Lumbar Total Disc Replacement (Anterior)
CPT / Procedures
- 22857 (total disc arthroplasty, anterior approach, 1 interspace lumbar) ± 22860 (each addl)
Attire
Size 8 gloves — Biogel underneath + size 8 white gloves on top
Size XL gown ×3
Approach / team
Dedicated approach surgeon (vascular/general) performs the retroperitoneal exposure and abdominal closure. Wide exposure for true-midline prosthesis placement.
Position & table
- Supine on Slider OR table with split leg attachments at the head of the table, and turn the table 180 degrees (keep base of table at the head towards anesthesia) so that C-arm is not obstructed by the base
- Arms out (~90°). Patient squared to table — midline is critical.
- Place foley
- Place O2 continuous pulse oximetry monitor on the left great toe
- Put bed into about 20 degrees of Trendelenburg (head down, feet upwards) such that the intended disc space (ie L5-S1) is ideally approachable.
- Clip hair for skin preparation from umbilicus to 2 inches below pubic symphysis
- Place NuVasive retractor arm clamp on bed BEFORE neuromonitoring wires are placed.
- Place a clamp on the patient’s right side just distal to the arm board, and on the patient’s left side - place another clamp at the level of the patient’s greater trochanter.
- Upper body bair hugger
Prep, drape & cautery
| Item — exact product | Size | Vendor | Catalog # | Open | PRN |
|---|---|---|---|---|---|
| Positioning · warming · DVT prophylaxis (non-sterile, in room) | |||||
| Sequential compression device (SCD) pump | Cardinal / Kendall | SCD 700 | 1 | ||
| SCD compression sleeves (Vasopress), size to patient | M / L | Cardinal | VP501MG / VP501LG | 1 pr | |
| Forced-air warming blanket, upper body (Bair Hugger) + unit | 3M | 52200 | 1 | ||
| Foam positioning kit / arm pads / gel rolls | Xodus | SPK10113 | 1 | ||
| Surgical skin marker (black) + field marker (purple) | Viscot | 1450XL | 1 | ||
| Foley catheter + insertion tray, 16 Fr | 16 Fr | BD | 903016A | 1 | |
| Skin prep · antisepsis | |||||
| Chlorhexidine (Hibiclens) scrub brush | 1 | ||||
| ChloraPrep applicator — 2% CHG / 70% IPA, tinted | 26 mL | BD (CareFusion) | 930815 | 2 | |
| BD Surgiphor wound irrigation — 0.5% PVP-I | 450 mL | BD | 910110 | 1 | |
| Major basin pack (RSP) | Novo Health | 124514C | 1 | ||
| Mastisol liquid adhesive vial | 0.66 mL | Ferndale | 52348 | 1 | |
| Draping | |||||
| Blue OR towels (per pack) | 17×30 in | Medical Action | 7048 | 2 | |
| Steri-Drape impervious towel drape ('1010') | 23×35 in | 3M | 1010 | 4 | |
| Medline InvisiShield towel drape ON ROLL (prep stand) | 18×12 in | Medline | DYNJSD1000RL | 1 | |
| Medline Sterile Surgical Utility Drapes with Tape, 200 EA/CS | 38×66 cm | Medline | DYNJP2405 | 4 | 2 |
| Ioban 2 antimicrobial incise drape (iodophor) | 33×35 in | 3M | 6651EZ | 1 | |
| Spine custom pack (PPMC) | Medline | DYNJ69083 | 1 | ||
| Split-sheet drape | 77×120 in | Medline | DYNJP8304 | 1 | |
| 3/4 sheet drape | Medline | DYNJP2414 | 1 | ||
| Pocketed CV top drape — bilateral pouches | Medline | DYNJP4220 | 1 | ||
| Instrument pouch — adheres to drape | 10×11 in | Microtek / Medline | 8918 | 1 | |
| C-arm drape (PPMC Ecolab / CCH Tidi C-Armor) | 27×60 in | Ecolab / Tidi | 4951 / 5523 | 1 | |
| Leg-cover drape | 31×48 in | Medline | DYNJP2460 | 1 | |
| Skin stapler | 35 W | Covidien Appose | 8886803712 | 1 | |
| Sponges | |||||
| Raytec gauze sponge, 12-ply, X-ray detectable | 4×4 in | Cardinal Health | 6939 | 2 | |
| Laparotomy sponge (lap pad), 18×18, per pack | 18×18 in | Medline | MDS72038 | 3 | |
| Lap-tape sponge (long/thin), X-ray detectable — narrow channels / gutters | 4×18 in | Medline | MDS251504LF | 2 | |
| Cottonoid patty (neuro) | 0.5×0.5 in | Integra | 801400 | 1 | |
| Sharps · needles · syringes | |||||
| Surgeon's blade #10 / #15 | #10 / #15 | Aspen | 371110 / 371115 | 1 ea | |
