Revision of a lumbar disc arthroplasty following late infection

Anterior removal of a lumbar total disc replacement implant is often a very technically demanding procedure. The anterior retroperitoneal anatomy is prone to scarring, limiting remobilization and making a direct anterior exposure above the L5–S1 level difficult if not impossible to achieve safely. Anterolateral approach strategies can be more safely achieved at L4–L5 and above, but may require vertebral osteotomy in order to remove a keeled prosthesis. Successful conversion to a fusion with implant removal can be achieved, even when osteotomy is needed for implant removal. This Grand Rounds case presentation involves an unusual late retroperitoneal abscess following two-level TDR with direct extension to one of the implants, and the subsequent nonoperative and operative management. Removal of a well-fixed keeled implant at the L4–L5 level following nonoperative treatment of a surrounding retroperitoneal abscess and conversion to fusion represents close to, if not a ‘worst-case’ scenario for revision TDR. However, with proper preoperative planning and surgical experience, a safe and successful procedure can be the end result.