Multilevel cervical disc replacement versus multilevel anterior discectomy and fusion: A meta-analysis

Abstract

Background: Cervical disc replacement (CDR) has been developed as an alternative surgical procedure to anterior cervical discectomy and fusion (ACDF) for the treatment of single-level cervical degenerative disc disease. However, patients with multilevel cervical degenerative disc disease (MCDDD) are common in our clinic. Multilevel CDR is less established compared with multilevel ACDF. This study aims to compare the outcomes and evaluate safety and efficacy of CDR versus ACDF for the treatment of MCDDD.

Methods: A meta-analysis was performed for articles published up until August 2016. Randomized controlled trials (RCTs) and prospective comparative studies associated with the use of CDR versus ACDF for the treatment of MCDDD were included in the current study. Two reviewers independently screened the articles and data following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement.

Results: Seven studies with 702 enrolled patients suffering from MCDDD were retrieved. Patients who underwent CDR had similar operative times, blood loss, Neck Disability Index (NDI) scores, and Visual Analog Scale (VAS) scores compared to patients who underwent ACDF. Patients who underwent CDR had greater overall motion of the cervical spine and the operated levels than patients who underwent ACDF. Patients who underwent CDR also had lower rates of adjacent segment degeneration (ASD). The rate of adverse events was significantly lower in the CDR group.

Conclusion: CDR may be a safe and effective surgical strategy for the treatment of MCDDD. However, there is insufficient evidence to draw a strong conclusion due to relatively low-quality evidence. Future long-term, multicenter, randomized, and controlled studies are needed to validate the safety and efficacy of multilevel CDR.

Figure 1

Flow chart of article selection process.

Figure 2

Risk of bias of the randomized controlled trials, +: low risk bias; ?: unclear risk bias; and −: high risk bias.

Figure 3

Surgery time. Forest plot of surgery time for CDR and ACDF. ACDF = anterior cervical discectomy and fusion, CDR = cervical disc replacement, CI = confidence interval, IV = inverse variance, SD = standard deviation.

Figure 4

Blood loss. Forest plot of blood loss for CDR and ACDF. ACDF = anterior cervical discectomy and fusion, CDR = cervical disc replacement, CI = confidence interval, IV = inverse variance, SD = standard deviation.

Figure 5

NDI. Forest plot of NDI for CDR and ACDF. ACDF = anterior cervical discectomy and fusion, CDR = cervical disc replacement, CI = confidence interval, IV = inverse variance, NDI Neck Disability Index, SD = standard deviation.

Figure 6

VAS. Forest plot of VAS for CDR and ACDF. ACDF = anterior cervical discectomy and fusion, CDR = cervical disc replacement, CI = confidence interval, IV = inverse variance, SD = standard deviation, VAS = Visual Analog Scale.

Figure 7

ROM of overall cervical spine. Forest plot of ROM of overall cervical spine for CDR and ACDF. ACDF = anterior cervical discectomy and fusion, CDR = cervical disc replacement, CI = confidence interval, IV = inverse variance, ROM = range of motion, SD = standard deviation.

Figure 8

ROM at the operated level. Forest plot of ROM at operated level for CDR and ACDF. ACDF = anterior cervical discectomy and fusion, CDR = cervical disc replacement, CI = confidence interval, IV = inverse variance, ROM = range of motion, SD = standard deviation.

Figure 9

ASD. Forest plot of ASD for CDR and ACDF. ACDF = anterior cervical discectomy and fusion, ASD = adjacent segment degeneration, CDR = cervical disc replacement, CI = confidence interval, M-H = Mantel–Haenszel.

Figure 10

Adverse events. Forest plot of adverse events for CDR and ACDF. ACDF = anterior cervical discectomy and fusion, CDR = cervical disc replacement, CI = confidence interval, M-H = Mantel–Haenszel.

Figure 11

Dysphagia. Forest plot of dysphagia for CDR and ACDF. ACDF = anterior cervical discectomy and fusion, CDR = cervical disc replacement, CI = confidence interval, M-H = Mantel–Haenszel.

Figure 12

Device-related adverse event. Forest plot of device-related adverse event for CDR and ACDF. ACDF = anterior cervical discectomy and fusion, CDR = cervical disc replacement, CI = confidence interval, M-H = Mantel–Haenszel.