Cervical disc arthroplasty: tips and tricks

Reoperation Strategy for Failure of Cervical Disc Arthroplasty at Index and Adjacent Levels

Cervical disc arthroplasty (CDA) is a motion-preserving alternative to anterior cervical discectomy and fusion (ACDF) for cervical degenerative disease, reducing adjacent segment degenerative disease (ASD). Despite its benefits, some patients experience CDA failure due to prosthesis-related complications, heterotopic ossification, segmental kyphosis, ASD, or facet joint degeneration, necessitating revision surgery. Reoperation strategies depend on the failure mechanism, instability, sagittal malalignment, and neural compression. Anterior revision is suited for prosthesis failure, recurrent disc herniation, or ASD, enabling prosthesis removal, decompression, and fusion. In select cases, reimplantation may restore motion. Posterior approaches are preferred for facet degeneration, multilevel stenosis, or posterior hypertrophy, with options including foraminotomy, laminoplasty, or laminectomy and fusion. Complex cases may require combined anterior and posterior surgery for optimal decompression and stability. This narrative review outlines revision strategies, emphasizing biomechanical assessment, radiographic evaluation, and patient-specific considerations. Despite surgical challenges, meticulous planning and execution can optimize outcomes.

Revision Strategies for Cervical Disc Arthroplasty

STUDY DESIGN

Narrative review.

OBJECTIVE

To review indications and strategies for revision of cervical disc arthroplasty (CDA).

SUMMARY OF BACKGROUND DATA

No data were generated as part of this review.

METHODS

A narrative review of the literature was performed.

RESULTS

No results were generated as part of this review.

CONCLUSIONS

CDA is a proven, motion-sparing surgical option for the treatment of myelopathy or radiculopathy secondary to cervical degenerative disc disease. As is the case with any operation, a small percentage of CDA will require revision, which can be a technically demanding endeavor. Here we review available revision strategies and associated indications, a thorough understanding of which will aid the surgeon in finely tailoring their approach to varying presentations.

Cervical Disc Arthroplasty Usage Has Leveled Out From 2010 to 2021

STUDY DESIGN

Descriptive epidemiologic study.

OBJECTIVE

To compare trends in utilization and predictive factors for single-level cervical disc arthroplasty (CDA) relative to anterior cervical discectomy and fusion (ACDF) over the years.

BACKGROUND

CDA is an alternative to ACDF for the treatment of cervical spine pathologies. With both procedures performed for similar indications, controversy on best practices exists.

MATERIALS AND METHODS

Patients who underwent single-level CDA or ACDF were identified in the 2010 through 2021 PearlDiver M151Ortho data set. The yearly number of CDAs performed and proportionality was assessed. Predictive patient factors for undergoing CDA as opposed to ACDF were determined. Kaplan Meyer survival analysis with an endpoint of cervical spine reoperation compared 5-year outcomes between CDA and ACDF.

RESULTS

From 2010 to 2021, 19,301 single-level CDAs and 181,476 single-level ACDFs were identified. The proportional utilization of CDA relative to ACDF increased from 4.00% in 2010 to 14.15% in 2018 ( P < 0.0001), after which there was a plateau between 2018 and 2021 where proportional utilization was 14.47% ( P = 0.4654). Multivariate analysis identified several predictors of undergoing CDA rather than ACDF, including: younger age [odds ratio (OR) per decade decrease: 1.72], having surgery performed in the Midwest, Northeast, or West (relative to South, OR: 1.16, 1.13, 2.26, respectively), having Commercial insurance (relative to Medicare, OR: 1.75), and having surgery performed by an orthopedic surgeon (relative to a neurological surgeon, OR: 1.54) ( P < 0.0001 for each). There was no statistically significant difference in 5-year survival to further cervical spine surgery between CDA and ACDF at 5 years (97.6% vs. 97.7%, P = 0.4249).

CONCLUSIONS

Although the use of CDA relative to ACDF rose from 2010 to 2018, its use has subsequently plateaued between 2018 and 2021 and remained a relatively low percentage of the single-level anterior cervical surgeries performed (14.47% in 2021). The causes for such changes in the trend are unclear.

