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Miller AK, Zakko P, Park DK, Chang VW, Schultz L, Springer K, Hamilton TM, Abdulhak MM, Schwalb JM, Nerenz DR, Aleem IS, Khalil JG. Cervical disc arthroplasty versus anterior cervical discectomy and fusion: an analysis of the Michigan Spine Surgery Improvement Collaborative Database. Spine J 2024; 24:791-799. [PMID: 38110089 DOI: 10.1016/j.spinee.2023.12.004] [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: 08/05/2023] [Revised: 11/08/2023] [Accepted: 12/14/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are established surgical options for the treatment of cervical radiculopathy, myelopathy, and cervical degenerative disc disease. However, current literature does not demonstrate a clear superiority between ACDF and CDA. PURPOSE To investigate procedural and patient-reported outcomes of ACDF and CDA among patients included in the Michigan Spine Surgery Improvement Collaborative (MSSIC) database. DESIGN Retrospective study of prospectively collected outcomes registry data. PATIENT SAMPLE Individuals within the MSSIC database presenting with radiculopathy, myelopathy, or cervical spondylosis refractory to typical conservative care undergoing primary ACDF or CDA from January 4, 2016, to November 5, 2021. OUTCOME MEASURES Perioperative measures (including surgery length, length of stay, return to OR, any complications), patient-reported functional outcomes at 2-year follow-up (including return to work, patient satisfaction, PROMIS, EQ-5D, mJOA). METHODS Patients undergoing ACDF were matched 4:1 with those undergoing CDA; propensity analysis performed on operative levels (1- and 2- level procedures), presenting condition, demographics, and comorbidities. Initial comparisons performed with univariate testing and multivariate analysis performed with Poisson generalized estimating equation models clustering on hospital. RESULTS A total of 2,208 patients with ACDF and 552 patients with CDA were included. Baseline demographics were similar, with younger patients undergoing CDA (45.6 vs 48.6 years; p<.001). Myelopathy was more frequent in ACDF patients (30% vs 25%; p=.015). CDA was more frequently planned as an outpatient procedure. Length of stay was increased in ACDF (1.3 vs 1.0 days; p<.001). Functional outcomes were similar, with comparable proportions of patients meeting minimal clinically important difference thresholds in neck pain, arm pain, PROMIS, EQ-5D, and mJOA score. After multivariate regression, no significant differences were seen in surgical or functional outcomes. CONCLUSIONS This study demonstrates similar outcomes for those undergoing ACDF and CDA at 2 years. Previous meta-analyses of CDA clinical trial data adhere to strict inclusion and exclusion criteria required by clinical studies; this registry data provides "real world" clinical outcomes reflecting current practices for ACDF and CDA patient selection.
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Affiliation(s)
- Alex K Miller
- Department of Orthopaedic Surgery, Corewell Health East William Beaumont University Hospital, 3601 W. 13 Mile Rd., Royal Oak, MI 48073, USA.
| | - Philip Zakko
- Department of Orthopaedic Surgery, Corewell Health East William Beaumont University Hospital, 3601 W. 13 Mile Rd., Royal Oak, MI 48073, USA
| | - Daniel K Park
- Department of Orthopaedic Surgery, Corewell Health East William Beaumont University Hospital, 3601 W. 13 Mile Rd., Royal Oak, MI 48073, USA; Oakland University William Beaumont School of Medicine, 586 Pioneer Dr., Rochester, MI 48309, USA
| | - Victor W Chang
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, USA
| | - Lonni Schultz
- Michigan Spine Surgery Improvement Collaborative, 3A Ford Pl., Detroit, MI 48202, USA
| | - Kylie Springer
- Michigan Spine Surgery Improvement Collaborative, 3A Ford Pl., Detroit, MI 48202, USA
| | - Travis M Hamilton
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, USA
| | - Muwaffak M Abdulhak
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, USA; Michigan Spine Surgery Improvement Collaborative, 3A Ford Pl., Detroit, MI 48202, USA
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, USA; Michigan Spine Surgery Improvement Collaborative, 3A Ford Pl., Detroit, MI 48202, USA
| | - David R Nerenz
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, USA; Michigan Spine Surgery Improvement Collaborative, 3A Ford Pl., Detroit, MI 48202, USA
| | - Ilyas S Aleem
- Department of Orthopaedic Surgery, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Jad G Khalil
- Department of Orthopaedic Surgery, Corewell Health East William Beaumont University Hospital, 3601 W. 13 Mile Rd., Royal Oak, MI 48073, USA; Oakland University William Beaumont School of Medicine, 586 Pioneer Dr., Rochester, MI 48309, USA
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Nin DZ, Chen YW, Kim DH, Niu R, Powers A, Chang DC, Hwang RW. Health Care Costs Following Anterior Cervical Discectomy and Fusion or Cervical Disc Arthroplasty. Spine (Phila Pa 1976) 2024; 49:530-535. [PMID: 38192187 DOI: 10.1097/brs.0000000000004917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/26/2023] [Indexed: 01/10/2024]
Abstract
STUDY DESIGN Observational cohort study. OBJECTIVE To describe the postoperative costs associated with both anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) in the two-year period following surgery. SUMMARY OF BACKGROUND DATA CDA has become an increasingly common alternative to ACDF for the treatment of cervical disc disorders. Although a number of studies have compared clinical outcomes between both procedures, much less is known about the postoperative economic burden of each procedure. MATERIALS AND METHODS By analyzing a commercial insurance claims database (Marketscan, Merative), patients who underwent one-level or two-level ACDF and CDA procedures between January 1, 2017 and December 31, 2017 were identified and included in the study. The primary outcome was the cost of payments for postoperative management in the two-year period following ACDF or CDA. Identified postoperative interventions included in the study were: (i) physical therapy, (ii) pain medication, (iii) injections, (iv) psychological treatment, and (iv) subsequent spine surgeries. RESULTS Totally, 2304 patients (age: 49.0±9.4 yr; male, 50.1%) were included in the study. In all, 1723 (74.8%) patients underwent ACDF, while 581 (25.2%) underwent CDA. The cost of surgery was similar between both groups (ACDF: $26,819±23,449; CDA: $25,954±20,620; P =0.429). Thirty-day, 90-day, and two-year global costs were all lower for patients who underwent CDA compared with ACDF ($31,024 vs. $34,411, $33,064 vs. $37,517, and $55,723 vs. $68,113, respectively). CONCLUSION Lower two-year health care costs were found for patients undergoing CDA compared with ACDF. Further work is necessary to determine the drivers of these findings and the associated longer-term outcomes.
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Affiliation(s)
- Darren Z Nin
- Department of Orthopedic Surgery, New England Baptist Hospital
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - David H Kim
- Department of Orthopedic Surgery, New England Baptist Hospital
- Tufts University School of Medicine
| | - Ruijia Niu
- Department of Orthopedic Surgery, New England Baptist Hospital
| | - Andrew Powers
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Raymond W Hwang
- Department of Orthopedic Surgery, New England Baptist Hospital
- Tufts University School of Medicine
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Nunna RS, Ryoo JS, Ostrov PB, Patel S, Godolias P, Daher Z, Price R, Chapman JR, Oskouian RJ. Single-level cervical disc replacement (CDR) versus anterior cervical discectomy and fusion (ACDF): A Nationwide matched analysis of complications, 30- and 90-day readmission rates, and cost. World Neurosurg X 2024; 21:100242. [PMID: 38221950 PMCID: PMC10787284 DOI: 10.1016/j.wnsx.2023.100242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 01/16/2024] Open
Affiliation(s)
- Ravi S. Nunna
- Department of Neurosurgery, University of Missouri Columbia Health Care, Columbia, MO, USA
| | - James S. Ryoo
- University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Philip B. Ostrov
- University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Saavan Patel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Zeyad Daher
- Swedish Neuroscience Institute, Seattle, WA, USA
- Dornsife College of Letters, Arts and Sciences, University of Southern California, Los Angeles, CA, USA
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Wang X, Lin Y, Wang Q, Gao L, Feng F. A Bibliometric Analysis of the Top 100 Cited Articles in Anterior Cervical Discectomy and Fusion. J Pain Res 2022; 15:3137-3156. [PMID: 36311292 PMCID: PMC9604433 DOI: 10.2147/jpr.s375720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022] Open
Abstract
Study design A bibliometric analysis. Objective To identify and analyze the top 100 cited articles in anterior cervical discectomy and fusion. Summary of Background Data Anterior cervical discectomy and fusion (ACDF) is one of the most routine surgical procedures in spine surgery. Many surgeons and academics have researched ACDF thoroughly and published numerous articles. However, there is no relevant bibliometric analysis. Therefore, our study aims to identify and analyze the top 100 cited articles in ACDF to identify the research trends. Methods We searched the Web of Science (WOS) Core Collection database with restrictions and identified the top 100 cited publications in ACDF for analysis. Results The citation counts of the top 100 cited publications ranged from 37 to 361 (mean 67.42). All studies were published between 2008 and 2019, with 2013 and 2015 the most prolific years. The journals Spine and Journal of Neurosurgery-Spine provided the majority of the articles. Overall, the 100 articles came from 12 countries, with the United States being the top producer, followed by China and South Korea. The most frequent keywords were "spine", "anterior cervical discectomy and fusion", "interbody fusion", 'arthrodesis', "follow-up", "decompression", and "ACDF". Conclusion ACDF has been regarded as a classical gold standard in anterior cervical surgery, and the emergence of new surgical procedures has not affected its status. Cervical disc arthroplasty still needs further research and development. As the first bibliometric analysis of ACDF, this bibliometric study is meant to provide guidance for clinicians and scholars to research the development trend of this field.
