Fusion surgery remains the gold standard for surgical treatment of lumbar degenerative disc disease (DDD). However, fusion surgery has many intrinsic problems related to altered biomechanics and balance. Total disc replacement (TDR) has received increasing attention over the last several years because of its capacity for both functional and symptomatic improvement and its avoidance of problems intrinsic to fusion surgery. Artificial disc replacement is not a new concept, the first attempts having been undertaken in the early 1950s. However, during the past 15 years, considerable advances have been made, with clinical success noted in several prospective randomized studies and mid-long term retrospective studies. Proper patient selection and surgical technique are key factors in achieving a successful outcome. TDR plays a limited role and has limited indications for replacing fusion surgery in patients with lumbar DDD. The main goal of TDR is restoration of normal intervertebral disc function. Varying degrees of motion can be restored through TDR; however, the pattern of motion and center of rotation are not physiologic. In spite of some favorable reports, many TDR-related problems remain to be solved. Successful disc function is measured not only in terms of quantity of motion, but also in terms of quality of motion and shock energy absorption capacity. For successful repair to be declared, facet unloading should be achieved, and fatigue strength should be improved. New procedures should be characterized by a reduction in the technical problems of implantation and retrieval. We expect that the next generation of TDR will overcome the limitations of first generation TDR. This therapeutic modality shows much promise for the treatment of lumbar DDD.
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