In which cases do surgeons specializing in total disc replacement perform fusion in patients with cervical spine symptoms?
PURPOSE
The purpose was to investigate reasons and their frequency for why total disc replacement (TDR) specialty surgeons performed anterior cervical discectomy and fusion (ACDF) rather than TDR.


METHODS
A consecutive series of 464 patients undergoing cervical spine surgery during a 5-year period by three TDR specialty surgeons was reviewed. For each ACDF, the reason for not performing TDR was recorded.


RESULTS
TDR was performed in 76.7% of patients (n = 356) and ACDF in 23.3% (n = 108). The most common reason for ACDF versus TDR was anatomical (conditions that may not be adequately addressed with TDR and/or may interfere with device function), which occurred in 64 of 464 patients (13.79%). The second most common reason was insurance (denial/lack of coverage n = 17, 3.23%), and deformity/kyphosis not addressable with TDR was noted in 13 (2.80%). Pseudoarthrosis repair led to ACDF in three patients (0.65%), two did not receive TDR due to osteoporosis (0.43%), and in two others (0.43%) ACDF was undertaken due to high risk of heterotopic ossification. There was one case (0.22%) each of: nickel allergy, trauma with posterior element fracture, TDR removal, multiple prior cervical spine surgeries, concern about artifact on future imaging studies, benign osteoblastic bone, and limitation to adequate surgical approach for TDR. ACDF patients' mean age was significantly greater than TDR patients' (55.3 vs. 46.7 years; p < 0.01). TDR group had significantly more single-level procedures than ACDF (60.8% vs. 43.5%; p < 0.05).


CONCLUSION
The most common reason for ACDF versus TDR was anatomy that may compromise segmental stability and/or TDR functionality. Older age and greater number of operated levels may be related to anatomical factors, primarily significant osteophytes and severely degenerated facets. These factors, as well as deformity/kyphosis, are more common in older patients and require multi-level treatment. This study found that many patients are good cervical TDR candidates; however, even among TDR specialists, ACDF may be preferred where it is prudent to not take undue risks. These slides can be retrieved under Electronic Supplementary Material.
['Guyer|Richard D|RD|', 'Ohnmeiss|Donna D|DD|', 'Blumenthal|Scott L|SL|', 'Zigler|Jack E|JE|']
D002574:Cervical Vertebrae D017586:Diskectomy D006801:Humans D055959:Intervertebral Disc Degeneration D011446:Prospective Studies D013123:Spinal Fusion D066231:Surgeons D059145:Total Disc Replacement D016896:Treatment Outcome
Total disc replacement Cervical spine Anterior cervical discectomy and fusion Indications