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