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Cervical disc replacement

80 citationsUpdated Oct 2026

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Overview

Cervical disc arthroplasty 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]. It serves as a surgical option for selected patients with traumatic cervical disc herniation who have no spinal cord injury, no fracture, and no instability [13]. For these indications, the procedure preserves segmental mobility [13] and provides clinical outcomes comparable with those of anterior cervical discectomy and fusion, with durable long-term motion preservation [22].

Meta-analyses of prospective randomized clinical trials indicate 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]. Specifically, total disc replacement results in significantly fewer adjacent segment diseases and reoperations compared with anterior cervical discectomy and fusion for one-level disease [9]. A meta-analysis of eight prospective randomized controlled trials further demonstrated 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 [20]. Disc replacement generally reduces the risk of adjacent segment disease [18].

While two studies reported that patients treated with cervical disc arthroplasty returned to work in significantly fewer days than those treated with anterior cervical diskectomy fusion [5], arthroplasty and fusion did not differ for disability, quality of life, or pain at 5 years in patients with cervical radiculopathy [7]. Cervical disc arthroplasty offers potential advantages over anterior cervical discectomy and fusion regarding length of stay, cost, and routine discharge [6]. However, the motion-preserving design may introduce novel complications and failure modalities that are poorly understood [6]. 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], and a sufficiently long follow-up, which has not yet been reached, will be necessary to establish definitively an advantage for total disc replacement, particularly in the cervical spine [14]. 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 [4]. Two-level disc arthroplasty may be an alternative for young patients depending on an evaluation of long-term results [10]. 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]. 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]. However, 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 [27].

Anatomy & Pathophysiology

Bony Anatomy

The spine comprises 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 or 5 fused coccygeal vertebrae [72]. The cervical spine assumes a lordotic curvature and consists of seven vertebrae [77]. Each vertebra features an anterior vertebral body and a posterior arch formed by the pedicle, facet, lamina, and spinous process [77]. The vertebral body is a cylindrical mass of bone connected by pedicles to the posterior arch [72]. It consists of an inner region of cancellous bone surrounded by a thin shell of cortical bone [77]. The vertebral bodies primarily bear weight and transfer forces to the pelvis and hips [72]. The posterior elements protect neural structures and function as a tension band [72]. The spinal canal is formed anteriorly by the vertebral body, posteriorly by the lamina, and laterally by the pedicles [72].

Cervical endplates exhibit a cup-in-saucer configuration, distinct from the flat endplates of the thoracic and lumbar vertebrae [89]. The posterior aspect of the transverse process guides cervical spinal nerves as they exit the spinal canal [89]. These nerves lie posterior to the vertebral artery within the transverse process, which forms a half-pipe configuration cradling the exiting nerve [89].

Intervertebral Disc Anatomy

The intervertebral disc (IVD) separates successive vertebral bodies, except between the atlas (C1) and axis (C2) [77]. It provides a unique combination of compressive stiffness and flexibility to support normal spine biomechanics [77]. The IVD comprises an inner nucleus pulposus (NP) and an outer anulus fibrosus (AF) [77]. The NP serves as an osmotic pump, attracting water to generate hydraulic pressure under significant loads [77]. The AF encapsulates the gelatinous NP, providing mechanical support to contain NP pressure and constrain intervertebral rotations [77]. The outer AF integrates with the vertebral rim via a fibrocartilage enthesis consisting of a thin layer of calcified cartilage, or "tidemark" [77].

The end plate is a bilayer of cartilage and bone separating the disk from adjacent vertebrae [77]. The cartilage end plate integrates with the inner AF to fully encapsulate the NP [77]. The end plate must be strong and thick to resist significant loads while remaining permeable to favor chemical transport and disk cellular vitality [77].

Biomechanics

Normal cervical alignment is approximately 15° of lordosis [76]. Spinal curvatures keep the head balanced over the pelvis and transmit axial forces to the pelvis [76]. Lordotic curvatures of the cervical and lumbar spine develop secondarily later in life to allow upright posture development [76]. The center of gravity runs from the odontoid process proximally through the sacral promontory caudally [76]. Changes in sagittal balance shifting the center of gravity too far ventrally can result in significant pain and disability [76].

