Abstract
Background Artificial disc replacement (ADR) has become an evidence-based alternative to traditional fusion surgery. Current guidelines for safe return-to-activity (RTA) levels following surgery have yet to be determined. This Modified Delphi study aimed to establish expert-sourced consensus for safe and optimized RTA recommendations following cervical disc arthroplasty.
Methods Ten expert spine surgeons with an average of 15 years of surgical experience participated in a 3-round Modified Delphi Method. The first round presented experts with 11 clinical cases and 19 multiple-choice questions regarding recommendations for patient RTA following surgery for 1-, 2-, or 3-level arthroplasty. First-round responses were analyzed and presented in second-round surveys to the experts, who repeated 19 multiple-choice questions. The third round presented consensus recommendation statements derived from the second round for the final assessment of the expert agreement.
Results Experts agreed on 19 of 22 (86.4%) postarthroplasty RTA recommendations. Eight recommendations achieved unanimous agreement; the most robust consensus (95%–100% agreement) included recommendations that patients may return to basic activities such as walking, social activities, sedentary work, air travel, and sexual activity within 2 weeks of arthroplasty surgery and that arthroplasty patients will have a shorter recovery, resuming normal activities sooner than fusion patients. Experts agreed that patients may return to light and heavy physical activity (strong consensus) earlier for 2- and 3-level ADR compared to hybrid constructs. Experts also agreed that ADR patients can resume light physical activity at 4 to 6 weeks and engage in intense conditioning and sport-specific training at 6 weeks. However, a weaker consensus was achieved for returning to physically demanding work at 4 to 6 weeks and high-intensity physical activity/sports at 6 weeks, indicating that individual patient factors and the specific nature of the activity should be considered.
Conclusion This study provides the first consensus-based recommendations for RTA following cervical disc arthroplasty.
Level of Evidence 4.
Introduction
Historically, anterior cervical decompression and fusion (ACDF) has been considered the standard of care for treating disorders of the cervical spine, accounting for more than 774,000 procedures performed between 2010 and 2022 and comprising approximately 62% of all cervical spine operations.1–3 Although ACDF has proven to be a useful means of reducing pain, impairment, and discomfort associated with cervical spine disease, potential long-term limitations exist. Longitudinal studies following ACDF patients suggest that more than 90% exhibit radiographic evidence of adjacent-segment degeneration (ASD), although clinical symptoms do not necessarily correlate with radiographic findings.4 The concept of fusion and the resulting loss of motion also seem antithetical to the natural kinematics of the spine, especially without instability (note that the majority of ACDF surgery is performed for degenerative conditions). Given these limitations, research on alternative approaches for treating cervical disc disorders has gained traction.
Cervical disc arthroplasty is an innovative and contemporary approach for the treatment of cervical spine disorders. Early investigation into cervical artificial implants dates back to the 1960s, when Fernstrom implanted a device consisting of a simple stainless-steel ball.5 Since then, cervical artificial arthroplasty has advanced significantly, and at the time of writing, more than 15 artificial discs have been used globally.6 Over the past 20 years, arthroplasty has gained popularity, increasing from just 4% of anterior cervical procedures in 2010 to around 14% by 2018, as a means of treating patients with cervical disc disorders owing to its established advantages over ACDF.7 While fusion has been as successful in alleviating discomfort at degenerative segments by eliminating nonphysiological motion, the drawbacks are not trivial.8,9 Greater distributive stresses and nonphysiological motion accelerate disc degeneration and increase the likelihood of ASD, a primary cause of reoperation following ACDF.10–12 While there has been considerable debate, level 1 evidence suggests that artificial disc replacement (ADR) mitigates these distributive stresses and therefore ASD and reoperations. Most of the literature on cervical ADR compares outcomes with ACDF, although some more recent trials have conducted head-to-head comparisons between ADR devices.13–20 Numerous trials have demonstrated the superiority of ADR over fusion, using many validated scales and metrics. Despite criticisms that many of these trials were industry-sponsored and therefore biased, the ACDF literature reports similar findings with similar biases over the decades.
As surgeons and patients gravitate more toward ADR surgery, especially in the younger, more athletic population, uncertainty remains around return-to-activity (RTA) guidelines. Previous research has established RTA consensus recommendations for athletes following cervical spine injury and surgery.21 This study was limited to patients who underwent ACDF. The purpose of this study was to therefore establish expert guidelines for RTA in patients who underwent “on-label” and “off-label” cervical ADR, consisting of 1-, 2-, and 3-level ADR, or hybrid surgery (HS; defined as a multi-level surgery utilizing at least 1 level of ADR and 1-level fusion). The study further aimed to determine whether ADR offers an advantage over ACDF in terms of RTA.
