Is Cervical Disc Arthroplasty Superior to Fusion for Treatment of Symptomatic Cervical Disc Disease? A Meta-Analysis
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
As the current standard treatment for symptomatic cervical disc disease, anterior cervical decompression and fusion may result in progressive degeneration or disease of the adjacent segments. Cervical disc arthroplasty was theoretically designed to be an ideal substitute for fusion by preserving motion at the operative level and delaying adjacent level degeneration. However, it remains unclear whether arthroplasty achieves that aim.
We investigated whether cervical disc arthroplasty was associated with (1) better function (neck disability index, pain assessment, SF-36 mental and physical health surveys, neurologic status) than fusion, (2) a lower incidence of reoperation and major complications, and (3) a lower risk of subsequent adjacent segment degeneration.
We conducted a comprehensive search in MEDLINE®, EMBASE, and Cochrane Central Register of Controlled Trials and identified 503 papers. Of these, we identified 13 reports from 10 randomized controlled trials involving 2227 patients. We performed a meta-analysis of functional scores, rates of reoperation, and major complications. The strength of evidence was evaluated by using GRADE profiler software. Of the 10 trials, six trials including five prospective multicenter FDA-regulated studies were sponsored by industry. The mean followups of the 10 trials ranged from 1 to 5 years.
Compared with anterior cervical decompression and fusion, cervical disc arthroplasty had better mean neck disability indexes (95% CI, −0.25 to −0.02), neurologic status (risk ratio [RR], 1.04; 95% CI, 1.00–1.08), with a reduced incidence of reoperation related to the index surgery (RR, 0.42; 95% CI, 0.22–0.79), and major surgical complications (RR, 0.45; 95% CI, 0.27–0.75) at a mean of 1 to 3 years. However, the operation rate at adjacent levels after two procedures was similar (95% CI, 0.31–1.27). The three studies with longer mean followups of 4 to 5 years also showed similar superiority of all four parameters of cervical disc arthroplasty compared with fusion.
For treating symptomatic cervical disc disease, cervical disc arthroplasty appears to provide better function, a lower incidence of reoperation related to index surgery at 1 to 5 years, and lower major complication rates compared with fusion. However, cervical disc arthroplasty did not reduce the reoperation rate attributable to adjacent segment degeneration than fusion. Further, it is unclear whether these differences in subsequent surgery including arthroplasty revisions will persist beyond 5 years.
- Anderson PA, Sasso RC, Riew KD. Comparison of adverse events between the Bryan artificial cervical disc and anterior cervical arthrodesis. Spine (Phila Pa 1976). 2008;33:1305–1312. CrossRef
- Baba H, Furusawa N, Imura S, Kawahara N, Tsuchiya H, Tomita K. Late radiographic findings after anterior cervical fusion for spondylotic myeloradiculopathy. Spine (Phila Pa 1976). 1993;18:2167–2173. CrossRef
- Burkus JK, Haid RW, Traynelis VC, Mummaneni PV. Long-term clinical and radiographic outcomes of cervical disc replacement with the Prestige disc: results from a prospective randomized controlled clinical trial. J Neurosurg Spine. 2010;13:308–318. CrossRef
- Cepoiu-Martin M, Faris P, Lorenzetti D, Prefontaine E, Noseworthy T, Sutherland L. Artificial cervical disc arthroplasty: a systematic review. Spine (Phila Pa 1976). 2011;36:E1623–1633. CrossRef
- Chagas H, Domingues F, Aversa A, Vidal Fonseca AL, de Souza JM. Cervical spondylotic myelopathy: 10 years of prospective outcome analysis of anterior decompression and fusion. Surg Neurol. 2005;64(suppl 1):S30–35; discussion S35–36 CrossRef
- Chen J, Wang X, Bai W, Shen X, Yuan W. Prevalence of heterotopic ossification after cervical total disc arthroplasty: a meta-analysis. Eur Spine J. 2012;21:674–680. CrossRef