The functional spinal unit consists of two vertebrae, the intervening disk, and the facet joints with their capsules [76]. This unit limits motion within the confines of protecting neural structures [76]. Vertebral bodies bear 70% to 90% of the static axial load of the spine [76]. Facet joints support 10% to 20% of axial load in standing, neutral alignment [76]. In extension, facet joints may bear up to 30% of the axial load [76]. In flexion, facet joints may be burdened with up to 50% of the anterior shear load [76].

The intervertebral disk absorbs axial loads by deforming the NP to redistribute axial forces radially [76]. Radial pressure from the NP is resisted by the tensile properties of alternating fiber bands within the AF [76]. Spinous and transverse processes act as lever arms, providing mechanical advantage for inserting muscles [76].

Vascular Anatomy

The cervical spine derives its circulation primarily from the vertebral arteries [81]. These arteries arise from the subclavian arteries and course superiorly [81]. They typically enter the transverse foramen at C6 and run proximally through the transverse foramina to C1 [81]. The vertebral arteries course posteriorly over the superior aspect of the C1 ring before turning proximally to enter the foramen magnum [81]. Segmental branches to each cervical vertebra arise from the vertebral artery and the deep cervical branch of the costocervical trunk [81].

There is significant variability in vertebral artery anatomy, with one side typically more dominant than the other [81]. The artery occasionally enters through the transverse foramen of C7 rather than C6 [81]. Anomalous courses, such as the vessel looping through a cervical vertebral body before returning to its longitudinal course, are not uncommon [81]. Care must be taken when planning cervical procedures such as corpectomy or instrumentation to evaluate the course of the vertebral artery [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 [100]. Disc degeneration does not always cause pain but can lead to internal disc derangement or disc herniation [100]. Approximately 80% of individuals are affected by nonspecific axial pain at some time in their lives [100]. The incidence of significant abnormalities shown by imaging studies in asymptomatic matched controls is 76% [100].

The 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 [100]. Specific gene loci associated with disc degeneration include the aggrecan gene, metalloproteinase-3 gene, collagen type IX, and alpha 2 and 3 gene forms [100]. Potential genetic factors for degenerative disk disease include those related to MMP-2 and collagen IX [97]. Potential genetic factors for ossification of the posterior longitudinal ligament include collagen VI and XI [97].

The degenerative process is divided into three stages: Dysfunction: Seen in individuals 15 to 45 years old, characterized by circumferential and radial tears in the disc anulus and localized synovitis of the facet joints [98]. Instability: Found in 35- to 70-year-old patients, characterized by internal disruption of the disc, progressive disc resorption, degeneration of the facet joints with capsular laxity, subluxation, and joint erosion [98]. Stabilization: Present in patients older than 60 years, characterized by progressive development of hypertrophic bone around the disc and facet joints leading to segmental stiffening or frank ankylosis [98].

Disc herniation is considered a complication of disc degeneration in the dysfunction and instability stages [98]. Spinal stenosis from degenerative arthritis is a complication of bony overgrowth compromising neural tissue in the late instability and early stabilization stages [98]. The natural history of degenerative disc disease involves recurrent episodes of pain followed by periods of symptomatic or complete relief [98].

Pathophysiologically, cervical myelopathy results from static compression, spinal malalignment leading to altered cord tension and vascular supply, and dynamic injury mechanisms [97]. The cascade of events after spinal cord compression includes ischemia, destruction of the blood–spinal cord barrier, demyelination, and neuronal apoptosis [97]. Congenital anomalies including spinal stenosis, Down syndrome, and Klippel–Feil syndrome may predispose to the development of cervical disk degeneration [97]. Cervical motion segment disorders are considered multifactorial, involving developmental size of the canal and foramina, pathological encroachment, biomechanical effects, and circulatory deficiencies [97]. Patients with cervical canal stenosis and cord compression secondary to spondylosis who present with clinical or electrophysiological evidence of cervical radicular dysfunction or central conduction deficits are at higher risk for developing myelopathy [97].

Adjacent Segment Pathophysiology

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]. Prevention of adjacent segment degeneration relies on the premise that mobile prostheses preserve motion [2]. Some sagittal balance parameters may be associated with the development of adjacent segment degeneration after anterior cervical surgery [58].