Restore cervical sagittal alignment by cervical disc arthroplasty and systematic total bilateral uncuscectomy in severe spondylosis: A prospective study

Introduction

Severe spondylosis is common and represents contraindication to achieve cervical disc arthroplasty (CDA).

Research question

Is it possible to restore cervical sagittal alignment using an adequate prosthetic model and performing systematic bilateral total uncuscectomy (or uncinectomy), even in cases of severe spondylosis ?

Material and methods

We propose a prospective clinical and radiological study comparing the evolution of preoperative and postoperative cervical sagittal balance 1 year after the interposition of a prosthesis with mobile bearing and systematic total uncuscectomy. VAS for brachialgia and cervicalgia, NDI, Odom's criteria, C2-C7 Cobb angle, C2-C7 SVA, T1 slope, C2 slope, C1-C2 Cobb angle, and segmental Cobb angle were analyzed preoperatively and 1 year postoperatively.

Results

73 patients for a total of 129 levels treated were analyzed. Patients showed significant improvements in VASb, VASc, NDI, and Odom's criteria one year after surgery without clinical differences in the severe spondylosis subgroup (41 patients for 77 levels treated). Our results showed an increase in the C2-C7 Cobb angle postoperatively and a better correlation between T1 slope and C2-C7 Cobb angle postoperatively than preoperatively. Postoperative radiological results were similar between the spondylosis and non-spondylosis subgroups. However preoperative C2-C7 Cobb angle and preoperative ROM were lower in the severe spondylosis subgroup.

Discussion and conclusion

This study showed the possibility of restoring cervical sagittal balance by performing cervical disc arthroplasty with systematic uncuscectomy, even in cases of severe spondylosis. Moreover, we propose a simplified mathematical formula to preoperatively evaluate the lack of angulation to restore sagittal cervical alignment.

Cervical disc arthroplasty with systematic total bilateral uncuscectomy - Adapted technique particularly in severe spondylosis: A prospective study

Introduction

Cervical disc arthroplasty (CDA) is mainly used in young patients with soft herniated discs and seems to have several advantages over anterior cervical discectomy and fusion (ACDF). Severe spondylosis is common and represents a contraindication for performing CDA.

Research question

Is it possible to expand the indications for the implantation of cervical prostheses by adapting the surgical technique, particularly for severe spondylosis, to benefit from the advantages of prostheses over ACDF ?

Materials and methods

We propose a prospective two-center study to compare the possible clinical benefit of the placement of a cervical prosthesis with systematic total bilateral uncuscectomy (or uncinectomy) compared to the classical technique of ACDF, particularly for severe spondylosis. Visual analog scales for brachialgia, cervicalgia, and neck disability index were measured before and one year after surgery. Odom's criteria were assessed one year after surgery.

Results

We compared 81 patients treated with CDA and systematic total bilateral uncuscectomy versus 42 patients treated with ACDF for symptomatic radicular or medullary compression. Patients treated with CDA and uncuscectomy showed greater improvements in VASb, VASc, NDI, and Odom's criteria than those treated with ACDF, with statistically significant results. Moreover, no difference was found between the severe spondylosis subgroup and the non-severe spondylosis subgroup treated with CDA and uncuscectomy.

Discussion and conclusion

This study assessed the value of systematic total bilateral uncuscectomy for cervical arthroplasty. Our prospective clinical results suggest a surgical technique to reduce cervical pain and improve function one year after surgery, even in cases of severe spondylosis.

