Fabienne Pohle
Sonja Häckel
Spinal arthroplasty remains one of the most promising concepts in spinal surgery. The appeal is clear: the pathology is treated, the motion segment is reconstructed, and mobility is preserved rather than eliminated. At the same time, this field has not developed uniformly along the entire spine. This is precisely what makes this review particularly valuable. By discussing cervical and lumbar disc replacement as well as lumbar facet arthroplasty together, Liu et al. [
1] demonstrate that preserving motion is no longer a single concept but rather a range of reconstructive strategies with very different levels of evidence, technical maturity, and clinical readiness. One of the strengths of the review is that it balances biomechanics, indications, outcomes, and future directions, rather than presenting arthroplasty as a purely implant-driven success story.
The section on the cervical spine is the most convincing, reflecting the fact that cervical disc replacement has become the most established form of spinal arthroplasty. As the review summarizes, randomized trials with follow-up periods of 5, 7, and 10 years have shown that cervical arthroplasty is at least noninferior to anterior cervical discectomy and fusion in appropriately selected single- or 2-segment diseases and is superior in several respects, including patient-reported outcomes, preserved segmental mobility, and a lower rate of secondary interventions for adjacent segment disease [
2,
3]. The complication profile appears acceptable, although heterotopic ossification, osteolysis, and rare revisions or implant removals remain relevant concerns [
4,
5]. Overall, the results support cervical arthroplasty as a durable and evidence-based option for selected patients. However, the practical recommendation is not to expand its use indiscriminately, but to continue adhering to strict indication criteria: Patients with single- or 2-level degenerative pathology, preserved facet function, and no major instability, deformity, or compromised bone quality are most likely to benefit. Broader application in older patients, in hybrid constructions, or in multilevel contexts may be appropriate but should continue to be based on evidence rather than enthusiasm.
The section on lumbar disc replacement is equally valuable, as it is appropriately more cautious. The lumbar spine is subject to greater compressive loads, shear forces, and coupled movements, and the clinical syndrome to be treated is often less clearly defined than cervical radiculopathy. This difference continues to shape the outcomes. As outlined in the review, total lumbar disc replacement can lead to significant improvements in Oswestry Disability Index (ODI), visual analogue scale (VAS), and quality-of-life measures and appears to be largely noninferior to fusion in carefully selected patients [
6,
7]. Mobility is preserved, and some study series suggest less degeneration of adjacent segments and fewer surgeries at adjacent levels. At the same time, no clear clinical superiority over fusion has been consistently demonstrated, long-term outcomes remain more variable, and revision surgeries can be challenging. For this reason, the recommendation should remain selective: lumbar disc arthroplasty is best reserved for carefully selected younger patients with a single-segment discogenic condition, preserved disc height, minimal facet arthropathy, and no significant deformity, instability, osteoporosis, or adverse host factors. In this section, the review highlights an important point: The next advances in lumbar arthroplasty will depend less on broader implantation and more on better patient stratification and data on long-term durability.
The inclusion of lumbar facet arthroplasty is another major strength of this review. All too often, motion preservation in the lumbar spine is discussed as if the intervertebral disc alone defined the functional unit. This is not the case. The posterior column is central to the mechanics of the lumbar spine, and any serious reconstructive strategy must take the three-joint complex into account. The early results presented in the review are encouraging. In particular, the TOPS (Total Posterior Spine System, Premia Spine, USA) data suggest superior 2-year overall success compared to transforaminal lumbar interbody fusion, with improvements in ODI, VAS back pain, and Zurich Claudication Questionnaire scores, preservation of motion, and low rates of symptomatic adjacent segment disease during the reported follow-up period [
8]. These findings support the technical feasibility and biomechanical plausibility of posterior motion preservation. Nevertheless, recommendations should remain cautious at this time. Lumbar facet arthroplasty appears most promising in carefully selected patients with single-segment lumbar stenosis and mild degenerative spondylolisthesis, preserved disc height, and no major deformity or multisegmental disease [
9]. Before it can be more widely applied, longer follow-up periods, clearer failure analyses, and practical revision strategies are essential.
Taken together, this manuscript is valuable mainly as a clear and timely overview of the current state of spinal arthroplasty rather than as a review that offers genuinely new conceptual insights. Its strength lies in bringing cervical disc replacement, lumbar disc replacement, and lumbar facet arthroplasty into one coherent discussion and in showing how differently these techniques have matured across the spine. At the same time, the perspective on future development remains relatively broad. Although the authors touch on longer follow-up, improved implant design, minimally invasive approaches, and possible expansion toward hybrid or multilevel constructs, the review gives less attention to the next practical step for the field: better diagnostics, more individualized patient selection, and more precise preoperative planning to optimize implant choice and restore a patient-specific center of rotation. In addition, as a narrative review, the manuscript would have benefited from a clearer description of how the literature was selected, since greater methodological transparency would help readers assess the balance of the evidence and the risk of selection bias. Seen in that light, this is a useful and well-structured summary of the field, but more a synthesis of existing knowledge than a review that substantially advances it.
NOTES
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Conflict of Interest
The authors have nothing to disclose.
REFERENCES
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