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Cervical disc replacement

76 citationsUpdated Sep 2026

Overview

Cervical disc replacement is a Food and Drug Administration (FDA)–approved motion-preserving alternative to anterior cervical diskectomy and fusion for 1-level and 2-level degenerative disk diseases [11]. The procedure is indicated for patients with cervical radiculopathy or degenerative disc disease, including selected cases of traumatic cervical disc herniation without spinal cord injury, fracture, or instability [14]. While Mobi-C arthroplasty is considered a safe and encouraging alternative to anterior cervical discectomy and fusion (ACDF) for single-level degeneration [66], two-level disc arthroplasty may serve as an alternative for young patients pending long-term result evaluation [10].

Compared with ACDF, cervical disc arthroplasty reduces the risk of adjacent segment disease [21] and is preferable in reducing the incidence of symptomatic adjacent-level disease requiring surgery at mid- to long-term follow-up [1]. For one-level cervical degenerative disc disease, total disc replacement results in significantly fewer adjacent segment diseases and reoperations than ACDF [9]. A meta-analysis of eight prospective randomized controlled trials demonstrated that cervical disc arthroplasty was superior to anterior discectomy and fusion regarding overall success, Neck Disability Index (NDI) success, neurological success, implant/surgery-related serious adverse events, secondary procedures, functional outcomes, patient satisfaction, and adjacent segment degeneration [22]. Additionally, patients treated with cervical disc arthroplasty returned to work in significantly fewer days than those treated with anterior cervical diskectomy fusion [5], and the procedure offers potential advantages regarding length of stay, cost, and routine discharge [6].

Despite these benefits, the motion-preserving design may introduce novel complications and failure modalities that are poorly understood [6]. In patients with cervical radiculopathy, arthroplasty and fusion did not differ for disability, quality of life, or pain at 5 years [7]. The long-term benefit of total disk arthroplasty over fusion for axial low back or neck pain remains to be determined [3], and a sufficiently long follow-up is necessary to definitively establish an advantage for total disc replacement in the cervical spine [17]. Outcomes are generally similar regardless of fusion versus arthroplasty techniques in patients with prolonged preoperative symptom duration [12], and Workers' Compensation status does not alter patient-reported outcomes, complications, reoperations, or return-to-work status after cervical disc arthroplasty [8]. However, patients with workers' compensation status undergoing surgery at an ambulatory surgical center may report inferior pain, function, and disability outcomes compared with those with private or government-provided insurance [26]. Smoking is associated with poor outcomes following hybrid surgery for multilevel cervical disc disease [13]. Intervertebral disc replacement may develop into a reasonable surgical option for appropriately selected patients if supported by proper scientific input, rigorous clinical trials, controlled marketing, and post-marketing surveillance [4].

Anatomy & Pathophysiology

Bony Anatomy

The spine comprises 7 cervical, 12 thoracic, and 5 lumbar vertebrae, along with 5 fused sacral and 4 or 5 fused coccygeal vertebrae [71]. Each vertebral body is a fairly cylindrical mass of bone connected via pedicles to the posterior arch, which consists of the lamina and spinous process [71]. Structurally, the vertebral body contains an inner region of cancellous bone surrounded by a thin shell of cortical bone [76]. The cervical vertebral body is oblong, with a coronal diameter larger than its sagittal diameter [88]. Cervical endplates exhibit a cup-in-saucer configuration, distinct from the normally flat endplates of the thoracic and lumbar vertebrae [88]. Posteriorly, the cervical transverse process guides exiting spinal nerves, which lie posterior to the vertebral artery [88]. The transverse process forms a half-pipe configuration that cradles the spinal nerve as it projects in an anteroinferior direction [88].

Intervertebral Disc Anatomy

The intervertebral disc (IVD) separates successive vertebral bodies, with the exception of the space between the atlas (C1) and axis (C2) [76]. The IVD consists of an inner nucleus pulposus (NP) and an outer anulus fibrosus (AF) [76]. The NP functions as an osmotic pump, attracting water to generate hydraulic pressure under significant loads [76]. The AF encapsulates the gelatinous NP, providing mechanical support to contain NP pressure and constrain intervertebral rotations [76]. The outer AF integrates with the vertebral rim via a fibrocartilage enthesis, characterized by a thin layer of calcified cartilage known as the "tidemark" [76]. The end plate is a bilayer of cartilage and bone that separates the disc from adjacent vertebrae [76]. The cartilage end plate integrates with the inner AF to fully encapsulate the NP [76]. To maintain cellular vitality, the end plate must be strong and thick enough to resist significant loads while remaining permeable for chemical transport [76].

Ligaments and Soft Tissue

Successive vertebrae connect anteriorly via the intervertebral disc and posteriorly via facet joints [76]. Passive support is provided by the anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, facet joint capsule, interspinous ligament, and supraspinous ligaments [76]. Spinal column stabilization is further achieved by paraspinal muscles, including the erector spinae, psoas, and multifidus [76]. The erector spinae runs longitudinally on the dorsal surface and functions to extend the spine [76]. The psoas runs longitudinally on the ventrolateral surface, serving to flex the hip or laterally bend the trunk [76]. The multifidus connects intersegmentally, acting like a bowstring to maintain lordosis and stabilize the spine [76].

