Long-term outcomes of total lumbar disc prosthesis: Sustained pain relief

Abstract

Background

Lumbar degenerative disc disease (DDD) is a leading cause of chronic low back pain and work-related disability. Total lumbar disc prosthesis offers motion preservation and may reduce adjacent segment degeneration compared to fusion. However, long-term functional and occupational outcomes remain underreported.

Methods

This retrospective cohort study included 130 patients (mean age 37.3±7.9 years; 71.54% male) who underwent total lumbar disc replacement between 2008 and 2020. Patients were assessed preoperatively and at a mean follow-up of 13.88 years using Visual Analog Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and occupational status. Statistical analyses included ANOVA, regression modeling, and correlation analysis.

Results

VAS scores improved significantly (back: 8.6±1.7 to 1.6±2.4; leg: 7.3±2.9 to 1.1±0.9; p<.001). ODI decreased from 46.12±7.3 to 27±9.3. At final follow-up, 73.84% of patients returned to their original job, 13.84% transitioned to alternative roles, and 3.07% were pensioned. Patient satisfaction was high (77.69% rated outcome as 10/10). Complication and reoperation rates were low (3.08% and 12.31%, respectively), with no prosthesis revisions.

Conclusions

Total lumbar disc prosthesis provides durable pain relief, functional improvement, and high rates of occupational reintegration. These findings support its use as a motion-preserving alternative to fusion in appropriately selected patients.

Introduction

Low back pain (LBP) is one of the most prevalent musculoskeletal disorders globally, affecting up to 80% of individuals at some point in their lives and representing a leading cause of both temporary and permanent work disability worldwide [1,2]. The societal and economic burden of LBP is substantial, contributing to reduced productivity, increased healthcare expenditures, and diminished quality of life [[3], [4], [5]]. Despite extensive research, the optimal surgical approach for managing chronic LBP associated with degenerative disc disease (DDD) remains a subject of ongoing debate.

Historically, lumbar spinal fusion has been the standard surgical treatment for DDD [[6], [7], [8]]. While effective in stabilizing the affected segment, fusion alters normal lumbar biomechanics and has been associated with an increased risk of adjacent segment degeneration (ASD) [9]. ASD has been reported in up to 24% of fusion patients [9,10], often necessitating additional surgical interventions and contributing to progressive disability and occupational limitations.

In response to these limitations, total lumbar disc prosthesis has emerged as a motion-preserving alternative designed to maintain segmental mobility and reduce biomechanical stress on adjacent levels [11,12]. Lumbar disc arthroplasty has demonstrated efficacy in relieving pain and improving function; however, long-term data on its durability and its impact on occupational reintegration remain limited [13].

Given that a substantial proportion of spine surgery patients are of working age, understanding the influence of lumbar disc prosthesis on return-to-work rates and long-term job retention is essential for evaluating its clinical utility. This study aims to provide a comprehensive, long-term evaluation of both clinical and occupational outcomes following total lumbar disc replacement.

Specifically, we assess the rate and nature of occupational reintegration, distinguishing between patients who return to their original jobs and those who require modifications in their professional roles. We also compare preoperative and postoperative pain and disability scores using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) to quantify functional recovery. Additionally, we evaluate surgical durability by documenting postoperative complications and the need for revision procedures. We also examine the potential impact of lifestyle factors—including smoking, alcohol consumption, and physical activity—on long-term outcomes.

Through this multifaceted approach, the study seeks to clarify the long-term viability of lumbar disc arthroplasty as a motion-preserving alternative to fusion, particularly in patients with physically demanding occupations.

Methods

Study approval and ethical considerations

This study was approved by the Institutional Review Board (CEIm 19/2024) and registered with ClinicalTrials.gov (NCT06989632). All procedures were conducted in accordance with the Declaration of Helsinki and applicable regulatory guidelines. Informed consent was obtained from all participants prior to inclusion.

Patient selection and study design

This retrospective cohort study included patients who underwent total lumbar disc replacement between January 1, 2008, and January 1, 2020. Eligible patients were between 18 and 56 years of age at the time of surgery. They had a diagnosis of degenerative disc disease (DDD) requiring lumbar arthroplasty at 1, 2, or 3 levels.

In cases where the L5–S1 disc was severely collapsed and the L4–L5 disc retained sufficient height to accommodate a prosthesis, an anterior lumbar interbody fusion (ALIF) was performed at L5–S1 in conjunction with disc replacement at L4–L5. All patients had a minimum postoperative follow-up of 5 years and no radiological evidence of zygapophyseal joint degeneration at the index or adjacent levels.

Patients were excluded if they had undergone any prior lumbar surgery, including discectomy, vertebroplasty, or spinal fusion. This exclusion criterion ensured a homogeneous, fusion-free cohort suitable for evaluating the long-term effects of motion-preserving surgery.

