| 20.02.
15 - 13:26
Complexities of Single- versus Multilevel Cervical Disc Arthroplasty
19 Complexities of Single- versus Multilevel Cervical
Disc Arthroplasty
William E. Neway III, Lisa Ferreara, and James Joseph Yue
19.1 Introduction
Cervical disc arthroplasty is indicated for cervical degenerative
disc disease causing cervical radiculopathy or myelopathy in
the adult patient. Currently, cervical disc arthroplasty is Food
and Drug Administration (FDA) approved for single-level proce-
dures using all approved prostheses and for single- or two-level
procedures with a limited number of devices. Although the pro-
cedure was initially evaluated for single-level disease, multile-
vel cervical disc arthroplasty has been performed and has been
shown to have favorable outcomes similar to those for single-
level replacements.1 Several prospective studies have demon-
strated significant improvement of self-assessment instruments
such as the Neck Disability Index (NDI), visual analog scale
(VAS), and Odoms scale for multilevel replacement, thus adding
to the validity of its use.2,3
Cervical total disc replacement (TDR) was developed with the
notion that neural element decompression could be achieved
while maintaining normal spine biomechanics. The benefits of
maintaining this motion would eliminate the abnormal strain
placed at levels adjacent to fusions. This reduction in strain
pattern will theoretically lower the incidence of adjacent level
disease and mechanical instability.
19.2 Indications and
Contraindications
The indications for cervical arthroplasty continue to evolve. The
most common indication for cervical arthroplasty is single-level
cervical herniated nucleus pulposus with radiculopathy and/or
myeloradiculopathy symptoms. The patients are usually treated
conservatively with at least a 6-week period of conservative
management including rest, physical therapy, possible bracing,
medications, and activity modification. Acute indications for
cervical disc replacement include a herniated nucleus pulposus
(HNP) in the presence of significant weakness or neurological
changes in the upper and possibly the lower extremities. In
these instances, profound weakness exhibited in a patient
requires more acute or urgent anterior decompression and
placement of cervical disc replacement. Additional indications
include multilevel cervical HNP cases in which there are find-
ings of multilevel cervical spondylosis and associated radiculop-
athy or myeloradiculopathy. Additionally, patients that have
had prior fusions with adjacent level changes are also candi-
dates for cervical disc replacement.4 In this adjacent level group
of patients, removal of a prior cervical plate may or may not be
necessary depending upon the configuration and fixation of the
cervical artificial disc replacement itself. If a keel device is used,
then removal of the cervical plate may or may not be necessary.
If a nonkeel device is used, then removal of a prior cervical plate
may not be necessary in most cases. Multilevel cases can be
broken down into two subgroups: the first subgroup would be
multilevel cervical disc replacement, and the second subgroup
would be a hybrid construct with fusion at one level and artifi-
cial disc replacement at other levels. Lastly, assuming there is
no evidence of any facet arthropathy, a less common indication
would be cervical axial neck pain secondary to degenerative
disc disease and discogenic cervical pain. In most instances, this
diagnosis should be conformed using cervical discography as
well as cervical facet blocks to be certain that there is no evi-
dence of any symptomatic facet disease that would preclude
the use of an artificial disc at one or more levels. Contraindica-
tions to cervical arthroplasty include significant facet arthropa-
thy, significant osteoporosis with a T-score less than 1.0, his-
tory of infection of the cervical spine, history of severe cervical
spondylosis with significant disc height loss and contracture
of the aected interspaces, cervical instability as defined by
subluxation greater than 1.5 mL on anterior flexion and/or
extension, significant scoliosis of the cervical spine greater
than approximately 6 to 10 degrees, and significant preexisting
kyphosis of the cervical spine greater than approximately 10
degrees past neutral.
