Cervical Disk Replacement
Michael Halperin, MD
As we are all aware, medicine has been rapidly
evolving over recent years. Developments have
been particularly rapid within medical and surgical
therapies. This article focuses on changes within
the realm of cervical disc surgery. Since the 1960s,
the most frequently performed surgical procedure
for cervical disc pathology has been the Anterior
Cervical Discectomy and Fusion (ACDF). This has
been a tried and true procedure that has brought
excellent clinical success, and has relieved pain and
neurologic symptoms predictably over the years.
However, despite still being by far the most commonly
performed neck operation, it is no longer the best
option for many patients.
Over the past decade, anterior cervical
discectomy and artificial disc replacement
(ACD/ADR) has been recognized as
being a better, more effective producer
for patients suffering from cervical
disc disease.
In both surgeries, the goal of treatment is to remove
pressure off the spinal cord or cervical spinal nerve
roots. Most commonly pressure results from herniated
discs, but also can also be caused by osteophytes or
from foraminal stenosis derived from degenerative
settling of the intravertebral segment. These conditions
can result in neck pain, radiating arm pain, paresthesia,
myelopathy, and in rare cases even paralysis. What
has not changed is that most of these conditions can
be successfully treated non-surgically. With the use of
anti-inflammatory medications, physical therapy, home
exercises, epidural steroid injections and chiropractic
care, most patients can be successfully relieved of their
symptoms without the need for surgery. But in those
cases where the patient’s condition is refractory to
conservative care, surgery becomes a viable option.
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Today, many cervical fusions are performed on an
outpatient basis. The procedure involves a small skin
incision in the anterior aspect of the neck, followed by
blunt dissection allowing for exposure of the vertebral
column. Retractors are placed and the pathological
cervical disc is removed in its entirety. This allows the
surgeon to visualize the dura and spinal cord, and
decompress the neuroforamen. Next, an interbody
spacer is selected and packed with either the patient’s
own bone, or a biological or synthetic bone substitute.
Whatever the origin, this bone is inserted into the disc
space, reestablishing the normal height and alignment
of the intervertebral segment. Final stabilization is
carried out with the use of plates and/or screws.
Postoperatively, depending on surgeon preference, the
patient may or may not be issued a brace or collar
to wear for a short period of time before resuming
motion.
With cervical disc arthroplasty the surgery is very
similar. In almost all cases surgery is performed on
an outpatient basis. The same patient positioning
in the operating room is utilized along with the
same surgical exposure to the spine. The disc and/
or osteophytes (or other offending structures) are
removed in the same exact manner as one would with
a fusion. The difference here is that instead of placing
a fusion device into the disc space, the surgeon inserts
the artificial disc replacement. This is a self-contained
device typically made up of several components
which allow for intra-segmental motion. No plates or
screws are necessary.
What are the advantage of artificial disc
replacement surgery versus fusion?
First, it allows for maintaining normal, or nearly
normal, motion of the cervical spine. With fusion
surgery motion is intentionally reduced.
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Second, it reduces the likelihood of accelerated adjacent segment disc degeneration. With fusion, the operated
segment no longer moves, therefore the adjacent segments have to compensate by moving a little bit more. This
can result in them wearing out or degenerating at an accelerated rate leading to new pain or neurologic symptoms
at the next level. This phenomenon of adjacent segment degeneration is believed to be less likely to occur with
artificial disc replacement by preserving motion at the operated segment. Such a conclusion has been drawn from
clinical studies comparing long-term follow-up of artificial disc replacement versus fusion in the cervical spine.

Third, unlike fusion surgery, cervical disc arthroplasty does not require a biologic process in order to heal. With
fusion, bone is required to grow from one segment to another. For example with a fusion at C5-6 the bone has to
grow from the C5 vertebra through the disc space and into C6. If there is incomplete growth across the disc space,
then a pseudarthrosis results which could necessitate a revision surgical procedure. Because artificial discs do not
require bone growing from one vertebra to the other, pseudarthrosis is a non-issue. As a result , and also due to
the fact that there is less of an issue with adjacent segment disc degeneration, reoperation rates are lower with disc
arthroplasty.

Finally, if for some reason a problem develops within the artificial disc implant it is revisable to either another
artificial disc replacement or to a fusion. With fusion surgery there is no going back. Once a segment is fused it will
always remain fused.

In summary, while artificial disc replacement is not indicated in every case, and although fusion still has its proper
place in cervical disc surgery, cervical arthroplasty offers the same relief of pain and neurologic symptoms as can
be achieved with fusion. But it has the distinct advantages of preserving motion, reducing the risk of accelerated
adjacent segment disease, eliminating any concerns of pseudarthrosis and having lower reoperation rates. g

Editor’s Note:
Dr. Halperin summarizes artificial cervical disc replacement Are there higher costs for the ACDR
(ACDR) with clarity, emphasizing its obvious benefits over procedure?
traditional disc space fusion. Several questions immediately ADR is slightly more expensive than fusion, but may be cheaper
come to mind. What are the limitations and unique risks? in the long run if one factors in that further surgical and non
Which patients are best suited for ACDR vs ACDF? Are there surgical treatments are less likely with ADR than with fusion.
higher costs for the ACDR procedure? Are the operating times
comparable? Are the artificial discs customized preoperatively or Are the artificial discs customized
are the discs molded and tailored at surgery? Is there long-term preoperatively or are the discs molded and
data regarding durability and complications? How many tailored at surgery?
patients have you treated with ACDR, and how many patients They are roughly the same.
have required revisions or subsequent fusion?
–Dennis E. Slater, MD Is there long-term data regarding durability
and complications?
Yes, data favors ADR over ACDF.
Reply to Editor’s Note:
What are the limitations and unique risks? How many patients have been treated
Limitations: Only FDA approved for up to two disc spaces. with ACDR, and how many patients have
Risks: The risks are similar to ACDF. required revisions or subsequent fusion?
I have done around 150 ADRs at Backus and at Constitution
Which patients are best suited for ACDR vs East Surgery Center. I have never revised or added on to any of
ACDF? Are there higher costs for the ACDR these cases.
procedure? - Michael Halperin, MD
ACD/ADR is ideal for patients with soft disc herniations or
with mild to moderate degenerative disc disease. ACDF is best
indicated for patients with instability or severe segment arthritis.

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