MILITARY MEDICINE, 182, 3/4:e1790, 2017

Outcomes Following Multilevel Cervical Disc Arthroplasty

in the Young Active Population
CPT Nicholas J. Zarkadis, MC USA*; CPT Andrew W. Cleveland, MC USA*;
CPT Nicholas A. Kusnezov, MC USA*; CPT John C. Dunn, MC USA*;
COL Pedro M. Caram, MC USAR (Ret.)†; LTC Joshua P. Herzog, MC USA*

ABSTRACT Background: Cervical radiculopathy is a common disorder that portends significant morbidity.
The presence of radiculopathy can have a debilitating effect on patients as well as a significant economic impact.
Active duty military patients with increased physical occupational demands can be significantly impacted by cervical
disease. The resulting disability can have a strong negative impact on operational readiness. Several studies have dem-
onstrated comparably good functional outcomes between cervical disc arthroplasty (CDA) and anterior cervical
discectomy and fusion for single-level disease. To date, no study has specifically evaluated the functional and occupa-
tional outcomes following adjacent 2-level CDA in a young, active patient population as represented by the active duty
military population. Purpose: To evaluate functional and occupational outcomes following adjacent 2-level CDA for
cervical radiculopathy in the U.S. military population. We hypothesized that this population would have excellent
symptomatic relief at the cost of a low return to duty rate. Methods: We performed a case series with prospective
follow-up of all patients who underwent adjacent two-level CDA at a single institution from 2011 to 2014. Each
patient completed the Neck Disability Index questionnaire to assess functional outcome. Primary outcomes of interest
were return to active military duty and complications. Results: Follow-up was available for 18 of 21 (85.7%) patients.
At an average follow-up of 21.4 ± 11.1 months, 12 patients (66.7%) reported complete symptomatic relief and were able
to return to preoperative levels of function. Average self-reported pain score improved from 8.3 preoperatively to 1.1 post-
operatively, and average postoperative Neck Disability Index score was 15.5 compared to 37.0 for those who medically
retired. Radiographic analysis did not show any evidence of subsidence, migration of hardware, or heterotopic ossifica-
tion. The average return to duty time was 9.6 weeks. Discussion: We demonstrate that adjacent two-level CDA is
capable of providing predictable symptomatic relief and maintenance of a high-demand preoperative level of function
for cervical radiculopathy among a population of young and highly active individuals. Adjacent two-level CDA offers
significant relief of symptoms with low risk of complication in a young, active, and high-demand cohort such as the
U.S. military. Adjacent two-level CDA can be performed with the expectation of improving function, relieving symp-
toms, returning to preoperative levels of activity, and maintaining operational readiness.

BACKGROUND disability can furthermore have a strong negative impact on

Cervical radiculopathy is a common disorder that portends
significant morbidity. The presence of radiculopathy can
have a debilitating effect on patients as well as a significant
economic impact.1,2 Cervical radiculopathy may present with
a myriad of symptoms, including localized neck pain, pain
radiating along a dermatomal distribution, paresthesia, motor
weakness, and diminished reflexes.3 Radiographic signs
include disc herniation, foraminal stenosis, instability, and
spondylosis. These findings are common with increasing age,
but not necessarily correlated with symptomatic disease.4,5
Risk factors for cervical radiculopathy in the active mili-
tary population have been elucidated and include age, female
sex, white race, and senior military positions.6 Active duty mili-
tary patients with increased physical occupational demands can
be significantly impacted by cervical disease.6 The resulting
*Department of Orthopaedics Surgery and Rehabilitation, William
Beaumont Army Medical Center, 5005 North Piedras, El Paso, TX 79920.
†Department of Neurosurgery, William Beaumont Army Medical
Center, 5005 North Piedras, El Paso, TX 79920.
This manuscript was presented as a poster at the Society of Military
Orthopaedic Surgeons 57th Annual Meeting in St. Petersburg, FL, on
December 7–11, 2015.
doi: 10.7205/MILMED-D-16-00085
operational readiness, especially at the individual unit level.
Several studies have demonstrated comparably good func-
tional outcomes between cervical disc arthroplasty (CDA) and
anterior cervical discectomy and fusion (ACDF) for single-
level disease since its approval by the Food and Drug Admin-
istration in 2007.7–14 CDA has also previously been described
for use in multilevel disease,7,15–22 with improved clinical out-
comes at short-term follow-up compared to ACDF.15,17,18
Although outcomes of single-level and multilevel CDA have
been reported in both civilian and military population,7–9,11–24
no study has specifically evaluated the functional and occupa-
tional outcomes following adjacent two-level CDA in a young,
active patient population as represented by the active duty
military population.
The purpose of this study was to evaluate functional and
occupational outcomes following adjacent two-level CDA
for cervical radiculopathy in the U.S. military population.
We hypothesized that this population would have excellent
symptomatic relief at the cost of a low return to duty (RTD) rate.
METHODS
Following institutional review board approval, the authors
conducted a case series with prospective follow-up of all

