Elsevier

The Spine Journal

Volume 17, Issue 10, October 2017, Pages 1549-1558
The Spine Journal

Review Article
The change of adjacent segment after cervical disc arthroplasty compared with anterior cervical discectomy and fusion: a meta-analysis of randomized controlled trials

https://doi.org/10.1016/j.spinee.2017.06.010Get rights and content

Abstract

Background Context

Many meta-analyses have been performed to study the efficacy of cervical disc arthroplasty (CDA) compared with anterior cervical discectomy and fusion (ACDF); however, there are few data referring to adjacent segment within these meta-analyses, or investigators are unable to arrive at the same conclusion in the few meta-analyses about adjacent segment. With the increased concerns surrounding adjacent segment degeneration (ASDeg) and adjacent segment disease (ASDis) after anterior cervical surgery, it is necessary to perform a comprehensive meta-analysis to analyze adjacent segment parameters.

Purpose

To perform a comprehensive meta-analysis to elaborate adjacent segment motion, degeneration, disease, and reoperation of CDA compared with ACDF.

Study Design

Meta-analysis of randomized controlled trials (RCTs).

Methods

PubMed, Embase, and Cochrane Library were searched for RCTs comparing CDA and ACDF before May 2016. The analysis parameters included follow-up time, operative segments, adjacent segment motion, ASDeg, ASDis, and adjacent segment reoperation. The risk of bias scale was used to assess the papers. Subgroup analysis and sensitivity analysis were used to analyze the reason for high heterogeneity.

Results

Twenty-nine RCTs fulfilled the inclusion criteria. Compared with ACDF, the rate of adjacent segment reoperation in the CDA group was significantly lower (p<.01), and the advantage of that group in reducing adjacent segment reoperation increases with increasing follow-up time by subgroup analysis. There was no statistically significant difference in ASDeg between CDA and ACDF within the 24-month follow-up period; however, the rate of ASDeg in CDA was significantly lower than that of ACDF with the increase in follow-up time (p<.01). There was no statistically significant difference in ASDis between CDA and ACDF (p>.05). Cervical disc arthroplasty provided a lower adjacent segment range of motion (ROM) than did ACDF, but the difference was not statistically significant.

Conclusions

Compared with ACDF, the advantages of CDA were lower ASDeg and adjacent segment reoperation. However, there was no statistically significant difference in ASDis and adjacent segment ROM.

Introduction

Anterior cervical discectomy and fusion (ACDF) has been known as the “gold standard” for patients with cervical radiculopathy or myelopathy since described by Smith and Robinson more than a half century ago [1]. However, adjacent segment degeneration (ASDeg) and adjacent segment disease (ASDis) were paid more and more attention after long-term follow-up of ACDF [2]. Adjacent segment disease is different from ASDeg, which is defined as asymptomatic radiographic ASDeg [3]. Several papers have shown that ACDF accelerated the incidence of ASDeg through altering adjacent segment biomechanics [4], [5]. In a 60-month follow-up study, Zigler et al. [6] showed that the rate of ASDeg after ACDF in second-level patients was up to 54.7%, and adjacent segment reoperation was even as high as 11.6%.

Cervical disc arthroplasty (CDA) was introduced to reduce ASDeg, with the theory of maintaining intervertebral range of motion (ROM) and reducing compensatory ROM of adjacent segment. In many controlled trials, even a randomized controlled trial (RCT) showed that the incidence of ASD after CDA was lower than ACDF [5], [7], [8]; however, Hisey et al. [9] found that there was no statistically significant difference in the rate of ASDis between ACDF and CDA. Hence, some meta-analyses [10], [11], [12], [13] have tried to solve the controversy by reviewing RCTs. However, investigators are still unable to arrive at the same conclusion because of a lack of sufficient clinical RCTs, and the above meta-analyses focused only on the incidence of adjacent segment reoperation or ASDis. In our study, we searched RCTs exhaustively and performed a comprehensive meta-analysis to compare adjacent segment ROM, degeneration, disease, and reoperation between ACDF and CDA.

Section snippets

Materials and methods

We used the guidelines of the Cochrane Collaboration to perform the meta-analysis [14].

Search results

There were 2,471 relevant studies included according to the search strategy. First, 614 records remained after duplicates were removed; second, 533 titles were excluded after assessing the abstract and title; third, 29 articles were eligible for the inclusion criteria after review of the full text [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42] (Fig. 1). Reasons excluding articles by

Discussion

Since first reported in 1958 by Robinson et al., ACDF has been known as the gold standard in the treatment of cervical radiculopathy and myelopathy [1]. However, ASDeg and ASDis have become serious complications after ACDF in the long-term follow-up. The CDA was introduced to reduce the ASDeg through preserving the intervertebral ROM and theoretically reducing compensatory ROM and load of the adjacent segment. Nevertheless, there was controversy about the pathologic process of the adjacent

Conclusion

Our meta-analysis indicated that, compared with the ACDF group, the CDA group has the advantage of a lower ASDeg and fewer adjacent segment reoperations. However, there were no statistically significant differences in ASDis and adjacent segment ROM. More high-quality RCTs are needed to confirm the results and eliminate publication bias.

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    FDA device/drug status: Not applicable.

    Author disclosures: LD: Grant: China Postdoctoral Science Foundation (A, Paid directly to institution/employer), pertaining to the submitted work. ZX: Grant: China Postdoctoral Science Foundation (A, Paid directly to institution/employer), pertaining to the submitted work. XC: Grant: China Postdoctoral Science Foundation (A, Paid directly to institution/employer), pertaining to the submitted work. DW: Grant: China Postdoctoral Science Foundation (A, Paid directly to institution/employer), pertaining to the submitted work. DL: Grant: China Postdoctoral Science Foundation (A, Paid directly to institution/employer), pertaining to the submitted work. TL: Grant: China Postdoctoral Science Foundation (A, Paid directly to institution/employer), pertaining to the submitted work. DH: Grant: China Postdoctoral Science Foundation (A, Paid directly to institution/employer), pertaining to the submitted work.

    China Postdoctoral Science Foundation project funds (2016M602845) were received in support of this work. There are no other relevant financial activities outside the submitted work.

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

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