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Affiliation(s)
- Xun Wang
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang310053, People’s Republic of China
| | - Yanze Lin
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang310053, People’s Republic of China
| | - Qiongtai Wang
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang310053, People’s Republic of China
| | - Liqing Gao
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang310053, People’s Republic of China
| | - Fabo Feng
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, People’s Republic of China,Correspondence: Fabo Feng, Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, People’s Republic of China, Email
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Schuermans VNE, Smeets AYJM, Boselie AFM, Zarrouk O, Hermans SMM, Droeghaag R, Curfs I, Evers SMAA, van Santbrink H. Cost-effectiveness of anterior surgical decompression surgery for cervical degenerative disk disease: a systematic review of economic evaluations. 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 2022; 31:1206-1218. [PMID: 35224672 DOI: 10.1007/s00586-022-07137-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/06/2021] [Accepted: 01/26/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE No clear consensus exists on which anterior surgical technique is most cost-effective for treating cervical degenerative disk disease (CDDD). One of the most common treatment options is anterior cervical discectomy with fusion (ACDF). Anterior cervical discectomy with arthroplasty (ACDA) was developed in an effort to reduce the incidence of clinical adjacent segment pathology and associated additional surgeries by preserving motion. This systematic review aims to evaluate the evidence regarding the cost-effectiveness of anterior surgical decompression techniques used to treat radiculopathy and/or myelopathy caused by CDDD. METHODS The search was conducted in PubMed, EMBASE, Web of Science, CINAHL, EconLit, NHS-EED and the Cochrane Library. Studies were included if healthcare costs and utility or effectivity measurements were mentioned. RESULTS A total of 23 studies were included out of the 1327 identified studies. In 9 of the 13 studies directly comparing ACDA and ACDF, ACDA was the most cost-effective technique, with an incremental cost effectiveness ratio ranging from $2.900/QALY to $98.475/QALY. There was great heterogeneity between the costs of due to different in- and exclusion criteria of costs and charges, cost perspective, baseline characteristics, and calculation methods. The methodological quality of the included studies was moderate. CONCLUSION The majority of studies report ACDA to be a more cost-effective technique in comparison with ACDF. The lack of uniform literature impedes any solid conclusions to be drawn. There is a need for high-quality cost-effectiveness research and uniformity in the conduct, design and reporting of economic evaluations concerning the treatment of CDDD. TRIAL REGISTRATION PROSPERO Registration: CRD42020207553 (04.10.2020).
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Affiliation(s)
- V N E Schuermans
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands. .,Department of Neurosurgery, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands. .,CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.
| | - A Y J M Smeets
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Neurosurgery, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands
| | - A F M Boselie
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Neurosurgery, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands
| | - O Zarrouk
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Neurosurgery, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands
| | - S M M Hermans
- Department of Orthopedic Surgery and Traumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - R Droeghaag
- Department of Orthopedic Surgery and Traumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - I Curfs
- Department of Orthopedic Surgery and Traumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - S M A A Evers
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Health Services Research, Focusing on Value-Based Care and Ageing and Department of Family Medicine, Maastricht University, Maastricht, The Netherlands.,Center of Economic Evaluation and Machine Learning, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - H van Santbrink
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Neurosurgery, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands.,CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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Ostrov PB, Reddy AK, Ryoo JS, Behbahani M, Mehta AI. Anterior Cervical Discectomy and Fusion Versus Cervical Disc Arthroplasty: A Comparison of National Trends and Outcomes. World Neurosurg 2022; 160:e96-e110. [PMID: 34973439 DOI: 10.1016/j.wneu.2021.12.099] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Anterior cervical discectomy and fusion (ACDF) has been considered the standard treatment for degenerative cervical disc disease; however, recent trials have shown comparable outcomes with cervical disc arthroplasty (CDA). This study aimed to observe disparities in treatment paradigms of single-level cervical disc diseases and compare inpatient outcomes between procedures. METHODS A retrospective cohort of patients treated for single-level cervical disc herniation or degeneration without myelopathy was queried from the Nationwide Inpatient Sample spanning 2012-2015. Multivariate logistic regression was performed to assess the effects of demographics, temporality of admission, and hospital characteristics on odds of receiving CDA versus ACDF. Propensity-score matching was performed to compare cost, length of stay (LOS), non-home discharge, and inpatient complications. RESULTS In total, 1028 CDAs and 44,374 ACDFs were performed for single-level cervical disc disease during 2012-2015. Matched comparison showed that while non-home discharges were not different between CDA and ACDF (P = 0.248), patients who received CDA had a 0.19-day shorter LOS (P < 0.001) and $4694 greater total cost (P < 0.001). There were no statistically significant differences in inpatient complication rates. Multivariate analysis showed that patients in the 26th-50th percentile, 51st-75th percentile, and 76th-100th percentile of median household income had greater odds of CDA compared with patients in the 0-25th percentile (odds ratio [OR] 1.35, P = 0.003; OR 1.31, P = 0.013; OR 1.34, P = 0.011, respectively). Patients with private insurance had greater odds of receiving CDA compared with patients on Medicare (OR 1.91, P < 0.001). CONCLUSIONS CDA was associated with shorter LOS but greater costs compared with ACDF. Patients with greater median income and private insurance were more likely to receive CDA.
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Affiliation(s)
- Philip B Ostrov
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Abhinav K Reddy
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - James S Ryoo
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mandana Behbahani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
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Lang RW, Yoder AJ, Porensky P. Perspectives on Cervical Arthroplasty in Navy and Marine Corps Tactical Jet Aircrew. Mil Med 2022; 187:204-208. [PMID: 35064263 DOI: 10.1093/milmed/usac012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/07/2022] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
Symptomatic cervical spondylosis is a progressive degenerative condition of the cervical spine commonly resulting in functionally-limiting pain, weakness, and/or limited dexterity. Symptomatic cervical spondylosis is believed to occur at higher rates in military aviators than civilian counterparts and is a disqualifying condition for all Navy and Marine Corps aircrew. This condition is non-waiverable for tactical jet (ejection-seat-based) aviators. Medical attrition of experienced tactical jet aircrew from the military aviation community results in substantial cost to the U.S. Government, reduces fleet combat capability, and adversely impacts career progression and retention. The clinical maturation of cervical total disc replacement (TDR) technology over the last 2 decades has revolutionized the treatment of symptomatic cervical spondylosis and enabled a return to duty for hundreds of military service members in non-aviation fields. TDR studies demonstrate equal or superior functional outcomes, rates of symptom resolution, reduced complication and reoperation rates, and lower long-term cost compared to traditional Anterior Cervical Discectomy and Fusion (ACDF). Although initial computational modeling studies have evaluated cervical arthroplasty performance during rotary-wing crash impacts, safety within the dynamic tactical jet environment has not yet been established. The purpose of this article is to review factors relevant to TDR safety and outcomes and to propose a framework to evaluate the safety of TDR in Navy and Marine Corps tactical jet aircrew, to ultimately inform aeromedical algorithms regarding return to flight after TDR.
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Affiliation(s)
- Richard W Lang
- Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Adam J Yoder
- Department of Physical & Occupational Therapy, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, San Diego, CA 92134, USA
| | - Paul Porensky
- Department of Neurological Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
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Guo Y, Liu H, Xu J, Deng Y, Tao X, Meng Y, Wang X, Hong Y, Wang B, Ding C, Wu W. Pretic-I was a safe and effective artificial cervical disc prosthesis--a retrospective and comparative study with 5-year follow-up. BMC Musculoskelet Disord 2021; 22:981. [PMID: 34819053 PMCID: PMC8611939 DOI: 10.1186/s12891-021-04813-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/14/2021] [Indexed: 02/08/2023] Open
Abstract
Background The newly designed cervical disc prosthesis, Pretic-I, had been finished its limited clinical use for over 5 years. At a short-term follow-up of 2 years, we obtained satisfactory clinical results. The long-term clinical efficacy and safety of Pretic-I will now be analyzed. Methods Peri-operative parameters included intra-operative blood loss, operation time, off-bed time. Clinical parameters included visual analogue scale (VAS) for arm and neck, neck disability index (NDI), and Japanese Orthopaedic Association (JOA) score. Radiological parameters included C2–7 Cobb angle, Shell angle, and the range of motion (ROM) of C2–7, functional segment unit (FSU), and adjacent FSU. The CDA-related complications included adjacent segment degeneration (ASDeg), adjacent segment disease (ASDis), heterotopic ossification (HO), prosthesis subsidence, prosthesis displacement, and dysphagia. Results A total 64 patients from two independent centers received a single-level CDA with Discover (n = 32) and Pretic-I (n = 32), and all of patients finished a 5-year follow-up. There’re no significant differences between two groups in peri-operative parameters. The clinical parameters improved greatly in Pretic-I group (p<0.0001), and there’s no statistical difference from Discover group. Furthermore, Pretic-I could slightly improve the cervical curvature (15.08 ± 11.75 to 18.00 ± 10.61, p = 0.3079) and perfectly maintain the Shell angle (3.03 ± 3.68 to 2.23 ± 4.10, p = 0.1988), cervical ROM (52.48 ± 14.31 to 53.30 ± 11.71, p = 0.8062) and FSU ROM (12.20 ± 4.52 to 10.73 ± 4.45, p = 0.2002). The incidence of high-grade HO (Grade III-IV) at the final follow-up was significantly lower in Pretic-I group than in Discover group (12.50% vs. 34.38%, p = 0.0389, Statistical Power = 95.36%). The incidences of other CDA-related complications in Pretic-I group were also well-accepted, comparable to the Discover group, without significant differences. Conclusion CDA with Pretic-I demonstrated a well-accepted and sustained clinical outcome, with a significantly lower incidence of high-grade HO. This newly designed prosthesis is expected to become an alternative choice for cervical disc prosthesis in the future. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04813-5.
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Affiliation(s)
- Yingjun Guo
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Liu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China.
| | - Jianzhong Xu
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, China.
| | - Yuxiao Deng
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoliang Tao
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yang Meng
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaofei Wang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Hong
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Beiyu Wang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Ding
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Wenjie Wu
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, China
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Parish JM, Asher AM, Coric D. Adjacent-Segment Disease Following Spinal Arthroplasty. Neurosurg Clin N Am 2021; 32:505-510. [PMID: 34538476 DOI: 10.1016/j.nec.2021.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Intuitively, the introduction of artificial discs into spinal surgery offered the promise of reducing the incidence of adjacent segment (AS) reoperation compared with fusion. Several early clinical studies reported nonstatistically significant differences in AS disease between total disc replacement and fusion. Given the relatively low rate of AS reoperation (∼1%-2% per year) following fusion, any appropriately powered study designed to demonstrate a statistically significant difference compared with arthroplasty would require thousands of patients and/or long-term follow-up (>5 years). Therefore, these differences only become apparent with large study size or meta-analyses and longer follow-up.
