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Subject: �Posterolateral approach to lumbar disc replacement�
Head department of spinal surgery in the Institute of neurosurgery, Ukraine: 
Yevheniy I. Slynko M.D., Ph.D., 

Address: Yevheniy I. Slynko M.D., Ph.D.,
                Department of spinal surgery
                Institute of neurosurgery 
                Manuilskv st.    32
                Kiev    04050
                Ukraine
Telephone number: Office: 0038 (044) 592-19-09
                                 Mobil: 0038 (050) 543-76-80
                                 Fax:     0038 (044) 483-95-73
                                 E-mail:  HYPERLINK "mailto:eu_slinko@yahoo.com" eu_slinko@yahoo.com

Iyad I. Al-Qashqish M.D.
Address:  Iyad I. Al-Qashqish            
                Department of spinal surgery
                Institute of neurosurgery 
                Manuilskv st.    32
                Kiev    04050
                Ukraine
Telephone number: Office: 0038 (044) 486-95-03
                                 Mobil: 0038 (050) 940-96-00
                                 Fax :    0038 (044) 483-95-73
                                 E-mail:   HYPERLINK "mailto:Iyad@mail.ru" Iyad@mail.ru


Posterolateral approach to lumbar disc replacement
Yevheniy I. Slynko M.D., Ph.D., Iyad I. Al-Qashqish M.D., 
Institute of Neurosurgery, Kiev, Ukraine.

Object. The goal of the present study was to develop a simple posterolateral approach for lumbar artificial disc replacement (ADR) and design the artificial disk suitable for this approach.
Methods. In our study, there were 50 operated patients whom posterolateral approach for lumbar disc replacement was used. All cases were single-level disk herniation. The mean duration of symptoms was 14 months (range 7 - 28 months). The age of these patients ranged from 21 to 62 (average, 37,7) years. All patients were accessible to supervision in the follow-up period. The average follow-up duration was 23 months, with a range of 8 to 49 months. Patients reported their pain on the Visual Analogue Scale (VAS) and completed the Oswestry Disability Index (ODI) questionnaire. All patients reported reduced LBP at follow-up after ADR. All patients at follow-up reported significantly reduced leg pain.  The mean Oswestry Disability Index score was 72.3+/-9.1 preoperatively and 26.2+/-1.44 at 5 months follow-up (p<.001). The average preoperative height of the affected discs was 7 mm, whereas postoperatively the height increased to a median of 12,5 mm. Motion at the affected disc level was increased from 5� preoperatively to 11� postoperatively. The adjacent-level disc heights did not significantly change. There were no cases of subsidence of the prosthesis. There were no cases of loosening, dislocation, or failure of the device�s metallic or polyethylene components. 
Conclusions. The development of posterolateral approach and modified implants may allow using disc replacement technique for patients with degenerative disc diseases (DDD) and disc subsidence accompanied by sciatica due to lumbar disc herniation. The posterolateral approach for ADR has some advantages over anterior surgery in lumbar disk herniation patients.
Key words: Total disc replacement, posterolateral approach, lumbar spine
Abbreviations used in this paper: ADR = artificial disc replacement; DDD = degenerative disc disease; TLIF = transforaminal lumbar interbody fusion.


