Skip to main content
SpringerLink
Log in

The safety and efficacy of hybrid surgery for multilevel cervical degenerative disc disease versus anterior cervical discectomy and fusion or cervical disc arthroplasty: a systematic review and meta-analysis

  • Review Article - Spine degenerative
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

Multilevel cervical degenerative disc disease (CDDD) can be treated surgically with anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (CDA), or a hybrid surgery (HS) of the two in which both procedures are used at different vertebral levels. A systematic review and meta-analysis was performed to compare the clinical and radiographical outcomes of HS against ACDF or CDA alone.

Methods

Three electronic databases were searched for articles published before December 2018. The literature was searched and assessed by independent reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

Results

Eight papers were identified as eligible with a total of 424 patients. Post-operative C2–C7 range of motion (ROM) was significantly greater after HS than ACDF (p = 0.004; mean difference (MD) 6.14°). The ROM of the superior adjacent segment was significantly lower after HS than ACDF (p < 0.0001; MD − 2.87°) as was the ROM of the inferior adjacent segment (p = 0.0005; MD − 3.11°). HS patients’ return to work was shorter than those who underwent ACDF (p < 0.00001; MD − 32.01 days) and CDA (p < 0.00001; MD − 32.92 days). There were no statistically significant differences in functional outcomes following CDA compared with HS. There was no significant difference in operation time, intra-operative blood loss, or post-operative complications between any of the procedures.

Conclusion

The number of included studies was small, the heterogeneity between them was substantial, and the quality of evidence was very low. Large randomised controlled trials are required to provide strong evidence that would enable recommendation of one intervention over another.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. Auerbach JD, Jones KJ, Fras CI, Balderston JR, Rushton SA, Chin KR (2008) The prevalence of indications and contraindications to cervical total disc replacement. Spine J 8(5):711–716

    Article  Google Scholar 

  2. Balshem H, Helfand M, Schünemann HJ et al (2011) GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 64(4):401–406

    Article  Google Scholar 

  3. Bohlman HH, Emery SE, Goodfellow DB, Jones PK (1993) 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 75(9):1298–1307

    Article  CAS  Google Scholar 

  4. Bydon M, Xu R, De la Garza-Ramos R, Macki M, Sciubba DM, Wolinsky J-P, Witham TF, Gokaslan ZL, Bydon A (2014) Adjacent segment disease after anterior cervical discectomy and fusion: incidence and clinical outcomes of patients requiring anterior versus posterior repeat cervical fusion. Surg Neurol Int 5(Suppl 3):S74–S78

    Article  Google Scholar 

  5. Chen C, Zhang X, Ma X (2017) Durability of cervical disc arthroplasties and its influence factors: a systematic review and a network meta-analysis. Medicine (Baltimore) 96(6):e5947

    Article  Google Scholar 

  6. Cho SK, Riew KD (2013) Adjacent segment disease following cervical spine surgery. J Am Acad Orthop Surg 21(1):3–11

    Article  Google Scholar 

  7. De La Garza-Ramos R, Xu R, Ramhmdani S, Kosztowski T, Bydon M, Sciubba DM, Wolinsky J-P, Witham TF, Gokaslan ZL, Bydon A (2016) Long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion. J Neurosurg Spine 24:885–891

    Article  Google Scholar 

  8. Findlay C, Ayis S, Demetriades AK (2018) Total disc replacement versus anterior cervical discectomy and fusion. Bone Joint J 100–B(8):991–1001

    Article  Google Scholar 

  9. Gandhi AA, Kode S, DeVries NA, Grosland NM, Smucker JD, Fredericks DC (2015) Biomechanical Analysis of Cervical Disc Replacement and fusion using single level, two level, and hybrid constructs. Spine (Phila Pa 1976) 40(20):1578–1585

    Article  Google Scholar 

  10. Gao WS, Tang XH, Li CJ, Ren B (2018) Comparison of three operative techniques in multilevel cervical spondylotic myelopathy: a meta-analysis. Int JClin Exp Med 11(5):4352–4370

  11. Gornet MF, Lanman TH, Burkus JK, Hodges SD, McConnell JR, Dryer RF, Copay AG, Nian H, Harrell FE (2017) Cervical disc arthroplasty with the Prestige LP disc versus anterior cervical discectomy and fusion, at 2 levels: results of a prospective, multicenter randomized controlled clinical trial at 24 months. J Neurosurg Spine 26(6):653–667

