title: Access strategies for revision or explantation of the Charité lumbar artificial disc replacement.
abstract: BACKGROUND
  Several lumbar disc prostheses are being developed with the goal of preserving mobility in patients with degenerative disc disease. The disadvantage of lumbar artificial disc replacement (ADR) compared with anterior interbody fusion (ALIF) is the increased potential for displacement or component failure. Revision or removal of the device is complicated by adherence of the aorta, iliac vessels, and the ureter to the operative site. Because of these risks of anterior lumbar procedures, vascular surgeons usually provide access to the spine. We report our experience with secondary exposure of the lumbar spine for revision or explantation of the Charité disc prosthesis.
  
  
  METHODS
  Between January 2001 and May 2006, 19 patients with prior implantation of Charité Artificial Discs required 21 operations for repositioning or removal of the device. Two patients had staged removal of prostheses at two levels. One patient had simultaneous explantation at two levels. The mean age was 49 years (range, 31 to 69 years; 56% men, 42% women). The initial ADR was performed at our institution in 14 patients (74%). The mean time from implantation to reoperation was 7 months (range, 9 days to 4 years). The levels of failure were L3-4 in one, L4-5 in nine, and L5-S1 in 12.
  
  
  RESULTS
  The ADR was successfully removed or revised in all patients that underwent reoperation. Three of the 12 procedures at L5-S1 were performed through the same retroperitoneal approach as the initial access. One of these three, performed after a 3-week interval, was converted to a transperitoneal approach because of adhesions. The rest of the L5-S1 prostheses were exposed from a contralateral retroperitoneal approach. Four of the L4-5 prostheses were accessed from the original approach and five from a lateral, transpsoas exposure (four left, one right). The only explantation at L3-4 was from a left lateral transpsoas approach. Nineteen of the 22 ADR were converted to ALIF. Two revisions at L5-S1 involved replacement of the entire prosthesis. One revision at L4-5 required only repositioning of an endplate. Access-related complications included, in one patient each, iliac vein injury, temporary retrograde ejaculation, small-bowel obstruction requiring lysis, and symptomatic, large retroperitoneal lymphocele. There were no permanent neurologic deficits, deep vein thromboses, or deaths.
  
  
  CONCLUSIONS
  Owing to vascular and ureteral fixation, anterior exposure of the lumbar spine for revision or explantation of the Charité disc replacement should be performed through an alternative approach unless the procedure is performed < or = 2 weeks of the index procedure. The L5-S1 level can be accessed through the contralateral retroperitoneum. Reoperation at L3-4 and L4-5 usually requires explantation and fusion that is best accomplished by way of a lateral transpsoas exposure.
authors.affiliation: Division of Vascular Surgery, Cedars-Sinai Medical Center and Century City Doctors Hospital, Los Angeles, CA 90048, USA. wagnerwh@cshs.org
authors.forename: Willis H
authors.initials: WH
authors.lastname: Wagner
authors.forename: John J
authors.initials: JJ
authors.lastname: Regan
authors.forename: Scott P
authors.initials: SP
authors.lastname: Leary
authors.forename: Todd H
authors.initials: TH
authors.lastname: Lanman
authors.forename: J Patrick
authors.initials: JP
authors.lastname: Johnson
authors.forename: Rajeev K
authors.initials: RK
authors.lastname: Rao
authors.forename: David V
authors.initials: DV
authors.lastname: Cossman
mesh_terms: D000328:Adult; D000368:Aged; D020878:Device Removal; D005060:Europe; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007403:Intervertebral Disc / Q000601:surgery*; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000009:adverse effects / Q000295:instrumentation; D011474:Prosthesis Design; D019919:Prosthesis Implantation / Q000009:adverse effects; D016032:Randomized Controlled Trials as Topic; D012086:Reoperation; D013122:Spinal Diseases / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States