Biomechanics and Alignment

Normal cervical alignment is approximately 15° of lordosis [75]. Spinal curvatures function to keep the head balanced over the pelvis and transmit axial forces to the pelvis [75]. The lordotic curvatures of the cervical and lumbar spine develop secondarily later in life, allowing the growing child to develop an upright posture [75]. The center of gravity of the spinal column runs from the odontoid process proximally through the sacral promontory caudally [75]. Changes in sagittal balance that shift the center of gravity too far ventrally can result in significant pain and disability [75]. The functional spinal unit consists of two vertebrae, the intervening disk, and the facet joints with their capsules [75]. This unit limits spinal motion within the confines of protecting contained neural structures [75]. Vertebral bodies bear 70% to 90% of the static axial load of the spine [75]. In a standing, neutral alignment, facet joints support 10% to 20% of axial load [75]. In extension, facet joints may bear up to 30% of the axial load [75]. In flexion, facet joints may be burdened with up to 50% of the anterior shear load [75]. As compressive forces apply to the disk, the NP deforms, redistributing axial forces radially [75]. This radial pressure is resisted by the tensile properties of the alternating fiber bands within the AF [75]. Spinous and transverse processes act as lever arms, providing mechanical advantage for muscles inserting along their surfaces [75].

Vascular Anatomy

The cervical spine derives its circulation primarily from the vertebral arteries [80]. These arteries arise from the subclavian arteries and typically enter the transverse foramen at the C6 level [80]. They run proximally through the transverse foramina to C1, then course posteriorly over the superior aspect of the C1 ring before entering the foramen magnum [80]. Segmental branches to each cervical vertebra arise from the vertebral artery and the deep cervical branch of the costocervical trunk [80]. Vertebral artery anatomy exhibits significant variability, with one side typically more dominant than the other [80]. The artery may enter through the transverse foramen of C7 rather than C6 [80]. Anomalous courses, such as looping through a cervical vertebral body before returning to the longitudinal course, are not uncommon [80]. The spinal cord’s vascular supply is primarily from medullary branches of segmental spinal arteries [80]. The anterior spinal artery supplies approximately 80% of the vascular supply to the spinal cord [80]. Three anterior medullary arteries typically supply the cervical region [80].

Neural Anatomy

A typical mixed spinal nerve contains motor, sensory, and sympathetic components [81]. Motor rootlets leave the anterolateral sulcus of the spinal cord to form motor roots, with fibers arising from anterior horn cells to innervate skeletal muscles [81]. Sensory fibers arise from pain, thermal, tactile, and stretch receptors, with cell bodies located within the dorsal root ganglia [81]. The sympathetic component of all 31 mixed spinal nerves leaves the spinal cord along only 14 motor roots [81]. The cells of origin for the sympathetic component are in the intermediolateral cell column, which extends throughout the thoracic and upper lumbar cord segments [81]. The anterior primary rami of all cervical, the first thoracic, and all lumbosacral nerves join to form plexuses [81]. The upper four cervical anterior rami form the cervical plexus [81]. The lower four cervical and first thoracic anterior rami form the brachial plexus [81]. The area of skin supplied by the fibers of a single spinal root is called a dermatome [81]. Segmental dermatomal patterns are well preserved in the thoracic region but not in the limbs [81].

Pathophysiology of Degeneration

Cervical degenerative disc disease is a pathophysiologic process incorporating a spectrum of disease states ranging from neck pain and headache to cervical radiculopathy and/or myelopathy [105]. Disc degeneration does not always cause pain but can lead to internal disc derangement or disc herniation [105]. Genetic influence on disc degeneration may be attributed to a small effect from multiple genes or a relatively large effect of a smaller number of genes [105]. Specific gene loci associated with disc degeneration include the aggrecan gene, metalloproteinase-3 gene, collagen type IX, and alpha 2 and 3 gene forms [105]. Approximately 80% of individuals are affected by nonspecific axial pain at some time in their lives [105]. The incidence of significant abnormalities shown by imaging studies in asymptomatic matched controls is 76% [105].

The degenerative process of the spine is divided into three stages: dysfunction, instability, and stabilization [103]. The dysfunction stage, seen in individuals 15 to 45 years old, is characterized by circumferential and radial tears in the disc anulus and localized synovitis of the facet joints [103]. The instability stage, found in 35- to 70-year-old patients, is characterized by internal disruption of the disc, progressive disc resorption, degeneration of the facet joints with capsular laxity, subluxation, and joint erosion [103]. The stabilization stage, present in patients older than 60 years, is characterized by progressive development of hypertrophic bone around the disc and facet joints leading to segmental stiffening or frank ankylosis [103]. Disc herniation is considered a complication of disc degeneration in the dysfunction and instability stages [103]. Spinal stenosis from degenerative arthritis is a complication of bony overgrowth compromising neural tissue in the late instability and early stabilization stages [103]. The natural history of degenerative disc disease involves recurrent episodes of pain followed by periods of symptomatic or complete relief [103].