Methods
A 3-round retrospective modified Delphi research protocol involving 10 expert spine surgeons was conducted. Both neurosurgical and orthopedic spine specialists were included. Selection criteria for the experts included having an active clinical practice, at least 5 years of posttraining experience, and routine management of both on- and off-label ADR. All surgeons were fellowship trained in spine surgery, and both subspecialties (orthopedic and neurosurgical) were represented. During the initial round, an online survey was created based on pertinent questions related to RTA in patients who underwent 1-, 2-, or 3-level cervical ADR or HS, with no pure fusion cases being included. The ADR devices represented in the clinical cases included the Orthofix M6, Baguera-C, and Prodisc Vivo prostheses. Surgeons received an online link via email that contained 11 unique clinical vignettes, including pre- and postoperative imaging, each with the same 19 questions in a multiple-choice format. All clinical vignettes represented patients with clear surgical indication, predominantly cervical spondylosis with neural compression (radiculopathy or myelopathy), herniated nucleus pulposus, or stenosis, consistent with standard criteria for arthroplasty surgery. The cases were evaluated anonymously, and all identifiable patient information was concealed. Following completion, the same clinical cases and questions were rearranged to account for priming bias and then resent to the surgeons. The results of this second round were then used to create clinical consensus recommendation statements. In the third and final phase, these recommendation statements were presented to the participating surgeons, who were then asked to agree or disagree. This study, the Delphi method protocol, and the survey were exempt from Institutional Review Board review. All patients provided informed consent prior to undergoing surgery and for ongoing data collection.
Results
Expert Demographics
The survey included 10 expert surgeons: 7 orthopedic surgeons and 3 neurosurgeons. Table 1 presents the demographic characteristics of the Expert Panel. The majority (70%) had more than 20 years of clinical experience, with the remaining participants having between 5 and 10 years of experience. The panel was composed of experts representing a balanced mix of practice environments, including surgeons from both private practice and academic institutions, reflecting the real-world distribution of arthroplasty care. Sixty percent of surgeons on the expert panel perform more than 50 cervical arthroplasty procedures annually, including 1 surgeon conducting more than 150 procedures per year. This high-volume expertise ensures that the responses reflect the practices of highly experienced and specialized surgeons in the field of cervical ADR. Each round of the survey yielded 100% participation among the surgeons (n = 10).
Expert panel demographics (N = 10).
Consensus Recommendations on Returning to Postsurgery Activity
Upon analysis of the first 2 rounds of survey results, 22 clinical recommendations were developed regarding the postsurgical timeline for resuming various activities following 1-, 2-, and 3-level ADR surgeries. Of the 22 recommendations surveyed, 8 achieved unanimous and strongest consensus, 4 achieved strong consensus, 7 achieved weak consensus, and 3 achieved no consensus (Table 2). These recommendations focused on the resumption of various daily and physical activities, including walking, returning to work, and engaging in physical activity following cervical arthroplasty.
Consensus statements regarding return to activity after cervical arthoplasty.
Return to Daily Activity Recommendations
Responses to recommendation statements for return to daily activity (Table 3) revealed unanimous agreement among surveyed surgeons (100%) that patients could safely begin walking immediately postoperatively, in all surgical subgroups. Participation in social activities, sexual activities, and travel by air was deemed safe within 2 weeks following ADR surgery at 1-, 2-, and 3-levels, with 100% agreement. In return to driving, no consensus was achieved regarding immediate return to driving following ADR surgery, with 50% agreement on patients returning immediately following surgery and 40% in disagreement.
Return to daily activity guidelines for cervical arthroplasty.
In resuming work, returning to sedentary work following ADR surgery (all subgroups) achieved the strongest consensus (100%) with return within 1 to 2 weeks postoperatively. A weak consensus was reached, with 70% of surgeons agreeing that it is safe for patients undergoing ADR surgery to return to physically demanding work within 4 to 6 weeks of surgery. Additionally, 60% of surgeons (weak consensus) agreed that there was no high-risk occupation in which patients were urged not to return to ADR surgery.
The survey revealed a unanimous agreement and the strongest consensus among surgeons (100%) that ADR surgeries generally have a shorter recovery timeline than spinal fusion surgeries. Regarding return to normal activities, surgeons unanimously agreed (100%) that cervical ADR patients are likely to resume normal activities sooner than spinal fusion patients.