If partial corpectomies are necessary to perform an ante-
rior decompression, then cervical arthroplasty should not be
used. A dysmorphic vertebral body such that implantation of
a cervical disc would cause instability of the implant is also
a contraindication. An inability to correctly visualize using
intraoperative fluoroscopic imaging is also a relative contra-
indication with placement of an artificial disc because visu-
alization in the anteroposterior (AP) and lateral projections
is mandatory for appropriate and safe placement of an artifi-
cial disc replacement. Any allergy to any of the components
of a particular arthroplasty device is a contraindication. His-
tory of any inflammatory arthropathy such as rheumatoid
arthritis, psoriatic arthritis, or others should be considered a
contraindication to cervical arthroplasty as well. A history of
any kind of spinal column tumor and/or malignancy should
be a contraindication, and lastly an insuciently sized verte-
bral body, such that a vertebral end plate is too small to
accept an implant, is also a relative contraindication.
Ossification of the posterior longitudinal ligament is also a
contraindication, as is congenital cervical stenosis with myelop-
athy. The presence of circumferential cervical spondylosis may
be a contraindication. Any findings of thickened or calcified lig-
amentum flavum in the posterior aspect of the spinal canal
should be a relative contraindication to cervical arthroplasty.
19.3 Preoperative Radiographic
Assessment
All patients being evaluated for a single- or multilevel cervical
artificial disc require AP, lateral, flexion, and extension plain
radiographs. These patients should also undergo a magnetic
resonance imaging (MRI) scan of sucient quality to assess for
areas of stenosis or spinal cord integrity ( Fig. 19.1a,b).
Patients older than 50, whether male or female, should have a
145
| 20.02.15 - 13:26
Restoration of the Cervical Movement Segment
Fig. 19.1 (a) Sagittal magnetic resonance imaging (MRI) of a patient with two-level cervical spondylosis. (b) Axial MRI of patient with two-level
cervical spondylosis. (c) Preop computed tomographic scan of a patient with two-level disc disruption.
bone density test. All smokers should have a bone density test.
Patients should also have a CT scan of the cervical spine to
assess for any facet arthropathy or other areas of bony abnor-
mality ( Fig. 19.1c). This would include, for instance, vertebral
body cysts and the location of these vertebral body cysts, the
absence or presence of any facet fractures or arthropathy, as
well as any ossification of the posterior longitudinal ligament.
19.4 Advantages and
Disadvantages of Cervical
Disc Replacement
There are several advantages to cervical disc replacement ver-
sus anterior cervical discectomy and fusion (ACDF). A first
advantage is healing time. The healing time for an anterior cer-
vical disc replacement is considerably shorter than that for a
fusion. The healing process for an anterior cervical disc replace-
ment mainly involves the healing of the skin and subcutaneous
tissues. There is minimal healing that occurs on a short-term
146
and long-term basis except for some osseointegration into the
end plate. This osseointegration usually occurs at the micro-
scopic level and does not usually preclude the patient from
returning to clerical and light-duty activities within 1 or
2 weeks or driving within 1 or 2 weeks of the cervical disc
replacement surgery. A fusion patient would require much lon-
ger time to heal, especially when allograft bone is used. The
osseointegration period can be at least 2 to 6 months, and not
all patients who have fusions will go on to fuse; some will suer
a pseudarthrosis requiring surgical revision. There is no risk of
pseudarthrosis in the artificial disc replacement patient, which
reduces the need for and risk of additional surgery. In addition,
the use of a multilevel standpoint, the use of multilevel cervical
disc replacement is from a biomechanical perspective much
more physiologic. Cervical disc replacement, especially at mul-
tiple levels, may decrease the formation of adjacent level symp-
tomatic degenerative disc disease and therefore decrease the
need for subsequent surgery ( Fig. 19.2a,b).
In some cases of multilevel cervical fusion, an iliac crest bone
graft is harvested. This bone graft harvesting is not necessary in
an artificial disc replacement, thereby obviating the potential
Fig. 19.2 (a) Lateral radiograph showing two-
level TDR, (b) Anteroposterior radiograph
showing two-level TDR.
| 20.02.15 - 13:26

Complexities of Single- versus Multilevel Cervical Disc Arthroplasty

Fig. 19.3 Synframe (Depuy-Synthes Spine, Rayhnam, MA) and table Fig. 19.4 Synframe (Depuy-Synthes Spine, Rayhnam, MA) with
mounts depicting frame angulation. retractor setup.