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Affiliation(s)
- Jonathan M Parish
- Department of Neurological Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | - Anthony M Asher
- University of North Carolina School of Medicine, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
| | - Domagoj Coric
- Carolina Neurosurgery and Spine Associates, 225 Baldwin Avenue, Charlotte, NC 28204, USA; Atrium Musculoskeletal Institute, Charlotte, NC, USA
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Patient Risk Factors Associated With 30- and 90-Day Readmission After Cervical Discectomy: A Nationwide Readmission Database Study. Clin Spine Surg 2020; 33:E434-E441. [PMID: 32568863 DOI: 10.1097/bsd.0000000000001030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE The aim of this study was to assess the patient-level risk factors associated with 30- and 90-day unplanned readmissions following elective anterior cervical decompression and fusion (ACDF) or cervical disk arthroplasty (CDA). SUMMARY OF BACKGROUND DATA For cervical disk pathology, both ACDF and CDA are increasingly performed nationwide. However, relatively little is known about the adverse complications and rates of readmission for ACDF and CDA. METHODS A retrospective cohort study was performed using the Nationwide Readmission Database from the years 2013 to 2015. All patients undergoing either CDA or ACDF were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and to identify 30- and 31-90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R). RESULTS There were a total of 13,093 index admissions with 856 (6.5%) readmissions [30-R: n=532 (4.0%); 90-R: n=324 (2.5%)]. Both overall length of stay and total cost were greater in the 30-R cohort compared with 90-R and Non-R cohorts. The most prevalent 30- and 90-day complications seen among the readmitted cohorts were infection, genitourinary complication, and device complication. On multivariate regression analysis, age, Medicaid status, medium and large hospital bed size, deficiency anemia, and any complication during index admission were independently associated with increased 30-day readmission. Whereas age, large hospital bed size, coagulopathy, and any complication during the initial hospitalization were independently associated with increased 90-day readmission. CONCLUSION Our nationwide study identifies the 30- and 90-day readmission rates and several patient-related risk factors associated with unplanned readmission after common anterior cervical spine procedures. LEVEL OF EVIDENCE Level III.
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Nunley P, Frank K, Stone M. Patient Selection in Cervical Disc Arthroplasty. Int J Spine Surg 2020; 14:S29-S35. [PMID: 32994303 PMCID: PMC7528765 DOI: 10.14444/7088] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Patient selection for cervical disc arthroplasty (CDA) in the United States remains a topic of debate among surgeons. Many surgeons base US patient selection for CDA implantation on the Food and Drug Administration (FDA) indications/contraindications. While off-label use does occur, the frequency and extent of off-label use in the US remains largely unknown. Outside the United States, patient selection is notably less stringent; however such data also remain largely unpublished or presented/published with a low level of evidence. Here, we will review the current approved US on-label patient selection criteria for CDA and discuss the rationale and supporting evidence to expand these criteria in the United States. METHODS A PubMed literature search was completed using the keywords "cervical disc arthroplasty" and "cervical disc replacement." The articles were evaluated by the authors for patient selection criteria. CONCLUSIONS The current published data do not conclusively prove that the patients excluded from CDA by strict adherence to FDA indications would benefit from CDA surgery over anterior cervical discectomy and fusion. As surgeons, it is a difficult decision regarding when to expand indications to include off-label use of CDA. In our practice, generally CDA patient selection agrees with the FDA indications and contraindications, as there is a lack of level 1 evidence to confirm effectiveness of CDA outside of the current FDA indications. We will likely need more well-constructed studies to include prospective and controlled trials that specifically evaluate the "off-label" applications before US surgeons are convinced to expand indications and insurance companies agree to reimburse.
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Affiliation(s)
| | - Kelly Frank
- Spine Institute of Louisiana, Shreveport, Louisiana
| | - Marcus Stone
- Spine Institute of Louisiana, Shreveport, Louisiana
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Financial Aspects of Cervical Disc Arthroplasty: A Narrative Review of Recent Literature. World Neurosurg 2020; 140:534-540. [PMID: 32353543 DOI: 10.1016/j.wneu.2020.04.150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/20/2020] [Indexed: 12/16/2022]
Abstract
Recently, there has been significant interest in understanding the cost-effectiveness of treatments in spine surgery as health care systems in the United States move toward value-based care and alternative payment models. Previous studies have shown comparable outcomes of cervical disc arthroplasty (CDA) and anterior cervical discectomy fusion; however, there is a lack of consensus on the cost-effectiveness of CDA to support full adoption. Evidence of the limitations of these cost-analysis studies also exists in the literature, including industry funding, potential selection bias, and varying methods of calculating value. The goal of this narrative review is to provide an overview of the cost-effectiveness of CDA compared with anterior cervical discectomy and fusion, and potential limitations with cost-analysis studies in spine surgery.
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Jain NS, Nguyen A, Formanek B, Alluri R, Buser Z, Hah R, Wang JC. Cervical Disc Replacement: Trends, Costs, and Complications. Asian Spine J 2020; 14:647-654. [PMID: 32213792 PMCID: PMC7595820 DOI: 10.31616/asj.2019.0246] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 11/12/2019] [Indexed: 12/16/2022] Open
Abstract
Study Design Retrospective review of insurance database. Purpose To investigate national trends, complications, and costs after cervical disc replacement (CDR) using an administrative insurance database representative of the United States population. Overview of Literature As CDR continues to be used to treat patients with cervical stenosis, it is important to gain a better understanding of its use on a national level, potential complications, and cost. This information will allow for optimal patient counseling, risk stratification, and healthcare cost assessments. Several prior studies have investigated complications associated with CDR, but they have been limited by small sample size, single institution experiences, limited follow-up, and potential conflicts of interest. Methods Patients who underwent single or multilevel CDR between 2007 and 2015 were identified using an insurance database. We collected data on annual trends, reimbursement costs, patient demographic information, hospital information, and information on complications from the time of operation to 1 year postoperative. Results Total of 293 patients underwent either single or multilevel CDR. The number of procedures increased nonlinearly over time at an average of 17% per year, with a greater increase seen in the outpatient setting. Less than 3.7% of patients had new onset pain within 1 year after CDR. Within 1 year, 12.3% of patients reported a mechanical and/or bone-related complication. There were no patients who indicated a new nerve injury within 6 months of follow-up. Less than 3.7% of patients presented with dysphagia or dysphonia within 6 months, infection within 3 months, or a revision or reoperation within 1 year. Average reimbursement for single-level inpatient versus outpatient CDR was US $33,696.28 and US $34,675.12, respectively (p=0.29). Conclusions This study demonstrated that the use of CDR continued to increase. The most common complication was mechanical and/or bone-related, and cost analysis demonstrated no significant difference between inpatient and outpatient CDR.
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Affiliation(s)
- Nickul Saral Jain
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ailene Nguyen
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Blake Formanek
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ram Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ray Hah
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey Chun Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Zuckerman SL, Devin CJ. Outcomes and value in elective cervical spine surgery: an introductory and practical narrative review. JOURNAL OF SPINE SURGERY 2020; 6:89-105. [PMID: 32309649 DOI: 10.21037/jss.2020.01.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
How we determine a successful clinical outcome and the value of a spine intervention are two major questions surrounding clinical spine research. Patient-reported outcomes (PROs), both LEGACY and Patient-Reported Outcomes Measurement Information System (PROMIS) measures, are becoming ubiquitous throughout the literature. Spine surgeons need a facile understanding of the financial landscape of their environment to influence change. In the current introductory, narrative review on outcomes and value in cervical spine surgery, we aim to: (I) define relevant outcome and cost terminology, (II) review recent cervical spine surgery literature, divided by specific pathology with a focus on LEGACY and PROMIS measures, and (III) discuss value and cost as they pertain to postoperative return to work and ambulatory surgery centers surgeries.
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Affiliation(s)
- Scott L Zuckerman
- Vanderbilt Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Steamboat Orthopaedic and Spine Institute, Steamboat Springs, CO, USA
| | - Clinton J Devin
- Vanderbilt Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Steamboat Orthopaedic and Spine Institute, Steamboat Springs, CO, USA
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Long-Term Comparison of Health Care Utilization and Reoperation Rates in Patients Undergoing Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disc Disease. World Neurosurg 2020; 134:e855-e865. [DOI: 10.1016/j.wneu.2019.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/02/2019] [Accepted: 11/04/2019] [Indexed: 12/20/2022]
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Abstract
Anterior cervical disc replacement (arthroplasty) has gained momentum over the past 2 decades. The ball-and-socket prosthesis design of arthroplasty has been shown to simulate normal motion in all 3 rotation planes at the level of surgery and replicates physiologic motion. Anterior cervical discectomy and fusion has been shown to be a safe and effective surgery over decades; cervical disc replacement counters some secondary effects owing to its preservation of segmental mobility, the potential to reduce adjacent segment degeneration, and the lack of plating or harvesting bone graft. The literature is growing in support of the success and longevity of arthroplasty.
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Sagittal Reconstruction and Clinical Outcome Using Traditional ACDF, Versus Stand-alone ACDF Versus TDR: A Systematic Review and Quantitative Analysis. Spine (Phila Pa 1976) 2019; 44:E1151-E1158. [PMID: 31261280 DOI: 10.1097/brs.0000000000003077] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To determine the difference in postoperative sagittal alignment when single level cervical radiculopathy or myelopathy is treated with an anterior cervical discectomy and fusion (ACDF) using a structural graft and plate, a stand-alone ACDF, or a total disc arthroplasty (TDR). We also wanted to determine if postoperative sagittal alignment impacted clinical outcomes in this patient population. SUMMARY OF BACKGROUND DATA Although there are several accepted techniques for interbody reconstruction during single level anterior cervical surgery, little is known on the impact of any of them on segmental and regional sagittal alignment. METHODS A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines of the PubMed, Embase, and Cochrane databases. Only studies which contained pre and postoperative C2-7 Cobb angles as well as Neck Disability Index (NDI) scores following single level traditional ACDF with plate and cage, stand-alone ACDF, or TDR with at least 1 year follow up were included. RESULTS There were 12 publications that fulfilled the inclusion criteria with a total of 658 patients. Cluster regression analysis showed no difference between treatment arms at each respective time-point or in the overall change in NDI from preoperative to postoperative (P = 0.88). Cluster regression analysis showed no difference between treatment arms at each respective time point or in the overall change in lordosis from pre-op to post-op (P = 0.93). CONCLUSION This review provides evidence that while NDI scores improved across all devices, there was no significant difference in NDI improvement or C2-7 Cobb angle change between single level traditional ACDF, stand-alone ACDF, or TDR. Although TDR has not been considered a lordosis producing operation, our investigation shows it does not differ significantly in sagittal profile from other cervical fusion techniques. Moreover, we show that the NDI score improved, regardless of device implanted. LEVEL OF EVIDENCE 1.