Surgical procedure and follow-up

All procedures were performed using the Baguera®L total lumbar disc prosthesis (Spineart, Plan-les-Ouates, Switzerland). Implantation was carried out at 1 or 2 levels—primarily L4–L5 and L5–S1—by experienced spine surgeons following standardized protocols. Only 2 patients underwent 3-level disc replacement involving L3–L4, L4–L5, and L5–S1. Postoperative follow-up assessments were conducted systematically, with final evaluations completed in the first trimester of 2025. In these assessments, patients were interviewed and underwent X-ray examinations (Fig. 1).

Fig. 1.

Follow-up X-ray examination at 7.5 years postoperatively.

Data collection and variables assessed

Comprehensive preoperative and postoperative medical records were reviewed, and data were extracted for statistical analysis. The primary outcomes assessed included Visual Analog Scale (VAS) scores for lower back and leg pain, Oswestry Disability Index (ODI) scores for functional assessment, occupational reintegration status, and the incidence of postoperative complications and reoperations.

Lifestyle factors such as smoking, alcohol consumption, and physical activity were also evaluated for their potential influence on surgical outcomes. Smoking and alcohol use were recorded preoperatively based on intake interviews and medical records, although these behaviors were not monitored longitudinally. In contrast, physical activity was assessed at the time of final follow-up to reflect the patients' current lifestyle status.

To minimize variability in outcome perception and reduce bias from psychological adaptation to chronic symptoms, a subgroup analysis was conducted using a fixed follow-up interval of 13±1 years, corresponding to the cohort's mean follow-up duration. This subgroup was used to validate the consistency of reported improvements in pain and disability scores.

Occupational reintegration was assessed through structured reviews of medical records and follow-up interviews. Patients were categorized into 3 groups: those who returned to their original job, those who transitioned to alternative roles, and those who retired because of permanent disability. Alternative roles were defined as employment involving a change in job function, physical demands, or sector, while maintaining active participation in the workforce. Although no standardized occupational reintegration instrument was used, this classification enabled consistent documentation of employment outcomes across the cohort. Additionally, the timing of occupational reintegration (eg, early vs. delayed return to work) was not consistently documented and remains a limitation.

Statistical analysis

Quantitative analyses were performed using Python (version 3.8, Anaconda, Jupyter Notebook). Descriptive statistics were used to summarize demographic and clinical variables. Bivariate analyses—including chi-square tests, t-tests, and analysis of variance (ANOVA)—were applied to assess differences between preoperative and postoperative outcomes. Multivariate regression modeling was used to identify predictors of functional recovery and occupational reintegration. Correlation matrices were constructed to explore associations between lifestyle factors and postoperative pain or satisfaction.

Prior to applying parametric tests, the normality of continuous variables (VAS and ODI scores) was assessed using the Shapiro–Wilk test. The data met normality assumptions, supporting the use of t-tests and ANOVA for group comparisons. A p-value of less than 0.05 was considered statistically significant. All statistical procedures were fully documented to ensure reproducibility.

Results

Patient demographics and follow-up

A total of 130 patients met the inclusion criteria, with a mean postoperative follow-up of 13.88 years (5,064±1,245 days; range: 11.82–17.24 years). Baseline demographic and clinical characteristics are summarized in Table 1. These data include age, sex, smoking and alcohol consumption, diagnosis type, disc prosthesis levels, and working status at the time of surgery. Three patients had follow-up durations ranging from 12.88 to 14.88 years. The cohort included 93 males (71.54%) and 37 females (28.46%), with a mean age at surgery of 37.3±7.9 years (range: 19–56 years). The most common age group was 30–45 years, accounting for 66.69% of the cohort, highlighting the relevance of motion-preserving spine surgery in working-age individuals. Body mass index (BMI) distribution was consistent with standard surgical candidacy criteria, and no statistically significant association was found between BMI and postoperative satisfaction (p>0.05).

Table 1.

Baseline demographic and clinical characteristics of the study cohort (n=130)

Characteristic	Value
Total patients	130
Mean age (years)	37.31
Sex distribution	Male: 93 (71.5%) Female: 37 (28.5%)
Mean cigarettes/Day	6.69
Mean alcohol consumption (ml/day)	2.27
Diagnosis type	DDD + disc herniation: 77 (59.2%) DDD alone: 53 (40.8%)
Disc prosthesis levels	L4–L5, L5–S1: 44 (33.8%) L5–S1: 42 (32.3%) L4–L5: 32 (24.6%) L3–L4, L4–L5: 10 (7.7%) L3–L4, L4–L5, L5–S1: 2 (1.5%)
Working status at time of surgery	Sick leave: 110 (84.6%) Works part time: 11 (8.5%) Works full time: 8 (6.2%) Retired: 1 (0.8%)

Disc prosthesis implantation and ALIF procedures

Disc prostheses were implanted at the L3–L4, L4–L5, and L5–S1 levels. The L4–L5 level was involved in 90.76% of cases, either alone (24.61%) or in combination with L5–S1 (33.84%). L5–S1 was the only level replaced in 32.3% of patients (Fig. 2). In 18 patients (13.07%), an anterior lumbar interbody fusion (ALIF) was performed at L5–S1 in addition to disc replacement at L4–L5 because of severe disc collapse that precluded prosthesis placement. One additional ALIF was required at L3–L4 due to an intraoperative vertebral body endplate fracture during prosthesis insertion. No posterior fusion was performed in any case (Fig. 3). These findings underscore the importance of individualized surgical planning, particularly in terms of implant selection and biomechanical integrity.