- Cheng L, Nie L, Li M, Huo Y, Pan X. Superiority of the Bryan® disc prosthesis for cervical myelopathy: a randomized study with 3-year followup. Clin Orthop Relat Res. 2011;469:3408–3414. CrossRef
- Coric D, Nunley PD, Guyer RD, Musante D, Carmody CN, Gordon CR, Lauryssen C, Ohnmeiss DD, Boltes MO. Prospective, randomized, multicenter study of cervical arthroplasty: 269 patients from the Kineflex|C artificial disc investigational device exemption study with a minimum 2-year follow-up: clinical article. J Neurosurg Spine. 2011;15:348–358. CrossRef
- Delamarter R, Murrey DB, Janssen ME, Goldstein J, Zigler J, Tay B, Darden BV. Results at 24 months from the prospective, randomized, multicenter Investigational Device Exemption Trial of ProDisc-C versus anterior cervical discectomy and fusion with 4-year follow-up and continued access patients. SAS Journal. 2010;4:122–128. CrossRef
- Dmitriev AE, Cunningham BW, Hu N, Sell G, Vigna F, McAfee PC. Adjacent level intradiscal pressure and segmental kinematics following a cervical total disc arthroplasty: an in vitro human cadaveric model. Spine (Phila Pa 1976). 2005;30:1165–1172. CrossRef
- Duggal N, Pickett GE, Mitsis DK, Keller JL. Early clinical and biomechanical results following cervical arthroplasty. Neurosurg Focus. 2004;17:E9. CrossRef
- Epstein NE. Reoperation rates for acute graft extrusion and pseudarthrosis after one-level anterior corpectomy and fusion with and without plate instrumentation: etiology and corrective management. Surg Neurol. 2001;56:73–80; discussion 80–81. CrossRef
- Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF, Johnston KW, Grigorian AA, Lee GP, Robinson JS Jr. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976). 2007;32:2310–2317. CrossRef
- Furlan AD, Pennick V, Bombardier C, van Tulder M; Editorial Board, Cochrane Back Review Group. 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine (Phila Pa 1976). 2009;34:1929–1941. CrossRef
- Goffin J, Van Calenbergh F, van Loon J, Casey A, Kehr P, Liebig K, Lind B, Logroscino C, Sgrambiglia R, Pointillart V. Intermediate follow-up after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis: single-level and bi-level. Spine (Phila Pa 1976). 2003;28:2673–2678. CrossRef
- Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011;64:380–382. CrossRef
- Heller JG, Sasso RC, Papadopoulos SM, Anderson PA, Fessler RG, Hacker RJ, Coric D, Cauthen JC, Riew DK. Comparison of BRYAN cervical disc arthroplasty with anterior cervical decompression and fusion: clinical and radiographic results of a randomized, controlled, clinical trial. Spine (Phila Pa 1976). 2009;34:101–107. CrossRef
- Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–1558. CrossRef
- Hilibrand AS, Robbins M. Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? Spine J. 2004;4(6 suppl):190S–194S. CrossRef
- Jawahar A, Cavanaugh DA, Kerr EJ 3rd, Birdsong EM, Nunley PD. Total disc arthroplasty does not affect the incidence of adjacent segment degeneration in cervical spine: results of 93 patients in three prospective randomized clinical trials. Spine J. 2010;10:1043–1048. CrossRef
- Jiang H, Zhu Z, Qiu Y, Qian B, Qiu X, Ji M. Cervical disc arthroplasty versus fusion for single-level symptomatic cervical disc disease: a meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg. 2012;132:141–151. CrossRef
- Leung C, Casey AT, Goffin J, Kehr P, Liebig K, Lind B, Logroscino C, Pointillart V. Clinical significance of heterotopic ossification in cervical disc replacement: a prospective multicenter clinical trial. Neurosurgery. 2005;57:759–763; discussion 759–763. CrossRef
- Majd ME, Vadhva M, Holt RT. Anterior cervical reconstruction using titanium cages with anterior plating. Spine (Phila Pa 1976). 1999;24:1604–1610. CrossRef
- McAfee PC, Cappuccino A, Cunningham BW, Devine JG, Phillips FM, Regan JJ, Albert TJ, Ahrens JE. Lower incidence of dysphagia with cervical arthroplasty compared with ACDF in a prospective randomized clinical trial. J Spinal Disord Tech. 2010;23:1–8. CrossRef
- Moatz B, Tortolani PJ. Cervical disc arthroplasty: pros and cons. Surg Neurol Int. 2012;3(suppl 3):216–224.