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Turner I, Choi D. NuNec™ Cervical Disc Arthroplasty Improves Quality of Life in Cervical Radiculopathy and Myelopathy: A 2-yr Follow-up. Neurosurgery 2019; 83:422-428. [PMID: 28973309 DOI: 10.1093/neuros/nyx424] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 07/11/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Anterior cervical disc replacement is an alternative to fusion for the treatment of selected cases of radiculopathy and myelopathy. We report clinical and radiological outcomes after disc replacement with the NuNec™ artificial cervical disc (Pioneer® Surgical Technology, Marquette, Michigan) with subgroup analysis. OBJECTIVE To review clinical and radiological outcomes after anterior cervical disc replacement with the NuNec™ artificial cervical disc. METHODS A consecutive case series of patients undergoing cervical disc replacement with the NuNec™ artificial disc was conducted. Clinical outcomes were assessed by questionnaires preoperatively and up to 2 yr postoperatively including neck and arm pain, Neck Disability Index, Euroqol 5-dimensions, and Short Form-36; x-rays from the same period were analyzed for range of movement and presence of heterotopic ossification. RESULTS A total of 44 NuNec™ discs were implanted in 33 patients. Clinical improvements were seen in all outcomes; significant improvements on the Neck Disability Index, Euroqol 5-dimensions, and physical domain of the Short Form-36 were maintained at 2 yr. There was a mean of 4° range of movement at the replacement disc level at 2 yr, a significant reduction from baseline; there was also progression in levels of heterotopic ossification. Complications included temporary dysphagia (10%) and progression of disease requiring foraminotomy (6%); no surgery for adjacent level disease was required. There was no significant difference in the outcomes of the radiculopathy and myelopathy groups. CONCLUSION Clinical outcomes using the NuNec™ disc replacement are comparable with other disc replacements. Although the range of movement is reduced, the reoperation rate is very low.
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Affiliation(s)
- Isobel Turner
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, Queen Square, London, England
| | - David Choi
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, Queen Square, London, England
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Kani KK, Chew FS. Cervical Disc Arthroplasty: Review and Update for Radiologists. Semin Roentgenol 2019; 54:113-123. [DOI: 10.1053/j.ro.2018.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
Over the last decade, several of the Food and Drug Administration-regulated investigational device exemption (IDE) trials have compared multiple cervical disk arthroplasty (CDA) devices to anterior cervical decompression and fusion (ACDF) showing comparable and even superior patient-reported outcomes. CDA has been an increasingly attractive option because of the positive outcomes and the motion-preserving technology. However, with the large burden that health care expenditures place on the economy, the focus is now on the value of treatment options. Cost-effectiveness studies assess value by evaluating both outcomes and cost, and recently several have been conducted comparing CDA and ACDF. The results have consistently shown that CDA is a cost-effective alternative, however, in comparison to ACDF the results remain inconclusive. The lack of incorporation of disease specific measures into health state utility values, the inconsistent methods of calculating cost, and the fact that a vast majority of the results have come from industry-sponsored studies makes it difficult to form a definitive conclusion. Despite these limitations, both procedures have proven to be safe, effective, and cost-efficient alternatives.
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Abstract
Anterior cervical diskectomy and fusion has been and remains the benchmark surgical management of cervical degenerative disk disease. However, an increased use of cervical disk arthroplasty (CDA) has been found in the past few years. The purported benefits of CDA included preserved motion, less adjacent-level degeneration, and less morbidity. Short-term results from randomized control trials clearly showed noninferiority of CDA compared with fusion. With long-term comparison data becoming available, results are equivalent and superior in many metrics compared, favoring CDA. Concerns remain regarding the best way to manage CDA failures. Nonetheless, appropriate patient selection and adherence to strict surgical technique make CDA a viable treatment.
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Cervical disc arthroplasty: tips and tricks. INTERNATIONAL ORTHOPAEDICS 2018; 43:777-783. [PMID: 30519869 DOI: 10.1007/s00264-018-4259-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 11/26/2018] [Indexed: 12/26/2022]
Abstract
Cervical disc arthroplasty (CDA) is a powerful, motion-sparing treatment option for managing cervical radiculopathy or myelopathy. While CDA can be an excellent surgery for properly indicated patients, it is also less forgiving than cervical fusion. Optimally resolving patient symptoms while maintaining range of motion relies on near perfection in the surgical technique. Different CDA options exist on the market, with some having long-term proven success and others in early stages of clinical trials. We discuss the different options available for use, as well as strategies of positioning, approach, disc space preparation, implantation, and fusion prevention that we believe can help improve performance and outcomes of CDA.
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The Seven-Year Cost-Effectiveness of Anterior Cervical Discectomy and Fusion Versus Cervical Disc Arthroplasty: A Markov Analysis. Spine (Phila Pa 1976) 2018; 43:1543-1551. [PMID: 29642136 DOI: 10.1097/brs.0000000000002665] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Markov model analysis. OBJECTIVE The aim of this study was to determine the 7-year cost-effectiveness of single-level anterior cervical discectomy and fusion (ACDF) versus cervical disc replacement (CDR) for the treatment of cervical disc degeneration. SUMMARY OF BACKGROUND DATA Both ACDF and CDR are acceptable surgical options for the treatment of symptomatic cervical disc degeneration. Past studies have demonstrated at least equal effectiveness of CDR when compared with ACDF in large randomized Investigational Device Exemption (IDE) studies. Short-term cost-effectiveness analyses at 5 years have suggested that CDR may be the preferred treatment option. However, adjacent segment disease and other postoperative complications may occur after 5 years following surgery. METHODS A Markov model analysis was used to evaluate data from the LDR Mobi-C IDE study, incorporating five Markov transition states and seven cycles with each cycle set to a length of 1 year. Transition state probabilities were determined from complication rates, as well as index and adjacent segment reoperation rates from the IDE study. Raw SF-12 data were converted to health state utility values using the SF-6D algorithm for 174 CDR patients and 79 ACDF patients. RESULTS Assuming an ideal operative candidate who is 40-years-old and failed appropriate conservative care, the 7-year cost was $103,924 for ACDF and $105,637 for CDR. CDR resulted in the generation of 5.33 quality-adjusted life-years (QALYs), while ACDF generated 5.16 QALYs. Both ACDF and CDR were cost-effective, but the incremental cost-effectiveness ratio (ICER) was $10,076/QALY in favor of CDR, which was less than the willingness-to-pay (WTP) threshold of $50,000/QALY. CONCLUSION ACDF and CDR are both cost-effective strategies for the treatment of cervical disc degeneration. However, CDR is the more cost-effective procedure at 7 years following surgery. Further long-term studies are needed to validate the findings of this model. LEVEL OF EVIDENCE 1.
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Vaccaro A, Beutler W, Peppelman W, Marzluff J, Mugglin A, Ramakrishnan PS, Myer J, Baker KJ. Long-Term Clinical Experience with Selectively Constrained SECURE-C Cervical Artificial Disc for 1-Level Cervical Disc Disease: Results from Seven-Year Follow-Up of a Prospective, Randomized, Controlled Investigational Device Exemption Clinical Trial. Int J Spine Surg 2018; 12:377-387. [PMID: 30276095 DOI: 10.14444/5044] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background This research was initiated to compare the long-term clinical safety and effectiveness of the selectively constrained SECURE-C (Globus Medical, Audubon, Pennsylvania) Cervical Artificial Disc to anterior cervical discectomy and fusion (ACDF). To preserve segmental motion, cervical total disc replacement (CTDR) was developed as an alternative to ACDF. Current CTDR designs incorporate constrained and unconstrained metal-on-metal or metal-on-polymer articulation with various means of fixation. Methods Eighteen investigational sites participated in this prospective clinical trial; 380 patients were enrolled and treated in the investigational device exemption study. The first 5 patients treated at each site were nonrandomized and received the investigational SECURE-C device. Patients were randomized, treated surgically, and evaluated postoperatively at 6 weeks, 3 months, 6 months, 12 months, 24 months, and annually thereafter through 84 months postoperative. Results Overall results for the randomized cohorts demonstrated statistical superiority of the investigational SECURE-C group over the control ACDF group at 84 months postoperative. SECURE-C showed clinically significant improvement in pain and function in terms of neck disability index and visual analog scale scores, and superiority in patient satisfaction was also achieved for patients treated with SECURE-C. Conclusion Clinical study results indicated that the selectively constrained SECURE-C Cervical Artificial Disc is as safe and effective as ACDF. Long-term results from the Post Approval Study demonstrated that SECURE-C is statistically superior to ACDF in terms of overall success and patient satisfaction. Lower rates of subsequent index-level surgeries and device-related adverse events were observed in the SECURE-C group than in the ACDF group. The long-term, level 1 clinical evidence presented here is consistent with other reports supporting the safety and efficacy of cervical arthroplasty, and furthers advocacy for motion preservation as a viable alternative to fusion.
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Postoperative Emergency Department Utilization and Hospital Readmission After Cervical Spine Arthrodesis: Rates, Trends, Causes, and Risk Factors. Spine (Phila Pa 1976) 2018; 43:1031-1037. [PMID: 29215499 DOI: 10.1097/brs.0000000000002518] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective state database analysis. OBJECTIVE To quantify the 30- and 90-day emergency department (ED) utilization and inpatient readmission rates after primary cervical arthrodesis, to stratify these findings by surgical approach, and to describe risk factors and conditions precipitating these events. SUMMARY OF BACKGROUND DATA Limited data exist on ED utilization and hospital readmission rates after cervical spine arthrodesis. METHODS The New York State all-payer health-care database was queried to identify all 87,045 patients who underwent primary subaxial cervical arthrodesis from 1997 through 2012. Demographic data and clinical information were extracted. Readmission data were available for the entire study period, whereas ED utilization data collection began later and was therefore analyzed starting in 2005. Incidences of these events within 30 and 90 days of discharge as well as trends over time were tabulated. The conditions prompting these encounters were also collected. Data were analyzed with respect to surgical approach. RESULTS The hospital readmission rate was 4.2% at 30 days and 6.2% at 90 days postoperatively. Approximately 6.2% of patients were managed in the ED without inpatient admission within 30 days and 11.3% within 90 days of surgery. The most common conditions prompting such events were dysphagia or dysphonia, respiratory complications, and infection. ED utilization and readmission rates were lowest after anterior surgeries. A preoperative Charlson Comorbidity Index of 1 or greater and traumatic pathologies were associated with increased risk of subsequent ED utilization or hospital readmission. Thirty-day hospital readmission rates declined after 2010, whereas 30-day ED utilization continued to increase. CONCLUSION Patient comorbidities, traumatic pathologies, and surgical approach are associated with increased postoperative complications. Anterior procedures carry the lowest risk, followed by posterior and then circumferential. Awareness of these findings should help to encourage development of strategies to minimize the rate of postoperative ED utilization and hospital readmission. LEVEL OF EVIDENCE 3.