Noncontinuous cervical disc arthroplasty could preserve intradiscal pressure and facet joint forces at the adjacent and intermediate levels to maintain the kinematics of the cervical spine near preoperative values [102]. The intermediate segment does not experience additive range of motion or stress in the intervertebral disc or facet joints after skip-level arthroplasty, which has fewer biomechanical effects on the intermediate segment than does skip-level fusion [119]. The mobility and stability of rotational and translational joints are key factors for fusion rate and adjacent segment degeneration progression [116]. Multiple plates fixation has a positive effect on increasing stiffness and maintaining the range of motion of adjacent segments, indicating a lower risk of construct failure and adjacent segment degeneration [133]. Full endoscopic laminotomy decompression has less impact on cervical spine kinematics and adjacent segmental degeneration compared to traditional anterior cervical discectomy and fusion [130].

Classification

Proposed cTDR Bone Change Classification: A proposed system for radiographic bone changes after cervical total disc replacement (cTDR) subdivides the superior and inferior vertebral bodies into three equal sections to record observed bone loss [138]. The classification records endplate rounding, cystic erosion adjacent to the endplate, and cystic erosion not adjacent to the endplate [138]. It also documents whether bone loss is progressive based on serial radiographs and measures severity by the percentage of the end plate involved [138]. Additional relevant bony changes and device observations included in the system are radiolucent lines, heterotopic ossification, vertebral body olisthesis, loss of core implant height, device migration, and subsidence [138]. In a study assessing this system using serial radiographs from 19 patients (25 devices), overall agreement of assessments ranged from 49.9% to 94.7% [138]. Reasonable agreement was observed on the presence or absence of bone loss or radiolucencies, with a range of 58.4% to 94.7% [138].

Pfirrmann Classification: The Pfirrmann classification system is widely accepted for grading the severity of radiographic lumbar disk degeneration [43]. It has been evaluated in the context of cervical spine disk degeneration [43]. Prior research has demonstrated excellent interrater and intrarater reliability for Pfirrmann grading when evaluating cervical disks [43]. Research has indicated that Pfirrmann grading correlates with legacy measures of disk health such as total end plate score and Modic changes [43]. 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 degeneration [43].

Radiographic Adjacent Segment Disease (RASD) Grading: A grading system for radiographic adjacent segment disease (RASD) after anterior cervical discectomy and fusion comprises four levels, where grade 0 represents normal discs and grade III represents severely degenerated discs [140]. A diagnosis of RASD is established if the MRI grading of cervical intervertebral disc degeneration exceeds level 0 [140].

Kellgren Classification: Disc degeneration on X-ray can be rated from grade 0 to 4 using the Kellgren classification system [63]. Adjacent segment degeneration (ASD) is defined as a Kellgren grade ≥ 2 [63].

Clinical Presentation

Patients presenting with cervical radiculopathy demonstrate notable improvements in physical function, disability, pain, and mental health following surgical intervention, regardless of whether fusion or arthroplasty techniques are employed [12]. The clinical presentation often involves shoulder, neck, occipital, and arm pain arising from a level with abnormal mechanics due to a degenerated intervertebral disc [31]. These abnormal mechanics can exist even before roentgenograms show significant intervertebral-space narrowing or remarkable spur formation [31]. Localizing signs may not be clear on physical examination in patients with discogenic disease and abnormal cervical spine mechanics [31].

Symptom characteristics significantly influence surgical prognosis. Patients with radicular symptoms had a higher rate of improvement than those whose symptoms were non-radicular [32]. A positive correlation was found between satisfactory results and either motor or sensory deficits in patients undergoing cervical discectomy and interbody fusion [32]. This correlation was greater when both motor and sensory findings were present [32]. Conversely, occipital headaches and non-radicular symptoms as the predominant complaints tended to reduce the likelihood of a desirable result from cervical discectomy and interbody fusion [32]. Patients with correlating symptoms and signs of root compression had better results from surgery than those whose treatment resulted in bone fusion [32].

Diagnostic imaging findings do not always correlate with clinical severity. In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery did not correlate with the severity of symptoms at presentation [35]. Similarly, MRI findings did not correlate with clinical outcomes at two years postoperatively [35]. Patients with apparently normal cervical spines on roentgenograms tended to have less desirable results from cervical discectomy and interbody fusion than those with osteophyte formation or narrowing of the interspace or both [32]. The value of discography and myelography was not clearly defined by long-term evaluation of cervical discectomy and interbody fusion patients [32]. Consequently, discography and myelography are of secondary importance to the clinical evaluation in cervical discectomy and interbody fusion [32].

