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Zavras AG, Acosta JR, Holmberg KJ, Semenza NC, Jayamohan HR, Cheng BC, Altman DT, Sauber RD. Effect of device constraint: a comparative network meta-analysis of ACDF and cervical disc arthroplasty. Spine J 2024; 24:1858-1871. [PMID: 38843960 DOI: 10.1016/j.spinee.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND CONTEXT Clinical trials have demonstrated that cervical disc arthroplasty (CDA) is an effective and safe alternative treatment to anterior cervical discectomy and fusion (ACDF) for cervical degenerative disc disease in the appropriately indicated patient population. Various devices for CDA exist, differing in the level of device constraint. PURPOSE To investigate outcomes following Anterior Cervical Discectomy and Fusion (ACDF) versus CDA stratified based on the level of device constraint: Constrained, Semiconstrained, and Unconstrained. STUDY DESIGN Systematic review and network meta-analysis. PATIENT SAMPLE A total of 2,932 CDA patients (979 Constrained, 1,214 Semiconstrained, 739 Unconstrained) and 2,601 ACDF patients from 41 studies that compared outcomes of patients undergoing CDA or ACDF at a single level at a minimum of 2 years follow-up. OUTCOME MEASURES Outcomes of interest included the development of adjacent segment degeneration (ASD), index and adjacent segment reoperation rates, range of motion (ROM), high-grade heterotopic ossification (HO, McAfee Grades 3/4), and patient-reported outcomes (NDI/VAS). METHODS CDA devices were grouped based on the degrees of freedom (DoF) allowed by the device, as either Constrained (3 DoF), Semiconstrained (4 or 5 DoF), or Unconstrained (6 DoF). A random effects network meta-analysis was conducted using standardized mean differences (SMD) and log relative risk (RR) were used to analyze continuous and categorical data, respectively. RESULTS Semiconstrained (p=.03) and Unconstrained CDA (p=.01) demonstrated a significantly lower risk for ASD than ACDF. All levels of CDA constraint demonstrated a significantly lower risk for subsequent adjacent segment surgery than ACDF (p<.001). Semiconstrained CDA also demonstrated a significantly lower risk for index level reoperation than both ACDF and Constrained CDA (p<.001). Unconstrained devices retained significantly greater ROM than both Constrained and Semiconstrained CDA (p<.001). As expected, all levels of device constraint retained significantly greater ROM than ACDF (p<.001). Constrained and Unconstrained devices both demonstrated significantly lower levels of disability on NDI than ACDF (p=.02). All levels of device constraint demonstrated significantly less neck pain than ACDF (p<.05), while Unconstrained CDA had significantly less arm pain than ACDF (p=.02) at final follow-up greater than 2 years. CONCLUSION CDA, particularly the unconstrained and semiconstrained designs, appears to be more effective than ACDF in reducing the risk of adjacent segment degeneration and the need for further surgeries, while also allowing for greater range of motion and better patient-reported outcomes. Less constrained CDA conferred a lower risk for index level reoperation, while also retaining more range of motion than more constrained devices.
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Affiliation(s)
- Athan G Zavras
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA.
| | - Jonathan R Acosta
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Kyle J Holmberg
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Nicholas C Semenza
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Boyle C Cheng
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Daniel T Altman
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Ryan D Sauber
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
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Hui N, Phan K, Lee MY, Kerferd J, Singh T, Mobbs RJ. The Changes in Cervical Biomechanics After CTDR and Its Association With Heterotopic Ossification: A Systematic Review and Meta-analysis. Global Spine J 2021; 11:565-574. [PMID: 32677512 PMCID: PMC8119929 DOI: 10.1177/2192568220922949] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
STUDY DESIGN A systematic review and meta-analysis. OBJECTIVES Cervical total disc replacement (CTDR) can preserve range of motion (ROM) of the operated spinal segment in cadaver studies. Evidence is less clear in clinical trials. The present study aims to investigate the differences in cervical biomechanics before and after CTDR and its association with heterotopic ossification (HO) development. METHOD Articles that reported the rate of HO and ≥1 difference in cervical biomechanics were included in quantitative analyses. We pooled the mean difference (MD) of cervical biomechanics before and after CTDR. Subgroup analyses and metaregression analyses were conducted to identify potential contributors to heterogeneity. RESULTS Of the 599 studies screened, 35 studies were included in the final analysis. In comparison with preoperative values, ROM of the spinal segment inferior (MD: 0.38; 95% CI: 0.02 to 0.74) and superior (MD: 0.43; 95% CI: 0.12 to 0.75) to the surgical spinal segment, functional spinal unit (FSU) angle (MD: 2.23; 95% CI: 1.11 to 3.35), and C2/C7 Cobb angle (MD: 3.49; 95% CI: 1.73 to 5.25) significantly increased after CTDR. In contrast, FSU and cervical ROM at baseline were no different from follow-up. On multivariable meta-regression analyses, HO and ROM-limiting HO were not associated with changes in cervical biomechanics. Single-level CTDR and duration of follow-up were associated with changes in cervical biomechanics. CONCLUSION Our study reported the pooled mean of biomechanics at baseline and final follow-up and their differences. The changes in biomechanics were not associated with the rates of HO and ROM-limiting HO.