Cytokines such as matrix metalloproteinases, phospholipase A2, nitric oxide, and tumor necrosis factor-α are thought to contribute to the development of low back pain [156]. Cells are sparse in the intervertebral disk, composing only 1% to 5% of the tissue volume [156]. Chondrocytes are the predominant cell types in the nucleus, and the number of cells decreases rapidly across the disk from the end plate to the nucleus [156].

Pathophysiologically, cervical myelopathy results from static compression, spinal malalignment leading to altered cord tension and vascular supply, and dynamic injury mechanisms [102]. The cascade of events after compression of the spinal cord includes ischemia, destruction of the blood–spinal cord barrier, demyelination, and neuronal apoptosis [102]. Potential genetic factors for degenerative disk disease include those related to MMP-2 and collagen IX [102]. Potential genetic factors for ossification of the posterior longitudinal ligament include collagen VI and XI [102]. Congenital anomalies including spinal stenosis, Down syndrome, and Klippel-Feil syndrome may predispose to the development of cervical disk degeneration [102]. Degeneration of the disc occurs with disc narrowing and subsequent ligamentous redundancy, which compromises the spinal canal area [85]. Instability resulting from disc degeneration precipitates the formation of facet overgrowth and ligamentous hypertrophy [85]. The ligamentum flavum may be markedly thickened into the lateral recess where it attaches to the facet capsule, causing nerve root compression [85].

Classification

Proposed classification system for radiographic bone changes: This system categorizes radiographic bone changes following cervical total disc replacement by subdividing the superior and inferior vertebral bodies into three equal sections to record observed bone loss [141]. It documents specific types of bone loss, including endplate rounding, cystic erosion adjacent to the endplate, and cystic erosion not adjacent to the endplate [141]. The classification also records whether bone loss is progressive based on serial radiographs and measures severity by the percentage of the end plate involved [141].

Additional bony changes: The system includes documentation of other relevant bony changes, such as radiolucent lines, heterotopic ossification, vertebral body olisthesis, loss of core implant height, and the presence of device migration and subsidence [141].

Other Considerations: In a study assessing this proposed classification system using serial radiographs from 19 patients (25 devices), the overall agreement of assessments by 6 investigators ranged from 49.9% to 94.7% [141]. Within the same study, there was reasonable agreement on the presence or absence of bone loss or radiolucencies, with a range of 58.4% to 94.7% [141].

Clinical Presentation

Symptom Duration and Severity: Patients with cervical radiculopathy secondary to cervical disk herniation demonstrate notable improvements in physical function, disability, pain, and mental health regardless of whether fusion or arthroplasty techniques are used, even when preoperative symptom duration is prolonged [12]. The type and extent of disc herniation measured on MRI prior to surgery does not correlate with the severity of symptoms at presentation [34]. Furthermore, this preoperative MRI assessment does not correlate with clinical outcomes at two years postoperatively [34].

Radicular vs. Non-Radicular Symptoms: Patients with radicular symptoms have a higher rate of improvement from cervical discectomy and interbody fusion than those whose symptoms are non-radicular [30]. A positive correlation exists between satisfactory results from cervical discectomy and interbody fusion and the presence of motor or sensory deficits [30]. This correlation is greater when both motor and sensory findings are present [30]. Conversely, occipital headaches and non-radicular symptoms as predominant complaints tend to reduce the likelihood of a desirable result from cervical discectomy and interbody fusion [30]. Patients with correlating symptoms and signs of root compression have better results from cervical discectomy than those whose treatment resulted in bone fusion [30].

Diagnostic Correlation and Imaging: A degenerated intervertebral disc can create abnormal mechanics in the cervical spine even before roentgenograms show significant intervertebral-space narrowing or remarkable spur formation [29]. Shoulder, neck, occipital, and arm pain may arise from a degenerated intervertebral disc level where localizing signs may not be clear on physical examination [29]. A discogram at the involved level should give a roentgenographic pattern typical of disc degeneration and reproduce the pain which forms the chief complaint [29]. Contrast medium flows with little resistance into a degenerated disc, whereas into a normal disc only a small amount can be inserted and only under great pressure [29]. The discogram of a degenerated disc shows an irregular extension of contrast medium beyond the central nucleus across the disc space to the region of the joints of Luschka and into the area of the intervertebral foramina [29].

Surgical Timing and Adjacent Segment Disease: Patients being considered for anterior cervical diskectomy and fusion who have substantial preoperative motor deficits may benefit from earlier surgical intervention [20]. Symptomatic adjacent-segment disease may affect more than one-fourth of all patients within ten years after an anterior cervical arthrodesis [25].

Investigations

Plain radiography: The lateral cervical spine view is the most important radiographic view; inadequate imaging misses over 20% of cervical injuries [100]. In the trauma setting, the series includes anteroposterior, right oblique, left oblique, and open-mouth (odontoid) views in addition to an initial cross-table lateral view, achieving 92% sensitivity when all five views are taken [100]. Specific measurements include prevertebral space limits of 10 mm at C1, 5 mm at C2, 7 mm at C3 and C4, and 20 mm at C5, C6, and C7 [100]. The atlanto-dental interval (ADI) normally measures less than 3 mm in adults and less than 4 mm in children [100]. Vertical widening of the interspinous distance at a given level greater than 1.5 times the level above and below indicates a hyperflexion injury with posterior instability or interlocking of the posterior facets [100]. A combined overhang of C1 lateral masses on C2 exceeding 6.9 mm is highly correlated with insufficiency of the transverse ligament and C1-C2 sagittal instability [100]. Radiographs, whether flexion-distraction or neutral, have limited utility in the acute setting due to high false-negative and false-positive rates [101]. In alert, asymptomatic patients without neck pain or distracting injury, with a normal neurological examination and complete range of motion, radiographic evaluation is not recommended and only clinical clearance is necessary [101].

