The implications of constraint in lumbar total disc replacement

Lumbar total disc replacement (TDR) is an evolving technique that has the potential to replace arthrodesis as the gold standard surgical treatment of degenerative disc disease. The interaction between host anatomy and physiology and the biomechanical properties of TDR implants will determine the quality of long-term clinical results. However, there is scant literature addressing this subject. The purpose of this article is to discuss the implications of biomechanical constraint in TDR. Based upon available data for normal motion segments and the design of two TDRs currently in clinical trials, unconstrained designs appear to have a kinematic advantage. They are more likely to provide a physiologic mobile instantaneous axis of rotation (IAR), which may explain why they display greater range of motion in vivo. Their lack of constraint may prevent excessive facet joint or capsuloligamentous loads in the extremes of flexion and extension. Furthermore, since the IAR is mobile, they may be less sensitive to small errors in implant placement. On the other hand, constrained devices appear to have an advantage in protection of the posterior elements from shear loading. Spinal shear loads of considerable magnitude occur during activities of daily living. Whether the transference of stresses to the implant and implant-bone interface is clinically significant is unknown. Although this article focuses on two specific TDR designs, future designs will need to account for the same kinematic and loading concerns regarding constraint. We hope this discussion will assist clinicians and researchers in the design, selection, and clinical comparison of present and future TDR implants.