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Li Y, Shen H, Khan KZ, Fang S, Liao Z, Liu W. Comparison of Multilevel Cervical Disc Replacement and Multilevel Anterior Discectomy and Fusion: A Systematic Review of Biomechanical and Clinical Evidence. World Neurosurg 2018; 116:94-104. [PMID: 29753897 DOI: 10.1016/j.wneu.2018.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study was to comprehensively compare the clinical and biomechanical efficiency of anterior cervical discectomy and fusion (ACDF) with anterior cervical disc replacement (ACDR) for treatment of multilevel cervical disc disease using a meta-analysis and systematical review. METHODS A literature search was performed using PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published between January 1960 and December 2017. Both clinical and biomechanical parameters were analyzed. Statistical tests were conducted by Revman 5.3. Nineteen studies including 10 clinical studies and 9 biomechanical studies were filtered out. RESULTS The pooled results for clinical efficiency showed that no significant difference was observed in blood loss (P = 0.09; mean difference [MD], 7.38; confidence interval [CI], -1.16 to 15.91), hospital stay (P = 0.33; MD, -0.25; CI, -0.76 to 0.26), Japanese Orthopaedic Association scores (P = 0.63; MD, -0.11; CI, -0.57 to 0.34), visual analog scale (P = 0.08; MD, -0.50; CI, -1.06 to 0.05), and Neck Disability Index (P = 0.33; MD, -0.55; CI, -1.65 to 0.56) between the 2 groups. Compared with ACDF, ACDR did show increased surgical time (P = 0.03; MD, 31.42; CI, 2.71-60.14). On the other hand, ACDR showed increased index range of motion (ROM) (P < 0.00001; MD, 13.83; CI, 9.28-18.39), lower rates of adjacent segment disease (ASD) (P = 0.001; odds ratio [OR], 0.27; CI, 0.13-0.59), complications (P = 0.006; OR, 0.62; CI, 0.45-0.87), and rate of subsequent surgery (P < 0.00001; OR, 0.25; CI, 0.14-0.44). As for biomechanical performance, ACDR maintained index ROM and avoided compensation in adjacent ROM and tissue pressure. CONCLUSIONS Multilevel ACDR may be an effective and safe alternative to ACDF in terms of clinical and biomechanical performance. However, further multicenter and prospective studies should be conducted to obtain a stronger and more reliable conclusion.
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Affiliation(s)
- Yang Li
- State Key Laboratory of Tribology, Tsinghua University, Beijing, China and Department of Mechanical Engineering, Tsinghua University, Beijing, China
| | - Hangkai Shen
- State Key Laboratory of Tribology, Tsinghua University, Beijing, China and Department of Mechanical Engineering, Tsinghua University, Beijing, China
| | - Kamran Z Khan
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shushu Fang
- School of Pharmacy, Peking University, Beijing, China
| | - Zhenhua Liao
- Biomechanics and Biotechnology Laboratory, Research Institute of Tsinghua University in Shenzhen, Shenzhen, People's Republic of China
| | - Weiqiang Liu
- Department of Mechanical Engineering, Tsinghua University, Beijing, People's Republic of China and Biomechanics and Biotechnology Laboratory, Research Institute of Tsinghua University in Shenzhen, Shenzhen, People's Republic of China.
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He A, Xie D, Qu B, Cai X, Kong Q, Yang L, Chen X, Jia L. Comparison between cervical disc arthroplasty and conservative treatment for patients with single level cervical radiculopathy at C5/6. Int J Surg 2018; 54:124-128. [PMID: 29409935 DOI: 10.1016/j.ijsu.2018.01.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/28/2017] [Accepted: 01/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cervical radiculopathy is a common disease that affects millions of people. Patients usually are managed by conservative therapy and surgical treatments. OBJECTIVE To compare the clinical outcomes between cervical disc arthroplasty (CDA) and conservative management for patients with single level cervical radiculopathy at C5/6. METHODS Seventy-two patients with cervical radiculopathy that only affect C5/6 joints were included and thirty-two of them received CDA surgery, and forty patients were treated with conservative management. All the patients were followed up around 4 years. Cervical curvature, cervical range of motion (CROM), horizontal displacement of cervical spine, and intervertebral gap were measured by radiological examination. RESULTS All the patients have comparable disease severity based on pre-surgical radiological assessments. At the 4-year follow-up examination, patients with CDA surgery had less CROM at C5/6 level, while greater CROM at C4/5 level, than control group. Similarly, the horizontal displacement in CDA group decreased at C5/6 vertebrae, and increased at C4/5 level at the 4-year follow-up examination. The intervertebral gaps of patients in CDA group were larger than control group at one-year and last follow-up examination. CONCLUSION CDA surgery stabilized C5/6 vertebrae and increased the CROM and horizontal displacement of upper adjacent C4/5 vertebrae.
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Affiliation(s)
- Axiang He
- Department of Orthopaedic Surgery, Changzheng Hospital, Shanghai 200003, China
| | - Dong Xie
- Department of Orthopaedic Surgery, Changzheng Hospital, Shanghai 200003, China
| | - Bo Qu
- Department of Orthopaedic Surgery, Changzheng Hospital, Shanghai 200003, China
| | - Xiaomin Cai
- Department of Orthopaedic Surgery, Changzheng Hospital, Shanghai 200003, China
| | - Qin Kong
- Department of Orthopaedic Surgery, Changzheng Hospital, Shanghai 200003, China
| | - Lili Yang
- Department of Orthopaedic Surgery, Changzheng Hospital, Shanghai 200003, China.
| | - Xiongsheng Chen
- Department of Orthopaedic Surgery, Changzheng Hospital, Shanghai 200003, China
| | - Lianshun Jia
- Department of Orthopaedic Surgery, Changzheng Hospital, Shanghai 200003, China
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Badve SA, Nunley PD, Kurra S, Lavelle WF. Review of long-term outcomes of disc arthroplasty for symptomatic single level cervical degenerative disc disease. Expert Rev Med Devices 2018; 15:205-217. [DOI: 10.1080/17434440.2018.1433533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Siddharth A. Badve
- Hartsville Orthopaedics & Sports Medicine, Carolina Pines Regional Medical Center, Hartsville, SC, USA
| | | | - Swamy Kurra
- Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - William F. Lavelle
- Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
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Nunley PD, Coric D, Frank KA, Stone MB. Cervical Disc Arthroplasty: Current Evidence and Real-World Application. Neurosurgery 2018; 83:1087-1106. [DOI: 10.1093/neuros/nyx579] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/07/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
| | - Domagoj Coric
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | | | - Marcus B Stone
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
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Radcliff K, Davis RJ, Hisey MS, Nunley PD, Hoffman GA, Jackson RJ, Bae HW, Albert T, Coric D. Long-term Evaluation of Cervical Disc Arthroplasty with the Mobi-C© Cervical Disc: A Randomized, Prospective, Multicenter Clinical Trial with Seven-Year Follow-up. Int J Spine Surg 2017; 11:31. [PMID: 29372135 DOI: 10.14444/4031] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Cervical total disc replacement (TDR) is an increasingly accepted procedure for the treatment of symptomatic cervical degenerative disc disease. Multiple Level I evidence clinical trials have established cervical TDR to be a safe and effective procedure in the short-term. The objective of this study is to provide a long-term assessment of TDR versus anterior discectomy and fusion for the treatment of one- and two-level disc disease. Methods This study was a continuation of a prospective, multicenter, randomized, US FDA IDE clinical trial comparing cervical TDR with the Mobi-C© Cervical Disc versus ACDF through 7 years follow-up. Inclusion criteria included a diagnosis of symptomatic cervical degenerative disc disease at one or two cervical levels. TDR patients were treated using a Mobi-C© artificial disc (Zimmer Biomet, Austin TX, USA). ACDF with allograft and anterior plate was used as a control treatment. Outcome measures were collected preoperatively and postoperatively at 6 weeks, at 3, 6, 12, 18 months, annually through 60 months, and at 84 months. Measured outcomes included Overall success, Neck Disability Index (NDI), VAS neck and arm pain, segmental range of motion (ROM), patient satisfaction, SF-12 MCS/PCS, major complications, and subsequent surgery rate. The primary endpoint was an FDA composite definition of success comprising clinical improvement and an absence of major complications and secondary surgery events. Results A total of 599 patients were enrolled and treated, with 164 treated with one-level TDR, 225 treated with two-level TDR, 81 treated with one-level ACDF, and 105 treated with two-level ACDF. At seven years, follow-up rates ranged from 73.5% to 84.4% (overall 80.2%).The overall success rates of two level TDR and ACDF patients were 60.8% and 34.2%, respectively (p<0.0001). The overall success rates of one level TDR and ACDF patients were 55.2% and 50%, respectively (p>0.05). Both the single and two level TDR and ACDF groups showed significant improvement from baseline NDI scores, VAS neck and arm pain scores, and SF-12 MCS/PCS scores (p<0.0001). In the single level cohort, there was an increased percentage of TDR patients who reported themselves as "very satisfied" (TDR 90.9% vs ACDF 77.8%; p= 0.028). There was a lower rate of adjacent level secondary surgery in the single level TDR patients (3.7%) versus the ACDF patients (13.6%; p = 0.007).In the two level TDR group, the NDI success rate was significantly greater in the TDR group (TDR: 79.0% vs. ACDF: 58.0%; p=0.001). There was significantly more improvement in NDI change score at 7 years in the TDR patients versus ACDF. The TDR group had a significantly higher rate of patients who were "very satisfied" with their treatment compared to the ACDF group (TDR: 85.9% vs. ACDF: 73.9%). The rate of subsequent surgery at the index level was significantly lower in the TDR group compared to the ACDF group (TDR: 4.4% vs. ACDF: 16.2%; p=0.001). The rate of adjacent level secondary surgery was significantly lower in the two level TDR (4.4%) patients compared to the ACDF (11.3%; p=0.03) patients. In both single and two level cohorts, the percentage of patients with worse NDI (2.5%-3.8% of two level surgeries and 1.2%-2.5% of single level surgeries) or worse neck pain (5%-6.8% of the two level surgeries and 1.3% - 3.8% of the single level surgeries) was strikingly low in both groups but trended lower in the TDR patients. Conclusions At seven years, the composite success analysis demonstrated clinical superiority of two level TDR over ACDF and non-inferiority of single level TDR versus ACDF. There were lower rates of secondary surgery and higher adjacent level disc survivorship in both groups. Both surgeries were remarkably effective in alleviating pain relative to baseline and the rate of patients with worse disability or neck pain was surprisingly low. Overall, greater than 95% of patients (from both groups) who underwent TDR and 88% of patients who underwent ACDF were "very satisfied" at seven years. The differences in clinical effectiveness of TDR versus ACDF becomes more apparent as treatment increases from one to two levels, indicating a significant benefit for TDR over ACDF for two-level procedures. Ethical Standards The Mobi-C Clinical Trial (ClinicalTrials.gov registration number: NCT00389597) was conducted at 24 sites in the US and was approved by the Institutional Review Board, Research Ethics Committee, or local equivalent of each participating site. Level of Evidence 1.
