Marc Darrow, MD, JD.
There are many options in helping people with neck pain or degenerative disease in their cervical spine. At our clinic we try to help as many people avoid surgery as we can although for some people surgery will be their only realistic option and we advise these people appropriately. Sometimes a person may think they need surgery because they have been told that the must have it even though the evidence for their needing a surgery may be based solely on an interpretation of an MRI. As researchers have pointed out most people will not need a neck surgery. In this article we will exam research from surgeons in providing information on surgery or no surgery and whether an artificial cervical disc replacement or Anterior cervical discectomy and fusion (ACDF) may be the surgery worth exploring further.
There are many different types of neck or cervical spine surgery. Most surgeries are recommended because a disc or multiple discs are being squeezed or flattened out and this is causing compression on the nerves that travel through the neck vertebrae. A neck pain sufferer may get a cervical discectomy or microdiscectomy which removes the disc pressing on the nerves. When this surgery fails, the patient may be recommended for a more aggressive surgery or no surgery at all.
Anterior cervical discectomy and fusion outcomes
A May 2023 paper (1) examined and compared long-term follow-ups on pain and disability after anterior cervical decompression and fusion surgery for cervical degenerative disc disease.
In this study, 50 people who had a ACDF surgery at least 20 years in the past, due to cervical radiculopathy were sent questionnaires. These people were asked about their neck pain and functionality. They were also asked about arm pain, headache, dizziness, their own abilities in performing routine tasks, and their quality of life.
Results: Eighty-eight per cent of participants experienced improvements 71% (pain) and 41% (neck disability index). However, a good majority of the patients reported residual disability. While 41% had functional improvement, 59% did not have clinically relevant improvements.
A September 2024 study (10) analyzed patient obesity on peri-operative complication rates in patients undergoing anterior cervical discectomy with fusion. Pre-operative comorbidities were identified as age, sex, race, smoking status, hypertension requiring medication, diabetes, history of congestive heart failure, history of bleeding disorder, and chronic obstructive pulmonary disease as risk factors. Risk for post-operative side-effects after an ACDF was significantly higher for obese classes I-III compared to non-obese patients.
Too much fusion surgery? Should adjacent asymptomatic levels be included in fusion surgery if they demonstrate severe radiographic degeneration?
An August 2021 study (2) questioned whether Anterior cervical discectomy and fusions (ACDFs) are generally limited to the levels causing neurological symptoms, but whether adjacent asymptomatic levels should be included if they demonstrate severe radiographic degeneration is a matter of controversy. In this study the researchers evaluated whether asymptomatic preoperative magnetic resonance imaging (MRI) abnormalities at adjacent levels were predictive of reoperation for symptomatic adjacent-segment degeneration (ASD) after the initial Anterior cervical discectomy and fusion. Their findings do not support including asymptomatic levels in an anterior fusion construct, even if severe MRI abnormalities are present preoperatively.
A January 2024 study (3) compared clinical outcomes of anterior cervical discectomy and fusion (ACDF) and cervical disk arthroplasty (disk replacement) at 20 years follow up.
- Forty-seven patients with single-level cervical radiculopathy were randomized to either disk replacement or anterior cervical discectomy and fusion (ACDF)
- At 20 years, patient-reported outcomes, including visual analog scales (VAS) for neck and arm pain, neck disability index (NDI), and reoperation rates, were analyzed.
According to the researchers: Both groups showed significantly better NDI, VAS arm pain, and VAS neck pain scores at 20 years versus preoperative scores. Comparing cervical disk arthroplasty versus ACDF, there was no difference at 20 years in mean scores for NDI, mean VAS arm pain, or mean VAS neck pain. There was a significant difference between CDA versus ACDF groups in the change in VAS neck pain score between 10 and 20 years. Reoperations were reported in 41.7% of ACDF patients and 10.0% of cervical disk arthroplasty patients.