Physical Activity and Therapy Recommendations
Concerning recommendations for returning to physical therapy (Table 4), surgeons unanimously agreed (100%) that patients could safely engage in light physical activity within 4 to 6 weeks of 1-, 2-, and 3-level ADR. Regarding high-intensity physical activity and sports, a weak consensus was achieved with 60% of surveyed surgeons agreeing that patients with a 1-level ADR surgery may resume high-intensity physical activity within 4 to 6 weeks of surgery, while 70% of surgeons agreed that multilevel ADR surgery patients can return to high-intensity sports after 6 weeks. When comparing the time to RTA for patients receiving a single vs multilevel surgery, no consensus was achieved. However, surveyed surgeons found a strong consensus (80%), agreeing that both 2- and 3-level ADR patients will return to light- and high-intensity physical activity quicker than patients receiving HS. Most surgeons (80%) agreed that intense conditioning should start at 6 weeks or more following ADR surgery, while for sports-specific training, 80% recommended beginning only after 6 weeks postoperatively.
Return to physical activity guidelines for cervical arthroplasty.
Postoperative Medications and Neck Collar
Concerning postoperative medication and neck collar recommendations (Table 5), a strong consensus (80%) was achieved among expert surgeons that patients can reduce or ideally discontinue prescribed narcotics 1 week postoperatively for all cohorts. No consensus was achieved regarding whether HS patients require more time to reduce narcotics compared to multilevel ADR patients.
Postoperative medication and collar guidelines for cervical arthroplasty.
Neck collars are not recommended following 1-, 2-, or 3-level ADR surgery by weak consensus (70%) from the surveyed surgeons. A weak consensus (60%) was also achieved for the recommendation of neck collar use in HS patients.
Discussion
As noted, there has been a marked increase in the utilization of ADR from 2009 to 2015, increasing nonlinearly by 17% each year, and the relative utilization of ADR compared with ACDF increased from 4.00% to 14.15% between 2010 and 2018.7,21,22 Despite increasing prevalence, there remains a lack of consensus regarding RTA recommendations following cervical ADR surgery. Much of the existing literature on RTA has focused on high-level athletes returning to sport in the context of fusion procedures, with comparatively less emphasis on ADR.23–25 Our study was designed to address this gap by surveying expert spine surgeons through a modified Delphi process, thereby providing consensus-based postoperative recommendations for returning to daily life and higher-intensity activity.
Evidence-based postoperative recommendations not only empower patients to safely resume their daily and recreational activities but also enhance clinician confidence when providing postoperative counseling. Such standardization has the potential to reduce complications, improve quality of life, and contribute to efficient healthcare resource utilization. Ultimately, these guidelines add value to the patient by providing a roadmap that minimizes uncertainty and accelerates their safe return to an active, fulfilling lifestyle.
The expert-derived consensus results are presented in Tables 3–5. Regarding daily activities, our panel achieved the strongest consensus (100%) that patients could safely begin walking immediately after 1-, 2-, or 3-level ADR. Equally, there was unanimous agreement that patients could resume sedentary work, attend social events, travel by air, and engage in sexual activity within 2 weeks postoperatively. These findings are in agreement with the existing literature, where 98% of ADR patients returned to driving within 12 days and 90% returned to work within 14 days.26 Similarly, Camino-Willhuber et al27 surveyed 91 surgeons and found that 2 weeks was the most frequent recommendation for resuming driving and sexual activity (56.2% and 54.8%, respectively). Although their study revealed greater variability, the predominant response supports our consensus that a 2‐week period is appropriate. For physically demanding work, they also found 56.2% of surgeons recommended returning at 6 weeks, whereas our own findings indicated a 70% agreement for returning after 4 to 6 weeks. Camino-Willhuber et al noted that variability in recommendations can be influenced by differences in surgeon experience and training, with more experienced surgeons tending to recommend quicker returns. This observation may help explain why our results, derived from a panel in which 60% of experts had more than 20 years of experience and 80% performed more than 50 arthroplasties annually, suggest a more accelerated return. Direct consensus recommendations for pure ACDF were not generated, and all comparisons to fusion are therefore based on expert opinion and published literature. This exclusion was intentional to maintain focus on motion-preserving procedures and to prevent survey fatigue that could result from an overly broad Delphi investigation. For contextual support, Camino-Willhuber et al reported surgeon survey data for ACDF patients, indicating that clinicians predominantly recommend return to driving within 2 weeks postoperatively, return to sedentary work by 2 weeks, and nonsedentary work within 6 to 13 weeks after a 1-level ACDF.27 This focus reflects the primary study aim of addressing gaps in ADR guidance rather than re-deriving existing ACDF protocols.
