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Cervical disc arthroplasty vs. ACDF for cervical disc disease
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May 2015
Cervical disc arthroplasty vs. ACDF for cervical disc disease
Study Type:Meta-analysis/Systematic Review
OE Level Evidence:1
Journal Level of Evidence:N/A
Cervical Total Disc Replacement is Superior to Anterior Cervical Decompression and Fusion: A Meta-Analysis of Prospective Randomized Controlled Trials
PLoS One. 2015 Mar 30;10(3):e0117826Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
19 randomized controlled trials were included in this systematic review and meta-analysis comparing outcomes following cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF). CDA resulted in lower Neck Disability Index scores and greater rates of at least a minimum 15-point improvement on the NDI, lower pain scores, higher range of motion at the operated level, lower rates of secondary surgery at the operated level in the short- and mid-term, lower rates of secondary surgery at adjacent levels in the short-term, and higher rate of overall success (min. 15-pt improvement in NDI, improvement or maintenance of neurological status, and no experience of severe adverse event) when compared to ACDF.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
National Nature Science Foundation of China, Science and Technology Planning Project of Zhenjiang Province, Nature Science Foundation of Zhenjiang Province
Conflicts:
None disclosed
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Introduction
4/4
Accessing Data
4/4
Analysing Data
4/4
Results
3/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Degenerative cervical disc disease is a relatively prevalent condition causing neck pain and disability. In patients unresponsive to conservative treatment, surgery may be considered. Anterior cervical decompression and fusion (ACDF) has long been performed in these cases, although more recently, cervical disc arthroplasty (CDA) has emerged as an effective treatment method. A recent point of interest in comparisons between these two methods of treatment is the incidence of adjacent segment degeneration, which is currently debated.
What was the principal research question?
How does efficacy and safety compare between CDA and ACDF in the treatment of cervical disc disease?
Study Characteristics
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Data Source:
PubMed, EMBASE, and the Cochrane Library were searched for relevant articles published up to December 2014.
Index Terms:
Search terms included: "anterior cervical decompression and fusion", "anterior cervical arthrodesis", "ACDF", "fusion", "artificial cervical disc replacement", "CTDR", "cervical arthroplasty", "disc implants", "disc prostheses", and "CDA".
Study Selection:
Inclusion criteria were the following: randomized controlled trial (RCT), performed in adult patients (>18 years) with symptomatic cervical disc disease, allocated participants to CDA and ACDF, followed-up patients for at least 2 years, and reported at least one outcome of interest (Neck disability index [NDI] and response rate, visual analog or numerical rating scales [VAS/NRS] for neck and arm pain, Short From 36 Item (SF-36) questionnaire scores, neurological status, range of motion at index and adjacent segments, incidence of secondary surgery, adverse events and complications. Search and selection was performed independently by two reviewers. A total of 19 RCTs with 4516 cases were selected for final inclusion.
Data Extraction:
Extraction was performed independently by two reviewers, with disagreement resolved with consultation with a third reviewer until agreement.
Data Synthesis:
Meta-analysis was performed using Review Manager software (RevMan 5.2). Effect sizes were expressed as odds ratios (OR) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes, both with 95% confidence intervals. The Chi-square test and I-squared statistic were used to assess heterogeneity, with a p-value <0.1 or I^2 >50% considered significant. A random-effects model was used in analyses with significant heterogeneity, and a fixed-effects models in cases of non-significant heterogeneity.
What were the important findings?
- NDI scores were significantly lower with CDA versus ACDF at both short-term (6 studies; SMD -0.35 [95%CI -0.68, 0.00]; p=0.05) and mid-term follow-up (2 studies; SMD -0.31 [95%CI -0.47, -0.15]; p=0.0002). Rate of NDI improvement >15 pts was also significantly higher with CDA versus ACDF (5 studies; OR 0.72 [95%CI 0.54, 0.95]; p=0.02).
- NRS and VAS neck pain scores were both demonstrated to be significantly lower with CDA versus ACDF at short-term follow-up (p=0.04 and 0.004, respectively). VAS arm pain scores were also significantly lower with CDA (p=0.02), though no significant difference was observed for NRS arm pain (p=0.56). Both NRS neck and arm pain scores at mid-term follow-up were significantly lower with CDA versus ACDF (p=0.0008 and 0.02, respectively).
- Short-term SF-36 PCS and MCS scores demonstrated no significant differences between CDA and ACDF in health-related quality of life (PCS: SMD -0.07 [95%CI -0.20, 0.06], p=0.28; MCS: SMD 0.05 [95%CI -0.13, 0.22], p=0.62).
- CDA demonstrated significantly higher range of motion (ROM) at the operated level compared to ACDF (SMD -5.20 [95%CI -6.77, -3.72]; p<0.00001). No difference was noted between CDA and ACDF when considering ROM of the superior level (SMD 0.42 [95%CI -0.28, 1.12]; p=0.24) or inferior level (SMD -0.90 [95%CI -1.84, 0.04]; p=0.06).
- In the short-term, CDA demonstrated lower rates of secondary surgery at both the operated level (OR 0.32 [95%CI 0.19, 0.53]; p<0.00001) and adjacent levels (OR 0.28 [95%CI 0.11, 0.72]; p=0.008). In the mid-term, rate of secondary surgery at the operated level remained significantly lower following CDA (OR 0.45 [95%CI 0.29, 0.68]; p=0.0002), though the difference in rate of secondary surgery at adjacent levels was no longer significant (OR 0.76 [95%CI 0.47, 1.22]; p=0.25).
- Rate of overall success (defined as min. 15-pt improvement in NDI, improvement or maintenance of neurological status, and no experience of severe adverse event) was significantly higher following CDA compared to ACDF (OR 0.59 [95%CI 0.48, 0.74]; p<0.00001).
What should I remember most?
Cervical disc arthroplasty was statistically favoured when considering pooled results of Neck Disability Index outcome at short and mid-term, neck pain in the short- and mid-term, range of motion at the operated level in the short-term, secondary surgery at the operated and adjacent levels in the short-term, secondary surgery at the operated level in the mid-term, and overall success rate when compared to anterior cervical discectomy and fusion.
How will this affect the care of my patients?
The results of this review and meta-analysis suggest that outcomes may be favourable following cervical disc arthroplasty when compared to anterior cervical disc arthroplasty. Additional studies with extended follow-up, and examining the progression of adjacent segment degeneration over the long-term are needed to more widely explore the long-term efficacy of these two surgical treatment options.
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