Fig. 2.

Distribution of discs replaced with the Baguera®L total lumbar disc prosthesis.

Fig. 3.

ALIF distribution.

Pain reduction and functional outcomes

Postoperative pain scores demonstrated a marked and sustained improvement. Lower back pain, measured by the Visual Analog Scale (VAS), decreased significantly from 8.6±1.7 preoperatively to 1.6±2.4 at final follow-up (p<.001) (Fig. 4). Leg pain improved from 7.3±2.9 to 1.1±0.9. The Oswestry Disability Index (ODI) also improved, decreasing from 46.12±7.3 to 27±9.3, indicating enhanced mobility and reduced disability (Table 2).

Fig. 4.

Postoperative lower back VAS score. 0, no pain; 10, maximum pain.

Table 2.

Comparison of preoperative and postoperative pain and disability scores (VAS and ODI) in patients undergoing total lumbar disc prosthesis

Outcome measure	Preoperative score (Mean±SD)	Postoperative score (Mean±SD)
VAS – lower back pain	8.6±1.7	1.6±2.4
VAS – leg pain	7.3±2.9	1.1±0.9
Oswestry disability index (ODI)	46.12±7.3	27±9.3

At final follow-up, 77 patients (59.23%) reported complete pain resolution, while 38 patients (29.22%) experienced only mild lower back pain and remained fully functional. Residual leg pain persisted in only 3 patients (2.30%), with minimal impact on occupational performance.

A stratified analysis comparing single-level (n=74) and multilevel (n=46) disc replacements revealed significant improvements in both groups. Although single-level patients had slightly better mean postoperative scores, the differences were not statistically significant (p>.05), indicating comparable long-term outcomes. A subgroup of patients with follow-up durations ranging from 12.88 to 14.88 years exhibited similar VAS and ODI scores to the overall cohort, confirming the robustness of long-term pain relief and functional improvement.

To evaluate the trajectory of pain relief over time and address concerns regarding psychological adaptation to chronic symptoms, we performed a stratified analysis of VAS pain scores across multiple follow-up intervals. Patients were grouped into 7 categories based on time since surgery: 4–6, 6–8, 8–10, 10–12, 12–14, 14–16, and >16 years. The results demonstrated consistently low pain scores across all intervals, with no evidence of symptom normalization or worsening (Table 3, Fig. 5). These findings support the durability of pain relief following lumbar disc prosthesis.

Table 3.

Mean VAS pain scores at different follow-up intervals

Follow-up interval	Mean VAS pain score
4–6 years	2.35
6–8 years	0.00
8–10 years	0.25
10–12 years	2.27
12–14 years	1.96
14–16 years	1.15
<16 years	0.94

Fig. 5.

Mean VAS pain scores at different follow-up intervals after lumbar disc prosthesis implantation. Pain relief remained stable and low across all time points, with no evidence of symptom normalization or worsening.

Occupational reintegration and job retention

Occupational reintegration represented a key outcome in this study. At final follow-up, 96 patients (73.84%) had resumed their original occupation, demonstrating the functional success of lumbar disc prosthesis (Fig. 6). An additional 18 patients (13.84%) transitioned to alternative roles, maintaining employment despite mild postoperative symptoms. Only 4 patients (3.07%) required permanent disability retirement due to persistent functional limitations.

Fig. 6.

Patients' job status at the last follow-up grouped.

Regarding job physical demands, 7 patients (5.38%) transitioned to roles with increased physical activity, while 9 patients (6.92%) moved to positions with reduced physical requirements. These findings contrast favorably with fusion-based studies, which report higher rates of occupational restriction and long-term disability, and underscore the role of motion-preserving surgery in workforce retention.

Postoperative complications and surgical revisions

Of the 130 patients included in the study, 114 (87.7%) did not require any additional surgical procedures following disc prosthesis implantation. Notably, no cases of Baguera®L implant revision were reported, underscoring the durability of the prosthesis.

Sixteen patients (12.31%) underwent additional surgeries. These included 3 lumbar zygapophyseal joint rhizotomies, 2 posterior spinal canal decompressions without fusion for spinal stenosis at the prosthesis level, 2 L4–L5 posterolateral fusions, 1 microdiscectomy at the level above the prosthesis, 5 sacroiliac joint rhizotomies, and 3 sacroiliac joint fusions. Sacroiliac joint dysfunction, which emerged 3 to 5 years postoperatively, was observed exclusively in female patients. These cases were considered part of the natural degenerative process rather than complications of the prosthesis. The high detection rate may reflect the thorough clinical evaluations performed in this cohort.