Our experts reached 100% consensus that ADR surgeries have shorter recovery and enable patients to resume normal activities sooner than fusion surgeries. Concordantly, Steinmetz et al found that at 6 weeks and 3 months, significantly more patients in the arthroplasty group were working than those in the fusion group.28 Similarly, driving disability scores at 6 weeks in ADR patients were lower compared to fusion patients, and ADR patients returned to driving quicker than ACDF patients.26,29 Camino-Willhuber et al’s survey of 91 surgeons did not demonstrate the same earlier return for ADR vs fusion, highlighting the ongoing variability in physician opinions and where analysis and considerations from arthroplasty experts can advance the field. The accelerated return to daily activities following ADR restores quality of life and minimizes the socioeconomic burden of prolonged recovery. Consequently, cost-effectiveness has repeatedly been demonstrated for ADR compared with ACDF.30 These findings underscore the importance of adopting evidence-based guidelines to optimize postoperative recovery and ensure patients’ timely reintegration into their routines.
Returning to heavy physical activity following cervical surgery has primarily focused on studying elite and professional athletes rather than the general population. Our study stands apart by providing value to both athletes and the general population. Our findings revealed 100% consensus that patients can safely resume light physical activity within 4 to 6 weeks. To return to high-intensity physical activity, there was a 60% consensus for single-level ADR to return to activity within 4 to 6 weeks and a 70% consensus for multilevel ADR patients to return in 6+ weeks. Our findings align with Reinke et al, who investigated the return to sports after cervical ADR in professional, semiprofessional, and hobby athletes and found a median time to resumption of sporting activities of 4 weeks.23 Camino-Willhuber et al further demonstrated that 6 weeks was the most frequent response for return to running, swimming, and biking following ADR surgery.27 The differences in these results can potentially be explained by the level of experience of our expert panel in ADR procedures or by a potential limitation of our study in the labeling of what qualifies as light vs intense physical activity. Regarding physical therapy, our experts reached a strong consensus (80%) for both intense conditioning and sports-specific physical therapy at 6 weeks after ADR surgery, which aligns with most protocols that suggest starting rehabilitation 4 to 6 weeks after surgery.31
Among all postoperative recommendations of our study, the return to physical activity revealed the greatest inconsistencies, as evidenced by the weak consensus for resuming high-intensity physical activity for both single- and multilevel ADR. This variability may result from differences in surgeon experience, professional training, or the specificity of questions posed regarding high-intensity activities. Further research is warranted to investigate the rationale behind recommendations on returning to common light, moderate, and intense physical activities, as well as the impact of the number of levels treated, hybrid constructs, patient demographics, medical history, and comorbidities. The premature resumption of intense physical activity can increase the risk of complications. Similarly, a delayed return to physical activity has the potential to result in diminished quality of life. This issue becomes even more critical in spinal arthroplasty because of the importance of preserving motion, preventing ASD, and maintaining spinal kinematics.
For postoperative medication recommendations, we found a strong consensus for discontinuing prescribed narcotic analgesics 1 week after ADR surgery, consistent with the literature, which reported that 98.3% of patients discontinued opioids in a median of 6 days.26 Early discontinuation of opioids is critical for patient well-being as it reduces the risk of dependency and mitigates side effects that can delay functional recovery. A topic that has incited disagreement among experts is the use of neck collars after cervical surgery. There is literature indicating that there is no advantage to wearing a cervical brace following ACDF at the 1- and 2-year time points, and there is no significant difference in fusion rates for these patients compared to those who did not use postoperative braces.31,32 Among the limited research on cervical collars for postoperative ADR patients, McKeon et al demonstrated that cervical collar usage was associated with increased rates of axial neck pain and decreased final range of motion.33 Our expert-derived recommendations aligned with this finding, with 70% agreement that neck collars are not recommended following ADR surgery at any level. Further investigations are recommended to elucidate the circumstances for the appropriate use of a cervical collar following arthroplasty surgery, especially because 60% of our experts agreed that neck collars are recommended for patients undergoing HS. This difference in recommendations for cervical collars between arthroplasty and fusion patients may reflect an expert surgeon’s understanding of the differences in recovery mechanisms and kinematics related to each surgical modality.
