Cervical Disc Arthroplasty (CDA) versus Anterior Cervical Discectomy and Fusion (ACDF) for Two-Level Cervical Disc Degenerative Disease: An Updated Systematic Review and Meta-Analysis

Abstract

Background: Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are both considered to be efficacious surgical procedures for treating cervical spondylosis in patients with or without compression myelopathy. This updated systematic review and meta-analysis aimed to compare the outcomes of these procedures for the treatment of cervical degenerative disc disease (DDD) at two contiguous levels. Methods: The PubMed, EMBASE, and Cochrane CENTRAL databases were searched up to 1 May 2023. Studies comparing the outcomes between CDA and ACDF in patients with two-level cervical DDD were eligible for inclusion. Primary outcomes were surgical success rates and secondary surgery rates. Secondary outcomes were scores on the Neck Disability Index (NDI) and Visual Analogue Scale (VAS) for neck and arm pain, as well as the Japanese Orthopaedic Association (JOA) score for the severity of cervical compression myelopathy and complication rates. Results: In total, eight studies (two RCTs, four retrospective studies, and two prospective studies) with a total of 1155 patients (CDA: 598; ACDF: 557) were included. Pooled results revealed that CDA was associated with a significantly higher overall success rate (OR, 2.710, 95% CI: 1.949-3.770) and lower secondary surgery rate (OR, 0.254, 95% CI: 0.169-0.382) compared to ACDF. In addition, complication rates were significantly lower in the CDA group than in the ACDF group (OR, 0.548, 95% CI: 0.326 to 0.919). CDA was also associated with significantly greater improvements in neck pain VAS than ACDF. No significant differences were found in improvements in the arm VAS, NDI, and JOA scores between the two procedures. Conclusions: CDA may provide better postoperative outcomes for surgical success, secondary surgery, pain reduction, and postoperative complications than ACDF for treating patients with two-level cervical DDD.

Keywords: anterior cervical discectomy and fusion (ACDF); cervical disc arthroplasty (CDA); degenerative disc disease (DDD); efficacy; two levels.

Figure 1

PRISMA flow diagram of study selection. The number of search hits are shown, corresponding to each step of the systematic literature search, qualitative review, and quantitative analysis. The basis for search hit exclusions are described.

Figure 2

Meta-analysis of the (A) overall success rate [26,27], (B) secondary surgery rate [23,26,27], (C) NDI [23,24,25,27,28,29,30], (D) neck pain VAS [23,25,27,28,29,30], (E) arm pain VAS [23,24,27,28], (F) JOA score [23,25,28], and (G) complication rate [23,26,27,29].

Figure 2

Meta-analysis of the (A) overall success rate [26,27], (B) secondary surgery rate [23,26,27], (C) NDI [23,24,25,27,28,29,30], (D) neck pain VAS [23,25,27,28,29,30], (E) arm pain VAS [23,24,27,28], (F) JOA score [23,25,28], and (G) complication rate [23,26,27,29].

Figure 3

Funnel plots for the verification of publication bias in the present meta-analysis. Egger’s test was utilized to verify the presence of publication bias in the meta-analysis of the (A) secondary surgery rate; (B) NDI; (C) neck pain VAS; (D) arm pain VAS; (E) JOA score; and (F) complication rate.

Figure 3

Funnel plots for the verification of publication bias in the present meta-analysis. Egger’s test was utilized to verify the presence of publication bias in the meta-analysis of the (A) secondary surgery rate; (B) NDI; (C) neck pain VAS; (D) arm pain VAS; (E) JOA score; and (F) complication rate.