Four patients experienced postoperative complications. One patient developed a persistent foot drop due to a pre-existing L4–L5 disc herniation and subsequently required posterior tibialis tendon transfer. Another patient developed a pelvic lymphocele, which resolved following CT-guided percutaneous drainage. Two male patients reported retrograde ejaculation; one of these cases resolved spontaneously. All 4 patients reported satisfactory pain scores at final follow-up (VAS ≤ 4).

Heterotopic ossification (HO) was observed in 4 patients (3.07%), all of whom were classified as Type III according to the McAfee classification (Fig. 7). These cases were asymptomatic and did not affect segmental mobility.

Fig. 7.

Heterotopic ossification (HO) was observed in a patient at 11 years of follow-up after a Baguera disc prosthesis at L3-L4 and L4-L5 and ALIF at L5-S1.

Patient satisfaction and quality of life

Overall, patient satisfaction was high, with 101 patients (77.69%) rating their outcome as 10 out of 10 (Fig. 8). Nearly half of the cohort resumed regular physical activity, and 78% reported complete satisfaction with the procedure. Patients who returned to full-time employment reported the highest satisfaction scores, which correlated with lower pain levels and better functional outcomes. In contrast, pensioned patients reported lower satisfaction (mean score: 6.89/10), likely reflecting the psychological impact of work disability (Fig. 9).

Fig. 8.

Patients' satisfaction on the last follow-up. 0, very dissatisfied; 10, completely satisfied.

Fig. 9.

Patient satisfaction degree on the last follow-up versus work status.

Lifestyle factors and their influence on outcomes

Lifestyle factors were also analyzed. Heavy smokers (more than 15 cigarettes per day) exhibited higher postoperative pain levels (mean VAS: 3/10), although no significant correlation was found between smoking and satisfaction (Fig. 10). Alcohol consumption showed no statistical association with either postoperative pain or satisfaction (Fig. 11). At final follow-up, 48.46% of patients reported engaging in regular physical activity, suggesting that lumbar disc prosthesis supports an active lifestyle comparable to that of the general population (Fig. 12).

Fig. 10.

Amount of cigarettes smoked per day and VAS on the last follow-up.

Fig. 11.

Mean preoperative cigarette and alcohol consumption by sex. Male patients reported higher average cigarette (7.24/day) and alcohol (2.74ml/day) consumption compared to female patients (5.32 and 1.08ml/day, respectively). Error bars represent standard deviation.

Fig. 12.

Sportive activities on the last follow-up.

Statistical analysis and correlations

Postoperative pain showed a moderate negative correlation with satisfaction (r = –0.56), indicating that lower pain levels were associated with higher subjective outcome scores. A weak positive correlation was observed between smoking and postoperative pain (r=0.09, p=.081), approaching statistical significance. No significant correlations were found between postoperative pain and age, sex, or alcohol consumption, suggesting that these variables had limited influence on surgical outcomes (Table 4).

Table 4.

Analysis of correlations between numerical variables

	Age	Sex	Height	Weight	Cigarettes/Day	ML Alcohol/Day	Vas at last follow-up	Degree satisfaction
Age	1.00	−0.04	−0.45	−0.51	0.03	0.19	0.07	0.06
Sex	−0.04	1.00	−0.27	−0.46	−0.09	−0.08	0.08	−0.04
Height	−0.45	−0.27	1.00	0.52	−0.10	−0.48	−0.07	−0.09
Weight	−0.51	−0.46	0.52	1.00	0.17	−0.34	0.04	0.06
Cigarettes/Day	0.03	−0.09	−0.10	0.17	1.00	0.10	0.009	0.05
ML alcohol/Day	0.19	−0.08	−0.48	−0.34	0.10	1.00	0.06	−0.05
VAS at last follow-up	0.07	0.08	−0.07	−0.04	0.09	0.06	1.00	−0.56
Degree satisfaction	0.06	0.15	−0.11	0.04	0.05	−0.05	−0.56	1.00

Discussion

Long-term efficacy of lumbar disc prosthesis

This study provides robust evidence supporting total lumbar disc replacement as a motion-preserving alternative to spinal fusion, particularly in active, working-age patients. With a mean follow-up of 13.88 years, the results demonstrate sustained pain relief—reflected in the reduction of VAS scores from 8.6 to 1.6 for lower back pain and from 7.3 to 1.1 for leg pain—and significant functional improvement, as indicated by the decrease in ODI scores from 46.12 to 27. These findings align with those reported by Park et al., who observed similar long-term improvements in VAS and ODI scores, with a clinical success rate of 76.9% and a satisfaction rate of 87.2% in well-selected patients [14].

