If you’ve been visiting our website and reading up on BalancedBack as a possible option for treating your leg and back pain, you might be looking for more detail about total disc replacement surgery itself. This article walks through the actual procedure step by step.
Total Disc Replacement Back Surgery
Before outlining the steps of the procedure, here’s a concise description of the BalancedBack concept for context:
BalancedBack is a “total” joint for the lumbar spine. BalancedBack allows surgeons to directly decompress painful pinched nerves, while at the same time addressing a variety of other root causes of pain, by replacing the function of the degenerated disc and facets with a motion device.
Wondering if you might be a good candidate for a total disc replacement? Read more about this new device and the conditions it treats.
How The Procedure Works
- Exposure. The first step is to expose the affected area of the spine. To do this, the surgeon makes an incision in the middle of your lower back. The length of the incision depends on the patient. For small, thin patients undergoing a single-level procedure (where the device is implanted on only one level of the spine), the incision might be just a couple of inches. For larger patients or more extensive pathology, it could be longer.
- Bony removal. Once the general area of soft tissue has been exposed, the surgeon decompresses the nerves and spinal cord (in this area the cauda equina) by removing the lamina and facet joints. The extent of the bony decompression depends on the extent of the pathology, but the goal is always the same: to remove painful and/or arthritic structures.
- Disc removal. Next, the surgeon carefully removes the disc itself through the space commonly referred to as Kambin’s Triangle. This space is considered a safe area in which to access the disc.1 In a motion-preserving procedure it is important to remove all of the disc material to prevent disc fragments from pinching or irritating nerves in the future.
- Determine height and length of the implant. Also through Kambin’s Triangle, the surgeon uses imaging to examine the area and determine the proper fit of the implant. He or she looks at the length and height of the space in order to determine proper implant size and perform the next step.
- Bone preparation. Once the height and length have been determined, the surgeon uses oscillating rasps to prepare the bones both above and below to accept the implant. The goals of this step are (1) to prepare the endplates for bone to grow into the implant and (2) to adjust the sagittal alignment of the segment. Also, the implant itself has a little keel—that’s the part of the device that actually goes into the bone and helps provide initial stability for the implant while the construct heals.
- Device implantation. Finally, the surgeon inserts the implant and seats it in the proper position. Once it’s in place, one screw is placed through the bottom of the implant to provide additional temporary fixation until the bone heals, securing it permanently. (You can read more details about the implant design here.)
By following these steps, the surgeon first decompresses then reestablishes the stability of your spine, while allowing your spine to continue moving naturally after surgery.
It typically takes about three months for new bone to grow around the implant and anchor it securely. To encourage bone growth and reduce the risk of stunting new bone growth, we require patients to stop smoking prior to surgery.2
BalancedBack instrumentation is contained completely within the bone and does not protrude in the back the way pedicle screws do in a fusion. The dramatic difference in postoperative back pain between BalancedBack patients and fusion patients is partly due to the simple fact that BalancedBack hardware is not rubbing against the muscles, as shown in the picture below.
Total Disc Replacement Surgery As Compared To Hip & Knee Surgery
BalancedBack follows closely in the footsteps of other total joint replacements, such as hip or knee total joint arthroplasty, and is based on the same principle: To maintain proper balance throughout your body you need mobility. This is true for ankle joints, knees, hips, shoulders, elbows, etc.—and spinal joints too.
Motion keeps us functioning in a normal way. In the old days, when hips were fused, it changed a person’s gait dramatically, putting a lot of additional force on the same side knee and on the opposite side hip. The abnormal gait made other joints wear out more quickly. The same was true of the knee. When a knee was fused, it put significant stress on the other knee, also making it wear out more quickly.
We now know that the spine needs motion to work properly. A standing spine has a curve that flattens out when you sit—that motion is very important to normal function. If a joint of the spine is removed, you create abnormal mechanical loads for the spine segments above and below the fusion, adding stress to the nearby facet joints and discs. When they work harder, they weaken and wear out; this condition is called adjacent segment degeneration. It is by far the most critical problem with spinal fusion, and can lead to the development of other problems down the line, in particular, spondylolisthesis or degenerative scoliosis.
There is one thing that makes the spine unique compared to hips and knees: It is the only motion joint that involves nerves. Hip and knee surgeries don’t have to contend with unpinching nerves, yet spine surgery does. Much of the time, nerve decompression leads to creating instability in the spine that must be addressed. In years past, only fusion provided the necessary re-stabilization, but it’s increasingly becoming clear how damaging fusion can be. Today, it’s also becoming clear that motion-preservation surgeries, like BalancedBack, have the potential to provide far better outcomes than fusion.3