    Article  Google Scholar 

  12. Grasso G (2015) Clinical and radiological features of hybrid surgery in multilevel cervical degenerative disc disease. Eur Spine J 24(S7):842–848

    Article  Google Scholar 

  13. Hey HWD, Hong CC, Long AS, Hee HT (2013) Is hybrid surgery of the cervical spine a good balance between fusion and arthroplasty? Pilot results from a single surgeon series. Eur Spine J 22(1):116–122

    Article  Google Scholar 

  14. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH (1999) Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am 81(4):519–528

    Article  CAS  Google Scholar 

  15. Jang S-R, Lee S-B, Cho K-S (2017) A comparison of anterior cervical discectomy and fusion versus fusion combined with artificial disc replacement for treating 3-level cervical spondylotic disease. J Korean Neurosurg Soc 60(6):676–683

    Article  Google Scholar 

  16. Ji GY, Oh CH, Shin DA, Ha Y, Kim KN, Shin HC, Yoon DH (2015) Artificial disk replacement combined with fusion versus 2-level fusion in cervical 2-level disk disease with a 5-year follow-up. J Spinal Disord Tech

  17. Kang L, Lin D, Ding Z, Liang B, Lian K (2013) Artificial disk replacement combined with midlevel ACDF versus multilevel fusion for cervical disk disease involving 3 levels. Orthopedics 36(1):e88–e94

    Article  Google Scholar 

  18. Lee JH, Kim JS, Lee JH, Chung ER, Shim CS, Lee S-H (2014) Comparison of cervical kinematics between patients with cervical artificial disc replacement and anterior cervical discectomy and fusion for cervical disc herniation. Spine J 14(7):1199–1204

    Article  Google Scholar 

  19. Leven D, Meaike J, Radcliff K, Qureshi S (2017) Cervical disc replacement surgery: indications, technique, and technical pearls. Curr Rev Musculoskelet Med 10(2):160–169

    Article  Google Scholar 

  20. Lu VM, Zhang L, Scherman DB, Rao PJ, Mobbs RJ, Phan K (2017) Treating multi-level cervical disc disease with hybrid surgery compared to anterior cervical discectomy and fusion: a systematic review and meta-analysis. Eur Spine J 26(2):546–557

    Article  Google Scholar 

  21. Mende KC, Kahl N, Detzner M, Lefering R, Franke J, Weber F (2015) Comparison of dual level fusion and hybrid treatment in the cervical spine based on patient outcome. J Spine. https://doi.org/10.4172/21657939.1000218

  22. Moatz B, Tortolani PJ (2012) Cervical disc arthroplasty: pros and cons. Surg Neurol Int 3(Suppl 3):S216–S224

    PubMed  PubMed Central  Google Scholar 

  23. Moher D, Liberati A, Tetzlaff J, Altman DG (2010) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 8:336–341

    Article  Google Scholar 

  24. Park D-H, Ramakrishnan P, Cho T-H, Lorenz E, Eck JC, Humphreys SC, Lim T-H (2007) Effect of lower two-level anterior cervical fusion on the superior adjacent level. J Neurosurg Spine 7(3):336–340

    Article  Google Scholar 

  25. Park C-K, Ryu K-S (2018) Are controversial issues in cervical total disc replacement resolved or unresolved?: A review of literature and recent updates. Asian Spine J 12(1):178

    Article  Google Scholar 

  26. Saavedra-Pozo FM, Deusdara RAM, Benzel EC (2014) Adjacent segment disease perspective and review of the literature. Ochsner J 14(1):78–83

    PubMed  PubMed Central  Google Scholar 

  27. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg 73(9):712–716

    Article  Google Scholar 

  28. Tian P, Fu X, Li Z-J, Sun X-L, Ma X-L (2015) Hybrid surgery versus anterior cervical discectomy and fusion for multilevel cervical degenerative disc diseases: a meta-analysis. Sci Rep 5(1):13454

    Article  CAS  Google Scholar 

  29. Van Eck CF, Regan C, Donaldson WF, Kang JD, Lee JY (2014) The revision rate and occurrence of adjacent segment disease after anterior cervical discectomy and fusion: a study of 672 consecutive patients. Spine (Phila Pa 1976) 39(26):2143–2147