Occupational reintegration was also notably high, with 73.84% of patients returning to their preoperative occupation. This result contrasts with fusion-based studies, which often report higher rates of long-term disability due to segmental rigidity [15]. Patients who underwent single- or 2-level disc prostheses at L4–L5 and L5–S1 demonstrated the most favorable mobility outcomes, consistent with prior studies suggesting that lumbar arthroplasty facilitates earlier and more stable workforce reintegration compared to fusion [16].

The stratification of patients into ideal and suboptimal candidates by Park et al. [14] underscores the importance of preoperative evaluation. Our findings similarly support the notion that optimal outcomes are achieved in patients without significant facet arthropathy, instability, or adjacent segment pathology. These findings are further corroborated by David's long-term study, which reported that 82.1% of patients achieved excellent or good outcomes and 89.6% returned to work, including 77.8% in physically demanding roles, after a mean follow-up of 13.2 years [17].

Pain reduction and functional improvement

The substantial reduction in pain and disability observed in our cohort confirms the long-term efficacy of lumbar disc arthroplasty. At final follow-up, 52.3% of patients reported complete resolution of pain, while an additional 33.07% experienced only minimal discomfort (VAS < 3). These outcomes are consistent with previous studies demonstrating superior pain relief with total disc replacement compared to spinal fusion [18], particularly during the first postoperative year [19]. As shown in Fig. 5, stratified analysis across follow-up intervals confirms the stability of pain relief over time, supporting the durability of outcomes with lumbar disc prostheses.

Functional improvement was similarly robust. The mean Oswestry Disability Index (ODI) score decreased from 46.12 to 27±9.3, indicating a significant reduction in disability and enhanced mobility. This finding aligns with systematic reviews reporting VAS improvements ranging from 51.1% to 70.5% and ODI reductions between 15.6% and 44.4%, with patient satisfaction rates ranging from 75.5% to 93.3% [[19], [20], [21]].

While our study confirms the durability of these improvements, the absence of standardized short- and intermediate-term follow-up data—such as assessments at 3, 5, and 7 years—limits our ability to characterize the trajectory of recovery. Future prospective studies should incorporate longitudinal evaluations to determine whether improvements are immediate and sustained or reflect gradual adaptation to persistent symptoms.

Additionally, although the ODI provides valuable insight into patient-reported disability, it does not capture objective biomechanical parameters such as radiographic motion or adjacent segment integrity. Due to the retrospective nature of this study, consistent radiographic data were unavailable, limiting the depth of functional assessment. This limitation has been acknowledged and should be addressed in future prospective investigations.

Although standardized radiographic motion assessments were not feasible in our setting, all patients underwent regular lumbar spine X-rays in AP, lateral, and flexion-extension views. Segmental mobility was qualitatively assessed by comparing current motion to the first postoperative evaluation at 1 month. No significant changes were observed over time, except in patients with heterotopic ossification, who showed moderate reductions in mobility. Significantly, these reductions did not correlate with increased pain or disability, and most retained near-normal motion.

Work activity and occupational outcomes

A key strength of this study lies in its focus on occupational reintegration, a critical outcome for working-age patients undergoing lumbar spine surgery. At final follow-up, 73.84% of patients had returned to their original job, while 8.46% transitioned to roles with equivalent physical demands. Additionally, 5.38% assumed more physically demanding positions, and 6.92% moved to less challenging roles. Only 3.07% of patients were pensioned due to persistent functional limitations.

These results compare favorably with those reported in fusion-based studies, which often document higher rates of occupational restriction and long-term disability [22,23]. For instance, a comparative analysis by Marnay et al. [24] demonstrated that patients undergoing disc arthroplasty returned to work earlier and with fewer limitations than those treated with spinal fusion. Our findings reinforce the notion that preserving lumbar mobility through disc replacement facilitates sustained workforce participation and supports long-term employment stability.

Although we did not employ validated reintegration instruments such as the Work Ability Index, the structured classification used in this study enabled consistent documentation of employment outcomes. Future research should incorporate standardized tools to enhance methodological rigor and improve comparability across studies.

Postoperative complications and revisions

The complication rate in our cohort was low (3.08%), and no prosthesis required revision or removal during the follow-up period. The majority of reoperations were related to sacroiliac joint dysfunction or isolated radicular symptoms, rather than failure of the disc prosthesis itself. These findings are consistent with previous reports highlighting the long-term durability of lumbar disc arthroplasty [25]. Similarly, Park et al. [14] reported a 9.3% reoperation rate, which occurred exclusively in patients with combined pathologies.

Interestingly, all patients who required sacroiliac joint fusion were female, suggesting the possibility of gender-specific biomechanical factors influencing postoperative outcomes [27]. Heterotopic ossification (HO) was observed in 3.07% of patients, all of whom were classified as Type III according to the McAfee classification [14]. These cases were asymptomatic and did not compromise segmental mobility. Notably, this incidence is lower than previously reported rates, which range from 13.2% to 15.3% [26,27].

