title: Do presence and location of annular tear influence clinical outcome after lumbar total disc arthroplasty? A prospective 1-year follow-up study.
abstract: BACKGROUND
  Lumbar total disc arthroplasty is often performed in patients with axial back pain. There are multiple etiologies for axial back pain, including disc degeneration and annular tears. The location of these annular tears can vary, producing differing preoperative symptomatology. Intraoperatively, disruptions in the annulus are identifiable, and it has been suggested that patients with discrete annular tears may have better clinical outcomes after surgery. The purpose of this study was to investigate whether the presence and location of annular tears have an effect on clinical outcomes after lumbar total disc arthroplasty.
  
  
  METHODS
  Patients undergoing a single-level anterior disc replacement from L3-S1 at a single site by a single surgeon were evaluated preoperatively for the presence or absence of annular tears with magnetic resonance imaging. All patients were part of either the ProDisc (n = 41) (Synthes, Paoli, Pennsylvania) or Activ-L (n = 19) (Aesculap [B. Braun Melsungen AG], Tuttlingen, Germany) lumbar prospective clinical trials. In those patients with annular tears, the location of the tear (central, paracentral, or lateral) was documented. Patients were assessed at 6 and 12 months after lumbar total disc arthroplasty with the Oswestry Disability Index (ODI), visual analog scale (VAS) score for back pain, VAS score for leg pain, and radiographic imaging. All radiographic evaluations were conducted by an attending neuroradiologist and an attending spinal surgeon, and reliability testing was performed. An analysis of variance was performed among the 3 anatomic locations of annular tears.
  
  
  RESULTS
  A total of 60 patients were included and had complete 12-month follow-up. The prevalence of annular tears among all patients was 42% (n = 25). Outcome data in patients without annular tears were as follows: ODI, 66% preoperatively and 26% postoperatively; VAS score for back pain, 8.0 preoperatively and 2.6 postoperatively; and VAS score for leg pain, 2.9 preoperatively and 1.2 postoperatively. Among those patients with tears, the prevalence of central tears was 80%, the prevalence of paracentral tears was 12%, and the prevalence of lateral tears was 8%. Outcome data in patients with central tears were as follows: ODI, 66% preoperatively and 26% postoperatively; VAS score for back pain, 7.8 preoperatively and 2.6 postoperatively; and VAS score for leg pain, 5.2 preoperatively and 0.5 postoperatively. Outcome data in patients with paracentral tears were as follows: ODI, 86% preoperatively and 59% postoperatively; VAS score for back pain, 8.8 preoperatively and 3.3 postoperatively; and VAS score for leg pain, 5.0 preoperatively and 5.4 postoperatively. Outcome data in patients with lateral tears were as follows: ODI, 6.5 preoperatively and 2.6 postoperatively; VAS score for back pain, 9.2 preoperatively and 0.2 postoperatively; and VAS score for leg pain, 1.4 preoperatively and 0.7 postoperatively. In those patients with paracentral tears, there was a significantly higher incidence of postoperative radicular symptoms both from an intensity standpoint and from a duration standpoint. Other complications did not vary among those patients with or without annular tears.
  
  
  CONCLUSIONS
  Although patients with annular tears and patients without annular tears improve after lumbar artificial disc replacement, those with central annular tears or without tears have significantly lower disability scores than those with paracentral tears or lateral tears, whose outcome scores showed significantly less improvement (P ≤ .03). In particular, patients with central tears have less postoperative leg pain than those with paracentral annular tears. In this study the presence or absence of an annular tear on magnetic resonance imaging was not a significant predictive factor for clinical outcome. Further investigation regarding the effects of paracentral annular tears and surgical techniques should be explored.
authors.affiliation: Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine/New Haven Hospital, New Haven, CT.
authors.forename: James J
authors.initials: JJ
authors.lastname: Yue
authors.affiliation: Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine/New Haven Hospital, New Haven, CT.
authors.forename: Connor
authors.initials: C
authors.lastname: Telles
authors.affiliation: Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine/New Haven Hospital, New Haven, CT ; Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Schlösser
authors.affiliation: Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine/New Haven Hospital, New Haven, CT.
authors.forename: Shawn
authors.initials: S
authors.lastname: Hermenau
authors.affiliation: Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine/New Haven Hospital, New Haven, CT.
authors.forename: Ravi
authors.initials: R
authors.lastname: Ramachandran
authors.affiliation: Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine/New Haven Hospital, New Haven, CT.
authors.forename: William D
authors.initials: WD
authors.lastname: Long
keywords: Annular tear; High intensity zone (HIZ); Lumbar disc arthroplasty