What is the role of surgery in the treatment of cervical disc disease?

Updated: Apr 16, 2020
  • Author: Michael B Furman, MD, MS; Chief Editor: Dean H Hommer, MD  more...
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Answer

Studies indicate that cervical HNP with radiculopathy can be managed conservatively. Surgery is warranted when neurogenic bowel or bladder dysfunction, deteriorating neurologic function, or intractable radicular or discogenic neck pain exists. Specifically, cervical spine surgical outcomes are most favorable for radicular pain, spinal instability, progressive myelopathy, or upper extremity weakness. [32]

Surgical outcomes for patients with myelopathy have been shown to be significantly greater with regard to motor recovery if surgical intervention is performed less than 1 year after the onset of symptoms. [8] A study by Fay et al suggested that cervical arthroplasty is about as effective in treating DDD-related cervical spondylotic myelopathy (CSM) as it is in treating DDD-related cervical radiculopathy. The study involved 151 patients with cervical DDD who underwent arthroplasty, including 72 patients with CSM and 53 with radiculopathy. The investigators found at 3-year postoperative follow-up that the clinical and radiographic outcomes in the myelopathy group were similar to those in the radiculopathy patients. [33]

The literature has demonstrated favorable cervical spine fusion outcomes for chronic discogenic axial neck pain when the presurgical evaluation has incorporated provocative cervical discography. Provocative discography identified the painful segment(s) and confirmed adjacent pain-free levels.

Fusion can increase intradiscal pressure and other stress at adjacent unfused levels, thereby accelerating postsurgical spinal degeneration. [9, 10, 11, 12, 13]

The possibility of obtaining the goals of anterior cervical decompression and fusion (ACDF) while maintaining adjacent segment motion led to the advent of total disc replacement (TDR). Currently, 3 devices for disc replacement have been approved with other trials underway. Studies have shown several advantages of TDR over ACDF, including reduction of bone graft site morbidity, adjacent segment disease, pseudarthrosis, reoperation rate, and anterior cervical plating. [34, 35]

For example, a literature review by Luo et al comparing TDR (889 patients) to ACDF (837 patients) found that in patients with one-level cervical DDD, TDR led to a significantly reduced rate of adjacent segment disease compared with ACDF, at 24-month postoperative follow-up. [36]

In another report, a nonblinded, prospective, randomized, industry-sponsored outcome study with 5-year follow-up (n=209), the rate of reoperation was less following cervical TDR (2.9%) than after conventional anterior cervical discectomy and fusion (14.5%). [37]

A prospective, randomized, multicenter, controlled clinical trial by Jackson and Johnson comparing anterior cervical discectomy and fusion with TDR, both performed at two contiguous levels, indicated that TDR produces better long-term results (7 years postsurgery) with regard to neurologic deterioration and adverse events, with range of motion preserved, less neck and arm pain experienced, and fewer subsequent surgeries required. [38]

However, disc replacement is not without complications and can lead to implant failure and bone-implant interface failure. Another documented complication is heterotrophic ossification and osteolysis, which can reduce the ROM at the replacement level. To date, no one surgical technique has been found to be statistically more favorable or superior to another. [39, 8, 40, 41]

A 2009 study sought to determine which factors are predictive of patient outcome following anterior discectomy and fusion. [42] Surgical outcomes that developed over a 2-year period were examined in patients who were treated for recalcitrant single-level subaxial radiculopathy or myelopathy. The study's results indicated that important prognostic factors include whether or not a patient is gainfully employed, has normal sensory function prior to surgery, has higher preoperative disability scores, and is involved in spine-related litigation.

A literature review by Joaquim and Riew suggested that multilevel cervical arthroplasty offers at least the same safety and efficacy as anterior cervical discectomy and fusion, with cervical motion preserved and potentially fewer reoperations required. [43]

Similarly, in a review of published and ongoing studies, Laratta et al indicated that the clinical outcomes of single-level cervical disc arthroplasty are equivalent to those of anterior cervical discectomy and fusion, while total cost and the need for secondary procedures are reduced. The investigators also reported that the efficacy of two-level cervical disc arthropathy and hybrid surgery may be the same as that of the single-level operation but that the evidence is not yet as strong. [44]

A literature review by Hu et al indicated that in the treatment of symptomatic cervical disc disease, the outcome of cervical disc arthroplasty is better than that of anterior discectomy and fusion with regard to overall and neurologic success, Neck Disability Index results, secondary procedures, functional outcomes, patient satisfaction, degeneration of the superior adjacent segment, and serious adverse events related to implants and surgery. [45]

A systematic literature review by Wullems et al indicated that percutaneous cervical nucleoplasty is a safe and effective treatment for contained herniated discs, even at long-term follow-up. The investigators cautioned, however, that the level of evidence found in their review was only moderate. [46]


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