Despite these minor complications, overall patient satisfaction remained high. A total of 77.69% of patients rated their outcome as 10 out of 10, underscoring the effectiveness of lumbar disc prostheses in restoring mobility and improving quality of life [28]. These results are consistent with the long-term findings reported by David, further reinforcing the clinical value of lumbar disc replacement [17].

Adjacent segment disease and long-term outcomes

One of the principal advantages of lumbar disc arthroplasty over spinal fusion is the reduced incidence of adjacent segment disease (ASD). In our cohort, only 1 patient required fusion at the level above the prosthesis due to advanced zygapophyseal joint arthropathy. This finding is consistent with the long-term results reported by David, who observed a similarly low adjacent-level reoperation rate of 2.8% following disc replacement [17].

In contrast, spinal fusion has been shown to increase mechanical stress on adjacent segments, often leading to accelerated degeneration and instability. Studies have reported that ASD requiring surgical intervention occurs in up to 24% of fusion patients [24]. This elevated risk is attributed to the loss of motion at the fused segment, which alters spinal biomechanics and increases shear forces at adjacent levels.

By preserving motion at the index level, total disc replacement maintains a more physiological distribution of spinal loads and reduces biomechanical stress on adjacent segments. A systematic review confirmed that patients treated with disc prostheses experience significantly lower rates of ASD compared to those who undergo fusion [22]. These findings support the long-term biomechanical and clinical benefits of motion-preserving technologies in appropriately selected patients.

Lifestyle factors and their impact on surgical outcomes

Lifestyle factors such as smoking, alcohol consumption, and physical activity were evaluated for their potential influence on long-term surgical outcomes. Smoking remains a debated risk factor in spine surgery, with previous studies suggesting that it may delay recovery and increase pain sensitivity, particularly in patients undergoing spinal fusion [29].

In our cohort, heavy smokers—defined as those consuming more than 15 cigarettes per day—exhibited higher postoperative pain levels, with a mean VAS score of 3/10. However, no statistically significant association was found between smoking and overall patient satisfaction. Similarly, alcohol consumption showed no significant correlation with either postoperative pain or satisfaction scores.

At final follow-up, 48.46% of patients reported engaging in regular physical activity. This finding suggests that lumbar disc prosthesis supports an active lifestyle comparable to that of the general population. The ability to maintain or resume physical activity is particularly relevant for patients seeking alternatives to fusion, as it reflects not only functional recovery but also broader improvements in quality of life.

These results indicate that, unless extreme, lifestyle habits such as smoking and alcohol use may have a limited impact on long-term outcomes following lumbar disc arthroplasty. While limited in scope, our analysis of lifestyle factors provides a clinically relevant context for interpreting variability in long-term outcomes. Nonetheless, promoting healthy behaviors remains advisable in the perioperative setting to optimize recovery and enhance overall well-being.

Comparison with spinal fusion outcomes

Compared to spinal fusion, lumbar disc arthroplasty offers several biomechanical and clinical advantages. Fusion eliminates motion at the treated segment, which can increase mechanical stress on adjacent levels and accelerate their degeneration, often resulting in higher revision rates [30,31]. In contrast, total disc replacement preserves physiological segmental motion, thereby reducing shear forces and biomechanical overload on adjacent segments [32].

Our findings are consistent with those of Park et al. [17], who reported preserved segmental range of motion in monosegmental total disc replacement (TDR) cases. However, motion was somewhat reduced in bisegmental procedures [14]. Patients in our cohort similarly reported superior mobility, improved functional scores, and earlier return to work—outcomes that align with those observed in randomized controlled trials comparing arthroplasty with fusion [16].

Notably, our reoperation rate of 13.07% was lower than the rates typically reported in fusion-based cohorts, further supporting the long-term durability and clinical utility of lumbar disc prostheses.

Clinical implications and future research

The findings of this study underscore the clinical value of total lumbar disc prosthesis as a motion-preserving and function-enhancing surgical strategy, particularly for working-age individuals with degenerative disc disease (DDD) who seek to maintain long-term mobility and occupational engagement. The high rate of occupational reintegration—73.84% of patients returning to their original jobs—demonstrates the procedure's capacity to support workforce retention and long-term employment stability, a critical consideration in surgical decision-making for active individuals.

In addition to favorable employment outcomes, the study revealed substantial and sustained reductions in pain. Visual Analog Scale (VAS) scores decreased from 8.6 to 1.6 for low back pain and from 7.3 to 1.1 for leg pain, confirming the long-term analgesic efficacy of lumbar disc arthroplasty. Functional improvement was similarly robust, as evidenced by a reduction in Oswestry Disability Index (ODI) scores from 46.12±7.3 to 27±9.3, indicating enhanced mobility and reduced disability.

The safety and durability of the procedure were also notable. The complication rate was low (3.08%), and the need for additional surgical interventions was limited (12.31%), with no cases requiring prosthesis revision. These outcomes compare favorably with those reported for spinal fusion, which is associated with higher rates of adjacent segment disease (ASD) and reoperation [24].