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 Outcomes Following Multilevel CDA in the Young Active Population
FIGURE 1. Postoperative anteroposterior and lateral cervical spine radiograph of an adjacent-level C5/C6 and C6/C7 cervical disc arthroplasty.
active duty military patients who have undergone adjacent
2-level CDA at our institution between May 2011 and July
2014 (Fig. 1). Surgical logs of the two primary surgeons
who performed adjacent two-level CDA procedures during
this period were reviewed. All arthroplasty procedures were
performed using either the ProDisc-C (DePuySynthes, West
Chester, Pennsylvania ) or the Mobi-C (LDR, Austin, Texas),
with the exception of 1 patient who received the Secure-C
(Globus Medical, Audubon, Pennsylvania).
The general indications for adjacent-level CDA included
the following: (1) clinical examination and history consis-
tent with cervical radiculopathy, (2) age <50 years old,
(3) evidence of cervical spondylosis on diagnostic imag-
ing, (4) absence of facet arthropathy, (5) nonexistence of
posterior instability, and (6) preservation of cervical lordosis.
Patients who underwent adjacent two-level CDA procedure,
were active duty and older than 18 years at time of surgery,
were reachable by phone for follow-up, and were a mini-
mum of 12 months from surgery at the time of follow-up
were included in this study. Once a patient list was gener-
ated, demographic data (age at time of surgery, rank at time
of surgery, race, tobacco use, body mass index, and level of
disease) and patient-centered variables (preoperative symp-
toms, level of discomfort, postoperative symptoms) were
extracted from the electronic medical record. Respective
contact information was obtained and all patients were then
interviewed via standardized telephone survey (Table I).
All patients were read a disclosure of risks associated with
release of their medical information and consent for par-
ticipation in the survey was obtained. Each patient com-
pleted the Neck Disability Index (NDI) questionnaire as a
metric of functional outcome, which is a validated mea-
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sure of neck pain and disability associated activities of
daily living.25
Occupational outcome was determined by an individual’s
ability to (1) maintain their preoperative military occupa-
tional specialty (MOS), classified according to the individ-
ual role in the army force structure,26 and (2) remain active
within the military. All U.S. military active duty personnel
are strictly required to adhere to regularly evaluated fitness
standards. Routine rigorous physical training is required in
the form of organized aerobic exercise, weight training,
and the performance of a multitude of core military tasks,
including the ability to march at least 2 miles while carry-
ing at least 40 pounds of military gear. Physical fitness
is formally evaluated semiannually with timed runs as
TABLE I. Telephone Survey
1. What Were Your Primary Symptoms Before Surgery?
2. What Was Your Preoperative Pain Score on a Scale of 0
(None) to 10 (Worst Pain I Ever Had)?
3. What Was Your Postoperative Pain Score on a Scale of 0
(None) to 10 (Worst Pain I Ever Had)?
4. Did the Surgery Provide You With Relief of Those Symptoms?
5. How Long Until You Were Back to Full Active Duty After
the Surgery (Quantified in Months)?
6. What Was Your MOS Before Surgery?
7. What Was Your MOS After Surgery?
8. Were You on Flight Status Before Surgery?
a. If Yes, Were You Able to Stay on Flight Status?
9. Were You on Airborne Status Before Surgery?
a. If Yes, Were You Able to Stay on Airborne Status?
10. Have You Deployed Since the Surgery?
11. Were There Any Adverse Outcomes Associated
With the Surgery?
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 Outcomes Following Multilevel CDA in the Young Active Population