    Article  Google Scholar 

  30. Wang K-F, Duan S, Zhu Z-Q, Liu H-Y, Liu C-J, Xu S (2018) Clinical and radiologic features of 3 reconstructive procedures for the surgical management of patients with bilevel cervical degenerative disc disease at a minimum follow-up period of 5 years: a comparative study. World Neurosurg 113:e70–e76

    Article  Google Scholar 

  31. Wu T-K, Wang B-Y, Meng Y, Ding C, Yang Y, Lou J-G, Liu H (2017) Multilevel cervical disc replacement versus multilevel anterior discectomy and fusion: a meta-analysis. Medicine (Baltimore) 96(16):e6503

    Article  Google Scholar 

  32. Xiong Y, Xu L, Yu X et al (2018) Comparison of 6-year follow-up result of hybrid surgery and anterior cervical discectomy and fusion for the treatment of contiguous two-segment cervical degenerative disc diseases. Spine (Phila Pa 1976) 43(20):1418–1425

    Article  Google Scholar 

  33. Yu S, Li F, Yan N, Yuan C, He S, Hou T (2014) Anterior fusion technique for multilevel cervical spondylotic myelopathy: a retrospective analysis of surgical outcome of patients with different number of levels fused. PLoS One 9(3):e91329

    Article  Google Scholar 

  34. Zang L, Ma M, Hu J, Qiu H, Huang B, Chu T (2015) Comparison of hybrid surgery incorporating anterior cervical discectomy and fusion and artificial arthroplasty versus multilevel fusion for multilevel cervical spondylosis: a meta-analysis. Med Sci Monit 21:4057–4067

    Article  Google Scholar 

  35. Zhang J, Meng F, Ding Y, Li J, Han J, Zhang X, Dong W (2016) Hybrid surgery versus anterior cervical discectomy and fusion in multilevel cervical disc diseases. Medicine (Baltimore) 95(21):e3621

    Article  Google Scholar 

  36. Zhao C-M, Chen Q, Zhang Y, Huang A-B, Ding W-Y, Zhang W (2018) Anterior cervical discectomy and fusion versus hybrid surgery in multilevel cervical spondylotic myelopathy: a meta-analysis. Medicine (Baltimore) 97(34):e11973

    Article  Google Scholar 

  37. Zhao H, Cheng L, Hou Y, Liu Y, Liu B, Mundra JJ, Nie L (2015) Multi-level cervical disc arthroplasty (CDA) versus single-level CDA for the treatment of cervical disc diseases: a meta-analysis. Eur Spine J 24(1):101–112

    Article  CAS  Google Scholar 

  38. Zhong Z-M, Zhu S-Y, Zhuang J-S, Wu Q, Chen J-T (2016) Reoperation after cervical disc arthroplasty versus anterior cervical discectomy and fusion: a meta-analysis. Clin Orthop Relat Res 474(5):1307–1316

    Article  Google Scholar 

  39. Zou S, Gao J, Xu B, Lu X, Han Y, Meng H (2017) Anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty (CDA) for two contiguous levels cervical disc degenerative disease: a meta-analysis of randomized controlled trials. Eur Spine J 26(4):985–997

    Article  Google Scholar 

Download references

Acknowledgements

Mrs Sheila Fisken, Medical Librarian, University of Edinburgh for advice and assistance with an optimal search strategy.

Funding

This study did not receive funding to carry out this research. Dr Salma Ayis was funded by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London.

Author information

Author notes

  1. Marcus A. Hollyer

    Present address: Mater Infirmorum Hospital (Belfast Health and Social Care Trust), 45-51 Crumlin Road, Belfast, BT14 6AB, UK

Authors and Affiliations

  1. University of Edinburgh Medical School, Edinburgh, UK

    Marcus A. Hollyer & Emma C. Gill

  2. Edinburgh Spinal Surgery Outcomes Study Group, Edinburgh, UK

    Marcus A. Hollyer & Andreas K. Demetriades

  3. Primary Care and Public Health Sciences, Kings College London, London, UK

    Salma Ayis

  4. Department of Neurosurgery, Western General Hospital, Edinburgh, UK

    Andreas K. Demetriades

Authors
  1. Marcus A. Hollyer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Emma C. Gill
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Salma Ayis
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andreas K. Demetriades
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marcus A. Hollyer.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Due to the nature of the study, informed consent from participants was not required.

