Long-Term Outcomes of Lumbar Total Disc Arthroplasty and Hybrid Constructs: A Systematic Review.

Abstract

Lumbar total disc arthroplasty (TDA) was developed as a motion-preserving alternative to fusion for axial low back pain from disc degeneration (DD) with the theoretical goal of reducing the risk of adjacent segment disease (ASD). While short-term outcomes are well described, the durability of clinical benefit and the long-term impact on reoperation and ASD remain incompletely characterized, particularly for multilevel and hybrid constructs. No systematic review has specifically synthesized long-term outcomes across all configurations of lumbar motion-preserving surgery. To systematically evaluate long-term (≥5-year) clinical outcomes, reoperation rates, and adjacent segment disease following lumbar TDA, including single-level, multilevel, and hybrid (i.e., fusion and TDA) constructs. Systematic review. A systematic review was conducted in accordance with PRISMA guidelines. PubMed (MEDLINE), Embase (via Ovid), and Cochrane CENTRAL were searched through December 31, 2025. The review was registered on PROSPERO. Eligible studies included prospective or retrospective cohort studies of adults with DD undergoing lumbar TDA (single-level, multilevel, or hybrid) with a minimum mean or median follow-up of five years and a sample size ≥30. Primary outcomes were adjacent segment disease requiring surgical intervention, index-level revision or reoperation, and patient-reported outcomes. The risk of bias was assessed using the ROBINS-I tool for non-randomized studies of interventions and RoB 2 for randomized controlled trials (RCTs). The results were synthesized narratively due to clinical heterogeneity. Eighteen studies (4 RCTs, 14 observational), encompassing 3,346 patients, met the inclusion criteria, with follow-up ranging from 5.0 to 19.4 years across 8 device types and 10 countries. Lumbar TDA was associated with sustained improvements in pain and function. Index-level revision rates ranged from 0.67% to 19.9%. RCT evidence demonstrated TDA to be comparable or superior to fusion at 5-14 years. Surgically defined ASD was reported in 12 of 18 studies, with rates ranging from 0.8% to 5.1%; however, no study demonstrated a definitive reduction in surgically defined ASD attributable to TDA. Lumbar TDA provides durable long-term improvements in pain and function with low index-level revision rates, especially for single-level procedures. Across 18 studies, RCT evidence supports the durability of TDA outcomes, demonstrating comparable or superior results to fusion at 5-14 years. However, despite extended follow-up, current evidence does not substantiate a clear protective effect against adjacent segment disease. High-quality, independently funded registry studies with standardized ASD definitions and long-term follow-up are needed to clarify the true benefits and limitations of lumbar TDA.