BackgroundThe effectiveness of lumbar total disc replacement (TDR) with different prostheses for sagittal alignment has been reported previously. However, there are only few reports on Activ L TDR and no specific evidence regarding whether sagittal alignment affects the clinical outcomes.MethodsEighty-seven patients who underwent mono- or bi-segmental lumbar TDR with Activ L were studied. The films of the upright anteroposterior and lateral spine in neutral, flexion, and extension positions were obtained before surgery and at 1month and 1 and 3years after surgery. The radiographic parameters such as lumbar lordosis (LL), index level lordosis (IL), pelvic incidence (PI), pelvic tilt (PT), segmental lordosis (SL), and sacral slope (SS) were measured based on the lateral upright radiographs. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI) and visual analog scale (VAS) pre- and post-operatively.ResultsEighty-seven patients with complete radiographic data were available for a 3-year follow-up period. Of these, 66 received a single-level TDR, and 21 received a 2-level TDR. At 1month, the mean LL was similar to the pre-operative data and then was significantly increased to 45.1 degrees at 3years. On average, the IL tended to significantly increase, while the mean SL at L-5 was increased from 16.5 degrees pre-operatively to 21.0 degrees at 3years. The mean SL at L1-2, L2-3, L3-4, and L5-S1; PI; PT; and SS showed no obvious difference after 3years. In contrast, VAS and ODI scores showed significant improvement after surgery.ConclusionsActiv L TDR showed a favorable effect on sagittal alignment, enhancing the IL while preserving the LL and SS. However, satisfactory clinical results for over a 3-year follow-up were not affected by sagittal alignment.