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Affiliation(s)
- Kris Radcliff
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Egg Harbor, NJ
| | | | | | | | | | | | - Hyun W Bae
- Cedars-Sinai Spine Center, Los Angeles, CA
| | - Todd Albert
- Hospital for Special Surgery, Cornell Medical College, New York, NY
| | - Dom Coric
- Carolinas Medical Center, Carolina Neurosurgery & Spine Associates, Charlotte, NC
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Abstract
STUDY DESIGN Retrospective database review. OBJECTIVE To determine how demographics and comorbid diagnoses influence hospital costs during admission for anterior cervical fusions (ACFs) in the elderly Medicare population. SUMMARY OF BACKGROUND DATA Elective ACFs to treat degenerative cervical pathology are extremely common within the elderly population. Although it is well known that every patient has a significantly different medical profile that guides treatment and postoperative care, little information is available regarding how hospital costs vary from patient to patient. METHODS Medicare records from the PearlDiver database (2011-2012) were retrospectively queried to select all 65- to 84-year-old patients who underwent primary, 1 to 2 level ACF (International Classification of Diseases, Ninth Revision, Clinical Modification: 81.02) for either cervical spondylosis or cervical disc disease. All patients with corpectomies, posterior cervical fusions, and all other same-day spine fusion surgeries were excluded. The primary outcome of this study was Medicare reimbursement from the full inpatient stay as associated with the selected International Classification of Diseases, Ninth Revision procedure code. The relative contributions of year, age, sex, region, myelopathy diagnosis, and various comorbidities to the total cost were determined with both univariate statistics and multivariate analysis. For all analyses, P < 0.001 was determined to be significant. RESULTS In total, 21,853 patients were selected for analysis. The average reimbursement for the full cohort was $13,648 ± $7306. On multivariate analysis, advanced age ($1083), diagnosis of myelopathy ($2150), diabetes mellitus ($1019), obesity ($651), congestive heart failure ($1523), chronic kidney disease ($1962), and chronic pulmonary disease ($489) were all factors that increased costs. Of note, sex, smoking history, and prior liver disease were not associated with changes in cost. CONCLUSION Medicare reimbursements provide a value means by which determinants of cost can be elucidated. Although multiple comorbidities, older age, and myelopathy diagnosis could be theorized to contribute to increased costs, there is still some uncertainty regarding their relative costs. These data are informative to practicing physicians as health care as a whole transitions to a more value-based approach. LEVEL OF EVIDENCE 4.
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Anterior cervical discectomy without fusion for a symptomatic cervical disk herniation. Acta Neurochir (Wien) 2017; 159:1283-1287. [PMID: 28451842 PMCID: PMC5486609 DOI: 10.1007/s00701-017-3189-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 04/11/2017] [Indexed: 11/02/2022]
Abstract
BACKGROUND Cervical radiculopathy is characterized by dysfunction of the nerve root usually caused by a cervical disk herniation. The most important symptom is pain, radiating from the neck to the arm. When conservative treatment fails, surgical treatment is indicated to relieve symptoms. During the last decades, multiple fusion techniques have been developed, although without clinical evidence for added value of fusion over non-fusion. METHODS The surgical procedure of anterior cervical discectomy without fusion is performed step by step, leading to removal of the entire intervertebral disk. CONCLUSION Anterior cervical discectomy without fusion is a safe and effective treatment for cervical disk herniation.
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Cervical disc replacement surgery: biomechanical properties, postoperative motion, and postoperative activity levels. Curr Rev Musculoskelet Med 2017; 10:177-181. [PMID: 28353143 DOI: 10.1007/s12178-017-9400-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Cervical disc arthroplasty (CDA) is an evolving technique used in the treatment of cervical disc disease. To remain up to date on studies regarding its efficacy, we sought to answer three questions: What do biomechanical studies demonstrate in regard to the kinematics of CDA? How does CDA affect cervical motion? What are the postoperative activity levels of patients after cervical disc arthroplasty? RECENT FINDINGS 1) In regard to biomechanics, recent data suggests that CDA maintains motion while possibly altering facet biomechanics. 2) Radiographic data indicates a reliable maintenance of motion in the short and medium term. 3) Postoperative activity levels are assessed with clinical outcome data which demonstrate reliable improvement in pain and function. The data reviewed here establishes CDA as an efficacious treatment in the relief of symptoms from CDD. It is important to note however that an evaluation of CDA would benefit from more robust data, specifically in regards to long-term clinical outcomes.
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Abstract
PURPOSE OF REVIEW Cervical disc replacement (CDR) has emerged as a motion-preserving alternative to anterior cervical discectomy and fusion in selected cases. Despite favorable literature, CDR is not universally accepted because of concerns regarding bias in the existing literature. The purpose of this review is to identify the possible biases in the disc replacement literature. RECENT FINDINGS Recent studies that compare CDR and ACDF have demonstrated equivalent or superior outcomes, lower rates of secondary surgery, and equivalent safety at medium- and long-term follow-up. In our review, we identified four types of bias that may affect the CDR literature: publication bias, external validity, confounding bias, and financial conflicts of interest. Bias, whether intentional or unintentional, can impact the interpretation and outcome of CDR studies. Recognition of this issue is critical when utilizing the existing literature to determine the efficacy of CDR and designing future studies.
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Abstract
STUDY DESIGN A questionnaire survey. OBJECTIVE To assess the preferred surgical technique, the optimal timing of surgery, and the expectations of different surgical techniques of neurosurgeons in the Netherlands, regarding patients with cervical disc herniation (CDH). SUMMARY OF BACKGROUND DATA To treat CDH, multiple surgical techniques are performed. Due to the lack of consensus, the daily routine management may vary. METHODS All 134 neurosurgeons of the Dutch Association of Neurosurgery were sent a survey, evaluating the operative management as well as the attitude towards different surgical treatments for CDH. RESULTS Ninety-six (74.4%) of the neurosurgeons treating CDH completed the survey. Anterior cervical discectomy with fusion (ACDF) was the standard procedure for the majority of neurosurgeons (76.3%). ACDF was expected to have the highest effectiveness on arm pain, yet also a higher risk for complications as compared with anterior cervical discectomy (ACD). Approximately, 47.9% of the surgeons regarded a minimal duration of 8 to 12 weeks of radicular arm pain before deciding to perform surgery. Regarding the risk of recurrent CDH, DCF was expected to give the highest risk, whereas ACDF the lowest. CONCLUSION Despite the lack of solid evidence in favor for ACDF this survey showed that ACDF is the preferred technique to treat cervical radiculopathy. A minimum duration of 8 to 12 weeks of radicular arm pain was considered the optimal timing to perform surgery for CDH by the majority of the neurosurgeons. Whether to fuse or not remains a controversial subject in degenerative spinal surgery. This study emphasizes the need of high-quality evidence on the optimal surgical management of CDH. LEVEL OF EVIDENCE N/A.
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Chin-See-Chong TC, Gadjradj PS, Boelen RJ, Harhangi BS. Current practice of cervical disc arthroplasty: a survey among 383 AOSpine International members. Neurosurg Focus 2017; 42:E8. [DOI: 10.3171/2016.11.focus16338] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The use of cervical disc arthroplasty (CDA) in spinal practice is controversial. This may be explained by the lack of studies with a large sample size and long-term outcomes. With this survey the authors aimed to evaluate the opinions of spine surgeons on the use of CDA in the current treatment of cervical disc herniation (CDH).
METHODS
A web-based survey was sent to all members of AOSpine International by email using SurveyMonkey on July 18, 2016. A single reminder was sent on August 18, 2016. Questions included geographic location; specialty; associated practice model; number of discectomies performed annually; the use of CDA, anterior cervical discectomy (ACD), and anterior cervical discectomy and fusion (ACDF); and the expectations for clinical outcomes of these procedures.
RESULTS
A total of 383 questionnaires were analyzed. Almost all practitioners (97.9%) were male, with a mean of 15.0 ± 9.7 years of clinical experience. The majority of responders were orthopedic surgeons (54.6%). 84.3% performed ACDF as the standard technique for CDH. 47.8% of the surgeons occasionally used CDA, whereas 7.3% used CDA as standard approach for CDH. The most common arthroplasty device used was the ProDisc-C. Low evidence for benefits and higher costs were the most important reasons for not offering CDA. The risk of adjacent-level disease was considered smaller for CDA as compared with ACDF. However, ACDF was expected to have the highest effectiveness on arm pain (87.5%), followed by CDA (77.9%), while ACD had the least (12.6%).
CONCLUSIONS
In this survey, CDA was not considered to be the routine procedure to treat CDH. Reported benefits included the reduced risk of adjacent-level disease and preservation of motion of the neck. Lack of enough evidence on its effectiveness as well as higher costs were considered to be disadvantages of CDA. More research should be conducted on the implementation impact of CDA and the cost-effectiveness from society's perspective.