A December 2023 study (9) examined patient frailty in surgical outcomes in cervical spondylotic myelopathy patients getting either anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF). Nearly 38,000 patient outcomes were assessed. The researchers found that frailty may impact outcomes after surgical treatment for cervical spondylotic myelopathy, with more frail patients having greater health care needs and a higher rate of adverse events or complications. The patients undergoing PCDF need more medical care post-surgery, compared to ACDF, whereas severely frail patients undergoing PCDF tended to have the longest length of stay and highest rate of non-routine discharge.
Artificial cervical disc replacement is an alternative to ACDF designed to preserve the neck and head range of motion and ROM and reduce adjacent segment disease.
Artificial cervical disc replacement was designed to alleviate the same problems that a fusion surgery was designed to do. That is to relive symptoms of nerve compression in the neck. Sufferers will recognize these symptoms as chronic neck pain, pain and numbness that may extend into the shoulders, arms, and hands. In severe cases requiring surgery, these symptoms may include walking difficulties, trouble with motor coordination, and loss of bladder or bowel control.
The artificial disc, as opposed to the fusion surgery, helps maintain a more normal range of motion. However, if bone spurs and advanced osteoarthritis is present, the artificial disc will not improve on the patient’s neck range of motion already present. A greater benefit may be that the artificial disc replacement surgery will prevent adjacent segment disease from occurring. Adjacent segment disease is the rapid degeneration of the cervical spine segments next to the fused area. If you have c4-C5 fusion the adjacent segments would be C3-C6.
Let’s have the surgeons discuss this further. A July 2022 paper (4) “Anterior cervical discectomy and fusion (ACDF) surgery is commonly performed to treat cervical degenerative disc disease. The loss of range of motion is also found after Anterior cervical discectomy and fusion, which contributes to degenerate in adjacent segment disease (ASD). Artificial cervical disc replacement (ACDR), an alternative to ACDF, is developed to preserve the ROM and reduce ASD. Prolonged operative duration, better overall success, neurological success, and NDI (a Neck Disability index score) success rates were found in Artificial cervical disc replacement group in all follow-up periods, with lower dysphagia/dysphonia during short-term follow-up. Moreover, a lower adjacent segment disease was found in Artificial cervical disc replacement group during long-term follow-up and overall analysis, with lower reoperation rates in all follow-up periods.”
A June 2020 paper (5) compared the efficacy and safety of the postoperative long-term effect of the treatment of single-level cervical spondylosis through anterior cervical discectomy and fusion (ACDF) and artificial cervical disc replacement (ACDR).
- A total of 113 patients were divided into two groups depending on the operation method and these patients receive more than 96 months of follow-up. The pain scores and Neck Disability index score of these two groups of patients significantly improved, when compared with those before the operation.
- In the last follow-up visit, six patients (12.77%) in the ACDR group and 18 patients (27.27%) in the ACDF suffered from adjacent segment degeneration (ASD). The general complication rate in the replacement group and fusion group was 38.31% and 37.88%, respectively, but the difference between the two groups was not statistically significant. Overall, the clinical efficacy and related complication rate of single-level cervical spondylosis after an anterior cervical approach operation was superior in the ACDR group when compared to the ACDF group.
A November 2021 study (6) Heterotopic ossification (abnormal growth bone in muscle and soft tissue) is a common complication after cervical disc replacement. Biomechanical factors including endplate damage resulting in loss of bone coverage and intervertebral disc height change may be related to Heterotopic ossification formation. Patients who underwent single-level or two-level cervical disc replacement are at risk for endplate damage and intervertebral disc height change.
A November 2023 study (7) provided a long-term follow up to seventy-five 75 patients who had cervical total disc replacement and developed adjacent segment degeneration. Complications noted were implant migration, subsidence and heterotopic ossification.
- The majority of adjacent segment diseases were at C4/5 (33.6%) and C6/7 (34.2%)
- Adjacent segment degeneration of C5/6 had the highest incidence (61.5%).