MRI: MRI is the standard for advanced spinal imaging and is superior to CT in most circumstances, particularly for identifying degenerative changes within discs [92]. It provides ideal evaluation of intervertebral discs, nerve roots, the posterior longitudinal ligament, and the intervertebral foramen due to high soft-tissue contrast and resolution [91]. MRI evidence of disc degeneration has been reported in 25% of patients younger than 40 years and in 60% of patients 60 years and older [92]. A normal disc exhibits signal hyperintensity on T2-weighted images due to high water content, while aging results in gradual desiccation and loss of T2 signal intensity [91]. Disc herniations or extrusions appear as convex or polypoid masses extending posteriorly into the ventral epidural space, frequently maintaining a signal intensity similar to that of the disc of origin [91]. Free disc fragments appear discontinuous with the intervertebral disc, usually of intermediate T1-weighted signal in contrast to hypointense cerebrospinal fluid [91]. Sagittal T2-weighted or gradient-echo images create a “myelographic” effect useful for evaluating subarachnoid space compromise [91]. Sagittal T1-weighted images should be closely examined to identify neuroforaminal narrowing, as normal T1-weighted hyperintense perineural fat provides excellent contrast to darker displaced disc material [91]. Far lateral disc herniations are best seen on selected axial images localized through disc levels [91]. Edema within the spinal cord is readily demonstrated as hyperintensity with T2 weighting [91]. In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of symptoms at presentation nor to clinical outcomes at two years postoperatively [34]. Increased signal intensity (ISI) of the spinal cord on T2-weighted imaging and a high degree of cranial adjacent disc degeneration are independent risk factors for poor neurological recovery after anterior cervical discectomy and fusion [68].

CT: CT scans allow excellent visualization of the bony architecture and paravertebral soft tissues of the cervical spine [100]. CT is now reserved for the assessment of bony architecture, which it does better than MRI [100]. Narrowing of the spinal canal is best demonstrated by computed tomography [97]. Destructive lesions of the spine may require both CT and MRI to show the extent of cord involvement [97]. Patients with neck tenderness and pain require multidetector CT (MDCT), which has a sensitivity of 97% to 100% [101]. Ligamentous injury of the cervical spine may not be clearly identifiable from MDCT images, but MRI images can reliably identify ligamentous injuries [101].

Laboratory: Blood and cerebrospinal fluid (CSF) investigations may be necessary, depending on the suspected diagnosis [97].

Other Considerations: Imaging studies must be concordant with clinical symptoms and signs to be of diagnostic value; an imaging study alone is insufficient to confirm a diagnosis [89]. The best way to obtain meaningful clinical information from MRI is to have a specific question derived from history and physical examination, posed using the parameters of neural compression, instability, and deformity [92]. Patients with presumed spinal cord injury should undergo MRI to determine the location and severity of the injury and to identify the cause of spinal cord compression [101]. Edema increases with time, reducing the ability to properly evaluate spinal cord lesions on MRI [101]. Patients presenting with a Glasgow Coma Scale of less than 15 and midline tenderness with neurological symptoms should be evaluated with MRI for possible ligamentous injury [101]. The Pfirrmann classification system is widely accepted for grading the severity of radiographic lumbar disk degeneration using decreased disk height, loss of intradiscal signal intensity, and structural abnormalities [42]. The Pfirrmann grading system has been evaluated in the context of cervical spine disk degeneration and has demonstrated excellent interrater and intrarater reliability [42]. In the lumbar spine, there is some evidence that higher preoperative Pfirrmann grade at adjacent levels to the fusion correlates with the development of adjacent segment disease [42]. Diffusion tensor imaging has been reported to demonstrate spinal cord impairment in patients with early stage cervical spondylosis before it is visible on plain MRI scans [95]. CT discography has been used in the evaluation of extreme lateral disc herniation [99]. Pressure-controlled discography has been evaluated for its ability to predict surgical and nonsurgical outcomes [99]. CT discography is a useful adjuvant in the precise diagnosis of pure foraminal-type cervical disc herniation [99]. Magnetic resonance imaging and discography have been evaluated for their value in determining the level of cervical discectomy and fusion [99].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, NSAIDs, or injections. Surgical intervention is presented as the primary topic of discussion for the indications and outcomes of cervical disc arthroplasty.

Operative

Indications: Cervical disc arthroplasty is an FDA-approved motion-preserving alternative to anterior cervical diskectomy and fusion for 1-level and 2-level degenerative disk diseases [11]. For selected patients with traumatic cervical disc herniation who have no spinal cord injury, no fracture, and no instability, cervical arthroplasty yields similar improvement in clinical outcomes to anterior cervical discectomy and fusion [14]. Arthroplasty-fusion is preferred for intervertebral disc degeneration in adjacent upper segments [67].