Introduction 
Artificial disc replacement is the encouraging and promising procedure of radical cure of degenerative lumbar disk diseases. However presently, there is no evidence-based consensus on indications or contraindications for ADR. As it is believed ADR can prevent at least four pathological processes that are so typical for DDD: disc height and intervertebral foramina reduction, reduction of motion range in segment with DDD, stress and increased motion in the segments adjacent to affected level, increased degenerative process at affected and adjusted levels [1, 8]. Nevertheless, the number of such operations is small; they are still practiced in limited number of neurosurgical centers. The main reason for this is that current artificial disc replacement has also several disadvantages. Among them the following are cited: specific anterior approach-related complications - 2.8% incidence of laceration to major abdominal vessels or ureter, retrograde ejaculation, sympathectomy related dysesthesia, deep vein thrombosis, arterial pulmonary embolism [5, 25]; devise-related complications - primary suboptimal implantation, segmental hyperlordosis after implanntation, loosening, dislocation, or failure of the device�s components; subsidence of the prosthesis, and loss of the range of an implant motion in some time [21, 22, 29, 6]. Most previous studies described complication rates for disc replacement procedures ranging from 8% to 17% [34, 35]. The anterior or anterolateral approach for ADR  itself has many limitations. This type of approach is more complicated compared to microdiscectomy, has higher rate of morbidity or even mortality, and is time-consuming [31, 26]. In some cases, the exposure of the disc space was not even possible due to the intraoperative anatomy of the vascular bifurcation [6]. The same authors used preoperative three-dimensional CT angiography with reconstruction of the individual topography of the prevertebral vessels for planning of the surgical access to levels L4-L5 and L5-S1 [29]. 
It is also more difficult to remove disk herniation and decompress nerve root from anterior or anterolateral approach, especially in case of sequestrated disk and dislocated sequesters. The venous bleeding from epidural veins sometimes might become troublesome, hard to control [2, 3]. It is the main reason why at present time a disc herniation with sciatica is a contraindication for an artificial disc replacement [4, 29, 26].
To solve this problem more simple method of ADR is needed as well as artificial disk suitable for this method. The goal of the present study was to develop a simple method of ADR and design the artificial disk suitable for this approach. 
Materials and Methods
Disk design
The artificial disk metal/plastic, unconstrained type was developed (Inmed, Ua). The disk is made of titanium alloy and mobile sliding core made of ultra-high molecular-weight polyethylene. Different sizes of disk were used in cadavers� studies and the most suitable sizes found out were: disk height 7-9-11 mm. The disk was round with the diameter of 23-26-29-32 mm. Two type of angles were suitable - 50 and 7.50. The surface of titanic plates was spherical with towering ledges that allowed a disk to occupy easily the necessary position owing to concurrence of convex titanic plates and endplates of vertebral bodies, having a deepening.  The round design of a disk allows introducing it between vertebrae in any orientation (Fig. 1). The new artificial disk is less in size than conventional artificial disk and in fact, it is more the nucleus replacement implant. In view of the fact that the disk is installed in the cavity remained after nucleus removal and the fibrous ring thus kept. The implant is rapidly secured in place by fibrous ring and vertical pressure of the spine. Thorn at the top and towering ledges of the implants� endplates is thought to hold implant in place as bone grows around it. 
The construction has two important instruments. The first one is an artificial disk imitator/distractor which is inserted in the disk space. This imitator allows estimation of the sufficient size of the cavity for subsequent introduction of the disk and increasing of the interbody space by swing movements by means of vertebral bodies� retraction. The second instrument is a holder, which allows to keep the disk in assembled position and insert artificial disk in disk space being assembled. 
Study design
At first, the artificial disk was introduced in 6 cadavers. We developed posterolateral approach to L4-5, L5-S1 intervertabral disk with one-side lower part of facet joints resection. The surgical approach for this technique was somewhat similar to one-side TLIF with the exception that we didn�t totally remove facet joint. To reach interbody space from posterolateral route it was enough to remove only the lower part of facet joint. 