well as maintenance of height and weight standards. RESULTS

If an active duty individual is deemed unable to maintain The average age of patients was 40.0 ± 5.8 years, and the
these requirements, a medical separation from service may majority of patients were men (83.3%) (Table II). Senior
be initiated. noncommissioned officer was the most common rank (61%).
Descriptive statistics including means and standard devia- The most common location of 2-level disease addressed was
tions (SDs) were calculated for continuous variables, and C5-6/C6-7 (83%), followed by the remainder of patients
counts and frequencies were obtained for categorical vari- with disease at C4-5/C5-6 (17%). The Mobi-C (LDR) cervi-
ables. A 2-tailed t test was performed for analysis of patient- cal arthroplasty system was predominantly used (72.2%).
reported outcomes. Given the limited sample size and Follow-up was available for 18 of the 21 (85.7%)
noncomparative nature of the study, further statistical analy- patients. At an average follow-up of 21.4 ± 11.1 (12.9–51.9)
sis was not performed. months, 12 patients (66.7%) reported complete symptomatic
relief and were able to return to preoperative levels of
function (MOS) and RTD, whereas 6 underwent medical
Surgical Technique retirement and subsequent separation from military service
The patient is positioned supine on the operating table. After for persistent disability. The average time to RTD was
induction of anesthesia, direct fluoroscopy is used to localize 9.1 weeks with the majority of patients returning to duty by
the surgical incision as well as to identify the indicated cer- 12 weeks postoperatively and only 1 patient returning to
vical level and ensure appropriate anteroposterior and lateral duty at 44 weeks.
positioning. The neck is then prepped and draped in usual Among those patients who were able to RTD (Table III),
sterile manner. The skin is then incised with a scalpel along the average pain score improved from 8.3 ± 1.7 preopera-
the previously marked area corresponding to the indicated tively to 1.1 ± 1.4 postoperatively ( p < 0.0001) versus 5.8 ±
cervical level. The incision is carried down to the level 1.6 and 3.5 ± 1.6 ( p < 0.01), for those who were medically
of the platysma with electrocautery and then the platysma retired (Table IV), respectively. The average postoperative
is opened. Sharp dissection is used through the interspace NDI score for the RTD group was 15.5 ± 12.1 compared
between the strap muscle and the sternocleidomastoid mus- to 37.0 ± 8.9 for those who were medically retired. Of the
cle. The carotid artery is palpated laterally, with the spine 6 patients (33.3%) who went on to medical retirement and
medial. Blunt (Kittner) dissection is used through the pre- separation from active duty, only 3 (50%) reported relief of
vertebral space to reveal the intervertebral disc. A spinal their symptoms after surgery.
needle is then placed into the intervertebral disc. Then the
fluoroscopy unit is used by the operating surgeon and radi-
ology technician to confirm the indicated disc space.
TABLE II. Summary of Patient Demographic and Surgical Data
The caudal disc space is then sharply incised and the
longus colli muscles are dissected from the cervical spine Total Patients 18
with the electrocautery unit. The discectomy is carried out Men 15
with a variety of pituitary rongeurs and curettes. The dura Women 3
mater is then identified as well as both exiting nerve roots Age (Year), Mean ± SD 40.0 ± 5.8
indicating an appropriate discectomy and decompression BMI (kg/m2), Mean ± SD 27.2 ± 1.6
of the nerve roots. Parallel distraction of the intervertebral Tobacco 61%
Follow-Up (Month), Mean ± SD 21.4 ± 11.1
disc space is then applied and the surgical trial implant is Follow-Up (Month), Range 12.9 – 51.9
then placed. The appropriate positioning of the permanent Rank
implant is confirmed with direct visualization and fluoro- Junior Enlisted 2
scopic guidance. The more cephalad intervertebral disc space Noncommissioned Officer 11
is then similarly identified and the surgical decompression Warrant Officer 3
Junior Officer 1
and implant placement is repeated. Senior Officer 1
After placement of the last implant is completed, final Level of Disease
X-rays are obtained and all surgical instrumentation is C4-5/C5-6 3
removed. The wound is then closed utilizing absorbable C5-6/C6-7 15
braided suture to the platysma in a simple running manner Implant
Mobi-C 13
following this closure of the subcutaneous fat with inverted ProDisc-C 4
absorbable braided suture, followed by skin approximation Secure-C 1
utilizing a running subcuticular absorbable monofilament
suture. A sterile dressing is then applied. BMI, body mass index; C4-5, cervical disc space between cervical spine
levels 4 and 5; C5-6, cervical disc space between cervical spine levels 5 and
The patient is then awakened from general anesthesia, 6; C6-7, cervical disc space between cervical spine levels 6 and 7; junior
extubated, and taken to the recovery room. A postoperative enlisted, E1-E4; junior officer, O1-O3; noncommissioned officer, E5 and
neurological examination is then performed. above; senior officer, O4 and above.

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 Outcomes Following Multilevel CDA in the Young Active Population