Surgical Approach / Technique: Anterior cervical hybrid construction appears to be an acceptable option in the management of multilevel cervical degenerative disc diseases and spondylotic spinal stenosis [52]. Three anterior cervical surgical approaches have good curative effects on single level cervical spondylotic myelopathy [117]. Increased anterior cervical discectomy and fusion case volume may lead to markedly decreased surgical time, blood loss, and length of postoperative stay as well as improved clinical outcomes in pain, disability, and physical function [163].

Implant Selection: The premise that mobile prostheses preserve motion is central to the prevention of adjacent segment degeneration following cervical disc arthroplasty [2]. The PCM cervical disc replacement demonstrated a lower volumetric wear rate per million cycles than that reported for contemporary hip and knee arthroplasty designs in the simulator study [16]. The PCM cervical disc replacement components exhibited functional durability that would suggest success in long-term in vivo use [16].

Alignment / Balancing Strategy: Some sagittal balance parameters may be associated with the development of adjacent segment disease after anterior cervical surgery [56].

Pain Management: Steroids have been successfully used in anterior cervical discectomy and fusion to prevent dysphagia [162].

Other Considerations: A meta-analysis of prospective randomized clinical trials suggests that cervical disc replacement is preferable to anterior cervical fusion in reducing the incidence of symptomatic adjacent-level disease requiring surgery at mid- to long-term follow-up [1]. For patients with one-level cervical degenerative disc disease, total disc replacement was found to have significantly fewer adjacent segment diseases and reoperations compared with anterior cervical discectomy and fusion [9]. A meta-analysis of eight prospective randomized controlled trials showed that cervical disc arthroplasty was superior over anterior discectomy and fusion in terms of overall success, NDI success, neurological success, implant/surgery-related serious adverse events, secondary procedure, functional outcomes, patient satisfaction and recommendation, and adjacent segment degeneration [22].

Cervical disc arthroplasty with Prestige-LP Disc demonstrated a maintained and satisfactory clinical outcome at a minimum of 6-year follow-up, with the majority of the prostheses remaining mobile [15]. Satisfactory clinical outcomes were observed following cervical disc arthroplasty for the treatment of single-level cervical disc disease at a minimum 5-year follow-up [37]. Conversion paralysis after cervical disc replacement is exceedingly rare [19]. Awareness of conversion paralysis allows for early diagnosis through detailed neurological evaluation and appropriate imaging [19].

Complications

Adjacent Segment Disease

Cervical disc replacement is associated with a lower incidence of symptomatic adjacent-level disease requiring surgery at mid- to long-term follow-up compared to anterior cervical fusion [1]. A meta-analysis of prospective randomized controlled trials indicated that cervical disc arthroplasty was superior to anterior discectomy and fusion regarding superior adjacent segment degeneration [22]. However, multiple clinical trials and subsequent follow-up studies have failed to demonstrate a significant reduction of adjacent segment disease when artificial disk replacement is performed instead of fusion [170]. Although hybrid surgery maintained cervical kinetics, it failed to reduce the incidence of adjacent segment degeneration [70]. Over 3 years, revisions for 85 patients with cervical adjacent segment disease represented a notable economic expense greater than $2.0 million [43].

Operative and Perioperative Complications

In a level-specific comparison at C5-C6, the cervical disc replacement cohort demonstrated markedly reduced surgical times and estimated blood loss compared to the anterior cervical discectomy and fusion cohort [62]. Increases in surgical time in spine surgery are associated with increased risk for urinary tract infections, cardiac complications, pneumonia, renal failure, and sepsis [62]. Single-level elective anterior cervical discectomy and fusion had low complication rates, with no additional risk seen with outpatient as compared with inpatient procedures [38]. Revision surgical procedures place patients at higher risk for rapid responses and complications [175]. Patients with preoperative anxiety undergoing single-level anterior cervical diskectomy and fusion had significantly higher odds of 90-day adverse events, including severe and minor complications, as well as increased rates of emergency department visits and readmissions [113]. Nontobacco nicotine dependence is associated with notable postoperative complications in patients undergoing cervical spinal fusion [174]. Patients should be counseled preoperatively about the potential risk of voice complications following anterior cervical discectomy and fusion and managed postoperatively to mitigate long-term impairments [164]. A case report documented a deep cervical abscess 30 days after anterior cervical discectomy and fusion, which was managed with radical neck dissection, implant removal, and antibiotics [139]. Anterior cervical discectomy and fusion has reported early and late postoperative infection rates of 0.1–1.6% [139].