The phenomenon of anterior bone loss is unique to cervical disc arthroplasty and has only recently gained notice
A July 2022 paper (8) Although cervical disc arthroplasty has reportedly been associated with similarly low incidences of complications to anterior cervical discectomy and fusion, the phenomenon of anterior bone loss is unique to cervical disc arthroplasty and has only recently gained notice. During the average follow-up of 2 years (in patients in this study undergoing cervical disc arthroplasty, anterior bone loss was a common radiologic finding. More than half of the patients (26 of 41 in this study, 63.4%) in the series gained cervical lordosis after cervical disc arthroplasty. These patients with increased cervical lordosis after cervical disc arthroplasty had higher grades of anterior bone loss.
Our treatments to restore cervical spine stability by repairing and regenerating the neck ligaments
When the patient says they are having success at the chiropractor with their cervical lordosis and their symptoms of dizziness, we know that we can have a realistic expectation that our treatments can help them as well. The chiropractic is helping because the vertebrae are pushed back towards a natural alignment. The reasons that the patient needs to see the chiropractor 2 – 3 times a week is because the the adjustments are not holding. We do get many referrals from chiropractors to help their patients by strengthening the cervical ligaments with our injection treatments.
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References:
1 Hermansen A, Hedlund R, Zsigmond P, Peolsson A. A more than 20-year follow-up of pain and disability after anterior cervical decompression and fusion surgery for degenerative disc disease and comparisons between two surgical techniques. BMC Musculoskeletal Disorders. 2023 Dec;24(1):1-8.
2 Kundu B, Eli I, Dailey A, Shah LM, Mazur MD. Preoperative magnetic resonance imaging abnormalities predict symptomatic adjacent segment degeneration after anterior cervical discectomy and fusion. Cureus. 2021 Aug 18;13(8).
3 Sasso WR, Ye J, Foley DP, Vinayek S, Sasso RC. 20-year Clinical Outcomes of Cervical Disk Arthroplasty: A Prospective, Randomized, Controlled Trial.
4 Peng Z, Hong Y, Meng Y, Liu H. A meta-analysis comparing the short-and mid-to long-term outcomes of artificial cervical disc replacement (ACDR) with anterior cervical discectomy and fusion (ACDF) for the treatment of cervical degenerative disc disease. International Orthopaedics. 2022 Feb 3:1-7.
5 Guo H, Sheng J, Sheng WB, Liang WD, Wang J, Xun CH. An eight‐year follow‐up study on the treatment of single‐level cervical spondylosis through intervertebral disc replacement and anterior cervical decompression and fusion. Orthopaedic Surgery. 2020 Jun;12(3):717-26.
6 Shen YW, Yang Y, Liu H, Rong X, Ding C, Meng Y, Wang BY, Hong Y. EFFECTS OF ENDPLATE COVERAGE AND INTERVERTEBRAL HEIGHT CHANGE ON HETEROTOPIC OSSIFICATION FOLLOWING CERVICAL DISC REPLACEMENT. Journal of Orthopaedic Surgery and Research. 2021 Dec;16(1):1-1.
7 Liang Y, Qian Y, Xia W, Guo C, Zhu Z, Liu H, Xu S. Adjacent segment degeneration after single-and double-level cervical total disc replacement: a cohort with an over 12-year follow-up. European spine journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society.
8 Kuo CH, Kuo YH, Wu JC, Chang HK, Ko CC, Tu TH, Chang CC, Yeh MY, Fay LY, Huang WC, Cheng H. Anterior Bone Loss in Cervical Disc Arthroplasty Correlates with Increased Cervical Lordosis. World Neurosurgery. 2022 Apr 4.
9 Elsamadicy AA, Sayeed S, Sherman JJ, Craft S, Reeves BC, Lo SF, Shin JH, Sciubba DM. Impact of Preoperative Frailty on Outcomes in Patients with Cervical Spondylotic Myelopathy Undergoing Anterior vs. Posterior Cervical Surgery. Journal of Clinical Medicine. 2023 Dec 25;13(1):114.
10 Goheer HE, Hendrix CG, Samuel LT, Newcomb AH, Carmouche JJ. Obesity is an Independent Risk Factor for Postoperative Pulmonary Embolism after Anterior Cervical Discectomy and Fusion. The Spine Journal. 2024 Sep 26.