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    A Viable Option for Treating Multilevel Cervical Degenerative Disc Disease

    A recently published randomized controlled trial demonstrates improved neurologic outcomes in patients treated with total disc replacement versus the gold standard of anterior cervical discectomy and fusion.

    Authors

    Yuhang Sun, MD; Shaleen Vira, MD; and Peter Passias, MD

    Article

    Jackson R, Johnson DE. Neurological outcomes of two-level total disc replacement versus anterior discectomy and fusion: 7-year results from a prospective, randomized, multicenter trial. Neurosurgery. 2016 Aug;63 Suppl 1:164. PMID 27399438.

    Summary

    In this prospective, multicenter, randomized controlled clinical trial, the authors followed 330 patients who had undergone 1 of 2 surgical procedures for multilevel cervical degenerative disc disease

    • Total disc replacement (TDR), 225 patients
    • Anterior cervical discectomy and fusion (ACDF), 105 patients

    Patients were treated at 2 contiguous levels from C3 to C7.

    At 7-year follow-up, the rate of neurologic deterioration was 13.4% for patients undergoing TDR versus 34.2% for patients undergoing ACDF (P=0.001).

    • Sensory: TDR 3.0% vs. ACDF 4.8%
    • Motor: TDR 0.9% vs. ACDF 1.9%
    • Reflex: TDR 0.4% vs. ACDF 1.0%
    • Visual Analog Scale neck pain: TDR 18.7 vs. ACDF 29.7
    • Visual Analog Scale arm pain: TDR 15.2 vs ACDF 18.8

    Device-related neurologic adverse events and device-related subsequent surgery were significantly lower for patients treated with TDR than with ACDF (5.1% vs 11.4%; P= 0.04 and 4.9% vs 16.2; P=0.001, respectively). Patients undergoing TDR maintained flexion extension ranges of motion at both the superior (9.4°) and inferior (7.5°) treated level.

    Clinical Relevance

    The current gold standard for treatment of cervical radiculopathy is anterior cervical discectomy and fusion (ACDF).

    However, this procedure is known to change the biomechanics of the spine, resulting in increased motion, stress, or disc pressure at adjacent levels. [1] When multiple levels are fused at once, the biomechanical changes can become additive, placing further stress at the adjacent levels.

    Multiple studies have demonstrated that patients undergoing single-level total disc replacement (TDR) have improved outcomes compared with patients undergoing ACDFs. [2-5]

    What about multiple-level procedures? Until this study, data with follow-up longer than 5 years had been more limited.

    With a longer follow-up period, this study adds to the evidence indicating that patients treated with 2-level TDRs demonstrate better long-term neurologic outcomes than patients who underwent ACDFs.

    Author Information

    Yuhang Sun, MD, and Shaleen Vira, MD, are orthopaedic surgery residents at NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York. Peter Passias, MD, is a Clinical Assistant Professor of Orthopaedic Surgery, Division of Spine Surgery, Department of Orthopaedic Surgery, at NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.

    References

    • Cepoiu-Martin M, Faris P, Lorenzetti D, et al. Artificial cervical disc arthroplasty: a systematic review. Spine. 2011; 36:E1623–E1633.
    • 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 (Phila Pa 1976) 2015 Apr 15;40(8):521–9. doi: 10.1097/BRS.0000000000000822.
    • Alvin MD, Qureshi S, Klineberg E, Riew KD, Fischer DJ, Norvell DC, et al. Cervical degenerative disease: systematic review of economic analyses. Spine (Phila Pa 1976) 2014 Oct 15;39:S53–64. doi: 10.1097/BRS.0000000000000547.
    • McAnany SJ, Overley S, Baird EO, Cho SK, Hecht AC, Zigler JE, et al. The 5-year cost-effectiveness of anterior cervical discectomy and fusion and cervical disc replacement: a Markov analysis. Spine (Phila Pa 1976) 2014 Nov 1;39(23):1924–33. doi: 10.1097/BRS.0000000000000562.
    • Wiedenhófer B, Nacke J, Stephan M, Richter W, Carstens C, Eichler M. Is Total Disc Replacement a Cost Effective Treatment for Cervical Degenerative Disc Disease? J Spinal Disord Tech. 2014 Oct 10.