iliac crest bone graft harvesting site issues such as pain and
infection as well as fracturing of the anterior superior iliac spine
prominence. Additional advantages of multilevel cervical disc
replacement include the fact that in a disc replacement there is
no anterior hardware that is directly posterior to the esopha-
gus; therefore, swallowing impingement issues may also be
decreased with artificial disc replacement as compared with an
anterior cervical fusion.
above and below, and distraction is then applied across the
interspace. Note that pins should be parallel in both coronal
and sagittal planes ( Fig. 19.5a,b). Complete resection of the
anterior annulus, the disc material, the posterior annulus, and
the posterior longitudinal ligament is performed with excision
of all osteophytes, palpation of both neuroforamina, and palpa-
tion behind each vertebral body to assess for proper levels and
the adequate level of decompression. Minimal end plate resec-
tion is performed. Minimal high-speed burring is performed,

19.4.1 Surgical Technique

Patients are usually admitted to the hospital on the day of sur-
gery. They are asked to stop smoking at least 2 weeks before
surgery in the event that fusion surgery is necessary. It is also
beneficial for the patient to stop smoking in order to decrease
the potential risk for infection. On the day of admission, the
patient is placed in a supine position. The arms are placed at
the side with slight traction. Usually, the shoulders are taped to
the end of the bed. A small support pad is placed behind the
cervical spine, and the head and neck are placed in a neutral
position. The head is generally taped to the bed in order to
secure the head from turning right and left. Fluoroscopic imag-
ing is then brought into the AP and lateral projections. The
patients rotation of the cervical spine is adjusted such that the
midportion of the spinous process is in the midportion of the
two pedicles on the AP view. On the lateral view, appropriate
skin markings are made anteriorly over the aected levels. In a
one- or two-level case, a small transverse incision will be made
between the two levels. In cases that are three levels or more, a
longitudinal oblique incision is used over the sternocleidomas-
toid, and careful dissection proceeds down through the layers
of the anterior cervical approach. The trachea and esophagus
are retracted to the opposite side, and the carotid contents to
the ipsilateral side of the dissection. The author (JY) prefers to
use a ring retractor that is fixed to the table. Retractors are then
placed in the lateral portions of the cervical spine and secured
Fig. 19.5 (a) Correct distractor pin placement with pins inline.
to the fixed ring that is present over the anterior cervical spine
(b) Incorrect pin placement with oblique orientation. The incorrect pin
( Fig. 19.3 and Fig. 19.4). Each level is carefully identified. A placement leads to asymmetric disc space distraction.
distractor pin is then placed into the aected vertebral body

147
| 20.02.15 - 13:26

Restoration of the Cervical Movement Segment

especially on the anterior portion of the vertebral bodies. Signif-

icantly, bleeding surfaces of bone anteriorly are covered using
bone wax. After decompression is performed, the distraction is
released, and then distraction is reapplied to two-finger tight-
ness distraction. The interspace is then trialed with an appro-
priately sized trial implant. The final implant is then inserted
from anterior to posterior under AP and lateral fluoroscopic
imaging. This process is repeated at additional adjacent levels if
necessary. Spinal cord monitoring is used in all cases to assess
the functional integrity of the spinal cord tissue as well as nerve
root function. After each level is performed, the cast bar pinhole
is covered with bone wax. If any keel grooves have been formed,
these keel grooves are also covered with an appropriate amount
of bone wax, and then dissection to the adjacent disc is per-
formed if necessary. When performing multilevel cervical
replacements, the most proximal and distal levels are per-
formed first. For instance, if a C3C4, C4C5, C5C6 three-level
Fig. 19.7 Insertion of a TDR above or below a previous ACDF is best
case is performed, the C3C4 level is performed first, then the
done with placement of the distractor pin in a proximal or distal screw
C5C6 followed by C4C5. If there is any concern that there will hole of the plate.