- Mummaneni PV, Burkus JK, Haid RW, Traynelis VC, Zdeblick TA. Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: a randomized controlled clinical trial. J Neurosurg Spine. 2007;6:198–209. CrossRef
- Mummaneni PV, Haid RW. The future in the care of the cervical spine: interbody fusion and arthroplasty. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine. 2004;1:155–159. CrossRef
- Murrey D, Janssen M, Delamarter R, Goldstein J, Zigler J, Tay B, Darden B. Results of the prospective, randomized, controlled multicenter Food and Drug Administration investigational device exemption study of the ProDisc-C total disc replacement versus anterior discectomy and fusion for the treatment of 1-level symptomatic cervical disc disease. Spine J. 2009;9:275–286. CrossRef
- Nabhan A, Ahlhelm F, Shariat K, Pitzen T, Steimer O, Steudel WI, Pape D. The ProDisc-C prosthesis: clinical and radiological experience 1 year after surgery. Spine (Phila Pa 1976). 2007;32:1935–1941. CrossRef
- Nabhan A, Ishak B, Steudel WI, Ramadhan S, Steimer O. Assessment of adjacent-segment mobility after cervical disc replacement versus fusion: RCT with 1 year’s results. Eur Spine J. 2011;20:934–941. CrossRef
- Nabhan A, Steudel WI, Nabhan A, Pape D, Ishak B. Segmental kinematics and adjacent level degeneration following disc replacement versus fusion: RCT with three years of follow-up. J Long Term Eff Med Implants. 2007;17:229–236. CrossRef
- Nunley PD, Jawahar A, Kerr EJ 3rd, Gordon CJ, Cavanaugh DA, Birdsong EM, Stocks M, Danielson G. Factors affecting the incidence of symptomatic adjacent-level disease in cervical spine after total disc arthroplasty: 2- to 4-year follow-up of 3 prospective randomized trials. Spine (Phila Pa 1976). 2012;37:445–451. CrossRef
- Park DK, Lin EL, Phillips FM. Index and adjacent level kinematics after cervical disc replacement and anterior fusion: in vivo quantitative radiographic analysis. Spine (Phila Pa 1976). 2011;36:721–730. CrossRef
- Pickett GE, Mitsis DK, Sekhon LH, Sears WR, Duggal N. Effects of a cervical disc prosthesis on segmental and cervical spine alignment. Neurosurg Focus. 2004;17:E5. CrossRef
- Pickett GE, Sekhon LH, Sears WR, Duggal N. Complications with cervical arthroplasty. J Neurosurg Spine. 2006;4:98–105. CrossRef
- Riina J, Patel A, Dietz JW, Hoskins JS, Trammell TR, Schwartz DD. Comparison of single-level cervical fusion and metal-on-metal cervical disc replacement device. Am J Orthop (Belle Mead NJ). 2008;37:E71–77.
- Salari B, McAfee PC. Cervical total disc replacement: complications and avoidance. Orthop Clin North Am. 2012;43:97–107. CrossRef
- Sasso RC, Anderson PA, Riew KD, Heller JG. Results of cervical arthroplasty compared with anterior discectomy and fusion: four-year clinical outcomes in a prospective, randomized controlled trial. J Bone Joint Surg Am. 2011;93:1684–1692. CrossRef
- Sasso RC, Best NM, Metcalf NH, Anderson PA. Motion analysis of bryan cervical disc arthroplasty versus anterior discectomy and fusion: results from a prospective, randomized, multicenter, clinical trial. J Spinal Disord Tech. 2008;21:393–399. CrossRef
- Singh K, Phillips FM, Park DK, Pelton MA, An HS, Goldberg EJ. Factors affecting reoperations after anterior cervical discectomy and fusion within and outside of a Federal Drug Administration investigational device exemption cervical disc replacement trial. Spine J. 2012;12:372–378. CrossRef
- Smith HE, Wimberley DW, Vaccaro AR. Cervical arthroplasty: material properties. Neurosurg Focus. 2004;17:E3.
- Steinmetz MP, Patel R, Traynelis V, Resnick DK, Anderson PA. Cervical disc arthroplasty compared with fusion in a workers’ compensation population. Neurosurgery. 2008;63:741–747; discussion 747.
- Wigfield C, Gill S, Nelson R, Langdon I, Metcalf N, Robertson J. Influence of an artificial cervical joint compared with fusion on adjacent-level motion in the treatment of degenerative cervical disc disease. J Neurosurg. 2002;96(1 suppl):17–21.
- World Health Organization. Toxic effects. WHO Handbook for Reporting Results of Cancer Treatment. No. 48. WHO offset publication. Geneva, Switzerland: World Health Organization; 1979:14–22.
- Yu L, Song Y, Yang X, Lv C. Systematic review and meta-analysis of randomized controlled trials: comparison of total disk replacement with anterior cervical decompression and fusion. Orthopedics. 2011;34:e651–658.
- Yue WM, Brodner W, Highland TR. Long-term results after anterior cervical discectomy and fusion with allograft and plating: a 5- to 11-year radiologic and clinical follow-up study. Spine (Phila Pa 1976). 2005;30:2138–2144. CrossRef
- Zechmeister I, Winkler R, Mad P. Artificial total disc replacement versus fusion for the cervical spine: a systematic review. Eur Spine J. 2011;20:177–184. CrossRef
- Zhang X, Zhang X, Chen C, Zhang Y, Wang Z, Wang B, Yan W, Li M, Yuan W, Wang Y. Randomized controlled, multicenter, clinical trial comparing BRYAN cervical disc arthroplasty with anterior cervical decompression and fusion in China. Spine (Phila Pa 1976). 2012;37:433–438. CrossRef
- Is Cervical Disc Arthroplasty Superior to Fusion for Treatment of Symptomatic Cervical Disc Disease? A Meta-Analysis
Clinical Orthopaedics and Related Research®
Volume 471, Issue 6 , pp 1904-1919
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- Industry Sectors
- Author Affiliations
- 1. Department of Orthopaedic Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Room 1501, Inpatient Building, No. 277, Yantawest Road, Xi’an, China
- 2. Department of Neurosurgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China