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Affiliation(s)
- Nicholas Hui
- NeuroSpine Surgery Research Group, Sydney, Australia,7800University of New South
Wales, Sydney, Australia
| | - Kevin Phan
- NeuroSpine Surgery Research Group, Sydney, Australia,7800University of New South
Wales, Sydney, Australia
| | - Mei-Yi Lee
- NeuroSpine Surgery Research Group, Sydney, Australia,85120Hong Kong Polytechnic
University, Hong Kong
| | - Jack Kerferd
- NeuroSpine Surgery Research Group, Sydney, Australia,7800University of New South
Wales, Sydney, Australia
| | - Telvinderjit Singh
- NeuroSpine Surgery Research Group, Sydney, Australia,7800University of New South
Wales, Sydney, Australia
| | - Ralph J. Mobbs
- NeuroSpine Surgery Research Group, Sydney, Australia,7800University of New South
Wales, Sydney, Australia,NeuroSpineClinic, Sydney, Australia,Ralph J. Mobbs, NeuroSpineClinic, Suite 7,
Level 7, Prince of Wales Private Hospital, Randwick, New South Wales 2031,
Australia.
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Kim LH, D'Souza M, Ho AL, Pendharkar AV, Sussman ES, Rezaii P, Desai A. Anterior Techniques in Managing Cervical Disc Disease. Cureus 2018; 10:e3146. [PMID: 30410821 PMCID: PMC6207169 DOI: 10.7759/cureus.3146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Surgical treatment may be indicated for select patients with cervical disc disease, whether it is cervical disc herniation or spondylosis due to degenerative changes, acute cervical injury due to trauma, or other underlying cervical pathology. Currently, there are various surgical techniques, including anterior, posterior, or combined approaches, in addition to new interventions being utilized in practice. Ideally, the surgical approach should be selected in consideration of each patient’s clinical presentation, imaging findings, and overall medical comorbidities on an individual basis. But the unique advantages and disadvantages of each surgical technique often complicate the therapy choice in managing cervical disc diseases. Although anterior cervical discectomy and fusion (ACDF) is the most widely accepted procedure performed for both single and multi-level cervical disc diseases, there are multiple modifications to this technique. Surgeons have access to different types of plates, screws, and cages and can adopt newer advances in the field such as stand-alone and minimally invasive techniques when indicated. In short, no consensus exists in terms of a single approach that is preferred for all patients. This article aims to review the standard of care for management of cervical disc disease with a focus on the surgical techniques and, in particular, the anterior approach, exploring the various surgical options within this technique.
