Recommended treatment protocol in the setting of a septic lumbar disk arthroplasty

Artificial lumbar disk replacement is not a new concept. Various attempts at developing disk prosthesis have been made over the past 40 years. Devices include disk nucleusreplacementsandtotaldiskreplacements.Disknucleus replacements require the anulus to be in relatively good condition. The PDN artificial nucleus (Raymedica, Minneapolis, MN, USA) is the prototypical nucleus replacement and is composed of a hydrogel core surrounded by a bioresorbable outer woven fiber. 1 Total disk replacements require removal of nucleus and anulus and are better suited for end-stage disease when the anulus is not competent. There are several different mechanical and materials designs being investigated. All metal devices are advantageous due to their fatigue strength. The Maverick (Medtronic Sofamor Danek, Memphis, TN, USA) is a ball-and-socket design, while the Flexicore (SpineCore, NJ, USA) is a semi-constrained device. Nonmetallic materials, such as elastomers, have the advantage of having a lower modulus of elasticity which may more closely replicate the dynamics of a native disk. The 3-df device is a three-dimensional fabric of woven ultrahigh molecular weight polyethylene fiber with a bioactive coating sprayed on the surface. 2 Combination devices utilizing a metal‐polymer‐metal sandwich design have attempted to combine the benefits of metal and nonmetal components. The Charite (Depuy Spine, Raynham, MA) has two cobalt chromium alloy endplates with a polyethylene oval spacer that is contoured to match the endplates. There have been three models of this device and it has been widely used in Europeforthepast15years.TheProDiscdeviceisacap‐cup articulation with cobalt‐chrome‐molybdenum endplates and an ultrahigh molecular weight polyethylene convex bearing surface that snaps into the caudal endplate. Recent design advances have led to the implantation of several devices in large numbers of patients, predominantly in Europe, over the past two decades. Reported complications have been primarily subluxation, dislocation, and subsidence. 3 No report of deep infection or its treatment following lumbar disk replacement has been reported. Fortunately, deep infection following anterior lumbar fusion is also rare. This chapter will discuss recommendations for evaluation and treatment of infection of lumbar disk replacements. In light of the significant lack of data in the literature on this subject, we suggest an approach similar to that taken for infection following lumbar interbody fusion.