Where Are We Now?
Is there a higher reoperation rate after anterior cervical discectomy and fusion when compared to cervical disc replacement? This is a common question asked by spinal surgeons determining the best intervention for patients with cervical radiculopathy due to soft-disc herniation or minor spondylosis. Generally, spine surgeons indicate a patient for cervical disc replacement if there is only one level of disease or, at most, two levels assuming there is minimal to no spondylosis. It is also thought (and hoped) that cervical disc replacement would lessen the rate of adjacent segment disease and the need for reoperation. A meta-analysis can help detemine whether this aspiration will come to fruition. A number of intermediate-term trials [5-10] have suggested an increased rate of reoperation and poor health-related quality of life outcomes with anterior cervical discectomy and fusion when compared to cervical disc replacement. However, these findings have not been consistent. Some studies show no difference between anterior cervical discectomy and fusion and cervical disc replacement, while others demonstrate superiority of cervical disc replacement [2, 4, 5].
Where Do We Need To Go?
At this point, we need excellent and comprehensive followup of the patients enrolled in the investigational device exemption trials in order to understand the durability and performance of these devices in the long-term. Further, we need to understand if there are particular devices that are better suited for particular patient types or specific radiographic findings. Finally, we need to determine whether these questions will have different answers for one- versus two-level disease.
How Do We Get There?
The investigational device exemption studies from multiple companies that led to approval of a number of these devices contain some of the richest and most complete outcome data available in spinal surgery [5-10]. This is because the studies were well controlled with very specific enrollment criteria, close monitoring, and excellent followup. These cohort of patients need to be followed to obtain longer-term answers to the questions posed above. Further subanalyses of the dataset may have the potential to answer specific questions regarding details of decision making and radiographic criteria with which to make intervention decisions. Cervical disc replacement has the potential to be an excellent long-term intervention in this patient subset with these answers and further innovation to improve upon the devices available [1, 3].
1. Beaurain J, Bernard P, Dufour T, Fuentes JM, Hovorka I, Huppert J, Steib JP, Vital JM, Aubourg L, Vila T. Intermediate clinical and radiological results of cervical TDR (Mobi-C) with up to 2 years of follow-up. Eur Spine J.
2. Burkus JK, Traynelis VC, Haid RW Jr, Mummaneni PV. Clinical and radiographic analysis of an artificial cervical disc: 7-year follow-up from the Prestige prospective randomized controlled clinical trial. J Neurosurg Spine.
3. 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.
4. Delamarter RB, Zigler J. Five-year reoperation rates, cervical total disc replacement versus fusion, results of a prospective randomized clinical trial. Spine (Phila Pa 1976).
5. Phillips FM, Geisler FH, Gilder KM, Reah C, Howell KM, McAfee PC. Long-term outcomes of the US FDA IDE prospective, randomized controlled clinical trial comparing PCM cervical disc arthroplasty with anterior cervical discectomy and fusion. Spine.
6. 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.
7. Radcliff K, Zigler J, Zigler J. Costs of cervical disc replacement versus anterior cervical discectomy and fusion for treatment of single-level cervical disc disease: An analysis of the blue health intelligence database for acute and long-term costs and complications. Spine.
8. Rihn JA, Radcliff K, Hipp J, Vaccaro AR, Hilibrand AS, Anderson DG, Albert TJ. Radiographic variables that may predict clinical outcomes in cervical disk replacement surgery. J Spinal Disord Tech.
9. Vaccaro A, Beutler W, Peppelman W, Marzluff JM, Highsmith J, Mugglin A, DeMuth G, Gudipally M, Baker KJ. Clinical outcomes with selectively constrained SECURE-C cervical disc arthroplasty: Two-year results from a prospective, randomized, controlled, multicenter investigational device exemption study. Spine.
10. Zigler JE, Delamarter R, Murrey D, Spivak J, Janssen M. ProDisc-C and anterior cervical discectomy and fusion as surgical treatment for single-level cervical symptomatic degenerative disc disease: five-year results of a Food and Drug Administration study. Spine.