Cervical Disc Cervical Disc ReplacementReplacementJulio Petilon MDJulio Petilon MDSpine Center AtlantaSpine Center Atlanta

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IntroductionIntroduction

Cervical disc Cervical disc replacement is an replacement is an alternative to cervical alternative to cervical fusion in people with fusion in people with neck pain, radiculopathy, neck pain, radiculopathy, myelopathy.myelopathy.

PresentationPresentation

Compression of nerve and/or Compression of nerve and/or spinal cord most commonly due spinal cord most commonly due to:to:– cervical spondylosiscervical spondylosis– disk herniationdisk herniation– combinationcombination

PathoanatomyPathoanatomy

Non Operative Non Operative TreatmentTreatment Immobilization- Immobilization-

Short term use for 1-Short term use for 1-2 weeks may relieve 2 weeks may relieve neck spasms. neck spasms.

TractionTraction Medication- NSAIDs, Medication- NSAIDs,

Opioids, Oral Opioids, Oral CorticosteroidsCorticosteroids

Physical TherapyPhysical Therapy Chiropractor / Chiropractor /

ManipulationManipulation EpiduralsEpidurals

Surgical TreatmentSurgical Treatment

IndicationsIndications Failure of 6-12 wks Failure of 6-12 wks

of conservative careof conservative care Neurologic deficit Neurologic deficit

(weakness or (weakness or numbness)numbness)

Imaging consistent Imaging consistent with clinical signs with clinical signs and symptomsand symptoms

Anterior Cervical Anterior Cervical Discectomy and Fusion Discectomy and Fusion (ACDF)(ACDF)

““Gold standardGold standard”” for for cervical cervical radiculopathyradiculopathy

Predictable results Predictable results with 80-90% with 80-90% satisfactory resultssatisfactory results

Issues include: Issues include: Adjacent segment Adjacent segment disease, disease, pseudarthrosispseudarthrosis

ACDF (Fusion)ACDF (Fusion)

ACDF: OutcomesACDF: Outcomes

122 pts with cervical radiculopathy122 pts with cervical radiculopathy Non instrumented ACDF with ICBGNon instrumented ACDF with ICBG F/U 2-15 yrs.F/U 2-15 yrs. 83% with mild or no neck pain at f/u. 108 pts. with no functional 83% with mild or no neck pain at f/u. 108 pts. with no functional

impairmentimpairment 24 cases pseudoarthrosis: 11% 1 one level, 27% in two level and three 24 cases pseudoarthrosis: 11% 1 one level, 27% in two level and three

level. P < .01. Pseudos only developed at one level.level. P < .01. Pseudos only developed at one level. Pseudos did not preclude satisfactory outcomesPseudos did not preclude satisfactory outcomes Only four pseudoarthroses required further surgeryOnly four pseudoarthroses required further surgery

19931993

Adjacent Segment Adjacent Segment DiseaseDiseaseHilibrand A et al.:Radiculopathy and Myelopathy at

Segments Adjacent to the Site of a Previous Anterior Cervical Arthrodesis, JBJS 1999 April; Vol.

81-A, No. 4, 519-528. 374 pts(409 procedures) retrospectively reviewed

over 20 yrs. 338 ACDFs and 71 ACCFs with strut grafts 2.9% per year incidence of adjacent segment

disease(ASD) 25% ASD at 10 years using K-M survivorship curve C5-6 and C6-7 highest risk 12% ASD in multilevel sx. vs. 18% ASD in single level sx. 27/55 pts went on to sx. for ASD

ACDFACDF Overall Still Very Good / Excellent Overall Still Very Good / Excellent

resultsresults However:However:

– Fails to restore normal biomechanics / Fails to restore normal biomechanics / kinematics of the cervical spinekinematics of the cervical spine

– Increases adjacent segment loadsIncreases adjacent segment loads

So is there another option?So is there another option?