Cervical and Lumbar Disc Arthroplasty: A Review of Current Implant Design and Outcomes

While spinal disc pathology has traditionally been treated using fusion-based procedures, recent interest in motion-preserving disc arthroplasties has grown. Traditional spinal fusion is associated with loss of motion, alteration of native spine kinematics, and increased risks of adjacent segment disease. The motion conferred by disc arthroplasty is believed to combat these complications. While the first implant designs resulted in poor patient outcomes, recent advances in implant design and technology have shown promising radiographic and clinical outcomes when compared with traditional fusion. These results have led to a rapid increase in the utilization of disc arthroplasty, with rates of cervical arthroplasty nearly tripling over the course of 7 years. The purpose of this review was to discuss the evolution of implant design, the current implant designs utilized, and their associated outcomes. Although disc arthroplasty shows significant promise in addressing some of the drawbacks associated with fusion, it is not without its own risks. Osteolysis, implant migration, and the development of heterotopic ossification have all been associated with disc arthroplasty. As interest in these procedures grows, so does the interest in developing improved implant designs aimed at decreasing these adverse outcomes. Though they are still relatively new, cervical and lumbar disc arthroplasty are likely to become foundational methodologies for the treatment of disc pathology.

The adjustable aiming device for caspar pin insertion in anterior cervical spine surgery

BACKGROUND

Creating a rectangular disc space is an important step during anterior cervical discectomy and fusion or cervical total disc replacement. The study aims to determine the accuracy of Caspar pin insertion by using a novel Adjustable Caspar Pin Aiming Device in anterior cervical procedures.

METHODS

Forty Caspar pins were placed using an Adjustable Caspar Pin Aiming Device in 20 human cadaveric cervical vertebral bodies from C3 to C7 after performing anterior discectomies. Accuracy of pin placement was assessed by lateral fluoroscopy, considering superior endplate slope (SE), inferior endplate slope (IE), Caspar pin slope (CP), and endplate-Caspar pin slope difference (SE/CP, IE/CP).

RESULTS

The mean superior endplate slope (SE), inferior endplate slope (IE), and Caspar pin slope (CP) were 10.82 ± 2.3°, 10.32 ± 3.2°, and 15.58 ± 7.9°, respectively. The average superior endplate-Caspar pin slope difference (SE/CP) and inferior endplate-Caspar pin slope difference (IE/CP) were 6.6 ± 0.8° and 7.7 ± 0.8°, respectively. The greatest slope difference was observed at the superior and inferior endplates of C3. No cervical endplate violations occurred.

CONCLUSION

Adjustable Caspar Pin Aiming Device allowed for a highly accurate Caspar pin placement with the average endplate-Caspar pin slope difference of less than 7.7°. It results in accurate placement of the superior and inferior Caspar pins parallel to the index vertebral endplates. Furthermore, it appears to facilitate the safe and effective insertion of Caspar pins for anterior cervical procedures.

Radiological Changes in Adjacent and Index Levels after Cervical Disc Arthroplasty

PURPOSE

The purpose of this retrospective study was to evaluate radiological and clinical outcomes in patients undergoing cervical disc arthroplasty (CDA) for cervical degenerative disc disease. The results may assist in surgical decision-making and enable more effective and safer implementation of cervical arthroplasty.

MATERIALS AND METHODS

A total of 125 patients who were treated with CDA between 2006 and 2019 were assessed. Radiological measurements and clinical outcomes included the visual analogue scale (VAS), the Neck Disability Index (NDI), and the Japanese Orthopaedic Association (JOA) myelopathy score assessment preoperatively and at ≥2 years of follow-up.

RESULTS

The mean follow-up period was 38 months (range, 25-114 months). Radiographic data demonstrated mobility at both the index and adjacent levels, with no signs of hypermobility at an adjacent level. There was a non-significant loss of cervical global motion and range of motion (ROM) of the functional spinal unit at the operated level, as well as the upper and lower adjacent disc levels, compared to preoperative status. The cervical global and segmental angle significantly increased. Postoperative neck VAS, NDI, and JOA scores showed meaningful improvements after one- and two-level CDA. We experienced a 29.60% incidence of heterotrophic ossification and a 3.20% reoperation rate due to cervical instability, implant subsidence, or osteolysis.

CONCLUSION

CDA is an effective surgical technique for optimizing clinical outcomes and radiological results. In particular, the preservation of cervical ROM with an artificial prosthesis at adjacent and index levels and improvement in cervical global alignment could reduce revision rates due to adjacent segment degeneration.

