Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 Mar;6(1):217-232.
doi: 10.21037/jss.2019.12.09.

Cervical disc arthroplasty versus anterior cervical discectomy and fusion: a meta-analysis of rates of adjacent-level surgery to 7-year follow-up

Jetan H Badhiwala  1 , Andrew Platt  2 , Christopher D Witiw  1 , Vincent C Traynelis  3
Affiliations

Cervical disc arthroplasty versus anterior cervical discectomy and fusion: a meta-analysis of rates of adjacent-level surgery to 7-year follow-up

Jetan H Badhiwala et al. J Spine Surg. 2020 Mar.

Abstract

Background: Anterior cervical discectomy and fusion (ACDF) is an effective treatment for cervical spondylosis. A limitation of ACDF is the risk of adjacent-segment degeneration (ASD), owing to arthrodesis of a motion segment. Cervical disc arthroplasty (CDA) has hence garnered significant attention; yet, compelling evidence of reduction in ASD requiring surgery is lacking. This systematic review and meta-analysis sought to compare long-term longitudinal adjacent-level operation rates with CDA versus ACDF.

Methods: An electronic literature search was conducted. Eligible studies were multi-center randomized controlled trials (RCTs) comparing CDA with ACDF for one- or two-level symptomatic cervical spondylosis. The primary outcome was adjacent-level operation. Index-level reoperation was a secondary outcome. Outcomes were evaluated at 1-year intervals from the index operation to last reported follow-up by random-effects meta-analyses.

Results: Eleven RCTs met criteria. For one-level spondylosis, there was no difference in the rate of adjacent-level operation between CDA (2.3%) and ACDF (3.6%) at 2 years. However, a large difference favoring CDA became evident at 5 years and persisted at 7 years (4.3% vs. 10.8%, P<0.001). Significantly fewer patients who underwent CDA required index-level reoperation at all time points out to 7 years (5.2% vs. 12.7%, P<0.001). Similar to one-level operations, there was no significant difference in adjacent-level operations with two-level CDA (1.7%) versus two-level ACDF (3.4%) at 2 years. At 7 years, a significant difference favoring CDA became apparent (5.1% vs. 10.0%, P=0.014). Two-level CDA resulted in fewer index-level reoperations out to 7 years (4.2% vs. 13.5%, P<0.001).

Conclusions: In this meta-analysis, the short-term rate of adjacent-level operation was similar with CDA or ACDF. However, around 5 years, a statistically significant divergence emerged, where the rate of adjacent-level surgery rose steeply for ACDF. Index-level reoperations were less frequent with CDA in both the short- and long-term. These data indicate CDA may have a superior longevity to ACDF with regard to need for subsequent adjacent-level operation.

Keywords: Anterior cervical discectomy and fusion (ACDF); arthrodesis; arthroplasty; artificial disc; cervical disc arthroplasty (CDA); cervical spine; cervical spondylosis; disc prosthesis; disc replacement; fusion; myelopathy; radiculopathy.

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest: The series “Advanced Techniques in Complex Cervical Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. Dr. Traynelis is a paid consultant for Medtronic, NuVasive, and Thompson Surgical, and receives IP royalties from Medtronic. The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Flowchart of study eligibility.
Figure 2
Figure 2
Pooled rates of adjacent-level reoperation for CDA compared with ACDF in patients with one-level symptomatic cervical spondylosis (derived from meta-analysis of nine randomized trials). CDA, cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion.
Figure 3
Figure 3
Forest plot of adjacent-level reoperations for CDA compared with ACDF in patients with one-level symptomatic cervical spondylosis (derived from meta-analysis of nine randomized trials). CDA, cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion.
Figure 4
Figure 4
Pooled rates of index-level reoperation for CDA compared with ACDF in patients with one-level symptomatic cervical spondylosis (derived from meta-analysis of nine randomized trials). CDA, cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion.
Figure 5
Figure 5
Pooled rates of index-level reoperation for CDA compared with ACDF in patients with one-level symptomatic cervical spondylosis (derived from meta-analysis of nine randomized trials). CDA, cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion.
Figure 6
Figure 6
Pooled rates of index-level reoperation for CDA compared with ACDF in patients with one-level symptomatic cervical spondylosis (derived from meta-analysis of nine randomized trials). CDA, cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion.
Figure 7
Figure 7
Forest plot of adjacent-level reoperations for CDA compared with ACDF in patients with two-level symptomatic cervical spondylosis (derived from meta-analysis of two randomized trials). CDA, cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion.
Figure 8
Figure 8
Pooled rates of index-level reoperation for CDA compared with ACDF in patients with two-level symptomatic cervical spondylosis (derived from meta-analysis of two randomized trials). CDA, cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion.
Figure 9
Figure 9
Forest plot of index-level reoperations for CDA compared with ACDF in patients with two-level symptomatic cervical spondylosis (derived from meta-analysis of two randomized trials). CDA, cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion.
See this image and copyright information in PMC

References

    1. Smith GW, Robinson RA. The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am 1958;40-A:607-24. 10.2106/00004623-195840030-00009 - DOI - PubMed
    1. Bohlman HH, Emery SE, Goodfellow DB, et al. Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one hundred and twenty-two patients. J Bone Joint Surg Am 1993;75:1298-307. 10.2106/00004623-199309000-00005 - DOI - PubMed
    1. Eck JC, Humphreys SC, Lim TH, et al. Biomechanical study on the effect of cervical spine fusion on adjacent-level intradiscal pressure and segmental motion. Spine (Phila Pa 1976) 2002;27:2431-4. 10.1097/00007632-200211150-00003 - DOI - PubMed
    1. Hilibrand AS, Carlson GD, Palumbo MA, et al. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am 1999;81:519-28. 10.2106/00004623-199904000-00009 - DOI - PubMed
    1. Nunley PD, Coric D, Frank KA, et al. Cervical Disc Arthroplasty: Current Evidence and Real-World Application. Neurosurgery 2018;83:1087-106. 10.1093/neuros/nyx579 - DOI - PubMed