Discography remains a specific diagnostic tool for confirming discogenic pain. A discogram at the involved level should give a roentgenographic pattern typical of disc degeneration and reproduce the pain which forms the chief complaint [31]. Contrast medium flows with little resistance into a degenerated disc whereas into a normal disc only a small amount can be inserted and that only under great pressure [31]. The discogram of a degenerated disc shows an irregular extension of the 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 [31]. In the lateral view, contrast medium usually proceeds out of the disc space up and down under the uncovertebral joints in a degenerated disc [31]. Pain arising during discography may occasionally be so diffuse that the patient will have difficulty associating it with the pain which he originally had [31].

Demographic and systemic factors also impact clinical presentation and outcomes. Men tended to have much better results from cervical discectomy than did women [32]. The factors responsible for cervical disc degeneration differed between men and women [117]. Smoking is associated with poor outcomes following hybrid surgery for multilevel cervical disc disease [19]. Signs of early disc degeneration related to tumor treatment can be seen in the intervertebral discs of survivors [37].

Post-operative Clinical Considerations

Post-operative clinical monitoring includes assessment for specific complications. Although 35.8% of patients in the cervical group reported symptoms of dysphagia at 30 days postoperatively, none demonstrated functional limitations [57]. Conversion paralysis after cervical disc replacement is exceedingly rare [16]. Awareness of conversion paralysis allows for early diagnosis through detailed neurological evaluation and appropriate imaging [16].

Clinical outcomes following cervical disc arthroplasty are comparable to anterior cervical discectomy and fusion for 1-level and 2-level cervical degenerative disc disease [22]. Satisfactory clinical outcomes were observed following cervical disc arthroplasty for the treatment of single-level cervical disc disease [38]. Cervical disc arthroplasty with Prestige-LP Disc demonstrated a maintained and satisfactory clinical outcome at a minimum of 6-year follow-up [21]. The majority of Prestige-LP Disc prostheses remained mobile at a minimum of 6-year follow-up [21]. In patients with cervical radiculopathy, arthroplasty and fusion did not differ for disability at 5 years [7]. In patients with cervical radiculopathy, arthroplasty and fusion did not differ for quality of life at 5 years [7]. In patients with cervical radiculopathy, arthroplasty and fusion did not differ for pain at 5 years [7].

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 [13]. Cervical arthroplasty for selected patients with traumatic cervical disc herniation preserves segmental mobility [13]. Patients with substantial preoperative motor deficits being considered for anterior cervical diskectomy and fusion may benefit from earlier surgical intervention [17].

Cervical disc arthroplasty provides durable long-term motion preservation for 1-level and 2-level cervical degenerative disc disease [22]. Cervical disc arthroplasty is associated with reduced adjacent segment degeneration compared to anterior cervical diskectomy and fusion [11]. Cervical disc arthroplasty is associated with comparable or improved clinical outcomes compared to anterior cervical diskectomy and fusion [11]. For patients with one-level cervical degenerative disc disease, total disc replacement was found to have significantly fewer adjacent segment diseases compared with anterior cervical discectomy and fusion [9]. For patients with one-level cervical degenerative disc disease, total disc replacement was found to have significantly fewer reoperations compared with anterior cervical discectomy and fusion [9].

A 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 [20]. A 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 Neck Disability Index success [20]. A 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 neurological success [20]. A 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 implant/surgery-related serious adverse events [20]. A 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 secondary procedure [20]. A 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 functional outcomes [20]. A 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 patient satisfaction and recommendation [20]. A 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 adjacent segment degeneration [20].

Cervical disc arthroplasty offers potential advantages over anterior cervical discectomy and fusion regarding length of stay [6]. Cervical disc arthroplasty offers potential advantages over anterior cervical discectomy and fusion regarding cost [6]. Cervical disc arthroplasty offers potential advantages over anterior cervical discectomy and fusion regarding routine discharge [6].