Disclaimer

The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health.

Additional information

Comments

The group from Edinburgh performed a systematic literature review and meta-analysis with the aim to compare clinical and radiological outcomes after hybrid surgery for multilevel cervical degenerative disc disease. Those outcomes were compared against both anterior cervical fusion and motion preserving disc arthroplasty. With a poor quality of underlying included studies that predominantly report on Asian populations, also the results of this pooled analysis have to be interpreted with caution and are unlikely to provide us with clear guidance as to whether this option should be offered to our patients more often. The data, however, point towards at least noninferiority of hybrid surgery. Offering it to selected patients therefore appears reasonable and safe. With more experience gained over time—or should high-quality RCT data provide better evidence—the role of hybrid surgery will be better defined. The authors provide us with a good starting point from where this treatment option can progressively be explored.

Martin N. Stienen

Zurich (CH)/Stanford (USA)

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Spine degenerative

This study was performed while the corresponding author was located at the University of Edinburgh.

Appendices

Appendix 1

((ACDF OR fusion OR discectomy) OR (disc replacement OR arthroplasty OR CDA OR ADR)) AND hybrid AND cervical

Appendix 2

Grade: HS vs ACDF

Question: HS compared with ACDF for cervical degenerative disc disease

Bibliography: Hybrid surgery versus ACDF or CDA for cervical degenerative disc disease. Cochrane Database of Systematic Reviews [Year], Issue [Issue].

figure c

CI: Confidence interval; MD: Mean difference; OR: Odds ratio

Explanation

a. Study Design: Only one of the studies that report this outcome is a RCT.

b. Bias downgraded 1 level: Inherent detection bias when measuring C2-C7 ROM as it is not possible to be blinded to patient's intervention as it is clear on the radiograph if they have a hybrid or ACDF.

c. Inconsistency downgraded 1 level: Statistical heterogeneity was high across all studies, but methodology similar using Cobb angles measured from lateral radiographs.

d. Imprecision downgraded 1 level: Number of participants is low.

e. Bias downgraded 1 level: Detection bias from self-reported outcomes via patient questionnaire, no mention of blinding of the staff assisting with clinical evaluation as to patients' treatment (with the exception of Kang et al).

f. Inconsistency downgraded 1 level: Statistical heterogeneity was high across all studies, but methodology in recording pain scores similar.

g. Inconsistency downgraded 2 levels: Statistical heterogeneity very high, and difference in type of prosthesis and 3-level/2-level surgery between studies may affect this outcome.

h. Moderate statistical heterogeneity

Grade: HS vs CDA

Question: HS compared with CDA for cervical degenerative disc disease

Bibliography: Hybrid surgery versus ACDF or CDA for cervical degenerative disc disease. Cochrane Database of Systematic Reviews [Year], Issue [Issue].

figure d

CI: Confidence interval; MD: Mean difference; OR: Odds ratio

Explanation

a. Bias downgraded 1 level: Inherent detection bias as it is not possible to be blinded to patient's intervention as it is clear on the radiograph if they have a disc replacement or a cage fusion.

b. Inconsistency downgraded 1 level: Statistical heterogeneity is high and data from Hey et al are median not mean values.

c. Imprecision downgraded 1 level. Number of patients analysed is very low, 95% CI of average effect size is very wide.

d. Bias downgraded 1 level: Detection bias from self-reported outcomes via patient questionnaire, no mention of blinding of the staff assisting with clinical evaluation as to patients' treatment.

e. Inconsistency downgraded 2 levels: Statistical heterogeneity is high and clinical heterogeneity that could effect this outcome relating to time in collar post op.

f. Imprecision downgraded 1 level: Number of patients analysed is very low.

g. Performance bias and detection bias inherent in surgical procedure and risk of bias from study design, however these are unlikely to affect this outcome.

h. Imprecision downgraded 1 level. Number of patients analysed is very low, but pooled effect estimate does not cross the line of null effect.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hollyer, M.A., Gill, E.C., Ayis, S. et al. The safety and efficacy of hybrid surgery for multilevel cervical degenerative disc disease versus anterior cervical discectomy and fusion or cervical disc arthroplasty: a systematic review and meta-analysis. Acta Neurochir 162, 289–303 (2020). https://doi.org/10.1007/s00701-019-04129-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-019-04129-3

Keywords

Search

Navigation