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Affiliation(s)
| | - Pravesh S. Gadjradj
- 1Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, and
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Makanji HS, Nwosu K, Bono CM. Editorial on "Long-term clinical outcomes of cervical disc arthroplasty: a prospective, randomized, controlled trial" by Sasso et al. JOURNAL OF SPINE SURGERY 2016; 2:353-356. [PMID: 28097258 DOI: 10.21037/jss.2016.12.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Heeren S Makanji
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Kenneth Nwosu
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
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Reoperation Rates After Surgery for Degenerative Cervical Spine Disease According to Different Surgical Procedures: National Population-based Cohort Study. Spine (Phila Pa 1976) 2016; 41:1484-1492. [PMID: 27031768 DOI: 10.1097/brs.0000000000001581] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN National population-based cohort study. OBJECTIVE To evaluate reoperation rates of cervical spine surgery for cervical degenerative conditions utilizing a national population database. SUMMARY OF BACKGROUND DATA There is an inherently low incidence of reoperation after surgery for cervical degenerative disease. Therefore, it is difficult to sufficiently power studies to detect differences between reoperation rates of different cervical surgical procedures. National population-based databases provide large, longitudinally followed cohorts that may help overcome this challenge. METHODS We used the Korean Health Insurance Review and Assessment Service national database to select our study population. We included patients with diagnosis of cervical spondylotic radiculopathy or myelopathy who underwent cervical surgeries from January 2009 to June 2014. We separated patients into three groups based on surgical procedures: discectomy or corpectomy with anterior fusion, laminoplasty, or laminectomy with posterior fusion. Age, sex, presence of diabetes, osteoporosis, associated comorbidities, number of operated cervical disc levels, and hospital types were considered potential confounding factors. Reoperation rates were analyzed over early and late periods. RESULTS The reoperation rate over the entire follow-up period was 3.31%. Overall, the reoperation rate was significantly higher after laminectomy with posterior fusion or laminoplasty than after discectomy or corpectomy with anterior fusion. A similar pattern was seen during the late period. In the early period, rates were higher only after laminectomy with posterior fusion than after discectomy or corpectomy with anterior fusion. Sex, presence of diabetes, associated comorbidities, and hospital types were noted to be risk factors for reoperation. CONCLUSION The reoperation rate was higher after laminectomy with posterior fusion or laminoplasty. Given clinical scenarios in which either anterior or posterior approaches can be utilized, risk of reoperation can be another variable to consider in surgical planning and patient education. LEVEL OF EVIDENCE 3.
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Radcliff K, Coric D, Albert T. Five-year clinical results of cervical total disc replacement compared with anterior discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease: a prospective, randomized, controlled, multicenter investigational device exemption clinical trial. J Neurosurg Spine 2016; 25:213-24. [DOI: 10.3171/2015.12.spine15824] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The purpose of this study was to report the outcome of a study of 2-level cervical total disc replacement (Mobi-C) versus anterior cervical discectomy and fusion (ACDF). Although the long-term outcome of single-level disc replacement has been extensively described, there have not been previous reports of the 5-year outcome of 2-level cervical disc replacement.
METHODS
This study reports the 5-year results of a prospective, randomized US FDA investigational device exemption (IDE) study conducted at 24 centers in patients with 2-level, contiguous, cervical spondylosis. Clinical outcomes at up to 60 months were evaluated, including validated outcome measures, incidence of reoperation, and adverse events. The complete study data and methodology were critically reviewed by 3 independent surgeon authors without affiliation with the IDE study or financial or institutional bias toward the study sponsor.
RESULTS
A total of 225 patients received the Mobi-C cervical total disc replacement device and 105 patients received ACDF. The Mobi-C and ACDF follow-up rates were 90.7% and 86.7%, respectively (p = 0.39), at 60 months. There was significant improvement in all outcome scores relative to baseline at all time points. The Mobi-C patients had significantly more improvement than ACDF patients in terms of Neck Disability Index score, SF-12 Physical Component Summary, and overall satisfaction with treatment at 60 months. The reoperation rate was significantly lower with Mobi-C (4%) versus ACDF (16%). There were no significant differences in the adverse event rate between groups.
CONCLUSIONS
Both cervical total disc replacement and ACDF significantly improved general and disease-specific measures compared with baseline. However, there was significantly greater improvement in general and disease-specific outcome measures and a lower rate of reoperation in the 2-level disc replacement patients versus ACDF control patients.
Clinical trial registration no. NCT00389597 (clinicaltrials.gov)
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Affiliation(s)
- Kris Radcliff
- 1Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute, Egg Harbor, New Jersey
| | - Domagoj Coric
- 2Carolinas Medical Center, Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina; and
| | - Todd Albert
- 3Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
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Gornet MF, Burkus JK, Shaffrey ME, Nian H, Harrell FE. Cervical Disc Arthroplasty with Prestige LP Disc Versus Anterior Cervical Discectomy and Fusion: Seven-Year Outcomes. Int J Spine Surg 2016; 10:24. [PMID: 27441182 PMCID: PMC4943164 DOI: 10.14444/3024] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cervical disc arthroplasty (CDA) has emerged as an alternative to anterior cervical discectomy and fusion (ACDF) for the treatment of cervical pathologies. Studies are on-going to assess the long term outcomes of CDA. This study assessed the safety and efficacy of the Prestige(®) LP Disc at 84-months follow up. METHODS Prospective data from 280 CDA patients with single-level cervical disc disease with radiculopathy or myelopathy were compared with 265 historical control ACDF patients. Clinical and radiographic follow up was completed pre-operatively, intraoperatively, and at intervals up to 84 months. RESULTS Follow-up rate was 75.9% for CDA and 70.0% for ACDF patients. Statistical improvements (p < 0.001) in Neck Disability Index (NDI), neck/arm pain, and SF-36 were achieved by 1.5 months in both groups and maintained through 84 months. At 84 months, 86.1% of CDA versus 80.1% of ACDF patients achieved NDI success, (≥15-point improvement over baseline). Mean NDI score improvements exceeded 30 points in both groups. SF-36 PCS/MCS mean improvements were 13.1±11.9/8.2±12.3 points for CDA and 10.7±11.8/8.3±13.6 points for ACDF. Neurological success was 92.8% for CDA and 79.7% for ACDF patients. The rate of Overall Success was 74.9% for CDA and 63.2% for ACDF. At 84 months, 17.5% of CDA and 16.6% of ACDF patients had a possibly implant- or implant-surgical procedure-related adverse event. Eighteen (6.4%) CDA and 29 (10.9%) ACDF patients had a second surgery at the index level. In CDA patients, mean angular motion at the target level was maintained at 24 (7.5°) and 84 (6.9°) months. Bridging bone was reported in 5.9%/9.5%/10.2%/13.0% of CDA patients at 24/36/60/84 months. Change in mean preoperative angulation of the adjacent segment above/below the index level was1.06±4.39/1.25±4.06 for CDA and (-0.23)±5.37/1.25±5.07 for ACDF patients. At 84 months, 90.9% of CDA and 85.6% of ACDF patients were satisfied with the results of their treatment. CONCLUSIONS Prestige LP maintained significantly improved clinical outcomes and segmental motion; statistical superiority of CDA was concluded for overall success. This investigational device exemption study was sponsored by Medtronic Spinal and Biologics, Memphis, TN. Study approved by the Hughston Sports Medicine Center Institutional Review Board on January 7, 2005. Clinical trial registered at clinicaltrials.gov: NCT00667459. All participants signed an informed consent.
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Affiliation(s)
| | | | - Mark E. Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Hui Nian
- Vanderbilt University School of Medicine, Department of Biostatistics, Nashville, Tennessee
| | - Frank E. Harrell
- Vanderbilt University School of Medicine, Department of Biostatistics, Nashville, Tennessee
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Zhong ZM, Zhu SY, Zhuang JS, Wu Q, Chen JT. Reoperation After Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion: A Meta-analysis. Clin Orthop Relat Res 2016; 474:1307-16. [PMID: 26831475 PMCID: PMC4814433 DOI: 10.1007/s11999-016-4707-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 01/08/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cervical discectomy and fusion is a standard surgical treatment for cervical radiculopathy and myelopathy, but reoperations sometimes are performed to treat complications of fusion such as pseudarthrosis and adjacent-segment degeneration. A cervical disc arthroplasty is designed to preserve motion and avoid the shortcomings of fusion. Available evidence suggests that a cervical disc arthroplasty can provide pain relief and functional improvements similar or superior to an anterior cervical discectomy and fusion. However, there is controversy regarding whether a cervical disc arthroplasty can reduce the frequency of reoperations. QUESTIONS/PURPOSES We performed a meta-analysis of randomized controlled trials (RCTs) to compare cervical disc arthroplasty with anterior cervical discectomy and fusion regarding (1) the overall frequency of reoperation at the index and adjacent levels; (2) the frequency of reoperation at the index level; and (3) the frequency of reoperation at the adjacent levels. METHODS PubMed, EMBASE, and the Cochrane Register of Controlled Trials databases were searched to identify RCTs comparing cervical disc arthroplasty with anterior cervical discectomy and fusion and reporting the frequency of reoperation. We also manually searched the reference lists of articles and reviews for possible relevant studies. Twelve RCTs with a total of 3234 randomized patients were included. Eight types of disc prostheses were used in the included studies. In the anterior cervical discectomy and fusion group, autograft was used in one study and allograft in 11 studies. Nine of 12 studies were industry sponsored. Pooled risk ratio (RR) and associated 95% CI were calculated for the frequency of reoperation using random-effects or fixed-effects models depending on the heterogeneity of the included studies. A funnel plot suggested the possible presence of publication bias in the available pool of studies; that is, the shape of the plot suggests that smaller negative or no-difference studies may have been performed but have not been published, and so were not identified and included in this meta-analysis. RESULTS The overall frequency of reoperation at the index and adjacent levels was lower in the cervical disc arthroplasty group (6%; 108/1762) than in the anterior cervical discectomy and fusion group (12%; 171/1472) (RR, 0.54; 95% CI, 0.36-0.80; p = 0.002). Subgroup analyses were performed according to secondary surgical level. Compared with anterior cervical discectomy and fusion, cervical disc arthroplasty was associated with fewer reoperations at the index level (RR, 0.50; 95% CI, 0.37-0.68; p < 0.001) and adjacent levels (RR, 0.52; 95% CI, 0.37-0.74; p < 0.001). CONCLUSIONS Cervical disc arthroplasty is associated with fewer reoperations than anterior cervical discectomy and fusion, indicating that it is a safe and effective alternative to fusion for cervical radiculopathy and myelopathy. However, because of some limitations, these findings should be interpreted with caution. Additional studies are needed. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Zhao-Ming Zhong
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515 China
| | - Shi-Yuan Zhu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515 China
| | - Jing-Shen Zhuang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515 China
| | - Qian Wu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515 China
| | - Jian-Ting Chen
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515 China
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Albert TJ. CORR Insights(®): Reoperation After Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion: A Meta-analysis. Clin Orthop Relat Res 2016; 474:1317-8. [PMID: 26906011 PMCID: PMC4814421 DOI: 10.1007/s11999-016-4753-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 02/11/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Todd J. Albert
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Buckland AJ, Baker JF, Roach RP, Spivak JM. Cervical disc replacement - emerging equivalency to anterior cervical discectomy and fusion. INTERNATIONAL ORTHOPAEDICS 2016; 40:1329-34. [PMID: 27055447 DOI: 10.1007/s00264-016-3181-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/27/2016] [Indexed: 12/30/2022]
Abstract
PURPOSE Cervical disc replacement has become an acceptable alternative to anterior cervical fusion for the surgical treatment of cervical spine spondylosis resulting in radiculopathy or myelopathy following anterior discectomy and decompression. This concise overview considers the current state of knowledge regarding the continued debate of the role of cervical disc replacement with an update in light of the latest clinical trial results. METHODS A literature review was performed identifying clinical trials pertaining to the use of cervical disc replacement compared to cervical discectomy and fusion. Single level disease and two level disease were considered. Outcome data from the major clinical trials was reviewed and salient points identified. RESULTS With lengthier follow-up data becoming available, the equivalence of CDR in appropriately selected cases is becoming clear. This is chiefly manifested by reduced re-operation rates and reduced incidence of adjacent level disease in those treated with arthroplasty. CONCLUSION Cervical disc replacement shows emerging equivalence in outcomes compared to the gold standard anterior cervical discectomy and fusion. Further longer term results are anticipated to confirm this trend.