not be adequate space, trial implants can be placed at all three
levels prior to placing final implants to be certain that the
implants can be placed at each level. If a hybrid procedure is
planned preoperatively, the artificial disc level is usually placed within 2 weeks of surgery. Perioperative antibiotics are used,
first, followed by placement of the graft or cage at the fusion and for any dental cleaning postoperatively, patients are pre-
level. scribed appropriate oral antibiotics prior to their dental
If artificial discs are placed at noncontiguous levels adjacent procedure.
to either single-, double-, or triple-level fusions, then two sepa-
rate incisions should be considered in order to decrease the 19.4.2 Biomechanics
amount of dissection that is necessary ( Fig. 19.6a,b). Distrac-
tor pins can be placed into prior plate screw holes, thereby Motion preservation strategies using cervical total disc arthro-
obviating the need for total plate removal ( Fig. 19.7). At the plasty (CTDA) in lieu of fusion or as a hybrid model to adjacent
conclusion of a case, the esophageal tissue is carefully inspected fusions have become a prevalent form of fixation for the degen-
to be certain there has been no erosion or impingement. The erative cervical spine. However, the clinical outcomes for cervi-
carotid is checked for appropriate pulsatile flow. A medium or a cal arthroplasty are dependent not only on patient selection
drain can be placed in the anterior cervical space, and then and indication, but also on the surgeons technique, as well as
appropriate closure is performed of the cervical incision. Most an understanding of the biomechanical interaction between the
patients are placed in a soft cervical collar for approximately degenerative environment and the implants mechanical char-
1 to 2 weeks following artificial disc replacement. They are acteristics. Cervical disc arthroplasty is still considered to be a
allowed to bear weight as tolerated and permitted to drive novel technology, resulting in a lack of available prospective

Fig. 19.6 (a) Lateral radiograph showing two-

level TDR above and below an ACDF. (b)
Anteroposterior radiograph showing two-level
TDR above and below an ACDF.

148
| 20.02.15 - 13:26
Complexities of Single- versus Multilevel Cervical Disc Arthroplasty
clinical studies and biomechanical literature to evaluate the
long-term eects of cervical disc arthroplasty on multiple
spinal segments.
Biomechanical studies have demonstrated an increase of the
motion at adjacent segments surrounding a multilevel cervical
fusion. However, a multilevel cervical disc arthroplasty did not
statistically demonstrate an increase in adjacent segment
motion for various designs of cervical disc prostheses. It has
been shown biomechanically that multilevel fusion of degener-
ative spinal segments may lead to adverse eects such as accel-
erated degeneration of the adjacent motion segment due to
altered stress transfer, altered kinematic behavior, increased
motion, and increased intradiscal pressures measured at the
adjacent segments surrounding the fusion site.5,6,7 Therefore,
total disc replacement for the cervical spine has become an
alternative solution to traditional ACDF by potentially reducing
the incidence of adjacent segment degeneration through
reduced stress transfer to surrounding tissues while preserving
segmental motion, thus allowing for the dampening of addi-
tional motion transmitted to adjacent tissues.5
Comparisons of single-level disc arthroplasty versus single-
level fusion fixation have shown that disc arthroplasty demon-
strated comparable short-term clinical results with those
attained for traditional ACDF. This is not surprising, given that
single-level fusion of the subaxial cervical spine is able to com-
pensate and maintain overall motion without significant loss.
