Jetan H Badhiwala1, Andrew Platt2, Christopher D Witiw1, Vincent C Traynelis3. 1. Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, ON, Canada. 2. Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA. 3. Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA.
Abstract
BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is an effective treatment for cervical spondylosis. A limitation of ACDF is the risk of adjacent-segment degeneration (ASD), owing to arthrodesis of a motion segment. Cervical disc arthroplasty (CDA) has hence garnered significant attention; yet, compelling evidence of reduction in ASD requiring surgery is lacking. This systematic review and meta-analysis sought to compare long-term longitudinal adjacent-level operation rates with CDA versus ACDF. METHODS: An electronic literature search was conducted. Eligible studies were multi-center randomized controlled trials (RCTs) comparing CDA with ACDF for one- or two-level symptomatic cervical spondylosis. The primary outcome was adjacent-level operation. Index-level reoperation was a secondary outcome. Outcomes were evaluated at 1-year intervals from the index operation to last reported follow-up by random-effects meta-analyses. RESULTS: Eleven RCTs met criteria. For one-level spondylosis, there was no difference in the rate of adjacent-level operation between CDA (2.3%) and ACDF (3.6%) at 2 years. However, a large difference favoring CDA became evident at 5 years and persisted at 7 years (4.3% vs. 10.8%, P<0.001). Significantly fewer patients who underwent CDA required index-level reoperation at all time points out to 7 years (5.2% vs. 12.7%, P<0.001). Similar to one-level operations, there was no significant difference in adjacent-level operations with two-level CDA (1.7%) versus two-level ACDF (3.4%) at 2 years. At 7 years, a significant difference favoring CDA became apparent (5.1% vs. 10.0%, P=0.014). Two-level CDA resulted in fewer index-level reoperations out to 7 years (4.2% vs. 13.5%, P<0.001). CONCLUSIONS: In this meta-analysis, the short-term rate of adjacent-level operation was similar with CDA or ACDF. However, around 5 years, a statistically significant divergence emerged, where the rate of adjacent-level surgery rose steeply for ACDF. Index-level reoperations were less frequent with CDA in both the short- and long-term. These data indicate CDA may have a superior longevity to ACDF with regard to need for subsequent adjacent-level operation. 2020 Journal of Spine Surgery. All rights reserved.
BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is an effective treatment for cervical spondylosis. A limitation of ACDF is the risk of adjacent-segment degeneration (ASD), owing to arthrodesis of a motion segment. Cervical disc arthroplasty (CDA) has hence garnered significant attention; yet, compelling evidence of reduction in ASD requiring surgery is lacking. This systematic review and meta-analysis sought to compare long-term longitudinal adjacent-level operation rates with CDA versus ACDF. METHODS: An electronic literature search was conducted. Eligible studies were multi-center randomized controlled trials (RCTs) comparing CDA with ACDF for one- or two-level symptomatic cervical spondylosis. The primary outcome was adjacent-level operation. Index-level reoperation was a secondary outcome. Outcomes were evaluated at 1-year intervals from the index operation to last reported follow-up by random-effects meta-analyses. RESULTS: Eleven RCTs met criteria. For one-level spondylosis, there was no difference in the rate of adjacent-level operation between CDA (2.3%) and ACDF (3.6%) at 2 years. However, a large difference favoring CDA became evident at 5 years and persisted at 7 years (4.3% vs. 10.8%, P<0.001). Significantly fewer patients who underwent CDA required index-level reoperation at all time points out to 7 years (5.2% vs. 12.7%, P<0.001). Similar to one-level operations, there was no significant difference in adjacent-level operations with two-level CDA (1.7%) versus two-level ACDF (3.4%) at 2 years. At 7 years, a significant difference favoring CDA became apparent (5.1% vs. 10.0%, P=0.014). Two-level CDA resulted in fewer index-level reoperations out to 7 years (4.2% vs. 13.5%, P<0.001). CONCLUSIONS: In this meta-analysis, the short-term rate of adjacent-level operation was similar with CDA or ACDF. However, around 5 years, a statistically significant divergence emerged, where the rate of adjacent-level surgery rose steeply for ACDF. Index-level reoperations were less frequent with CDA in both the short- and long-term. These data indicate CDA may have a superior longevity to ACDF with regard to need for subsequent adjacent-level operation. 2020 Journal of Spine Surgery. All rights reserved.
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