Primary subaxial cervical spine arthrodeses had a probability of revision approaching 13% over a 16-year period, with elevated reoperation rates in patients undergoing anterior-only surgical procedures [167]. Cervical disc arthroplasty with the Prestige-LP Disc demonstrated maintained and satisfactory clinical outcomes at a minimum of 6-year follow-up, with the majority of prostheses remaining mobile [15]. Two studies reported that patients treated with cervical disc arthroplasty returned to work in significantly fewer days than patients treated with anterior cervical diskectomy fusion [5]. After cervical disc arthroplasty, patients receiving Workers' Compensation had outcomes similar to those not receiving Workers' Compensation in terms of patient-reported outcomes, surgery-related complications, reoperations, and return-to-work status [8]. For selected patients with traumatic cervical disc herniation without spinal cord injury, fracture, or instability, cervical arthroplasty yields similar improvement in clinical outcomes to anterior cervical discectomy and fusion and preserves segmental mobility [14]. Mobi-C arthroplasty is a safe and encouraging alternative to anterior cervical discectomy and fusion surgery particularly in patients with single level cervical disc degeneration who require surgery [66]. Short-term results from randomized control trials clearly showed noninferiority of cervical disc arthroplasty compared with fusion [168].

Postoperative Management and Rehabilitation

A systematic review and meta-analysis revealed no significant differences in the 6-week postoperative cervical range of motion, fusion rate, or neck disability index between the cervical collar group and the no cervical collar group after anterior cervical discectomy and fusion [166]. Regarding motion-preserving procedures such as cervical laminoplasty, patients with prolonged postoperative cervical collar use demonstrated increased rates of axial neck pain and decreased final range of motion [147]. Regarding anterior and posterior fusion procedures, cervical collar use demonstrated improved short-term patient-reported outcomes and pain control [147]. The majority of studies demonstrated no significant difference in fusion rates between patients who wore a cervical collar and those who did not after anterior and posterior fusion procedures [147].

Recovery

Functional milestones: Validated outcome measures demonstrate sustained improvement in Neck Disability Index (NDI), pain scores, range of motion, and sagittal alignment at 10 years for both one- and two-level cervical disc arthroplasty (CDA) compared to baseline [63]. Satisfactory clinical outcomes are observed following CDA for single-level cervical disc disease [37]. The Prestige LP disc arthroplasty maintains favorable clinical outcomes, preserves overall cervical alignment, and preserves the range of motion of the treated level and adjacent levels [69]. A meta-analysis indicates that cervical disc arthroplasty is superior to anterior discectomy and fusion regarding overall success, NDI success, neurological success, functional outcomes, patient satisfaction, and recommendation [22].

Other Considerations: Long-term kinematic data indicate that total disc replacement results in significantly fewer adjacent segment diseases and reoperations compared with anterior cervical discectomy and fusion (ACDF) for one-level cervical degenerative disc disease [9]. Cervical disc arthroplasty also demonstrates superior outcomes regarding implant/surgery-related serious adverse events, secondary procedures, and adjacent segment degeneration compared to anterior discectomy and fusion [22]. The premise that mobile prostheses preserve physiological cervical spine motion to prevent adjacent segment degeneration is the focus of ongoing study protocols [2]. However, a sufficiently long follow-up, which has not yet been reached, is necessary to definitively establish an advantage for total disc replacement in the cervical spine [17]. Postoperative adjacent segment degeneration, implant subsidence, T1 slope, and C2–7 Cobb angle are associated with the recurrence of postoperative cervical kyphosis [171].

Perioperative Factors and Complications: Patients in the CDR cohort demonstrate markedly reduced surgical times and estimated blood loss (EBL) compared to the ACDF cohort [62]. Specifically, the CDR cohort reports 24.4 mL of blood loss, whereas the ACDF cohort reports 43.6 mL [62]. ACDF involves an almost 10-minute increase in surgical time relative to CDR, which translates to an approximate 4% increase in the risk of complications [62]. The time course and impact of dysphagia following anterior cervical surgery for degenerative pathology are characterized using both subjective and objective measures [53].

Neurological Recovery and Risk Factors: Increased signal intensity (ISI) of the spinal cord on T2-weighted imaging and a high degree of cranial adjacent disc degeneration are independent risk factors for poor neurological recovery after anterior cervical discectomy and fusion [68].

Economic Impact: Increased worker earnings resulting from disc herniation surgery may offset the increased direct medical costs associated with the procedure [134]. A study protocol anticipates that results will provide evidence to support physiotherapeutic rehabilitation applied after surgery for cervical radiculopathy due to cervical disc disease [123].