Conversely, multilevel ACDFs of the cervical spine have shown
lower success rates than single-level ACDFs due to the added
motion induced across each fusion site and greater stress trans-
fer to the adjacent segments, resulting in a higher pseudarthro-
sis rate often seen at the inferior segment.8,9 In this situation,
the biomechanical environment of a multilevel fusion is com-
promised to a greater extent with added levels of rigidity to
multiple spinal segments, contributing to greater motion,
increased intradiscal pressures, and adverse stress across adja-
cent segments, which can lead to augmented degeneration at
these levels.1013 In this multilevel fusion scenario, greater
stress and motion are transferred to surrounding spinal tissues,
resulting in a degenerative domino eect at the adjacent spi-
nal levels. Therefore, cervical disc arthroplasty can provide an
alternative strategy for the degenerative cervical spine by pre-
serving the motion at the diseased or unstable spinal segment,
which in turn allows for the dampening of detrimental stress
and strains. In essence, artificial disc technology tries to focus
on energy dissipation and shock absorption of the normal and
impact forces that occur along the spine during ambulation
and daily activities. The motion of the TDR when implanted will
aid in dissipating the impact energy and reduce detrimental
stress transfer to surrounding tissues. The eventual goal of the
artificial disc is to mimic the behavior of the natural disc tissue
and thereby emulate the viscoelastic function of the healthy
native intervertebral disc. The natural viscoelastic behavior of
the intact disc exhibits a strain-rate response that can be pro-
tective to the surrounding tissues yet is dicult to incorporate
into the design of an artificial disc.
Nonbiological materials are used to fabricate currently availa-
ble cervical artificial discs. Although these materials are bio-
compatible, they are not biological and lack the true viscoelastic
nonlinear properties of the native material, resulting in a finite
lifespan for these implants. These materials pose additional
biomechanical challenges with respect to implant lifespan, fixa-
tion at the bone interface, long-term tissue response, and tissue
adaptation to altered load transfer across the functional spinal
unit (FSU) and along the cervical spine as a result of maintain-
ing or restoring motion across the degenerative segment.
It has been dicult for device manufacturers to mimic the
normal viscoelastic behavior of the intervertebral disc for
replacement because the technology with biomaterials cannot
yet replicate the nonlinear and dynamic adaptive nature of
actual living tissue. As we age, the ligamentous and spinal tis-
sues stien due to dessiccation related to the natural course of
aging, thereby altering the load profile and kinematic behavior
across an FSU. Placement of a cervical artificial disc with a pro-
posed expected lifespan of 15 to 20 years with the mechanical
performance steadily maintained over the course of that time
can significantly alter the biomechanical profile of the patients
cervical spine as the patient moves from the fourth or fifth dec-
ade of life into the sixth or seventh decade. Significant changes
occurring in the chemical, physical, and mechanical properties
of the native spinal tissue can result in mismatched bio-
mechanical profiles between the cervical TDR and the cervical
spine, possibly resulting in adverse outcomes that may dier
greatly from those observed with fusion.
Coupling these challenges with multilevel cervical TDRs fur-
ther complicates matters from a biomechanical perspective.
Alignment of the cervical TDRs along the neutral axis of the cer-
vical spine is crucial to maintain sagittal balance, optimal load
transfer, favorable kinematics, and resistance to expulsion,
migration, or catastrophic failures, to name a few. Misalignment
of one or more TDRs can result in eccentric stress transfers to
surrounding tissue that can result in further degeneration or
tissue failures, shortened implant lifespans, or failed fixation.
The greater the number of consecutive levels implanted, the
more complex the kinematic behavior and thus the bio-
mechanical profile becomes, and the greater the risk for early
failures. Furthermore, leaving an intact intervertebral disc
between two implanted levels can create eccentric stress trans-
fer to the intact levels surrounding the TDRs, further augment-
ing degeneration or causing other detrimental responses such
as failures at the bone interface of the fixation site, migration of
the implants, adverse tissue adaptation to significantly altered
stress profiles, and eventual failure of the FSU or implant.
There are many biomechanical challenges involved in the
design and success of a total disc arthroplasty implant for the
cervical spine. Although the device must preserve and maintain
motion across the degenerative level, there is still the issue of
technology that lacks the ability to fully imitate tissue.