Importantly, lumbar disc replacement preserves spinal motion, thereby mitigating biomechanical stress on adjacent segments. This preservation of physiological kinematics may reduce the risk of ASD and the need for future surgical interventions, further supporting the long-term viability of disc arthroplasty [23].

Given these favorable outcomes, total lumbar disc prosthesis should be considered a first-line surgical option for appropriately selected patients. Ideal candidates include those with preserved facet joint integrity, adequate disc height, and no history of prior spinal fusion. As emphasized by David [18] and others, optimal results are achieved in patients with discogenic pain, minimal facet degeneration, and good bone quality.

Beyond clinical outcomes, the high satisfaction rate (77.69%) and successful reintegration into the workforce suggest that lumbar disc arthroplasty may confer broader socioeconomic benefits. These include reduced disability claims, lower healthcare utilization, and preserved occupational productivity—factors of increasing relevance in health policy and cost-effectiveness analyses.

While the current findings reinforce the efficacy and durability of total disc prosthesis, further research is warranted. Prospective, multicenter randomized controlled trials comparing lumbar disc replacement with spinal fusion across diverse populations are essential to refine patient selection criteria and confirm long-term superiority. Additionally, biomechanical studies assessing motion preservation, implant survivability, and adjacent segment integrity will provide deeper insights into the structural advantages of disc arthroplasty.

In summary, this study supports the integration of lumbar disc replacement into the standard surgical armamentarium for DDD, particularly in patients for whom mobility preservation and occupational reintegration are paramount. Continued research will be critical to optimizing outcomes and expanding the evidence base for this motion-preserving technology.

Future directions

Despite the compelling long-term outcomes demonstrated in this study, several avenues for future research remain essential to validate further and expand the clinical utility of lumbar disc arthroplasty. Prospective, multicenter randomized controlled trials comparing lumbar disc replacement with spinal fusion are particularly warranted. Such studies should include diverse patient populations to enhance the generalizability of findings and refine selection criteria for optimal surgical candidates.

In addition to clinical trials, biomechanical investigations are needed to assess the long-term preservation of segmental motion, implant survivability, and the structural integrity of adjacent spinal levels. These studies could provide critical insights into the mechanical advantages of disc prostheses and help elucidate the mechanisms underlying the reduced incidence of adjacent segment disease observed in arthroplasty patients [23].

Cost-effectiveness analyses also represent a valuable area of future inquiry. Given the substantial socioeconomic burden of work-related disability due to degenerative disc disease, evaluating the economic impact of lumbar disc replacement—particularly in terms of reduced disability claims, lower reoperation rates, and improved workforce reintegration—could further support its adoption as a first-line surgical option.

Moreover, future research should incorporate standardized, longitudinal follow-up protocols to characterize the trajectory of recovery better. Intermediate assessments at 3, 5, and 7 years postoperatively would help determine whether improvements in pain, function, and occupational status are immediate, progressive, or subject to plateau or decline over time.

Finally, integrating objective outcome measures—such as radiographic assessments of motion preservation, gait analysis, and adjacent segment kinematics—would provide a more comprehensive evaluation of functional recovery. These parameters, combined with patient-reported outcomes, would offer a multidimensional understanding of the long-term efficacy and durability of lumbar disc prostheses.

In summary, while the current study provides robust evidence supporting the clinical and occupational benefits of lumbar disc arthroplasty, future research should aim to strengthen the evidence base through rigorous, prospective, and multidimensional investigations.

Clinical significance

This study provides compelling long-term evidence supporting total lumbar disc prosthesis as a viable motion-preserving alternative to spinal fusion in patients with degenerative disc disease (DDD). The findings demonstrate that lumbar disc arthroplasty not only delivers sustained pain relief and functional restoration but also facilitates high rates of occupational reintegration, making it a particularly valuable option for working-age individuals seeking to preserve mobility and maintain employment.

The observed occupational reintegration rate of 73.84% highlights the procedure's capacity to support long-term workforce participation. This issue is especially relevant in the context of spine surgery, where postoperative disability and job loss are common concerns. The ability of patients to return to their original jobs or transition to alternative roles with minimal functional compromise underscores the broader socioeconomic benefits of disc replacement.

Clinically, the procedure yielded significant reductions in pain, with VAS scores decreasing from 8.6 to 1.6 for low back pain and from 7.3 to 1.1 for leg pain. These improvements were accompanied by a marked reduction in disability, as reflected by the decrease in ODI scores from 46.12±7.3 to 27±9.3. Such outcomes confirm the long-term efficacy of lumbar disc arthroplasty in alleviating symptoms and restoring function.

The safety profile of the procedure was also favorable. The low complication rate (3.08%) and limited need for reoperation (12.31%)—with no cases requiring prosthesis revision—demonstrate the durability and reliability of the Baguera®L disc prosthesis. These findings compare favorably with those of spinal fusion, which is associated with higher rates of adjacent segment disease and subsequent surgical interventions [24].