After sufficient disk material removal the artificial disk was introduced between endplates of vertebral bodies. After that, the lumbar spine in cadaver�s model was removed and radiographs (AP, lateral, flexion�extension, and lateral bending) were obtained. We measured intervertebral disc heights of the affected and adjacent levels, angular intervertebral disc motion. 
After cadavers study was reported we received institutional board and bioethics commission approval for performing of such type of operation in 50 patients with lumbar disk herniation. 
Patients� selection and evaluation
This study is a prospective analysis of 50 patients on whom posterolateral approach for lumbar disc replacement was used. All procedures were performed by the senior author (S.E.I.) at a single institution. All cases were single-level disk herniation. There were 22 men and 28 women. All patients had undergone at least six months of nonoperative treatment before. The mean duration of symptoms was 14 months (range 7 - 28 months). The age of these patients ranged from 21 to 62 (average, 37,7) years. 
Indications for ADR were: disabling discogenic lumbar back pain (LBP) caused by mild to moderate DDD, accompanied by loss in disc height more than 20% plus radicular symptoms due to L4-5, L5�S1 soft or hard disk herniation.  
Exclusionary criteria included the following: patients with spinal stenosis accompanied by neurogenic claudication, osteoporosis defined in a T-score greater than 2.5, history of previous spine surgery, chronic infections, metal allergies, inadequate vertebral endplate size, pregnancy, workers� compensation recipients, body mass index greater than 35, and/or any isthmic or degenerative spondylolisthesis. Patients with significant facet joint arthrosis evidenced by bridging osteophytes and/or cystic changes with irregular and erosive changes were excluded from disk replacement surgery. Patients in whom there were minimal extraarticular facet joint changes (calcifications) were not excluded. Surgery was performed after complete radiographic assessment (including AP, lateral, flexion�extension, and lateral bending radiographs), CT scanning, and MR imaging. 
Measurements were performed and standardized according to Kim K.A et al [15] and Lim MR et al [19]. Plain x-ray films were compared for the following measurements: X, the anterior disc height; Y, the middle disc height; Z, the posterior disc height; W, the height from the lower pedicle border of the upper spinal level to the superior pedicle border of the lower spinal level at the pedicle�laminar junction; (Vu-Vl), the measurement of slippage between the upper and lower spinal levels; and U, the Cobb angle. Dynamic flexion-extension and lateral bending radiographs were performed and segmental range of motion (ROM) was measured using the Cobb method.
To standardize plain radiographs, the measurement Q was used as the standard unit for comparing pre- with postoperative images [15, 19]. To establish the standard deviation of Q, three independent measurements of Q were obtained on each image and the standard deviation was calculated in pixels per millimeter and then converted to percentage of measurement. The mean Q value was obtained for each image and used to standardize and compare pre- and postoperative images. Using the average measurements of each value, Q, a universal standard deviation for imageJ was obtained (+/- 3.2% of the mean measurement), and was used throughout the study as the assumed error rate of measurement. To establish the standard deviation of U, three independent measurements of U were obtained on each preoperative Cobb angle analysis and calculated in degrees and then converted to percentage of mean measurement. The mean U value was obtained for each image. An inherent angle measurement error (standard deviation of 2.1%) was established. The same measurements were performed on the patients� MR images as those performed on the radiographs. A 5-mm scale on each MR image was used for analysis. As was the case with x-ray films, an inherent MR imaging error of +/- 3.2% as measured was assumed to occur due to ImageJ use. 
	All abovementioned measurements on preoperative images were compared with those  on postoperative ones.