19.4.3 Implant Tribology
Radiostereometric analysis of cervical disc arthroplasty showed
implants to be well fixed at 3 to 6 months postoperatively.
Small but measureable micromotion was noted in two patients
up to the 6-month follow-up visit, after which all implants
were stable up to the 2-year follow-up. In addition, subsidence
of the implants was observed up to the 6-month mark where
all implants demonstrated secure ingrowth. No subsidence
was seen after complete ingrowth up to the final follow-up at
2 years. There was no correlation between early motion
and clinical outcomes at 24-month follow-up. In addition to
149
| 20.02.15 - 13:26
Restoration of the Cervical Movement Segment
concerns regarding implant fixation and subsidence, implant
wear could have significant eects, such as osteolysis, as occurs
in large joint arthroplasty.14 Volumetric and linear wear leads
to microscopic polyethylene and metal debris from the bearing
surfaces. These particles initiate an immunological cascade
from giant cells and macrophages, leading to osteoclastic
resorption at the boneimplant interface. The limited range of
motion of the cervical spine likely results in considerably lower
volumetric wear compared with other prosthetic joint arthro-
plasty. As a result, the overall eects of third-body wear in cer-
vical TDR are essentially minimal. These results are in line with
the published data by Anderson et al using a caprine model,
which showed very little inflammatory reaction around cervi-
cal disc replacements.15 Pseudotumor formation has resulted
from metal hypersensitivity due to metal-on-metal cobalt-
chromium prosthetic implants.16
19.4.4 Complications Overview
Complications associated with cervical TDR share many of the
same approach-related complications of ACDF. Namely, tran-
sient vocal cord paralysis, dysphagia, retropharyngeal hema-
toma, esophageal perforation, wound infection, cerebrospinal
fluid leaks, vertebral artery injury, vertebral body fracture, and
dislodgment have been reported following cervical total disc
replacement.6
Approach-Related Complications
Transient vocal cord paralysis
Dysphagia
Retropharyngeal hematoma
Esophageal perforation
Wound infection
Cerebrospinal fluid leaks
Vertebral artery injury
Vertebral body fracture
Cervical TDR also has a separate group of complications inher-
ent to total joint replacements. These complications include
problems with implant fixation, implant wear, HO, segmental
kyphosis, migration, and subsidence17,18 ( Table 19.1).
19.5 Implant-Specific
Complications
19.5.1 Segmental Kyphosis
The sagittal balance of the cervical spine may be altered as a
result of cervical TDR. Loss of the normal cervical lordosis has
Table 19.1 Total disc replacement failure modes
Implant failure Bearing surface wear
Iatrogenic deformity Segmental kyphosis
Boneimplant failure Fixation, migration, subsidence,
dislodgment
Host response HO, osteolysis
150
been demonstrated in several studies. Segmental kyphosis has
implications for the biomechanical function of the implant as
well as adjacent levels and surrounding musculature. This can
result in the need for additional surgeries or continued pain
and discomfort. Pickett et al demonstrated a statistically signifi-
cant increase in postoperative kyphosis among patients treated
with two-level arthroplasty.3
19.5.2 Positioning
Overdistraction of the facets and disc space has been reported
as a cause of postoperative neck pain. Consideration should be
given to the disc height to avoid this phenomenon. This is
especially important prior to undergoing a multilevel cervical
TDR due to the additive eect of the number of levels. Contri-
buting to this pain may be preexisting facet arthropathy.
Therefore, a thorough clinical and radiographic evaluation is
essential preoperatively. Implant subsidence, malpositioning,
and vertebral body fracture are all known complications with
cervical TDA.
