Contemporary decision-making factors leading to cervical disc replacement vs. fusion for the treatment of single-level degenerative cervical radiculopathy or myelopathy: survey opinions from members of the Society of Minimally Invasive Spine Surgeon and Cervical Spine Research Society.

Abstract

Background: Degenerative cervical radiculopathy and myelopathy are frequently encountered pathologies in spine surgery. Cervical disc replacement (CDR) offers a motion-preserving alternative to conventional anterior cervical discectomy and fusion (ACDF). Presently, there is limited consensus on which variables impact the decision to perform fusion vs. arthroplasty for this disease.

Purpose: This study aims to characterize current practices for the treatment of single-level degenerative cervical radiculopathy or myelopathy and to identify and rank clinical and radiographic variables that most influence surgical decision making with regards to ACDF and arthroplasty.

Study design/setting: Descriptive, cross-sectional survey SUBJECT SAMPLE: An 11-item survey was distributed to surgeon attendees of the Cervical Spine Research Society's (CSRS) 52nd Annual Meeting and members of Society for Minimally Invasive Spine Surgery (SMISS) in 2024.

Outcome measures: Surgeons reported practice demographics, CDR training, attitude towards current literature, and adoption patterns. Surgeons were asked to rank 7 clinical factors and 8 radiographic parameters in order of importance when deciding between CDR vs ACDF.

Methods: Primary analysis was performed to summarize demographic data, surgeon attitudes, and adoption. Descriptive and stratified analysis was performed to identify significant trends and associations among these factors. Clinical and radiographic parameters were ranked in order of importance and were compared. Rankings for each parameter were reported as means, highest and lowest rankings, and percentiles. Each parameter's ranking frequency was then reported as most important, top 3 most important, and top 5 most important.

Results: Seventy-five completed responses were received. Most respondents performed fewer than 25% CDR for primary cases, with only 4% reporting utilization rates of >75%. More private surgeons (50%) adopt CDR in >25% of their cases compared to academic surgeons (13%). CDR adoption varied significantly by region, with the Southwest (71%) and Southeast (57%) regions having the highest proportions of surgeons adopting >25% CDR in their practices as opposed to ACDF. The most cited barrier was risk-benefit trade-offs (28%). 87% of respondents viewed the current evidence for CDR as high quality, 11% rated it as low quality and unconvincing. Hypermobility/connective tissue disease and severe myelopathy were clinical deterrents for CDR. Segmental instability and significant kyphotic deformity were radiographic determinants for choosing ACDF over CDR.

Conclusions: There is limited evidence on the variables that most affect surgical decision-making when choosing between ACDF and CDR for degenerative cervical radiculopathy/myelopathy. Geographic location and practice type appear to be associated with CDR adoption rates. Hypermobility, severe myelopathy, segmental instability, and kyphotic deformity were agreed upon deterrents to CDR. These findings highlight the need for future prospective studies to reevaluate historical absolute contraindications and to develop clear guidelines for implementing CDR into modern clinical practice.