The facet measurements were performed on CT. Taking into consideration that we planned resections of the lower part of facet joint, we noted position of upper points of medial and lateral facets and measured distances between them on the vertical and horizontal axes of coordinates. After operation, we took the same measurements. If after operation, the interval between upper points of medial and lateral facets had increased on the same distances from both sides only in vertical direction we regarded this sign as a good attribute of increase in an intervertebral disk space. If, from the side of operation the upper point of medial facet moved downwards in relation to the upper point of lateral facet and on the opposite side the distance between upper points of medial and lateral facets had increased on horizontal axis we called this "subsidence of facet joint remnants" because of undersize artificial disk and insufficient intervertebral disk space distraction. 
The same radiographic assessment (AP, lateral, flexion�extension, and lateral bending radiographs), CT scanning, and MR imaging was performed on patients after surgery being in hospital and every 5 months in follow-up period: for example 5, 10, 15, 20 months, etc in follow-up.
In all films, comparisons and calculations were made with image measurement system GIMP, image software of Linax 2006. 
We considered as an ideal position of an artificial disk such situation when the center of an artificial disk was on the line passing through the center of the vertebral body on antero-posterior and lateral projection roentgenograms. Disc mal-positioning was defined when the center of a disk was displaced aside in any direction from these central lines more than 10% from the radiological size of a vertebral body. The position of the disk between range �ideal position� and �disc mal-positioning� we considered as acceptable.
All our patients suffered preoperatively from discogenic LBP, with radicular and/or neurogenic symptoms. We assessed primary outcome measurements based on patients� responses in questionnaires. Patients reported their pain on the Visual Analogue Scale (VAS) and completed the Oswestry Disability Index (ODI) questionnaire before surgery, after surgery being in hospital and every 5 months in follow-up period: for example 5, 10, 15, 20 months in follow-up. The neurological deficit (root tension, reflexes, muscle strength, and sensory deficits) was assessed by a neurologist in 3-6 point scores before, after surgery, and in the follow-up period when directly it was possible to survey the patient.
All patients were accessible to supervision in the follow-up period. The average follow-up duration was 23 months, with a range of 8 to 49 months.
After the aforementioned data were compiled, they were analyzed by an independent examiner (K.A.) who had no interaction with the patients or involvement in the surgical procedures at any time during this study.
The data were recorded using OpenOffice.org Calc 2.2.1. (Sun Microsystems Inc.) for Mandriva Linax 2007 and transferred to STATISTICA (StatSoft, Inc.) for statistical analysis. Continuous variables (such as ODI and VAS) and numeric data (radiologic measurements) were collected each time (before operation, after and in follow-up period) and used for analysis. For group sample analysis 2-tailed Mann-Whitney U-Wilcoxon's rank sum test was performed. Statistical significance was defined and accepted as P < 0.05.
Results
Surgical technique
The patient was placed prone on rolls in a manner that promotes normal lumbar lordosis. A transverse skin incision at the level of surgery followed by a transverse fascial incision was used. The incision began from midline and continued 4-6 cm laterally to the midline. A muscle-splitting technique was not used. Instead the muscle was easily retracted laterally after fascia transversal incision. This maneuver allowed access to the ipsilateral facet joint. Access was established with blunt finger or Cobb periosteal dissection at L4�5 or L5-S1. Fluoroscopy was performed to confirm the levels exposed. Once the facets were palpated and the capsule became accessible, the ipsilateral transverse processes and pars interarticularis as well as the caudal facet got exposed. After Williams or Meyerding retractor was placed the dorsolateral approach was performed using direct visualization. The lower half of facet was removed with osteotomes and rongeurs as well as with a high-speed pneumatic drill. The decompression continued until the triangular working space was exposed at the inferomedial aspect of the neural foramen. The inferior side of the triangle was the superior margin of the caudal pedicle. The medial edge was the dural sac, and the superolateral edge was the exiting nerve root. The disc space was identified within this triangle. After exposure of the posterior longitudinal ligament, the plane between the dura mater and the ligament could be developed, and the dura could be freed from where it could be adherent to the anulus. This allowed  