Cervical Disc Cervical Disc ReplacementReplacement

Motion preserving surgeryMotion preserving surgery Treat painful / pathologic process Treat painful / pathologic process

while restoring/maintaining motionwhile restoring/maintaining motion Decreased stress in adjacent levelsDecreased stress in adjacent levels May prevent problems of adjacent May prevent problems of adjacent

segment disease, secondary surgery, segment disease, secondary surgery, pseudoarthrosispseudoarthrosis

Cervical Disc Cervical Disc ReplacementReplacement

Cervical Cervical ArthroplastyArthroplasty

Mummaneni P et al.: Mummaneni P et al.: Clinical and Clinical and radiographic analysis of cervical disc radiographic analysis of cervical disc arthroplasty compared with allograft arthroplasty compared with allograft fusion: A randomized control trialfusion: A randomized control trial, J , J

Neurosurg Spine, 2007 Mar, 6(3);198-203.Neurosurg Spine, 2007 Mar, 6(3);198-203. 541 pts: 276 arthroplasty and 265 ACDF541 pts: 276 arthroplasty and 265 ACDF 2 yr f/u2 yr f/u Higher neurologic success, lower revision sx, Higher neurologic success, lower revision sx,

and earlier return to work in arthroplasty and earlier return to work in arthroplasty groupgroup

7 degrees of maintained motion 7 degrees of maintained motion

Cervical Cervical ArthroplastyArthroplastySasso R et al., Sasso R et al., Artificial Disc Artificial Disc VersusVersus Fusion: A Fusion: A

Prospective, Randomized Study With 2-Prospective, Randomized Study With 2-Year Follow-up on 99 Patients, Year Follow-up on 99 Patients, Spine:Volume Spine:Volume

32(26)15 December 2007pp 2933-2940 32(26)15 December 2007pp 2933-2940 99 pts 1:1 Arthroplasty: ACDF99 pts 1:1 Arthroplasty: ACDF 2 yr2 yr f/u Statistically significant better NDI, Arm pain, Statistically significant better NDI, Arm pain,

VAS, and SF-36 scores in arthroplasty groupVAS, and SF-36 scores in arthroplasty group 4 reoperations in the ACDF group vs. 2 4 reoperations in the ACDF group vs. 2

reoperations in the arthroplasty group.reoperations in the arthroplasty group. 7.9 degrees of retained motion 7.9 degrees of retained motion

Cervical Cervical ArthroplastyArthroplasty

Kesman et al. Evid Based Spine Care J 2012Kesman et al. Evid Based Spine Care J 2012– Prospective RCT; 22 pts in each arm ACDA/ACDF with 7 yr Prospective RCT; 22 pts in each arm ACDA/ACDF with 7 yr

f/uf/u– NDI improved in Prodisc-C more than ACDF (54.2 to 14.1 v NDI improved in Prodisc-C more than ACDF (54.2 to 14.1 v

53.6 to 26.9)53.6 to 26.9)– ROM maintained in prodisc groupROM maintained in prodisc group– 7 reoperations in ACDF gp. (3 same level; 4 adjacent 7 reoperations in ACDF gp. (3 same level; 4 adjacent

level); No reoperations for ACDAlevel); No reoperations for ACDA Zigler et al. Spine 2013Zigler et al. Spine 2013

– 103 ProDisc; 106 ACDF with 5 yr f/u103 ProDisc; 106 ACDF with 5 yr f/u– Both gps showed significant improvement in all outcomesBoth gps showed significant improvement in all outcomes– Reoperation rate greater for ACDF – 11.3% v 2.9%Reoperation rate greater for ACDF – 11.3% v 2.9%

Mobi-C Disc Mobi-C Disc ReplacementReplacement

Approved for 1 or 2 level

Adjacent Segment Adjacent Segment Degeneration Through 5 yrsDegeneration Through 5 yrs

Secondary Surgeries Secondary Surgeries Through 5 yrsThrough 5 yrs

Return to WorkReturn to Work

ContraindicationsContraindications

Questions?Questions?

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