19.5.3 Heterotopic
Ossification
Development of heterotopic ossification (HO) is counter-
productive to TDR surgery because it mitigates the underlying
principles of the procedure. The purpose is to provide pain-
free movement through a diseased joint. HO is the develop-
ment of organized bone formation in the periarticular soft
tissue. It may result from local trauma to a joint or traumatic
brain injury. Wu et al found that HO occurred at a significantly
higher rate (66% vs 25%, p < 0.001) in the multilevel cervical
arthroplasty compared with single-level replacement.19 How-
ever, despite the higher rate of formation in the multilevel
group there was no dierence in mobility or clinical outcomes.
McAfee et al published a classification system for HO of
TDRs20,21 ( Table 19.2 and Fig. 19.8). They demonstrated
two cases where fusion occurred across the disc space and
limited motion. Chen et al performed a meta-analysis on the
prevalence of HO formation after cervical TDR.22 They showed
a prevalence of advanced HO (McAfee grades IIIIV) to be
11.1% at 12 months and 16.7% at 24 months. They also con-
cluded that a higher prevalence of HO formation did not corre-
late to clinical improvement. Review of the multicenter study
revealed a lower rate of HO in the center using nonsteroidal
anti-inflammatories postoperatively.21
Table 19.2 Classification of HO in total disc replacement
Grade 0 No HO present
HO detectable in front of vertebral body but not in the
Grade I
anatomical interdiscal space
HO is growing into the disc space, possibly affecting
Grade II
prosthesis function
Bridging ossifications that still allow movement of the
Grade III
prosthesis
Complete fusion of the treated segment without
Grade IV
movement in flexion-extension
| 20.02.15 - 13:26
Complexities of Single- versus Multilevel Cervical Disc Arthroplasty
Fig. 19.8 Grade 1 HO is detectable (arrow), but not in the intervertebral
space.
19.5.4 Adjacent Level Ossification
Development
Adjacent level ossification development (ALOD) may be consid-
ered a subgroup of HO formation. A positive association has
been established between ALOD and the plate-to-disc distance.
It has been previously demonstrated that ALOD develops in 59%
of individuals undergoing ACDF procedures. The rate of forma-
tion is accelerated 2.8-fold when the plate is < 5 mm of the adja-
cent disc.23 A systematic review by Kim et al found the use of
anterior instrumentation resulted in ALOD, with the cranial
adjacent segment being at two-fold higher risk.24 No time
course for the development of ALOD was able to be established.
Overall, lower rates for the development of ALOD were seen for
TDR (624%) than for ACDF (4164%). To date no studies have
been performed on the incidence and eects of ALOD on multi-
level cervical TDR.
19.6 Summary
Early results for cervical TDR have shown outcomes similar to
those for ACDF while having lower reoperation rates for adja-
cent level disease. Although complications tend to increase with
multilevel compared to single-level TDR, they have thus far
proven to be clinically insignificant. Long-term studies are still
needed to assess the safety and elucidate the complexities of
multilevel cervical arthroplasty.
19.7 References
[1] Cardoso MJ, Rosner MK. Multilevel cervical arthroplasty with artificial disc
replacement. Neurosurg Focus 2010; 28: E19
[2] Pimenta L, McAfee PC, Cappuccino A, Cunningham BW, Diaz R, Coutinho E.