medial retraction of the dura and lateral retraction of the traversing nerve root. In most cases, this was sufficient for discectomy, endplate preparation, and insertion of the artificial disc. After decompressive discectomy, the interbody space was prepared for insertion of the artificial disc by means of removing much of the disc material and cartilaginous endplates with a series of curettes. Then, the instrument which we call the �artificial disk imitator/distractor� was inserted into the disk space. With the help of this imitator we estimated the sufficient size of the cavity for subsequent introduction of a disk. The size of the artificial disc was evaluated intraoperatively. Also by swing movements of �artificial disk imitator/distractor� we were increasing interbody space by vertebral body retraction. The distractor was positioned in the center of the vertebral endplate. The traction was applied without  circumferential release. The traction force was controlled manually, avoiding excessive tension at once.  We used repeated swing movements, gradually replacing distractors for bigger size ones.   After that the artificial disk was put in the holder that allowed to keep the disk in assembled position and then the disk was inserted into the space. By striking light blows on the holder the artificial disk was inserted into the disk space. We placed the artificial disc in the center of the disc space (Fig.2,3). Positioning of the prosthesis was confirmed by the fluoroscopy. A drain was always placed. The fascia was closed and the subcutaneous tissues were apposed with 2-0 sutures. Sutures were also used for the skin closure. No lumbar corset was used after operation. 
The average operating time was 61.5 minutes (range, 45 to 110 minutes), and the average estimated blood loss was 170 ml (range 100�350 ml). The average duration of hospital stay was 3 days (range 2�6 days). There were no approach-related complications. There were no new postoperative radiculopathies or malpositioned artificial disks (Fig.4).
Clinical outcomes
In all patients with preoperative radiculopathy we attained resolution of their symptoms postoperatively, and in all patients with mechanical low-back pain improvement of this symptom was noted. 
All patients were accessible to supervision in the follow-up period. The average follow-up duration was 23 months, with a range of 8 to 49 months.
Patients reported their pain on the Visual Analogue Scale and completed the Oswestry Disability Index questionnaire.
All patients on VAS reported reduced LBP at follow-up after ADR. All patients at follow-up reported significantly improved leg pain (tab. 1).
The mean Oswestry Disability Index score was 72.3+/-.91 preoperatively and 26.2+/-1.44 at 5 months follow-up (p<.001) (tab. 1).
Radiographic Analysis
In follow-up period, the imaging studies were done including MRI, CT, X-ray. We realized that partial resection of the facet could create instability at operated level and produce significant biomechanical challenges to a disc replacement device. Therefore special attention was given to the height of the affected discs; motion at the affected disc level; signs of implant migration.  We analyzed functional X-ray images to catch signs of instability. Spiral CT was analyzed to visualize if there was any subsidence of facet joint remnants. 
The mean height of the affected discs before surgery and its� dynamics after operation is presented on table 2. The adjacent-level disc heights did not significantly change. During the first 15 months, the height of a disk slightly decreased, further it remained stable. In view of small reduction of height of a disk, we consider it not as artificial disc subsidence, but that the artificial disk has occupied the normal, stable position. 
There were no cases of loosening, dislocation, or failure of the device�s metallic or polyethylene components. 
The range of motion at the affected disc level is presented on table 3. During the first 15 months, the ROM at the fitted prosthesis levels slightly decreased, further it remained identical. It most likely was caused by formation of scarring around artificial disks.
There were no cases of one side facet joint remnants subsidence or skew of adjacent vertebral bodies due to unilateral facet joint remnants subsidence. There were no cases of instability found out by functional X-ray.
Modic changes (MT1 � 4 patients, MT2 � 2 patients) were seen before surgery in 6 patients. Presence of Modic changes did not have any significant influence on overall outcome (clinical or radiological) compared with patients without Modic changes.
In follow-up period were no incidences of radiolucency, loss of disc height, or spontaneous fusion.

