Describe the workup of a patient with persistent low back pain following lumbar total disc arthroplasty

A variety of diagnoses are considered in the patient who presents with continued or new-onset symptoms following lumbar total disc arthroplasty:

• Implant malposition, migration, subsidence, or instability

• Pain due to posterior facet joint arthrosis

• Pain due to neural impingement or excessive elevation of disc space height

• Symptomatic adjacent level pathology

• Pain of unknown etiology

After a detailed history and physical examination are completed, imaging is initiated with plain radiography including standing anteroposterior (AP) and lateral views and flexion-extension views. Fluoroscopy may be valuable to assess the operative level under dynamic loading conditions. CT imaging including axial, sagittal, and coronal views can add information. If neurologic compression is a concern, CT-myelography is indicated because MRI evaluation of currently approved lumbar TDRs is compromised by metal artifact. Injection studies including facet blocks, adjacent level discography, and periprosthetic anesthetic injection may be of value in diagnosis of facet-mediated pain, symptomatic adjacent level disc degeneration, and determining whether the surgical level is the source of pain. Angiography and venography are considered when vessel impingement by displaced prosthetic components is suspected. Periprosthetic infection can be challenging to diagnose, and potentially useful imaging studies include technetium radionuclide scans or positron emission tomography (PET)-CT scans in combination with laboratory studies (complete blood count [CBC], erythrocyte sedimentation rate [ESR], C-reactive protein).

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