Among the limitations of the present study, the modified Delphi method utilized a relatively small panel of 10 expert spine surgeons, which may limit the generalizability of our findings, and future iterative investigations could benefit from expanding the number of experts. Additionally, the consensus recommendations were derived from expert opinions rather than prospective clinical outcome data, rendering the results inherently subjective. The potential for survey fatigue among respondents may also have influenced the consistency and depth of their responses. Additionally, pure fusion (ACDF only) vignettes were not included in this study’s Delphi survey. This study was designed to address the specific deficit of standardized RTA guidance for ADR and hybrid procedures. While including fusion cases may have provided complementary insights, survey burden and protocol focus precluded this; our recommendations for ACDF are thus limited to contextual comparisons supported by published data and expert commentary. Moreover, our survey did not stratify the results for detailed patient-specific variables, such as age, bone quality, occupation, or baseline cervical mobility, which could influence recommendations and outcomes. Subgroup analyses comparing consensus strength between on-label (single- and 2-level ADR) and off-label (3-level ADR or hybrid) cases were not performed due to sample size limitations, and detailed proportions of off-label cases performed by the experts were not systematically captured. This is an area for future investigation. Last, most clinical vignettes featured the Orthofix M6 prosthesis, with fewer cases using Baguera-C and Prodisc Vivo, preventing device-specific recommendations, and future studies can examine the distinctions of return to activity recommendations for these devices. These limitations underscore the need for future prospective studies that incorporate objective outcome measures and detailed patient data to validate and refine expert-derived recommendations.
Future research should focus on prospective, multicenter studies that correlate RTA timelines with objective clinical outcomes, including patient-reported outcomes, radiographic healing, and biomechanical assessments, such as cervical range-of-motion tracking. Stratification of patients by specific procedure type will be critical in refining these guidelines. The emerging trend toward hybrid constructs introduces additional complexity in postoperative rehabilitation as RTA guidelines for these procedures remain less defined. The variability in healing mechanisms at different operative levels may also contribute to a more heterogeneous recovery profile, underscoring the need for future research to delineate structured RTA timelines for distinctive procedures. Further analysis of the economic impact, including cost savings associated with earlier return to work and reduced rehabilitation time, would be valuable. Additional research should explore the underlying reasons behind the variability in expert recommendations, such as differences in surgeon training, regional practices, and patient demographics.
Conclusion
In conclusion, our consensus-based study fills a critical gap in the literature by offering expert-derived RTA recommendations for patients receiving cervical arthroplasty that can guide clinicians as well as frame patient expectations and experiences. Our findings contribute to the growing body of literature highlighting the benefits of cervical arthroplasty in enabling an earlier return to daily activities than fusion-based procedures (ACDF). This is supported by a 100% consensus among our surveyed experts, indicating that patients undergoing ADR experience a shorter recovery period and resume normal activities sooner than those undergoing fusions. These findings have the potential to provide clinicians with consistent, scientifically validated postoperative recommendations, thereby enhancing patient counseling and optimizing recovery protocols.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Previous Presentation Spine Summit 2025, February 20-23, 2025, Tampa, Florida.
Disclosures Jared D. Ament reports consulting fees from Premia Spine and Cerapedics Spine (paid to institution). Amir Vokshoor reports research support from Synergy, SpineArt, and Orthofix; royalties/licenses from Globus Medical; payment for a lecture and support for attending meetings/travel from Orthofix; and is the president and founder of the Institute of Neuro Innovation. Jack Petros has nothing to report. Tina Zabehi has nothing to report. Armen Khachatryan reports consulting fees from Centinel Spine, Highridge Medical, Synergy Spine Solutions, SpineArt, and 3Spine (all paid to institution) and serves on the Board of Directors for Dymicron. Matthew Scott-Young is a board member for ISASS. J. Alex Sielatycki reports consulting fees from Premia Spine, Centinel Spine, and 3Spine and support for attending meetings/travel and stock/stock options from 3Spine. Rick C. Sasso has nothing to report. Jason Cuellar reports consulting fees from Centinel Spine. Jack Zigler reports consulting fees from Centinel Spine and Highridge. Richard D. Guyer has nothing to report. Scott Blumenthal reports payment/honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Centinel Spine and Globus/Nuvasive and stock/stock options from Centinel Spine and Fziomed. Todd Lanman has nothing to report.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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