Elsevier

World Neurosurgery

Volume 113, May 2018, Pages 225-231
World Neurosurgery

Literature Review
Rate of Adjacent Segment Degeneration of Cervical Disc Arthroplasty Versus Fusion Meta-Analysis of Randomized Controlled Trials

https://doi.org/10.1016/j.wneu.2018.02.113Get rights and content

Highlights

  • Twenty-one studies were included in our meta-analysis.

  • The pooled data revealed that the CDA group had significantly fewer adjacent segment diseases than the ACDF group did.

  • There were fewer adjacent segment reoperations in the CDA group compared with the ACDF group.

Background

The concern of adjacent segment disease (ASD) has led to the development of motion-preserving technologies, such as cervical disc arthroplasty (CDA). However, there is still controversy whether CDA is superior to anterior cervical decompression and fusion (ACDF) as to the incidence of ASD. The purpose of this study is to evaluate the rate of ASD between CDA and ACDF.

Methods

Systematic searches of all relevant studies through November 2017 were identified from the Cochrane Library, PubMed, Embase, and CNKI. Randomized controlled trials comparing the clinical effectiveness of CDA and ACDF for cervical degenerative disc disease (DDD) were included. Two independent reviewers searched and assessed all literature according to the standard of Cochrane systematic review. Data extraction and quality assessment were conducted, and RevMan 5.2 was used for data analysis. The random effects model was used if there was heterogeneity between studies; otherwise, the fixed effects model was used.

Results

Twenty-one studies were included in our meta-analysis. The pooled data revealed that the CDA group had significantly lower adjacent segment diseases than the ACDF group did. Furthermore, there were fewer adjacent segment reoperations in the CDA group compared with the ACDF group.

Conclusions

In this meta-analysis, we conclude that CDA was better than the ACDF in terms of ASD and adjacent segment reoperations. This conclusion suggests that CDA is a superior alternative invention for the treatment of cervical DDD to preserve cervical range of motion and reduce the risk of ASD; however, this requires further validation and investigation in larger sample-size prospective and randomized studies with long-term follow-up.

Introduction

Anterior cervical discectomy and fusion (ACDF) has been considered a gold standard for symptomatic cervical degenerative disc disease (DDD)1, 2, 3; however, there is evidence showing that this procedure usually results in the loss of motion at the operated level4, 5 and accelerated adjacent level disc degeneration.6 A previous long-term follow-up study reported that the incidence of adjacent segment disease (ASD) after ACDF was up to 54.7%, and adjacent segment reoperation was even as high as 11.6%.7

Cervical disc arthroplasty (CDA) is an alternative to fusion after anterior neural decompression.8 CDA offers the theoretical advantage of preservation of the motion patterns and the range of motion (ROM), reconstitution of disc height and spinal alignment, and earlier recovery of cervical function.9, 10 However, many controlled trials reported controversial results with the incidence of ASD after CDA.11, 12, 13, 14, 15, 16, 17, 18

Previous meta-analyses have compared the rate of ASD between CDA and ACDF19, 20, 21, 22, 23; however, there is still no consensus concerning the superiority of CDA or ACDF regarding the incidence of ASD. To further clarify controversies in the current literature, we performed a meta-analysis to evaluate the incidence of ASD between CDA and ACDF.

Section snippets

Search Strategy and Study Selection

Electronic searches were performed using Cochrane Library, PubMed, and Embase from their dates of inception to November 2017. No language was restricted. The following search terms were used: “anterior cervical decompression and fusion”, “cervical arthrodesis”, “disc replacement”, “disc prostheses”, and “cervical arthroplasty” and “clinical trial” as either keywords or MeSH terms. Reference lists of all included studies were scanned to identify additional potentially relevant studies.

Data Extraction

Two reviewers independently extracted the data using a standardized form, which covered the following items: study design, first author, publication date, mean age, sample size, length of follow-up, rate of ASD, adjacent segment reoperation, preoperative and postoperative C2–C7 ROM, and prosthesis type.

Results

The process of identifying relevant studies is summarized in Figure 1. From the selected databases, 9993 references were obtained, of which 1859 remained after excluding duplicates. After screening the titles and abstracts, 1767 trials were excluded because they did not reach the standard of inclusion criteria. The retaining 92 potential articles were retrieved for further full-text evaluation. Finally, 21 RCTs were included in our meta-analysis.11, 12, 13, 14, 15, 25, 26, 27, 28, 29, 30, 31, 32

Discussion

ACDF is an effective and safe procedure for the surgical treatment of patients with cervical DDD. However, ACDF increases the stress on adjacent segments, which can accelerate disc degeneration and lead to ASDs.41, 42, 43 In addition, multilevel fusion will cause a compensatory increase of the motion at the adjacent levels, which will cause ASD consequently in long-term follow-up.44 Recently, a long-term prospective cohort study concluded that secondary surgeries were performed for

Conclusion

In conclusion, our meta-analysis reveals CDA had significantly fewer ASD and adjacent segment reoperations compared with the ACDF. CDA is superior to ACDF in ASD. This suggests CDA is an effective alternative invention for the treatment of cervical DDD to preserve cervical range of motion and reduce the risk of ASD. However, this requires further validation and investigation in larger sample-size prospective and randomized studies with long-term follow-up.

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    • Anterior Cervical Discectomy and Fusion Versus Cervical Disc Arthroplasty: A Comparison of National Trends and Outcomes

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      This modality of surgery provides an avenue for decompression of the spinal cord and nerve roots while allowing for restoration of the disc height and cervical alignment.21 However, the fusion component of the procedure, both through instrumentation as well as subsequent bony growth within the construct, lends to loss of mobility within the fused segments.22,23 The biomechanical force distribution resulting from the loss of mobility within the fused joint spaces increases stress on adjacent disc spaces and results in adjacent-segment disease (ASD).24,25

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    Jiaquan Luo, Hongbo Wang and Jun Peng equally contributed to this work.

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