Insurance status may influence reported outcomes. After cervical disc arthroplasty, patients receiving Workers' Compensation had outcomes similar to those of patients not receiving Workers' Compensation in terms of patient-reported outcomes [8]. After cervical disc arthroplasty, patients receiving Workers' Compensation had outcomes similar to those of patients not receiving Workers' Compensation in terms of surgery-related complications [8]. After cervical disc arthroplasty, patients receiving Workers' Compensation had outcomes similar to those of patients not receiving Workers' Compensation in terms of reoperations [8]. After cervical disc arthroplasty, patients receiving Workers' Compensation had outcomes similar to those of patients not receiving Workers' Compensation in terms of return-to-work status [8]. However, patients with workers' compensation status undergoing cervical disc arthroplasty at an ambulatory surgical center may report inferior pain outcomes compared with those with private or government-provided insurance [27]. Patients with workers' compensation status undergoing cervical disc arthroplasty at an ambulatory surgical center may report inferior function outcomes compared with those with private or government-provided insurance [27]. Patients with workers' compensation status undergoing cervical disc arthroplasty at an ambulatory surgical center may report inferior disability outcomes compared with those with private or government-provided insurance [27].

Investigations

MRI: Magnetic resonance imaging is the standard for advanced spinal imaging and offers superior soft-tissue contrast and resolution compared to CT [91]. It provides detailed evaluation of intervertebral discs, nerve roots, the posterior longitudinal ligament, and the intervertebral foramen [91]. MRI is particularly effective for assessing the spinal cord, where edema appears as hyperintensity on T2-weighted images [91]. It is superior to CT in most circumstances for identifying degenerative disc changes [92]. Diffusion tensor imaging has demonstrated spinal cord impairment in early-stage cervical spondylosis before such changes are visible on plain MRI scans [95].

CT: Computed tomography has largely replaced plain radiographs as the initial screening study for cervical spine fractures due to its high sensitivity and specificity [93]. CT provides additional three-dimensional detail, which is useful for differentiating compression fractures from burst fractures and identifying features such as facet widening [93]. The primary disadvantage of CT compared to MRI is its inferior visualization of soft tissues [93].

Other Considerations: MRI evidence of disc degeneration is present in 25% of patients younger than 40 years and 60% of patients aged 60 years and older [92]. Findings must be carefully correlated with the clinical impression, as anatomical abnormalities may be asymptomatic [92]. Meaningful clinical information is obtained by posing specific questions derived from history and physical examination regarding neural compression, instability, and deformity [92].

In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither with the severity of symptoms at presentation nor with clinical outcomes at two years postoperatively [35]. Increased signal intensity of the spinal cord on T2-weighted images and a high degree of cranial adjacent disc degeneration are independent risk factors for poor neurological recovery after anterior cervical discectomy and fusion [69]. Patients considered for anterior cervical diskectomy and fusion who have substantial preoperative motor deficits may benefit from earlier surgical intervention [17].

The Pfirrmann classification system is widely accepted for grading the severity of radiographic lumbar disk degeneration and has been evaluated in the context of cervical spine disk degeneration [43]. Preoperative Pfirrmann grading at adjacent levels to the index fusion correlates with the development of adjacent segment disease in the lumbar spine [43]. The Modic-endplate-complex phenotype adds valuable data to the prognostic assessment of degenerative cervical spine patients [40].

Postoperative Imaging: A significant progression of degenerative changes can be observed on radiographs after anterior cervical discectomy and titanium cage fusion without clinical consequences for the patients [66]. Approximately one-quarter of patients developed significant intervertebral disc height loss after posterior cervical surgery for ossification of the posterior longitudinal ligament [42]. Radiological exploration of adjacent segments after total cervical disc replacement with Prodisc-C prosthesis has been documented [29]. Cervical disc arthroplasty with Prestige-LP Disc demonstrated maintained and satisfactory clinical outcomes at a minimum of 6-year follow-up, with the majority of prostheses remaining mobile [21]. The Prestige LP disc arthroplasty maintains favorable clinical outcomes and preserves the overall cervical alignment, range of motion of the treated level, and range of motion of adjacent levels [70].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as physical therapy, NSAIDs, or injections. However, patients with prolonged preoperative symptom duration due to cervical disk herniation demonstrated notable improvements in physical function, disability, pain, and mental health regardless of whether fusion or arthroplasty techniques were used [12].

Operative

Indications: Cervical arthroplasty is indicated for selected patients with traumatic cervical disc herniation who have no spinal cord injury, no fracture, and no instability [13]. It is also appropriate for patients with one-level or two-level cervical degenerative disc disease (DDD) [22].

Surgical Approach / Technique: The primary objective of the surgical protocol is to determine whether cervical disc arthroplasty restores or preserves physiological cervical spine motion compared to simple discectomy, as the prevention of adjacent segment degeneration relies on the premise that mobile prostheses preserve motion [2]. For intervertebral disc degeneration in adjacent upper segments, arthroplasty-fusion is preferred according to finite element analysis of hybrid constructions [68].