| Surgeon's blade #11 | #11 | Aspen | 371211 | 1 | |
| Hypodermic needle 22G / 25G | BD | 305127 | 1 | ||
| IV catheter / angiocath 18G (local / irrigation) | 18G | BD | 381454 | 1 | |
| Luer-lock syringe 20 cc | BD | 302830 | 1 ea | ||
| Spinal needle — level localization 18G | BD | 405181 | 1 | ||
| Needle counter box, magnetic | 40-ct | Medline | NC40FBR | 1 | |
| Hemostasis | |||||
| Floseal (10 cc), bone wax | ✓ | ||||
| Recothrom + Thrombin 5000 units – uses on cottonoids | ✓ | ||||
| In case there is an iliac vein injury: Large Surgicel wrapped over thick Surgifoam (~6cm x 3cm folded in half). Use this loaded on a ring forcep clamp to hold pressure/tamponade the bleeding | ✓ | ||||
| Cautery & suction | |||||
| ESU pencil + integrated holster | Valleylab / Bovie | E2515H / ESPH | 1 | ||
| Bovie tip scratch pad | Bovie | ESSP | 1 | ||
| Bipolar forceps cord + adaptor (Storz) + pedal | Storz | — | 1 | ||
| Grounding pad / return electrode (REM) | Medtronic | 7507 | 1 | ||
| Yankauer suction tip + Poole (anterior) | Sage | 006629 | 1 | ||
| Disposable plastic Frazier suction tips — 16Fr ×2, 12Fr ×2, 10Fr ×2 | 1 | ||||
| Neptune 2 Ultra suction unit + tubing + canister | Stryker | — | 1 | ||
| Closure · drains · dressing | |||||
| Abdominal wall / fascia closed with #1 Maxon (or PDS) – open x2 | ✓ | ||||
| Dermis closed with 3-0 Vicryl – open x2 | ✓ | ||||
| Skin 3-0 clear stratfix (of V-loc) | ✓ | ||||
| Dermabond. | ✓ | ||||
| none | ✓ | ||||
| Smith & Nephew [6⅛" × 3⅜"] OpSite dressing | ✓ | ||||
| Cautery settings: Bovie 35 / 35 cut-coag, Bipolar 35 · 1 bovie (open) + 1 additional bovie PRN (if co-surgeon) · 2 suctions off bottom of field · grounding pad on thigh. Meds (pharmacy): Local: bupivacaine 0.25% w/ epi; TXA (tranexamic acid): 30 mg/kg load + 1 mg/kg/hr infusion throughout the case; Antibiotic: 2g Ancef unless patient has an allergy | |||||
Imaging
C-arm, drape C-arm and use C-armor for lateral images
Neuromonitoring
MEPs, SSEPs, EMG
Sets & instruments
Open these sets — click for the full tray list
- Core: Spine Basic, Lumbar Spine Extras, Anterior Lumbar (ALIF/TDR)
- Retractor: Thompson retractor + LONG custom bone levers (custom-length Synthes/DePuy Synthes 698344857).
- Long clip appliers (red/blue/green); vascular tray; Doppler.
- Midline marker, keel-cut chisels, trial spacers, prosthesis inserter (in implant system).
- Curettes: Chroma-Line Curettes
- Kerrisons: Black Kerrisons (1–5 mm) or Life Spine Kerrisons
- Bipolar: Silverglide bayonet.
- Long clip appliers set (red, blue, green).
- Vascular tray: DeBakey/Satinsky, bulldogs, vessel loops; Doppler for vessel/iliac check.
Implant (loaner / rep-brought — confirm vendor at new site)
Lumbar disc prosthesis (e.g., ProDisc-L). Full trial set, keel punch, inserter.
Graft
None (motion-preserving).
Power
Stryker Sumex Pi Drive 2+ aka TPS drill set (#1588-001 OR #1588-002) (primary) / MidasRex MR8 (alternative); high-speed burr + endplate prep instruments.
Vessel hemostasis adjuncts (have ready)
Vessel loops, papaverine, heparinized saline, topical thrombin, Floseal, Surgicel, Surgifoam.
Hemostasis
Floseal (10 cc), bone wax
Recothrom + Thrombin 5000 units – uses on cottonoids
In case there is an iliac vein injury: Large Surgicel wrapped over thick Surgifoam (~6cm x 3cm folded in half). Use this loaded on a ring forcep clamp to hold pressure/tamponade the bleeding
Medications
- Local: bupivacaine 0.25% w/ epi.
- TXA (tranexamic acid): 30 mg/kg load + 1 mg/kg/hr infusion throughout the case.
- Antibiotic: 2g Ancef unless patient has an allergy
Drain
none
Closure
Abdominal wall / fascia closed with #1 Maxon (or PDS) – open x2
Dermis closed with 3-0 Vicryl – open x2
Skin 3-0 clear stratfix (of V-loc)
Dermabond.
Dressing
Smith & Nephew [6⅛" × 3⅜"] OpSite dressing