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Affiliation(s)
- Aaron J Buckland
- Department of Spine and Spinal Deformity Surgery, Hospital for Joint Diseases NYU Langone Medical Center, 301 East 17th Street, New York, 10003, NY, USA
| | - Joseph F Baker
- Department of Spine and Spinal Deformity Surgery, Hospital for Joint Diseases NYU Langone Medical Center, 301 East 17th Street, New York, 10003, NY, USA.
| | - Ryan P Roach
- Department of Spine and Spinal Deformity Surgery, Hospital for Joint Diseases NYU Langone Medical Center, 301 East 17th Street, New York, 10003, NY, USA
| | - Jeffrey M Spivak
- Department of Spine and Spinal Deformity Surgery, Hospital for Joint Diseases NYU Langone Medical Center, 301 East 17th Street, New York, 10003, NY, USA
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Hisey MS, Zigler JE, Jackson R, Nunley PD, Bae HW, Kim KD, Ohnmeiss DD. Prospective, Randomized Comparison of One-level Mobi-C Cervical Total Disc Replacement vs. Anterior Cervical Discectomy and Fusion: Results at 5-year Follow-up. Int J Spine Surg 2016; 10:10. [PMID: 27162712 DOI: 10.14444/3010] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION There is increasing interest in the role of cervical total disc replacement (TDR) as an alternative to anterior cervical discectomy and fusion (ACDF). Multiple prospective randomized studies with minimum 2 year follow-up have shown TDR to be at least as safe and effective as ACDF in treating symptomatic degenerative disc disease at a single level. The purpose of this study was to compare outcomes of cervical TDR using the Mobi-C(®) with ACDF at 5-year follow-up. METHODS This prospective, randomized, controlled trial was conducted as a Food and Drug Administration regulated Investigational Device Exemption trial across 23 centers with 245 patients randomized (2:1) to receive TDR with Mobi-C(®) Cervical Disc Prosthesis or ACDF with anterior plate and allograft. Outcome assessments included a composite overall success score, Neck Disability Index (NDI), visual analog scales (VAS) assessing neck and arm pain, Short Form-12 (SF-12) health survey, patient satisfaction, major complications, subsequent surgery, segmental range of motion, and adjacent segment degeneration. RESULTS The 60-month follow-up rate was 85.5% for the TDR group and 78.9% for the ACDF group. The composite overall success was 61.9% with TDR vs. 52.2% with ACDF, demonstrating statistical non-inferiority. Improvements in NDI, VAS neck and arm pain, and SF-12 scores were similar between groups and were maintained from earlier follow-up through 60 months. There was no significant difference between TDR and ACDF in adverse events or major complications. Range of motion was maintained with TDR through 60 months. Device-related subsequent surgeries (TDR: 3.0%, ACDF: 11.1%, p<0.02) and adjacent segment degeneration at the superior level (TDR: 37.1%, ACDF: 54.7%, p<0.03) were significantly lower for TDR patients. CONCLUSIONS Five-year results demonstrate the safety and efficacy of TDR with the Mobi-C as a viable alternative to ACDF with the potential advantage of lower rates of reoperation and adjacent segment degeneration, in the treatment of one-level symptomatic cervical degenerative disc disease. CLINICAL RELEVANCE This prospective, randomized study with 5-year follow-up adds to the existing literature indicating that cervical TDR is a viable alternative to ACDF in appropriately selected patients. LEVEL OF EVIDENCE This is a Level I study.
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Affiliation(s)
| | | | - Robert Jackson
- Saddleback Memorial Medical Center, Laguna Hills, California
| | | | - Hyun W Bae
- Cedars Sinai Spine Center, Los Angeles, California
| | - Kee D Kim
- Department of Neurological Surgery, University of California, Davis, Sacramento, California
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Radcliff K, Lerner J, Yang C, Bernard T, Zigler JE. Seven-year cost-effectiveness of ProDisc-C total disc replacement: results from investigational device exemption and post-approval studies. J Neurosurg Spine 2016; 24:760-8. [PMID: 26824587 DOI: 10.3171/2015.10.spine15505] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the 7-year cost-effectiveness of cervical total disc replacement (CTDR) versus anterior cervical discectomy and fusion (ACDF) for the treatment of patients with single-level symptomatic degenerative disc disease. A change in the spending trajectory for spine care is to be achieved, in part, through the selection of interventions that have been proven effective yet cost less than other options. This analysis complements and builds upon findings from other cost-effectiveness evaluations of CTDR through the use of long-term, patient-level data from a randomized study. METHODS This was a 7-year health economic evaluation comparing CTDR versus ACDF from the US commercial payer perspective. Prospectively collected health care resource utilization and treatment effects (quality-adjusted life years [QALYs]) were obtained from individual patient-level adverse event reports and SF-36 data, respectively, from the randomized, multicenter ProDisc-C total disc replacement investigational device exemption (IDE) study and post-approval study. Statistical distributions for unit costs were derived from a commercial claims database and applied using Monte Carlo simulation. Patient-level costs and effects were modeled via multivariate probabilistic analysis. Confidence intervals for 7-year costs, effects, and net monetary benefit (NMB) were obtained using the nonparametric percentile method from results of 10,000 bootstrap simulations. The robustness of results was assessed through scenario analysis and within a parametric regression model controlling for baseline variables. RESULTS Seven-year follow-up data were available for more than 70% of the 209 randomized patients. In the base-case analysis, CTDR resulted in mean per-patient cost savings of $12,789 (95% CI $5362-$20,856) and per-patient QALY gains of 0.16 (95% CI -0.073 to 0.39) compared with ACDF over 7 years. CTDR was more effective and less costly in 90.8% of probabilistic simulations. CTDR was cost-effective in 99.8% of sensitivity analysis simulations and generated a mean incremental NMB of $20,679 (95% CI $6053-$35,377) per patient at a willingness-to-pay threshold of $50,000/QALY. CONCLUSIONS Based on this modeling evaluation, CTDR was found to be more effective and less costly over a 7-year time horizon for patients with single-level symptomatic degenerative disc disease. These results are robust across a range of scenarios and perspectives and are intended to support value-based decision making.
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Affiliation(s)
- Kris Radcliff
- Department of Orthopedic Surgery, Rothman Institute, Egg Harbor Township, New Jersey
| | | | | | - Thierry Bernard
- Biostatistics and Data Management, DePuy Synthes Spine, West Chester, Pennsylvania; and
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Mendoza-Lattes S. Cervical Disc Replacement: Are We There Yet? Commentary on an article by Michael E. Janssen, DO, et al.: "ProDisc-C Total Disc Replacement Versus Anterior Cervical Discectomy and Fusion for Single-Level Symptomatic Cervical Disc Disease. Seven-Year Follow-up of the Prospective Randomized U.S. Food and Drug Administration Investigational Device Exemption Study". J Bone Joint Surg Am 2015; 97:e71. [PMID: 26537171 DOI: 10.2106/jbjs.o.00750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sergio Mendoza-Lattes
- Division of Spine Surgery, Department of Orthopaedic Surgery and Rehabilitation, Duke University Medical Center, Durham, North Carolina
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Pugely AJ, Martin CT, Harwood J, Ong KL, Bozic KJ, Callaghan JJ. Database and Registry Research in Orthopaedic Surgery: Part I: Claims-Based Data. J Bone Joint Surg Am 2015; 97:1278-87. [PMID: 26246263 DOI: 10.2106/jbjs.n.01260] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The use of large-scale national databases for observational research in orthopaedic surgery has grown substantially in the last decade, and the data sets can be grossly categorized as either administrative claims or clinical registries. Administrative claims data comprise the billing records associated with the delivery of health-care services. Orthopaedic researchers have used both government and private claims to describe temporal trends, geographic variation, disparities, complications, outcomes, and resource utilization associated with both musculoskeletal disease and treatment. Medicare claims comprise one of the most robust data sets used to perform orthopaedic research, with >45 million beneficiaries. The U.S. government, through the Centers for Medicare & Medicaid Services, often uses these data to drive changes in health policy. Private claims data used in orthopaedic research often comprise more heterogeneous patient demographic samples, but allow longitudinal analysis similar to that offered by Medicare claims. Discharge databases, such as the U.S. National Inpatient Sample, provide a wide national sampling of inpatient hospital stays from all payers and allow analysis of associated adverse events and resource utilization. Administrative claims data benefit from the high patient numbers obtained through a majority of hospitals. Using claims, it is possible to follow patients longitudinally throughout encounters irrespective of the location of the institution delivering health care. Some disadvantages include lack of precision of ICD-9 (International Classification of Diseases, Ninth Revision) coding schemes. Much of these data are expensive to purchase, complicated to organize, and labor-intensive to manipulate--often requiring trained specialists for analysis. Given the changing health-care environment, it is likely that databases will provide valuable information that has the potential to influence clinical practice improvement and health policy for years to come.
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Affiliation(s)
- Andrew J Pugely
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242. E-mail address for A.J. Pugely:
| | - Christopher T Martin
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242. E-mail address for A.J. Pugely:
| | - Jared Harwood
- Department of Orthopaedics, The Ohio State University Hospital, 376 West 10th Avenue, Suite 725, Columbus, OH 43210
| | - Kevin L Ong
- Exponent, Inc., 3440 Market Street, Suite 600, Philadelphia, PA 19104
| | - Kevin J Bozic
- Department of Orthopaedic Surgery, University of California San Francisco, 3333 California Street, Suite 265, Box 0936, San Francisco, CA 94118
| | - John J Callaghan
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242. E-mail address for A.J. Pugely:
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