Rationale: Total disc replacement (TDR) was developed to relieve pain, restore disc height, and maintain the natural motion of the spine. Developers of artificial cervical discs sought to eliminate the problems associated with anterior cervical discectomy and fusion (ACDF) such as the need for a hip bone autograft, disease recurrence, adjacent segment degeneration, or need for additional surgeries.

Technology Description: Patients with cervical degenerative disc disease (DDD) who experience cervical disc symptoms, even after conservative treatment regimens, are now presented with various surgical treatment alternatives, including TDR and ACDF, to provide relief of radiculopathy and mitigate progression of cervical myelopathy. TDR involves the removal of a damaged intervertebral disc and replacement with a prosthetic device; this process preserves some or most of a physiological range of motion.

Controversy: Cadaveric and clinical studies have demonstrated that ACDF causes biomechanical changes in the adjacent segments, including increased shear strains, higher intradiscal pressure, and increased adjacent segment motion, which have the potential to accelerate the natural progression of DDD. A recent meta-analysis examined data from 83 studies comparing TDR and ACDF that reported rates of ASD (Kong et al., 2016). The authors found that the pooled prevalence of ASD after single-level fusion surgery was higher than rates observed after multilevel procedures and the risk for ASD appeared to be lower with TDR than with ACDF (relative risk [RR]=0.55; P<0.01).

Key Questions:

  • How does multilevel cervical total disc replacement (TDR) compare with anterior cervical discectomy and fusion (ACDF) with regard to improvement in signs and symptoms of cervical degenerative disc disease (DDD)?
  • How does multilevel cervical TDR compare with fusion with regard to impact on health-related quality of life (HRQOL)?
  • How does multilevel cervical TDR compare with fusion with regard to operative complications and long-term safety, including development of adjacent joint degeneration?
  • Have definitive patient selection criteria been established for multilevel TDR?

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