Implant Selection: The Prestige-LP Disc has demonstrated maintained and satisfactory clinical outcomes at a minimum of 6-year follow-up, with the majority of prostheses remaining mobile [21]. The PCM cervical disc replacement exhibited a lower volumetric wear rate per million cycles than contemporary hip and knee arthroplasty designs in simulator studies, suggesting functional durability for long-term in vivo use [23].

Comparative Outcomes vs. Fusion: For patients with one-level cervical degenerative disc disease, total disc replacement results in significantly fewer adjacent segment diseases and reoperations compared with anterior cervical discectomy and fusion (ACDF) [9]. A systematic review and meta-analysis of eight prospective randomized controlled trials indicates that cervical disc arthroplasty is superior to anterior discectomy and fusion regarding overall success, NDI success, neurological success, implant/surgery-related serious adverse events, secondary procedures, functional outcomes, patient satisfaction, and adjacent segment degeneration [20]. Clinical outcomes are comparable between cervical disc arthroplasty and ACDF for one-level and two-level DDD, with durable long-term motion preservation [22]. For selected patients with traumatic cervical disc herniation without spinal cord injury, fracture, or instability, cervical arthroplasty yields similar clinical improvement to ACDF while preserving segmental mobility [13].

Long-Term Efficacy and Durability: Satisfactory clinical outcomes have been observed following cervical disc arthroplasty for single-level cervical disc disease in minimum 5-year follow-up studies [38]. However, a sufficiently long follow-up, which has not yet been reached, is necessary to definitively establish an advantage for total disc replacement, particularly in the cervical spine [14].

Complications and Safety: Conversion paralysis after cervical disc replacement is exceedingly rare; awareness of this complication allows for early diagnosis through detailed neurological evaluation and appropriate imaging [16]. Single-level elective anterior cervical discectomy and fusion carries low complication rates, with no additional risk observed in outpatient compared to inpatient procedures [39].

Setting of Care: Outpatient cervical spine surgery is a safe and convenient alternative that decreases the cost of care, owing to short operative time and moderate postoperative pain [143].

Other Considerations: Some sagittal balance parameters may be associated with the development of adjacent segment disease after anterior cervical surgery [58]. 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 [159]. Steroids have been successfully used in ACDF to prevent dysphagia [158].

Complications

Adjacent Segment Disease

Adjacent segment disease: The evidence regarding the impact of cervical disc replacement on adjacent segment disease is mixed. For patients with one-level cervical degenerative disc disease, total disc replacement has been associated with significantly fewer adjacent segment diseases and reoperations compared with anterior cervical discectomy and fusion (ACDF) [9]. A meta-analysis of eight prospective randomized controlled trials similarly found that cervical disc arthroplasty was superior to anterior discectomy and fusion regarding superior adjacent segment degeneration [20]. Conversely, 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 [71].

Adjacent segment morbidity: Symptomatic adjacent-segment disease may affect more than one-fourth of all patients within ten years after an anterior cervical arthrodesis [25]. The economic burden of this complication is substantial; over 3 years, revisions for 85 patients with cervical adjacent segment disease represented a notable economic expense greater than $2.0 million [44].

Operative and Perioperative Complications

Adverse events: A meta-analysis revealed that cervical disc arthroplasty demonstrated a lower rate of adverse events compared with ACDF [106]. Furthermore, a meta-analysis of eight prospective randomized controlled trials showed that cervical disc arthroplasty was superior over anterior discectomy and fusion in terms of implant/surgery-related serious adverse events [20].

Surgical metrics: In a level-specific comparison at C5-C6, the cervical disc replacement cohort reported 24.4 mL of blood loss compared to 43.6 mL in the ACDF cohort [64]. The cervical disc replacement cohort also demonstrated markedly reduced surgical times compared to the ACDF cohort [64]. An increase in surgical time of just 1 minute is associated with a 1% increase in complications, extending up to a 21% increase for every additional hour in the operating room [64].

Patient-specific risk factors: Revision surgical procedures place patients at higher risk for rapid responses and complications [170]. 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 [108]. Nontobacco nicotine dependence is associated with notable postoperative complications in patients undergoing cervical spinal fusion [169].