Significantly, the preservation of spinal motion achieved through disc arthroplasty mitigates biomechanical stress on adjacent segments, thereby reducing the risk of adjacent segment degeneration [23]. This advantage is particularly relevant for younger, active patients who may otherwise face progressive spinal deterioration following fusion.

Given these favorable outcomes, lumbar disc prosthesis should be considered a first-line surgical option for carefully selected patients. Ideal candidates include those with preserved facet joints, adequate disc height, and no prior spinal fusion. As emphasized in previous studies, optimal results are achieved in patients with discogenic pain, minimal facet degeneration, and good bone quality [17].

Beyond clinical metrics, the high satisfaction rate (77.69%) and successful return to work observed in this cohort suggest that lumbar disc arthroplasty contributes meaningfully to patients' quality of life and socioeconomic stability. These broader benefits reinforce the value of disc replacement not only as a biomechanically superior intervention but also as a cost-effective strategy in managing DDD.

In conclusion, the clinical significance of this study lies in its demonstration that total lumbar disc prosthesis offers a durable, safe, and functionally restorative alternative to fusion. It enables patients to maintain mobility, reduce pain, and remain active in the workforce—outcomes that are particularly important in the context of modern spine care.

Limitations and future research

While this study provides valuable long-term insights into the clinical and occupational outcomes of total lumbar disc prosthesis, several limitations must be acknowledged.

First, the single-center design may limit the generalizability of the findings. Although surgical protocols and follow-up assessments are standardized, outcomes may vary across institutions due to differences in patient populations, surgical expertise, and rehabilitation practices.

Second, the absence of a direct comparison group limits the ability to draw definitive conclusions regarding the superiority of disc arthroplasty over spinal fusion. Although the outcomes observed compare favorably with those reported in fusion-based studies [24], future research should include matched cohorts or randomized controlled trials to provide more robust comparative data.

Third, the retrospective nature of the study introduces inherent limitations, including potential recall bias and incomplete documentation. Although efforts were made to ensure data accuracy through structured interviews and comprehensive chart reviews, prospective studies with predefined data collection protocols would enhance methodological rigor.

Additionally, the lack of consistent short- and intermediate-term follow-up intervals restricts our ability to characterize the temporal dynamics of recovery. Without standardized assessments at 3, 5, or 7 years postoperatively, it remains unclear whether improvements in pain, function, and occupational status occur early and are sustained, or whether they evolve gradually over time.

Another limitation is the absence of objective biomechanical assessments. Radiographic evaluations of segmental motion, adjacent segment integrity, and implant positioning were not consistently available, limiting the ability to correlate clinical outcomes with structural parameters. Future studies should incorporate imaging-based metrics and gait analysis to provide a more comprehensive understanding of functional recovery.

Finally, although occupational reintegration was a key outcome, no validated instruments—such as the Work Ability Index or the Occupational Reintegration Scale—were used. While the structured classification employed in this study allowed for consistent documentation, the use of standardized tools in future research would enhance comparability and methodological robustness.

In light of these limitations, future investigations should prioritize prospective, multicenter designs with standardized follow-up intervals, objective biomechanical assessments, and validated outcome measures. Comparative studies evaluating disc arthroplasty versus fusion across diverse patient populations will be essential to refine surgical indications and optimize long-term outcomes.

Conclusions

This study reinforces the long-term effectiveness of total lumbar disc replacement in reducing pain, restoring function, and facilitating occupational reintegration in patients with degenerative disc disease (DDD). With a mean follow-up of nearly 14 years, the findings demonstrate that lumbar disc arthroplasty offers durable symptomatic relief, high patient satisfaction, and a low incidence of complications and reoperations.

The preservation of spinal motion achieved through disc prosthesis implantation appears to mitigate the biomechanical stress responsible for adjacent segment degeneration—a common limitation of spinal fusion. This advantage, combined with the high rate of return to work and sustained functional improvement, positions lumbar disc replacement as a compelling alternative to fusion, particularly for working-age individuals seeking to maintain mobility and avoid long-term disability.

Significantly, the procedure was associated with a high satisfaction rate (77.69%) and a low rate of prosthesis-related complications, with no cases requiring implant revision. These outcomes underscore the safety, durability, and clinical utility of the Baguera®L lumbar disc prosthesis in appropriately selected patients.

Given the growing emphasis on value-based care and long-term functional outcomes, lumbar disc arthroplasty should be considered a first-line surgical option for patients with discogenic low back pain who meet strict eligibility criteria. Future prospective multicenter studies with standardized follow-up protocols and biomechanical assessments are warranted to validate these findings further and refine patient selection strategies.

In conclusion, total lumbar disc replacement represents a viable, motion-preserving solution that not only addresses the clinical burden of degenerative disc disease but also supports broader socioeconomic objectives, including workforce retention and the restoration of quality of life.

Funding

This study received no funding.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.