Discussion
The current surgical interventions for symptomatic disc degeneration include nucleotomy, discectomy, and spinal fusion [33]. Discectomy or nucleotomy is an effective method for nerve roots decompression and has proven to be effective in the reduction of radicular pain and/or radiculopathy caused by disc herniation. But, decrease in disc height was noted after conventional nucleotomy was performed; the total loss of disc height was 3,1 mm [30]. Mechanical low back pain, radicular pain and/or radiculopathy due to disc subsidence, degenerative deformities, instability caused by DDD are demanding fusion of symptomatic levels. Fusion has been established as so-called gold standard for the treatment of true deformities and instability. Nevertheless, its role for the treatment of lumbar degenerative disc disease remains debated. Fusing single or multiple segments is associated with a variety of side effects and surgical access-related collateral damage, accelerated adjacent segment degeneration, spinal stenosis due to secondary facet joint degeneration, symptomatic facet and iliosacral joint problems, etc.[29, 10, 22]. 
	To maintain the mobility of the spinal motion segment a number of prosthetic devices have been developed. Currently there are two strategies: a lumbar total disk replacement (TDR)  or replacement of the nucleus pulposus (PDN) [33]. 
TDR using various implants has been suggested as a substitute for spinal arthrodesis [4, 18, 27]. The major purpose of TDR is to preserve segmental motion. It is intended to provide dynamic stability and prevent junctional degeneration at the adjacent segments. However, lumbar TDR is still a complicated procedure that demands careful patients� selection and a good knowledge of the spine�s functional anatomy and biomechanics [14]. Presently, indications for TDR remain a matter of debate, and an increasing number of reports are available that describe disc replacement procedures for extended indications or even commonly accepted contraindications, such as spinal canal stenosis, degenerative scoliosis, residual intersegmental instability following previous fusion, degenerative scoliosis and mobile degenerative spondylolisthesis (Grade I and II) [13, 4, 16, 20, 1]. Generally application of TDR on lumbar level is limited for degenerative deformities and instability. Sciatica caused by disc herniation usually is an exclusion criterion in most researches. The main reason is difficulties in removing of dick herniation and sequesters from anterior approach. All modern artificial lumbar disc models require anterior approach [11]. Nevertheless, Wenger and Markwalder, in a recent study, described favorable early results following anterior microdiscectomy in cases of soft disc herniation and following total disc arthroplasty [32]. Recently Pimenta L and coworkers [24] have described the new minimally invasive endoscopic assistant technique of lumbar disk replacement by extreme-lateral approach. This approach despite of its advantages is complicated by: deep operative wound, unfamiliar for most surgeons anatomy of extreme-lateral approach at lumbar level and need for endoscopic assistant technique.  There is no sense to mention that during extreme-lateral approach it is also extremely difficult to remove posterolateral disk herniation. This technique is exclusively useful in cases of degenerative disc disease, and a disk that has lost its height.
Potential complications are the major limitations of anterior approach to the lumbar spine. They are: great vessel injury, retrograde ejaculation, deep vein thrombosis, ureter injury. The risk of complications in total disc replacement procedures is even higher because it requires wider exposure of the target vertebral level [2, 3, 4].
One of the advantages of replacement of the nucleus pulposus by the prosthetic disk nucleus (PDN) is that it preserves the existing anatomical structures, which include the annulus, the endplates of the vertebral bodies, and the ligaments. In addition to maintaining mobility,  replacement of the nucleus has the potential to reestablish the disc height [33]. Among the advantages of PDN it is necessary to note the opportunity of its installation from posterior access with minimal resection of bone structures [28]. 
For example, PDN prosthetic disc nucleus, which has the most clinical data, consists of a hydrogel core encased in a polyethylene jacket. The hydrogel core can absorb up to 80% of its weight in water, which allows the device to expand and maintain or restore disc space height. The implantant jacket prevents overexpansion and subsequent overdistraction of the disc space that could cause endplate fracture. The PDN device has been placed through a posterior approach following  annulotomy. Early versions of the design were used in a paired configuration, while later versions used a single PDN (PDN-SOLO�), with the long axis of the implant oriented in the coronal plane [9, 17, 28]. The PDN also has its main drawback. Because of its soft consistence it is impossible to fully restore a disk height as it is possibly to do using TDR [28]. Another problem is high frequency of device migration from 95 up to 38% [9, 17].
Experience with one-side posterolateral approach for interbody fusion (TLIF) shows no risk of listed above complications of anterior approach to the lumbar spine but may be associated with nerve root injury [12]. Development of approach with less complication risk will give more advantage to disc replacement over fusion. 
Thus, the new procedure has derived from the essence of three ideas: technique of PDN, technique of TDR and technique of TLIF. As well as in procedure of TDR we installed instead of a native disk rigid mobile implant; as in procedure of PDN we replaced only nucleus pulposus; and as in procedure of TLIF we used posterior access with partial resection of facet joints. The advantage of new procedure is simple posterolateral approach, an opportunity of wide nerve root revision, and installation of mobile prosthetic device.  
TDR have been used almost exclusively in cases of DDD [4, 7, 31]. Sciatic pain is usually not an indication for TDR [1, 6, 11, 26]. Such patients have much benefit from conventional posterior discectomy � procedure with minimal risk of complications. Anterior disectomy on lumbar level is also inadequate for disc herniation with free fragment in spinal canal. That is why only few reports concerning application of disc prosthesis in lumbar disc herniation with sciatica are available [32]. Nevertheless, some patients with sciatic pain require stabilization of lumbar spine in addition to decompression procedure. They usually are candidates for posterior discectomy and interbody fusion [12]. For this patient group artificial disc replacement via posterolateral approach presents a new treatment modality. Its potential advantages (over conventional discectomy, anterior and posterior interbody fusion) are: direct visualization of nervous structures for decompression, dynamic stabilization of the segment, prevention of recurrent disc herniation and instability, avoidance of anterior approach complications, prevention of adjacent segment degeneration. 