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Affiliation(s)
- Lily H Kim
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Marissa D'Souza
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Allen L Ho
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | | | - Eric S Sussman
- Neurosurgery, Stanford University School of Medicine, West Orange, USA
| | - Paymon Rezaii
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Atman Desai
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
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Kong L, Ma Q, Meng F, Cao J, Yu K, Shen Y. The prevalence of heterotopic ossification among patients after cervical artificial disc replacement: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e7163. [PMID: 28614250 PMCID: PMC5478335 DOI: 10.1097/md.0000000000007163] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Prevalence estimates of heterotopic ossification (HO) following cervical artificial disc replacement (ADR) varied widely in previous studies. We conducted a systematic review and meta-analysis to summarize its point prevalence. METHODS Electronic searches of PubMed, Web of Science, Embase, and Cochrane Library databases were conducted to identify studies that reported prevalence of HO. Definitions of HO and severe HO were based on McAfee grading system. Random-effects model was used to estimate the pooled prevalence. We conducted subgroup analyses according to the different length of follow-up time, and performed univariate metaregression analyses to explore the effects of potential variables on the overall prevalence. RESULTS A total of 38 studies were included in this study. The pooled data showed that the prevalence of HO after cervical ADR within the 1 to 2 years, 2 to 5 years, and 5 to10 years of follow-up was 38.0% (95% confidence interval [CI], 30.2%-46.5%), 52.6% (95% CI, 43.1%-61.9%), and 53.6% (95% CI, 40.0%-66.7%), respectively, while the prevalence of severe HO was 10.9% (95% CI, 9.0%-13.2%), 22.2% (95% CI, 15.5%-30.7%), and 47.5% (95% CI, 30.0%-65.8%), respectively. Follow-up time was positively associated with the prevalence of severe HO (P < .01), and the 1-month growth of mean follow-up went with 0.63% increase of severe HO. CONCLUSION This meta-analysis reported data on the prevalence of HO and severe HO after cervical ADR, and provided information on its process of development. These should be useful to enable surgeons and patients to gain a better understanding of HO after cervical ADR.
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Maharaj MM, Mobbs RJ, Hogan J, Zhao DF, Rao PJ, Phan K. Anterior cervical disc arthroplasty (ACDA) versus anterior cervical discectomy and fusion (ACDF): a systematic review and meta-analysis. JOURNAL OF SPINE SURGERY (HONG KONG) 2016; 1:72-85. [PMID: 27683682 DOI: 10.3978/j.issn.2414-469x.2015.09.01] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Surgical approaches are usually required in cases of severe cervical disc disease. The traditional method of anterior cervical disc fusion (ACDF) has been associated with reduced local mobility and increased occurrence of adjacent segment disease. The newer method of anterior cervical disc arthroplasty (ACDA) relies upon artificial discs of various products. Current literature is inconsistent in the comparative performance of these methods with regards to clinical, radiological and patient outcomes. METHODS Electronic databases, including OVID Medline, PubMed, Scopus, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, were comprehensively searched to retrieve studies comparing the treatment outcomes of ACDF and ACDA. Baseline characteristics and outcome data were extracted from eligible articles. RESULTS Two hundred and fifty five articles were identified through the database searches, and after screening 28 studies were included in the systematic review and meta-analysis. A total of 4,070 patients were included (2156 ACDA, 1914 ACDF). There was no significant difference between the two groups in operation time, blood loss during operation, long-term all-complication rate and reoperation rate at the level of injury. The ACDA group had significantly better neurological outcomes, as well as a significantly lower rate of adjacent segment diseases. CONCLUSIONS Compared with ACDF, the ACDA procedure is associated with improved reoperation rate and reduction in neurological deficits amongst previously demonstrated benefits. There is heterogeneity in ACDA devices; future studies are required to investigate the impact of this technique on treatment outcomes.
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Affiliation(s)
- Monish M Maharaj
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia;; NeuroSpine Clinic, Prince of Wales Private Hospital, Randwick, Sydney, Australia;; University of New South Wales, Sydney, Australia
| | - Ralph J Mobbs
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia;; NeuroSpine Clinic, Prince of Wales Private Hospital, Randwick, Sydney, Australia;; University of New South Wales, Sydney, Australia
| | - Jarred Hogan
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia;; NeuroSpine Clinic, Prince of Wales Private Hospital, Randwick, Sydney, Australia;; University of New South Wales, Sydney, Australia
| | | | - Prashanth J Rao
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia;; NeuroSpine Clinic, Prince of Wales Private Hospital, Randwick, Sydney, Australia;; University of New South Wales, Sydney, Australia
| | - Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia;; NeuroSpine Clinic, Prince of Wales Private Hospital, Randwick, Sydney, Australia;; University of New South Wales, Sydney, Australia;; University of Sydney, Sydney, Australia
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