Relative Efficacy of Cervical Total Disc Arthroplasty Devices and Anterior Cervical Discectomy and Fusion for Cervical Pathology: A Network Meta-Analysis

Abstract

Study design: Systematic Review and Meta Analysis.

Objective: This study sought to compare patient-reported outcomes, success, complications, and radiographic outcomes directly and indirectly between different cervical total disc arthroplasty (TDA) devices and anterior cervical discectomy and fusion (ACDF).

Methods: Patients of prospective randomized controlled trials of 1-level cervical TDA with a minimum of 2 years follow up were identified in the literature. A frequentist network meta-analysis model was used to compare each outcome across the different TDA devices included and ACDF using the mixed effect sizes.

Results: 15 studies were included for quantitative analysis, reporting the outcomes of 2643 patients with an average follow-up was 67.3 months (range: 24-120 months), 1417 of whom underwent TDA and 1226 of whom underwent ACDF. Nine TDA devices were compared to ACDF, including the Bryan, Discover, Kineflex, M6, Mobi-C, PCM, Prestige ST, ProDisc-C, and Secure-C cervical prostheses. Several devices outperformed ACDF for certain outcomes, including Visual Analog Scale (VAS) Arm, Physical Component Score of the Short-Form Health Survey (SF PCS), neurological success, satisfaction, index-level secondary surgical interventions (SSI), and adjacent level surgeries. Cumulative ranking of each intervention assessed demonstrated the highest performance with the M6 prosthesis (P = .70), followed by Secure-C (P = .67), PCM (P = .57), Prestige ST (P = .57), ProDisc-C (P = .54), Mobi-C (P = .53), Bryan (P = .49), Kineflex (P = .49), Discover (P = .39), and ACDF (P = .14).

Conclusion: Cervical TDA was found to be superior on most outcomes assessed in the literature of high-quality clinical trials. While most devices demonstrated similar outcomes, certain prostheses such as the M6 were found to outperform others across several outcomes assessed. These findings suggest that the restoration of near-normal cervical kinematics may lead to improved outcomes.

Keywords: cervical; degenerative disc disease; disc herniation; disc replacement.

Figure 1.

Risk of bias assessment for the included studies.

Figure 2.

PRISMA flow chart summarizing the search strategy.

Figure 3.

Forest plots demonstrating the MD and 95% CI of each device compared to ACDF as the reference for (A) NDI, (B) VAS Neck, (C) VAS Arm, and (D) SF PCS.

Figure 4.

Forest plots demonstrating the MD or log OR and 95% CI of each device compared to ACDF as the reference for (A) overall success, (B) neurological success, (C) categorical satisfaction, and (D) VAS satisfaction.

Figure 5.

Forest plots demonstrating the log OR and 95% CI of each device compared to ACDF as the reference for (A) dysphagia, (B) adverse events, (C) index level SSI, and (D) adjacent segment surgeries.

Figure 6.

Forest plots demonstrating the MD or log OR and 95% CI of each device compared to ACDF as the reference for (A) segmental ROM and (B) bridging bone across the operative segment.

Figure 7.

Heat map of computed P-Scores assigned to each treatment modality for all outcomes assessed. Green denotes good performance, while red denotes poor performance.

Figure 8.

Cumulative ranking of each treatment based on average P-Score.