Thus, the indications for simple nucleotomy or nucleotomy plus artificial disc replacement are different. Classic indication for simple nucleotomy is a disc herniation (with or without free fragment in spinal canal), nerve root compression with radicular symptoms and leg pain. Nucleotomy plus artificial disc replacement is meaningful in those cases when along with a disc herniation there are degenerative disk diseases (DDD). The DDD must be mild to moderate; be accompanied by loss of disc height more than 20% compared to adjacent normal disc height; resulted in discogenic low back pain (LBP) beingthe predominant, leading complaint and having impact on quality of life. Nucleotomy plus artificial disc replacement is indicated for patients with DDD and soft disc herniation as well as for patients with DDD and hard disc herniation. However, in the last group the implant height was restricted to the smallest height because distraction of the segment with significant degeneration from posterolateral approach was limited. Unlike anterior approach distraction of the segment from posterolateral approach is more difficult. Therefore, the cases with significant degenerative disc changes, a collapse more than 40% of height of a disk are undesirable for posterolateral approach. Another exclusory criteria for nucleotomy plus artificial disc replacement are similar to TDR and include: patients with spinal stenosis, osteoporosis, prior fusion surgery, chronic infections, metal allergies, facet arthrosis, inadequate vertebral endplate size, more than one level of spondylosis, neuromuscular disease, pregnancy, Workers' Compensation, spinal litigation, body mass index greater than 35, and/or any isthmic or degenerative spondylolisthesis greater than Grade 1.
Accompanying Modic changes did not have a statistically significant influence on outcome of ADR. Therefore, some authors conclude that monosegmental symptomatic DDD with or without Modic changes can be regarded as an acceptable indication for total lumbar disc replacement [29]. We also noticed no differences in follow-up period between patients with or without Modic changes. 
It is also necessary to mention, that the described procedure of ADR has a huge advantage in the opportunity of changing the surgical tactic during operative intervention. For example, an operation could begin as a simple nucleotomy or microdiskectomy, and then if it was possibly and necessary to do ADR the lower half of facet was removed and an artificial disc was installed. Alternatively, at adverse coincidence of circumstances - impossibility or inexpediency of ADR the facets were removed completely and the operation was finished by one-side or bilateral TLIF. 
Disadvantages of the nucleotomy plus artificial disc replacement via posterolateral approach are as follows: more dissection required for paravertebral muscles and their retraction, unilateral one-side lower part of facet joints resection, nerve root and dura retraction. 
It is possible to reduce potential complications and drawbacks of the new procedure taking into consideration following principles. It is always necessary make resection of lower part of facet joints as less as possible, just enough to expose the root and the disk located under it. If the space for manipulation it is not large enough, it is possible to pick up a disk of smaller diameter and height as installation of abig one will entail significant nerve root and dura traction. Certainly,  selection and installation of an artificial disk via posterolateral approach on the center of a vertebral body is difficult. However, with gaining of a surgical experience these surgical stages become simpler and take less time. 
Partial facet joint resection can affect stability of the motion segment. In our series, there were no cases of one side facet joint remnants subsidence or skew of adjacent vertebral bodies due to unilateral facet joint remnants subsidence. In addition, there were no cases of instability found out by functional X-ray. However, the average follow-up duration in our series was 23 months with a range of 8 to 49 months. It was less possible that instability appeared in the remote period.  Considering that in described technique facet joint was removed partially, the fibrous ring was not essentially compromised, only nucleus pulposus were replaced, the occurrence of instability was less possible. However, it is necessary to remember, that the bigger artificial disc in size is, the more its ROM is, the more considerable resection of facet joint is required the more probability of instability as consequence of significant ROM and great volume of facet joint resection is. 
A number of authors have addressed the problem of artificial disc revision. McAfee et al. reported a reoperation rate of 8.8% (52 of 589 patients) [23]. According to Siepe C.J. et al. the overall rate of revision surgery was 8.1% [29]. The rate of revision surgery increased from 7.0% following TDR at L5-S1 to 20% following bisegmental TDR at L4-L5 + L5-S1. The nonkeeled design of the Charit� prosthesis allows removal without sacrificing vertebral bone, although the primary revision approach is a posterior instrumented fusion unless neural or anterior vascular structures are compromised. Revision anterior surgery is potentially more difficult than primary surgery due to scarring around the vessels. Anterior revision procedure should be performed with the assistance of a vascular surgeon [23, 29].
Certainly, the presented artificial disc also needs a revision strategy. If neural structures are compromised, the prosthesis needs to be removed or repositioned. It is possibly to do from anterior approach because there is no scarring around the vessels. The operation can be finished by ALIF or installation of another, greater size mobile devices like Charit� prosthesis. 
The present artificial disc can also be removed from posterior approach on the other side from previous operation where there is no scarring. The last variant of removal of an artificial disc from the same access is expanded up to full facet joint resection. Such operation should befinished by TLIF. No necessity to delete the described artificial disk  arises if it is not displaced, but nevertheless instability may appear or increase. In such cases, it is expedient to do bilateral TLIF with inserting two rectangular cages on each side from an artificial disc and fixing vertebrae by transpedicular system.