TABLE III. Return to Duty Patients nificant improvement in their average pain scores postopera-
tively. Furthermore, surgery had no impact on MOS, as all
Returned to Duty 12/18 (66.7%)
Age (Year), Mean ± SD 39.5 ± 4.8
personnel who returned to active duty were able to go back
Relief After Surgery 12 (100.0%) to their previous roles.
Reported Adverse Outcomes The demographic captured in our series is consistent with
Chronic Pain 1 that of those typically affected by cervical radiculopathy.1,2,6
Paresthesia 1 Our cohort is unique in that the mean age (40 years old)
Preoperative Pain Score 8.3 ± 1.7
Postoperative Pain Score 1.08 ± 1.4
and activity level have not previously been investigated.
p < 0.0001 CDA has been shown to be effective for pain relief while
Neck Disability Index 15.5 ± 12.1 preserving cervical motion and decreasing the incidence
Military Occupational Specialty of adjacent-level disease.8–11,13,23,24,27 Single-level CDA
Combat Arms 5 (41.7%) has furthermore been described as a good option for treating
Combat Support 3 (25.0%)
Combat Service Support 4 (33.3%)
active duty military patients.19,23,24,26 There have been
Time to RTD (Week), Mean ± SD 9.6 ± 11.7 several studies comparing multilevel CDA to multilevel
Maintained Flight Status 1/1 (100%) fusions.15 In a comparison of two-level CDA to two-level
Maintained Airborne Status n/a ACDF, the authors found similar outcomes at 3-month
Postop Combat Deployment 0 follow-up.15,17,18 At 24 months, however, CDA demon-
n/a, not applicable. strated improved subjective functional outcomes. In the
largest comparative study to date, Davis et al17 compared
standardized outcome measures following two-level CDA to
There were not any device-related or approach-related two-level fusion in a multicenter prospective randomized
complications encountered for any of the patients. Cervical trial at 2 and later 4-year18 follow-up. The CDA cohort dem-
spine radiographs were available for 17 of 21 (80.9%) onstrated a statistically significant improvement in the NDI
subjects, for which radiographic analysis did not show scores, SF-12 physical component scores, patient satisfaction
any evidence of subsidence, migration of hardware, or as well as decreased reoperation rates when compared to
heterotopic ossification at final follow-up. Three patients two-level fusion.17,18 Neither study evaluated the occupa-
reported chronic pain (16.7%) and 1 reported unilateral tional outcomes following surgery or controlled for activity
upper extremity paresthesia postoperatively (6%). No patient level of the cohort. The patient population in our study
went on to require revision surgery or reoperation within the could be considered a closed more homogeneous population
study period. of young athletic individuals.
Literature on multilevel CDA in a military population is
DISCUSSION limited. The two existing studies16,19 reported >95% reso-
We demonstrate that adjacent two-level CDA is capable lution of symptoms and return to active duty following
of providing predictable symptomatic relief and maintenance multilevel CDA. However, patients with multilevel CDA
of a high-demand preoperative level of function for cervi- were evaluated only in a limited subgroup analysis. As a
cal radiculopathy among a population of young and highly result, little prognostic information could be extrapolated
active individuals. We found that the majority of subjects from the findings in either study and neither functional nor
(66.67%) were able to return to full activities at their previ- occupational outcomes of the multilevel CDA subgroup
ous level of functionality by 12 weeks and that both the were evaluated. In this study, this cohort of interest was spe-
RTD and medical evaluation board (MEB) groups had sig- cifically isolated. Our results were more dramatic than those
of the previous studies in that 83% of patients reported com-
plete symptomatic resolution and 2 of 3 patients were able
TABLE IV. Medical Evaluation Board Patients to continue on active duty. Although the results of those
Medical Evaluation Board 6/18 (33.3%) patients who were able to remain active were exceptional,
Age (Year), Mean ± SD 41.2 ± 7.7
this study highlights shortcomings of multilevel CDA in
Relief After Surgery 3 (50%) the high-demand patients. The rate of complications in our
Reported Adverse Outcomes series was similarly low (6%).
Chronic Pain 2 There are several limitations to this study. First, this is a
Preoperative Pain Score 5.8 ± 1.6 relatively small case series with retrospective reviewed data.
Postoperative Pain Score 3.5 ± 1.6
p < 0.01
As a result, this study lacks adequate power for greater statis-
Neck Disability Index 37.0 ± 8.9 tical analysis. It is further limited by the lack of a control
Military Occupational Specialty group. However, given the unique nature of this patient popu-
Combat Arms 2 (33.3%) lation, our findings contribute to the growing but still limited
Combat Support 0 (0%) body of literature evaluating functional outcomes following
Combat Service Support 4 (66.7%)
multilevel CDA. Our average follow-up additionally allows

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 Outcomes Following Multilevel CDA in the Young Active Population
us to prognosticate primarily short- and midterm outcomes.
Finally, as we did not control for other patient comorbidities,
it is possible that patients who went on to MEB for separation
had other issues beyond the surgery that influenced their abil-
ity to return to active duty. Future studies with greater patient
numbers and longer follow-up will provide for increased
external validity so as to guide spine surgeons in the manage-
ment of multilevel cervical radiculopathy in the young, active,
and high-demand cohort.
The impact of our findings support the current literature
that adjacent 2-level CDA offers significant relief of symp-
toms with low risk of complication in a young, active, and
high-demand cohort such as the U.S. military. We have
further demonstrated that the majority of individuals will
be able to return to high-demand activity in the short term within
a relatively short period following multilevel spinal surgery.
As a result of the present findings, we would recommend
that an adjacent two-level CDA be used to treat multilevel
cervical disease in active high-demand patients. In doing so, the
spine surgeon can perform this operation with the expectation
of improving function, relieving symptoms, returning to pre-
operative levels of activity, and maintaining operational readiness.
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