Key Evidence

  • [L1] Our review suggests that cervical disc replacement is preferable to anterior cervical fusion in reducing the incidence of symptomatic adjacent-level disease requiring surgery at mid- to long-term follow-up. [1] (10.1186/s13018-020-01957-3)
  • [L1] The study protocol aims to investigate whether cervical disc arthroplasty restores or preserves physiological cervical spine motion compared to simple discectomy, as prevention of adjacent segment degeneration relies on the premise that mobile prostheses preserve motion. [2] (10.1186/s12891-015-0479-4)
  • [L5] The long-term benefit of total disk arthroplasty over fusion for the treatment of axial low back or neck pain remains to be determined. [3] (10.5435/00124635-200612000-00002)
  • [L5] Intervertebral disc replacement may develop into a reasonable surgical option for some appropriately selected patients if supported by proper scientific input, rigorous clinical trials, controlled marketing, and post-marketing surveillance, avoiding becoming a dangerous fad. [4] (10.2106/00004623-200402000-00029)
  • [L2] Two studies reported that patients treated with cervical disc arthroplasty returned to work in significantly fewer days than did patients treated with anterior cervical diskectomy fusion. [5] (10.5435/00124635-201010000-00006)
  • [Paper] Cervical disc arthroplasty offers potential advantages over anterior cervical discectomy and fusion regarding length of stay, cost, and routine discharge, but the motion-preserving design may introduce novel complications and failure modalities that are poorly understood. [6] (10.2106/jbjs.rvw.25.00208)
  • [L1] In patients with cervical radiculopathy, arthroplasty and fusion did not differ for disability, quality of life, or pain at 5 years. [7] (10.2106/jbjs.22.00305)
  • [L2] After cervical disc arthroplasty, patients receiving Workers' Compensation had outcomes that were similar to those of patients not receiving Workers' Compensation in terms of patient-reported outcomes, surgery-related complications, reoperations, and return-to-work status. [8] (10.2106/jbjs.o.00324)
  • [L1] For patients with one-level cervical degenerative disc disease, total disc replacement was found to have significantly fewer adjacent segment diseases and reoperations compared with ACDF. [9] (10.1007/s00402-014-2125-2)
  • [L3] Two-level disc arthroplasty may be an alternative for young patients depending on an evaluation of long-term results. [10] (10.1016/j.otsr.2016.06.018)
  • [Paper] Cervical disk arthroplasty (CDA) is a Food and Drug Administration (FDA)–approved motion-preserving alternative to anterior cervical diskectomy and fusion for 1-level and 2-level degenerative disk diseases, supported by high-level evidence and associated with reduced adjacent segment degeneration and comparable or improved clinical outcomes. [11] (10.2106/jbjs.rvw.26.00041)
  • [L3] Patients with prolonged preoperative symptom duration due to cervical disk herniation demonstrated notable improvements in physical function, disability, pain, and mental health regardless of fusion versus arthroplasty techniques. [12] (10.5435/jaaos-d-23-00655)
  • [L3] Smoking is associated with poor outcomes following hybrid surgery for multilevel cervical disc disease. [13] (10.1186/s12891-021-04501-4)
  • [L3] For selected patients with traumatic cervical disc herniation (no spinal cord injury, no fracture, and no instability), cervical arthroplasty yields similar improvement in clinical outcomes to ACDF and preserves segmental mobility. [14] (10.1186/s12891-015-0692-1)
  • [L4] Cervical disc arthroplasty with Prestige-LP Disc demonstrated a maintained and satisfactory clinical outcome at a minimum of 6-year follow-up, with the majority of the prostheses remaining mobile. [15] (10.1186/s12891-018-2201-9)
  • [L5] The PCM cervical disc replacement demonstrated a lower volumetric wear rate per million cycles than that reported for contemporary hip and knee arthroplasty designs in the simulator study, with components exhibiting functional durability that would suggest success in long-term in vivo use. [16] (10.2106/jbjs.j.00814)
  • [L2] A sufficiently long follow-up, which has not yet been reached, will be necessary to establish definitively an advantage for TDR, particularly in the cervical spine. [17] (10.1016/j.otsr.2013.06.018)
  • [Case_report] Conversion paralysis after cervical disc replacement is exceedingly rare; awareness of this complication allows for early diagnosis through detailed neurological evaluation and appropriate imaging. [19] (10.1016/j.otsr.2015.06.001)
  • [L3] Patients being considered for anterior cervical diskectomy and fusion who have substantial preoperative motor deficits may benefit from earlier surgical intervention. [20] (10.5435/jaaos-d-16-00606)
  • [L1] Disc replacement reduces the risk of adjacent segment disease. [21] (10.1302/0301-620x.100b8.bjj-2018-0120.r1)
  • [L1] This meta-analysis showed that cervical disc arthroplasty was superior over anterior discectomy and fusion for the treatment of symptomatic cervical disc disease in terms of overall success, NDI success, neurological success, implant/surgery-related serious adverse events, secondary procedure, functional outcomes, patient satisfaction and recommendation, and superior adjacent segment degeneration. [22] (10.1371/journal.pone.0149312)
  • [L3] Symptomatic adjacent-segment disease may affect more than one-fourth of all patients within ten years after an anterior cervical arthrodesis. [25] (10.2106/00004623-199904000-00009)
  • [L3] Patients with workers' compensation status undergoing cervical disc arthroplasty at an ambulatory surgical center may report inferior pain, function, and disability outcomes compared with those with private or government-provided insurance. [26] (10.5435/jaaos-d-22-00892)
  • [L4] [29] (10.2106/00004623-195840030-00009)
  • [L4] [30] (10.2106/00004623-196850020-00006)
