six randomised trials compared disc replacement with spinal fusion surgery. Most of these studies had a high potential for bias, raising the possibility that they might not have provided a fair test of the treatments under study. These trials found that patients who underwent total disc replacement had slightly better outcomes in terms of back pain and function than those who had fusion surgery. But again the differences did not appear clinically significant.

The review could not find evidence of any other benefits of total disc replacement, and the studies provided no insights on the long-term risks associated with it. Given the gaps in the evidence, the review concluded that the spine surgery community should be prudent about adopting this technology on a large scale.



Rights: © The Cochrane Collaboration
Suggested citation:

Jacobs, W., et al. (2012) Total disc replacement for chronic back pain in the presence of disc degeneration [Online]. Available from: [Accessed: 19th July 2019].


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