Iatrogenic Contributions to Cervical Adjacent Segment Pathology

Review Article



Anterior cervical discectomy and fusion (ACDF) is widely accepted as a predictably excellent procedure. On the other hand, adjacent level pathology following ACDF is a well-known phenomenon which undercuts surgical outcome. However, the extent to which ACDF accelerates this phenomenon in the naturally degenerating cervical spine is still to be understood.


To summarize the current evidence concerning adjacent segment pathology in the light of biomechanics, natural history, postoperative course, and comparison between ACDF and total disc replacement (TDR).


This is a study of published articles. Articles were searched by the topic of adjacent disc pathology in cervical spine through Google Scholar and Pubmed. After review, 37 published articles were deemed suitable for the subject of this study.


Biomechanical and clinical data strongly suggest that ASP is a presentation of the iatrogenically accelerated natural aging process of cervical spine. However, power study analysis with assumption showed that current RCTs are unlikely to prove this suggestion.


Available data suggests that iatrogenic factors play a significant role in adjacent segment pathology following ACDF.

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  1. 1.

    Anderson P, Sasso R, Metcalf N, et al. Reoperation rates for cervical arthroplasty vs. arthrodesis. Spine J. 2005; 5: 76 s-77 s.

    Article  Google Scholar 

  2. 2.

    Anderson PA, Sasso RC, Riew KD. Comparison of adverse events between the Bryan artificial cervical disc and anterior cervical arthrodesis. Spine. 2008; 33: 1305-12.

    Article  PubMed  Google Scholar 

  3. 3.

    Anderson PA, Andersson GBJ, Arnold PM, et al. Terminology. Spine. 2012; 37(22S): 8-9.

    Article  Google Scholar 

  4. 4.

    Auerbach J, Anakwenze O, Milby A, et al. Segmental contribution toward total cervical range of motion: a comparison of cervical disc arthroplasty and fusion. Spine. 2011; 36: E1593-9.

    Article  PubMed  Google Scholar 

  5. 5.

    Baba H, Furusawa N, Imura S, et al. Late radiographic findings after anterior cervical fusion for spondylotic myeloradiculopathy. Spine. 1993; 18: 2167-73.

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    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: 308-18.

    Article  PubMed  Google Scholar 

  7. 7.

    Carrier CS, Bono CM, Lebl DR. Evidence-based analysis of adjacent segment degeneration and disease after ACDF: a systematic review. Spine J 2013

  8. 8.

    Delamarter RB, Zigler J. Five-year reoperation rates, cervical total disc replacement versus fusion, results of a prospective randomized clinical trial. Spine. 2013; 38(9): 711-717.

    Article  PubMed  Google Scholar 

  9. 9.

    Dmitriev AE, Cunningham BW, Hu N, et al. Adjacent level intradis- cal pressure and segmental kinematics following a cervical total disc arthroplasty: an in vitro human cadaveric model. Spine. 2005; 30: 1165-72.

    Article  PubMed  Google Scholar 

  10. 10.

    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. 2002; 27: 2431-4.

    Article  PubMed  Google Scholar 

  11. 11.

    Goffin J, Geusens E, Vantomme N, et al. Long-term follow-up after interbody fusion of the cervical spine. J Spinal Disord Tech. 2004; 17: 79-85.

    Article  PubMed  Google Scholar 

  12. 12.

    Gore DR. Roentgenographic findings in the cervical spine in asymptomatic persons; a ten-year follow-up. Spine. 2001; 26(22): 2463-2466.

    Article  CAS  PubMed  Google Scholar 

  13. 13.

    Gore DR, Sepic SB. Anterior cervical fusion for degenerated or pro- truded discs: a review of one hundred forty-six patients. Spine. 1984; 9(7): 667-71.

    Article  CAS  PubMed  Google Scholar 

  14. 14.

    Gore DR, Gardner GM, Sepic SB, et al. Roentgenographic findings following anterior cervical fusion. Skeletal Radiol. 1986; 15: 556-559.

    Article  CAS  PubMed  Google Scholar 

  15. 15.

    Grunhagen T, Shirazi-Adl A, Fairbank JCT, et al. Intervertebral disk nutrition: a review of factors influencing concentrations of nutrients and metabolites. Orthop Clin N Am. 2011; 42: 465-477.

    Article  Google Scholar 

  16. 16.

    Helgeson MD, Bevevino AJ, Hilibrand AS. Update on the evidence for adjacent segment degeneration and disease. Spine J. 2013; 13: 342-351.

    Article  PubMed  Google Scholar 

  17. 17.

    Hilibrand AS, Robbins M. Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? Spine J. 2004; 4: 190s-194s.

    Article  PubMed  Google Scholar 

  18. 18.