Posterior intraprosthetic dislocation of cervical arthroplasty: illustrative case

BACKGROUND

Cervical disc herniation is a common condition usually treated with anterior cervical discectomy and fusion (ACDF) or, more recently, with cervical disc arthroplasty (CDA). Both treatments offer similar clinical results. However, CDA has been found to offer fewer medium- to long-term complications as well as potential reduction of long-term adjacent disc degeneration.

OBSERVATIONS

A 40-year-old man was treated with cervical discectomy and arthroplasty due to a C6-C7 disc herniation with left C7 radiculopathy. After the treatment, his postoperative follow-up appointments were uneventful for 9 months. However, after 9 months, he reported cervical pain and a right C7 radiculopathy after neck extension. Imaging confirmed a posterior intraprosthetic dislocation, the first case reported to date. The patient was received emergency surgery under neuromonitoring, and the prosthesis was replaced by an ACDF and anterior plate. The insert presented a rupture of the anterior horn. The patient presented no preoperative or postoperative neurological deficit, and his follow-up review revealed no issues.

LESSONS

Posterior intraprosthetic dislocation is an extremely rare complication. It may occur with Mobi-C cervical arthroplasty in the case of rupture and oxidation of the polyethylene insert. Spine surgeons should be aware of this potential major complication.

Cervical disc arthroplasty: What we know in 2020 and a literature review

Cervical disc arthroplasty (CDA) is a safe and effective option to improve clinical outcomes (e.g., NDI, VAS, and JOA) in degenerative cervical disc disease and compressive myelopathy. CDA's two main purported benefits have been that it maintains physiologic motion and thereby minimizes the biomechanical stresses placed on adjacent segments as compared to an ACDF. CDA might reduce the degeneration of adjacent segments, and the need for adjacent-level surgery. Reoperation rates of CDA have been reported to range from 1.8% to 5.4%, with a minimum 5-year follow-up. As the number of CDA procedures performed continues to increase, the need for revision surgery is also likely to increase. When performed skillfully in appropriate patients, CDA is an effective surgical technique to optimize clinical outcomes and radiological results. This review may assist surgical decision-making and enable a more effective and safer implementation of cervical arthroplasty for cervical degenerative disease.

Association of cervical sagittal alignment with adjacent segment degeneration and heterotopic ossification following cervical disc replacement with Prestige-LP disc

PURPOSE

Cervical sagittal balance plays important roles in transmitting the load of the head and maintaining global spinal balance. This study aimed to identify the association of cervical sagittal alignment with adjacent segment degeneration (ASD) and heterotopic ossification (HO) after Prestige-LP cervical disc replacement (CDR).

METHODS

We enrolled 132 patients who underwent one-level Prestige-LP CDR with 2-10 years of follow-up. Cervical sagittal alignment parameters, including the degree of C2-C7 lordosis (CL), functional spinal unit angle (FSUA), sagittal vertical axis (SVA),, and T1 slope (T1s), were measured. ASD and HO were evaluated at the last follow-up. Unpaired t tests and logistic regression analysis were used to identify the associations of cervical sagittal alignment with ASD and HO.

RESULTS

We found that patients who developed ASD showed significantly lower FSUA (2.1° vs. -1.4°, p < 0.001) and T1s values (28.4° vs. 25.5°, p = 0.029) after surgery. Similarly, the postoperative CL was significantly better in patients without ASD or HO (18.0° vs. 14.4°, p = 0.043). The decrease in the T1s at the last follow-up was significantly larger in the patients with ASD (-11.0° vs. -3.2°, p = 0.003), HO (-6.7° vs. -2.7°, p = 0.050), and ASD or HO (-7.0° vs. -0.8°, p < 0.001) than in those without ASD or HO. Multivariate logistic regression analysis showed that both the FSUA and T1s are associated with ASD and that the degree of CL is associated with postoperative complications.

CONCLUSION

The results imply that maintaining cervical sagittal alignment after Prestige-LP CDR is important.