Superiority of multilevel cervical arthroplasty outcomes versus single-level
outcomes: 229 consecutive PCM prostheses. Spine 2007; 32: 13371344
[3] Pickett GE, Sekhon LH, Sears WR, Duggal N. Complications with cervical
arthroplasty. J Neurosurg Spine 2006; 4: 98105
[4] DiAngelo DJ, Roberston JT, Metcalf NH, McVay BJ, Davis RC. Biomechanical
testing of an artificial cervical joint and an anterior cervical plate. J Spinal Dis-
ord Tech 2003; 16: 314323
[5] Puttlitz CM, DiAngelo DJ. Cervical spine arthroplasty biomechanics. Neuro-
surg Clin N Am 2005; 16: 589594, v
[6] Maiman DJ, Kumaresan S, Yoganandan N, Pintar FA. Biomechanical eect of
anterior cervical spine fusion on adjacent segments. Biomed Mater Eng 1999;
9: 2738
[7] DiAngelo DJ, Roberston JT, Metcalf NH, McVay BJ, Davis RC. Biomechanical
testing of an artificial cervical joint and an anterior cervical plate. J Spinal Dis-
ord Tech 2003; 16: 314323
[8] Samartzis D, Shen FH, Matthews DK, Yoon ST, Goldberg EJ, An HS. Compari-
son of allograft to autograft in multilevel anterior cervical discectomy and
fusion with rigid plate fixation. Spine J 2003; 3: 451459
[9] DiAngelo DJ, Gilmour LJ, Schwab JS, Foley KT, German JW, Kelly BP. Bio-
mechanical comparison of multi-level cervical disc arthroplasty versus
fusion: ProDisc-C versus Prestige LP. Paper presented at the SAS10 Annual
Conference. The International Society for the Advancement of Spine
Surgery
[10] Cherubino P, Benazzo F, Borromeo U, Perle S. Degenerative arthritis of the
adjacent spinal joints following anterior cervical spinal fusion: clinico-
radiologic and statistical correlations. Ital J Orthop Traumatol 1990; 16: 533
543
[11] DiAngelo DJ, Roberston JT, Metcalf NH, McVay BJ, Davis RC. Biomechanical
testing of an artificial cervical joint and an anterior cervical plate. J Spinal Dis-
ord Tech 2003; 16: 314323
[12] Dmitriev AE, Cunningham BW, Hu N, Sell G, Vigna F, McAfee PC. Adjacent
level intradiscal pressure and segmental kinematics following a cervical total
disc arthroplasty: an in vitro human cadaveric model. Spine 2005; 30: 1165
1172
[13] Matsunaga S, Kabayama S, Yamamoto T, Yone K, Sakou T, Nakanishi K. Strain
on intervertebral discs after anterior cervical decompression and fusion.
Spine 1999; 24: 670675
[14] Lind B, Zoga B, Anderson PA. A radiostereometric analysis of the Bryan Cer-
vical Disc prosthesis. Spine 2007; 32: 885890, discussion 891
[15] Anderson PA, Squire M. Now AAOS. Adverse inflammatory reactions in disc
arthroplasty. http://www.aaos.org/news/aaosnow/nov10/research5.asp
[16] Buchowski JM, Sekhon JH, Yoon DH. Adverse events of cervical arthroplasty.
Tech Orthop 2010; 25: 138144
[17] Salari B, McAfee PC. Cervical total disc replacement: complications and avoid-
ance. Orthop Clin North Am 2012; 43: 97107, ix
[18] Interactive Educational Program. Total Disc Replacement. http://www.spine-
iep.com/iep/User/Chapters.aspx
[19] Wu JC, Huang WC, Tsai TY et al. Multilevel arthroplasty for cervical spondylo-
sis: more heterotopic ossification at 3 years of follow-up. Spine 2012; 37:
E1251E1259
[20] McAfee PC, Cunningham BW, Devine J, Williams E, Yu-Yahiro J. Classification
of heterotopic ossification (HO) in artificial disc replacement. J Spinal Disord
Tech 2003; 16: 384389
[21] Mehren C, Suchomel P, Grochulla F et al. Heterotopic ossification in total cer-
vical artificial disc replacement. Spine 2006; 31: 28022806
[22] Chen J, Wang X, Bai W, Shen X, Yuan W. Prevalence of heterotopic ossification
after cervical total disc arthroplasty: a meta-analysis. Eur Spine J 2012; 21:
674680
[23] Park JB, Cho YS, Riew KD. Development of adjacent-level ossification in
patients with an anterior cervical plate. J Bone Joint Surg Am 2005; 87: 558
563
[24] Kim HJ, Kelly MP, Ely CG, Dettori JR, Riew KD. The risk of adjacent-level ossifi-
cation development after surgery in the cervical spine: are there factors that
aect the risk? A systematic review. Spine 2013; 38: E49
151