Implant-Specific and Long-Term Complications

Implant longevity and wear: Cervical disc arthroplasty with the 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 [21]. 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 [23].

Infection: Deep cervical infection should be considered if a patient has a history of ACDF even in the absence of esophageal perforation [136]. 0.1–1.6% of early and late postoperative infection have been reported following anterior cervical discectomy and fusion [136].

Long-term revision: 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 [163].

Functional and Quality of Life Outcomes

Clinical outcomes: 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 [13]. Short-term results from randomized control trials clearly showed noninferiority of cervical disc arthroplasty compared with fusion [165]. Although ACDF may increase the risk of additional surgery, clinical outcomes indicated that both Mobi-C artificial cervical disc replacement and ACDF were reliable [171].

Postoperative Management and Rehabilitation

Cervical collar use: 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 [162]. 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 [142]. Regarding anterior and posterior fusion procedures, cervical collar use demonstrated improved short-term patient-reported outcomes and pain control [142].

Voice complications: 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 [160].

Recovery

Functional milestones: Patients treated with cervical disc arthroplasty returned to work in significantly fewer days than patients treated with anterior cervical diskectomy fusion [5]. Cervical disc arthroplasty demonstrated superiority over anterior discectomy and fusion regarding functional outcomes, patient satisfaction, and recommendation rates [20]. At a minimum 5-year follow-up, satisfactory clinical outcomes were observed for single-level cervical disc disease [38]. The Prestige LP disc arthroplasty maintains favorable clinical outcomes and preserves overall cervical alignment, as well as the range of motion of the treated and adjacent levels [70]. At 10-years, both 1- and 2-level cervical disc arthroplasty demonstrate sustained improvement of Neck Disability Index (NDI), pain scores, range of motion, and sagittal alignment compared to baseline [65].

Other Considerations: 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 ACDF cohort [64]. Specifically, estimated blood loss was 24.4 mL in the cervical disc replacement cohort versus 43.6 mL in the ACDF cohort [64]. The ACDF procedure incurred an almost 10-minute increased surgical time relative to cervical disc replacement [64]. This time difference translates to an approximate 4% increase in the risk of complications, given that increases in surgical time of just 1 minute lead to a 1% increase in complications, extending up to a 21% increase for every additional hour in the operating room [64]. Although hybrid surgery maintained cervical kinetics, it failed to reduce the incidence of adjacent segment degeneration [164].