  • [L2] In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively. [34] (10.1302/0301-620x.104b11.bjj-2022-0657.r2)
  • [L3] Satisfactory clinical outcomes were observed following CDA for the treatment of single-level cervical disc disease. [37] (10.1186/s13018-016-0440-8)
  • [L3] Single-level elective anterior cervical discectomy and fusion had low complication rates, with no additional risk seen with outpatient as compared with inpatient procedures. [38] (10.2106/jbjs.m.00767)
  • [L3] [42] (10.5435/jaaos-d-25-00728)
  • [L4] Over 3 years, revisions for 85 patients with cervical adjacent segment disease represented a notable economic expense greater than $2.0 million. [43] (10.5435/jaaosglobal-d-22-00058)
  • [L4] Anterior cervical hybrid construction appears to be an acceptable option in the management of multilevel cervical degenerative disc diseases and spondylotic spinal stenosis. [52] (10.1186/s13018-021-02393-7)
  • [L2] The aim of this study was to characterize the time course and impact of dysphagia following anterior cervical surgery for degenerative pathology with use of both subjective and objective measures. [53] (10.2106/jbjs.25.00847)
  • [L1] Some sagittal balance parameters may be associated with the development of ASD after anterior cervical surgery. [56] (10.1186/s12891-019-2800-0)
  • [L3] [62] (10.5435/jaaos-d-21-01276)
  • [L2] At 10-years, both 1- and 2-level CDA demonstrate sustained improvement of NDI, pain scores, range of motion and sagittal alignment compared to baseline. [63] (10.1016/j.spinee.2019.05.132)
  • [L1] Mobi-C arthroplasty is a safe and encouraging alternative to ACDF surgery particularly in patients with single level cervical disc degeneration who require surgery. [66] (10.1302/0301-620x.98b6.36381)
  • [L5] Arthroplasty-fusion is preferred for intervertebral disc degeneration in adjacent upper segments. [67] (10.1186/s13018-023-03537-7)
  • [L3] Increased signal intensity (ISI) of the spinal cord on T2WI and high degree of cranial adjacent disc degeneration are independent risk factors for poor neurological recovery after anterior cervical discectomy and fusion. [68] (10.1186/s13018-024-04886-7)
  • [L4] The Prestige LP disc arthroplasty maintains favorable clinical outcomes, preserves the overall cervical alignment, ROM of treated level and adjacent levels. [69] (10.1007/s00402-013-1689-6)
  • [L1] Although hybrid surgery maintained cervical kinetics, it failed to reduce the incidence of adjacent segment degeneration. [70] (10.1302/0301-620x.102b8.bjj-2019-1666.r1)
  • [L3] Patients with preoperative anxiety undergoing single-level anterior cervical diskectomy and fusion had significantly higher odds of 90-day adverse events, including severe and minor complications, as well as increased rates of emergency department visits and readmissions. [113] (10.5435/jaaosglobal-d-24-00204)
  • [L3] Three anterior cervical surgical approaches have good curative effects on single level cervical spondylotic myelopathy. [117] (10.1186/1471-2474-15-233)
  • [L2] The paper is a study protocol and does not report results or conclusions; it anticipates that the results will provide evidence to support physiotherapeutic rehabilitation applied after surgery for cervical radiculopathy due to cervical disc disease. [123] (10.1186/1471-2474-15-34)
  • [L2] Increased worker earnings resulting from disc herniation surgery may offset the increased direct medical costs associated with surgery. [134] (10.1007/s11999-013-3440-6)
  • [Case_report] [139] (10.1186/s12891-019-2783-x)
  • [L4] [141] (10.1186/s13018-024-04679-y)
  • [L3] [147] (10.2106/jbjs.rvw.24.00114)
  • [L5] [156] (10.5435/00124635-200403000-00006)
  • [L4] Steroids have been successfully used in anterior cervical discectomy and fusion (ACDF) to prevent dysphagia, in spinal cord injuries to improve neurological function, in acute back and neck pain for pain control, and in spinal metastasis. [162] (10.5435/jaaos-d-22-00971)
  • [L4] Increased ACDF case volume may lead to markedly decreased surgical time, blood loss, and length of postoperative stay as well as improved clinical outcomes in pain, disability, and physical function. [163] (10.5435/jaaos-d-21-01080)
  • [L2] Patients should be counseled preoperatively about the potential risk, and managed postoperatively to mitigate long-term impairments. [164] (10.1186/s13018-025-05464-1)
  • [L1] This systematic review and meta-analysis revealed no significant differences in the 6-week postoperative cervical range of motion, fusion rate, or neck disability index between the cervical collar group and the no cervical collar group. [166] (10.1186/s13018-024-04661-8)
  • [L3] Primary subaxial cervical spine arthrodeses had a probability of revision approaching 13% over a 16-year period, with elevated reoperation rates in patients undergoing anterior-only surgical procedures. [167] (10.2106/jbjs.15.00938)
  • [L5] Short-term results from randomized control trials clearly showed noninferiority of CDA compared with fusion. [168] (10.5435/jaaos-d-17-00231)
  • [L5] Multiple clinical trials and subsequent follow-up studies have failed to demonstrate a significant reduction of adjacent segment disease when artificial disk replacement is performed instead of fusion. [170] (10.5435/jaaos-21-01-3)
  • [L3] Furthermore, postoperative adjacent segment degeneration, implant subsidence, T1 slope, and C2–7 Cobb were associated with recurrence of postoperative cervical kyphosis. [171] (10.1186/s13018-020-01905-1)
  • [L3] This study highlights notable postoperative complications in patients with nontobacco nicotine dependence undergoing cervical spinal fusion. [174] (10.5435/jaaos-d-24-00801)
  • [L3] Revision surgical procedures place patients at higher risk for rapid responses and complications. [175] (10.2106/jbjs.21.01356)

See Also

References

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i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.