Revision strategies following ESP-L lumbar disc arthroplasty complicated by osteolysis and recurrent symptoms

Background: Viscoelastic lumbar total disc replacements (TDRs) can develop periprosthetic osteolysis likely attributable to wear debris and micromotion at the core-endplate interface. Early recognition and revision are essential to avoid prosthesis explantation. Here, we present two patients with cystic osteolysis following Elastic Spine Pad - Lumbar (ESP-L) viscoelastic lumbar disc arthroplasty. Methods: Two patients developed symptomatic cystic osteolysis within 5 years of ESP-L implantation documented utilizing multimodal imaging (i.e., radiographs and computed tomography). Revision surgery in two cases was based on cyst morphology and implant stability. Case 1 had a large posterior osteolytic cavity and underwent posterior cortical bone trajectory (CBT) fusion with autologous bone grafting. Case 2, with a contained lesion adjacent to an otherwise stable implant, was treated with targeted percutaneous cement augmentation. Results: Longitudinal imaging and clinical follow-up showed symptomatic improvement and radiologic stabilization in both patients. In Case 1, the osteolytic cavity fully resolved within 18 postoperative months, whereas Case 2 achieved immediate mechanical reinforcement and sustained pain reduction following cement injection. Conclusion: Cystic osteolysis is a potential complication of viscoelastic lumbar TDRs. These cases demonstrated that posterior CBT fusion or percutaneous cement augmentation could provide effective symptomatic relief and radiologic stabilization, avoiding the need to remove the prosthesis.