    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.

    CAS  PubMed  Google Scholar 

  19. 19.

    Ishihara H, Kanamori M, Kawaguchi Y, et al. Adjacent segment disease after anterior cervical interbody fusion. Spine J. 2004; 4: 624-8.

    Article  PubMed  Google Scholar 

  20. 20.

    Jawahar A, Cavanaugh DA, Kerr EJ 3rd, et al. 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: 1043-8.

    Article  PubMed  Google Scholar 

  21. 21.

    Kelly MP, Mok JM, Frisch RF, Tay BK. Adjacent segment motion after anterior cervical discectomy and fusion versus prodisc-c cervical total disk arthroplasty: analysis from a randomized, controlled trial. Spine. 2011; 36: 1171-9.

    Article  PubMed  Google Scholar 

  22. 22.

    Lee MJ, Dettori JR, Standaert CJ, et al. The natural history of degeneration of the lumbar and cervical spines: a systematic review. Spine. 2012; 37(22S): S18-S30.

    Article  PubMed  Google Scholar 

  23. 23.

    Maldonado CV, Paz RD, Martin CB. Adjacent-level degeneration after cervical disc arthroplasty versus fusion. Eur Spine J. 2011; 20(3 Suppl): 403-7.

    Article  PubMed Central  PubMed  Google Scholar 

  24. 24.

    Matsumoto M, Okada E, Ichihara D, et al. Anterior cervical decompression and fusion accelerates adjacent segment degeneration: comparison with asymptomatic volunteers in a ten-year magnetic resonance imaging follow-up study. Spine. 2010; 35: 36-43.

    Article  PubMed  Google Scholar 

  25. 25.

    Mummaneni PV, Burkus JK, Haid RW, et al. Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: a randomized controlled clinical trial. J Neurosurg Spine. 2007; 6: 198-9.

    Article  PubMed  Google Scholar 

  26. 26.

    Okada E, Matsumoto M, Fujiwara H, et al. Disc degeneration of cervical spine on MRI in patients with lumbar disc herniation: comparison study with asymptomatic volunteers. Eur Spine J. 2011; 20(4): 585-591.

    Article  PubMed Central  PubMed  Google Scholar 

  27. 27.

    Park JB, Cho YS, Riew KD. Development of adjacent-level ossification in patients with an anterior cervical plate. J Bone Joint Surg Am. 2005; 87: 558-63.

    PubMed  Google Scholar 

  28. 28.

    Robertson JT, Papadopoulos SM, Traynelis VC. Assessment of adjacent-segment disease in patients treated with cervical fusion or arthroplasty: a prospective 2-year study. J Neurosurg Spine. 2005; 3: 417-23.

    Article  PubMed  Google Scholar 

  29. 29.

    Robinson RA, Smith GW. Anterolateral cervical disc removal and interbody fusion for cervical disc syndrome. (Abstract.) Bull. Johns Hopkins Hosp. 1955; 96: 223-224.

    Google Scholar 

  30. 30.

    Sasso RC, Smucker JD, Hacker RJ, et al. Artificial disc versus fusion. Spine. 2007; 26(32): 2933-2940.

    Article  Google Scholar 

  31. 31.

    Sasso R, Anderson P, Riew K, et al. 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: 1684-92.

    Article  PubMed  Google Scholar 

  32. 32.

    Satyajit M, Girardi F, Sama A, et al. National trends in anterior cervical fusion procedures. Spine. 2010; 35(15): 1454-1459.

    Google Scholar 

  33. 33.

    Smith GW, Robinson RA. The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Jt Surg. 1958; 40-A: 607-624.

    CAS  Google Scholar 

  34. 34.

    Wilder FV, Hall BJ, Barrett JP. Smoking and osteoarthritis: is there an association? the clearwater osteoarthritis study. Osteoarthritis Cartilage 2003;11:29.

  35. 35.

    Wilder FV, Fahlman L, Donnelly R. Radiographic cervical spine osteoarthritis progression rates: a longitudinal assessment. Rheu- matol Int 2011;31:45

  36. 36.

    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. 2005; 30: 2138-44.

    Article  PubMed  Google Scholar 

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Conflict of Interest

Haruki Ueda, MD, Russel C. Huang, MD, and Darren R. Lebl, MD have declared that they have no conflict of interest

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Correspondence to Haruki Ueda MD.

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Ueda, H., Huang, R.C. & Lebl, D.R. Iatrogenic Contributions to Cervical Adjacent Segment Pathology. HSS Jrnl 11, 26–30 (2015). https://doi.org/10.1007/s11420-014-9409-5

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  • adjacent segment pathology
  • anterior cervical discectomy and fusion
  • total disc arthroplasty
  • prognosis
  • reoperation