Conclusion
Thus, development of posterolateral approach and modified implants allow applying disc replacement technique for patients with DDD and sciatica due to lumbar disc herniation. 


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Figures legend 
Figure 1. The artificial disk used for ADR via posterolateral approach. 
Figure 2. Artist�s drawing showing posterolateral exposure and artificial disk replacement. 
Figure 3. Intraoperative photo after artificial disk replacement: 1- working space after bone resection between superior and inferior lamina; 2 � artificial disk; 3 � dura covered by epidural fat; 4 �  dura holder; 5 � suction tube.
Figure 4. CT of a patient after artificial disk replacement. The position of artificial disk, resection of the lower half of the facet joint are seen. 

Table 1. Summary of ODI and VAS clinical outcome -data


Measurement PeriodODI ScoreVAS ScorePreoperative72.3 �0.918.6 � 0.51Postoperative:after surgery, patients  being in hospital31.2 � 1.423.3 � 0.65 months26.2 � 1.442.1 � 0.710 months16.3 � 1.271.5 � 0.215 months14.50� 1.811.8 � 0.3420 months12.7 � 1.771.2 � 0.2125 months 12.34 � 1.81.84 � 0.6
Data are presented as the mean � standard error of the mean.

Table 2 Dimensions of the intervertebral height (mm) at L4-5, L5-S1. Presented data is a �Y�, the middle disc height.

Measurement PeriodLevelL4-5L5-S1Preoperative0.82 �0.380.66 � 0.22Postoperative:after surgery patients being in hospital12.2 � 0.510.5 � 0.25 months11.8 � 0.710.2 � 0.310 months11.6 � 0.210.0 � 0.615 months11.5� 0.79.5 � 0.220 months11.5 � 0.89.4 � 0.625 months 11.5 � 0.89.4 � 0.3
Data are presented as the mean � standard error of the mean.



Table 3. The mean ROM at the L4-5, L5-S1 levels. 

Measurement PeriodLevelL4-5L5-S1ROM in flexion-extension (�)ROM in lateral bending (�)ROM in flexion-extension (�)ROM in lateral bending (�)LeftRightLeftRightPreoperative7.27 �1.64.6� 0.54.7� 0.25.69 � 0.52.4� 0.42.6� 0.3Postoperative:After surgery patients being in hospital12.9 � 0.26.4� 0.36.3� 0.49.7 � 0.43.9� 0.53.9� 0.45 months12.4 � 0.76.1� 0.56.1� 0.39.7 � 0.63.9� 0.73.9� 0.110 months11.6 � 0.216.1� 0.36.0� 0.79.6 � 0.13.8� 0.23.8� 0.315 months11.5� 0.716.0� 0.56.0� 0.19.5 � 0.43.8� 0.33.8� 0.620 months11.5 � 0.86.0� 0.46.0� 0.49.4 � 0.53.7� 0.43.7� 0.425 months 11.5 � 0.356.0� 0.36.0� 0.59.4 � 0.43.7� 0.23.7� 0.3
Data are presented as the mean � standard error of the mean.











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