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] 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. [13] (10.1186/s12891-015-0692-1)
• [L5] 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. [14] (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. [16] (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. [17] (10.5435/jaaos-d-16-00606)
• [L1] Disc replacement reduces the risk of adjacent segment disease. [18] (10.1302/0301-620x.100b8.bjj-2018-0120.r1)
• [L3] Smoking is associated with poor outcomes following hybrid surgery for multilevel cervical disc disease. [19] (10.1186/s12891-021-04501-4)
• [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. [20] (10.1371/journal.pone.0149312)
• [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. [21] (10.1186/s12891-018-2201-9)
• [L1] Cervical disc arthroplasty (CDA) provides clinical outcomes comparable with those of anterior cervical discectomy and fusion (ACDF) for 1-level and 2-level cervical degenerative disc disease (DDD), with durable long-term motion preservation. [22] (10.2106/jbjs.26.00323)
• [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. [23] (10.2106/jbjs.j.00814)
• [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. [27] (10.5435/jaaos-d-22-00892)
• [L4] The study provides radiological exploration on adjacent segments after total cervical disc replacement with Prodisc-C prosthesis. [29] (10.1186/s13018-019-1249-z)
• [L4] [31] (10.2106/00004623-195840030-00009)
• [L4] [32] (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. [35] (10.1302/0301-620x.104b11.bjj-2022-0657.r2)
• [L3] Signs of early disc degeneration related to tumor treatment can be seen in the intervertebral discs of survivors. [37] (10.1186/s12891-023-06509-4)
• [L3] Satisfactory clinical outcomes were observed following CDA for the treatment of single-level cervical disc disease. [38] (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. [39] (10.2106/jbjs.m.00767)
• [L3] These findings add valuable data to the prognostic assessment of degenerative cervical spine patients. [40] (10.1002/jor.25042)
• [L3] Approximately one-quarter of patients developed significant intervertebral disc height loss after posterior cervical surgery for OPLL. [42] (10.1186/s13018-025-06410-x)
• [L3] [43] (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. [44] (10.5435/jaaosglobal-d-22-00058)
• [L2] Although 35.8% of patients in the cervical group reported symptoms of dysphagia at 30 days postoperatively, none demonstrated functional limitations. [57] (10.2106/jbjs.25.00847)
• [L1] Some sagittal balance parameters may be associated with the development of ASD after anterior cervical surgery. [58] (10.1186/s12891-019-2800-0)
• [L3] [63] (10.1007/s00402-018-2929-6)
• [L3] [64] (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. [65] (10.1016/j.spinee.2019.05.132)
• [L2] A significant progression of degenerative changes can be observed on radiographs without clinical consequences for the patients. [66] (10.1055/s-0029-1220940)
• [L5] Arthroplasty-fusion is preferred for intervertebral disc degeneration in adjacent upper segments. [68] (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. [69] (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. [70] (10.1007/s00402-013-1689-6)
• [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. [71] (10.5435/jaaos-21-01-3)
• [L5] Noncontinuous CDA could preserve IDP and facet joint forces at the adjacent and intermediate levels to maintain the kinematics of cervical spine near preoperative values. [102] (10.1186/s13018-020-1549-3)
• [L1] The meta-analysis revealed that CDA demonstrated superiorities in better neurological success, greater motion preservation at the operated level, lower rate of adverse events and fewer secondary surgical procedures compared with ACDF. [106] (10.1007/s00402-014-2122-5)
• [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. [108] (10.5435/jaaosglobal-d-24-00204)
• [L5] The mobility and stability of rotational and translational joints are key factors for fusion rate and adjacent segment degeneration progression. [116] (10.1186/s13018-024-04629-8)
• [L4] The factors responsible for cervical disc degeneration differed between men and women. [117] (10.1186/s12891-018-2055-1)
• [L5] The intermediate segment does not experience additive range of motion or stress in the intervertebral disc or facet joints after skip-level arthroplasty, which has fewer biomechanical effects on the intermediate segment than does skip-level fusion. [119] (10.1186/s12891-019-2425-3)
• [L3] Full endoscopic laminotomy decompression is demonstrated to be an efficacious alternative technique to traditional ACDF for the treatment of single-segment CSS, with the advantages of less trauma, faster recovery, and less impact on cervical spine kinematics and adjacent segmental degeneration. [130] (10.1186/s13018-024-04710-2)
• [L5] Multiple plates fixation has a positive effect on increasing stiffness and maintaining the ROM of adjacent segments, indicating lower risk of construct failure and adjacent segment degeneration. [133] (10.1186/s12891-022-05796-7)
• [Case_report] [136] (10.1186/s12891-019-2783-x)
• [L4] [138] (10.1186/s13018-024-04679-y)
• [L3] [140] (10.1186/s12891-025-08285-9)
• [L3] [142] (10.2106/jbjs.rvw.24.00114)
• [L1] Because of short operative time and moderate postoperative pain, outpatient cervical spine surgery is a safe and convenient alternative procedure, which also decrease the cost of care. [143] (10.1186/s40001-016-0229-6)
• [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. [158] (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. [159] (10.5435/jaaos-d-21-01080)
• [L2] Patients should be counseled preoperatively about the potential risk, and managed postoperatively to mitigate long-term impairments. [160] (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. [162] (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. [163] (10.2106/jbjs.15.00938)
• [L1] Although hybrid surgery maintained cervical kinetics, it failed to reduce the incidence of adjacent segment degeneration. [164] (10.1302/0301-620x.102b8.bjj-2019-1666.r1)
• [L5] Short-term results from randomized control trials clearly showed noninferiority of CDA compared with fusion. [165] (10.5435/jaaos-d-17-00231)
• [L3] This study highlights notable postoperative complications in patients with nontobacco nicotine dependence undergoing cervical spinal fusion. [169] (10.5435/jaaos-d-24-00801)
• [L3] Revision surgical procedures place patients at higher risk for rapid responses and complications. [170] (10.2106/jbjs.21.01356)
• [L1] Although ACDF may increase the risk of additional surgery, clinical outcomes indicated that both Mobi-C artificial cervical disc replacement and ACDF were reliable. [171] (10.1007/s00264-014-2497-5)

See Also

• Anterior cervical discectomy and fusion
• Cervical radiculopathy
• Cervical myelopathy

References

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