Int J Clin Exp Med 2019;12(8):10597-10604

www.ijcem.com /ISSN:1940-5901/IJCEM0096248

Original Article
Comparative study of artificial cervical disc
replacement and anterior cervical discectomy/fusion
in the treatment of cervical spondylotic myelopathy
Xianjun Chen, Lin Shi, Xiao Yu, Qingjiang Pang, Ji Yang

Department of Orthopedics, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang
Province, China
Received April 29, 2019; Accepted July 5, 2019; Epub August 15, 2019; Published August 30, 2019

Abstract: Objective: The aim of the current study was to compare efficacy levels of artificial cervical disc replacement
(ACDR) and anterior cervical discectomy/fusion (ACDF) in the treatment of cervical spondylotic myelopathy. Meth-
ods: A total of 60 patients with single-segment cervical spondylotic myelopathy, requiring surgery, were randomly
divided into the ACDR group (group A) and ACDF group (group B), with 30 patients in each group. Operative times,
blood loss, hospitalization times, and re-operation rates between the two groups were compared. Visual analogue
scores (VAS), Japanese Orthopedic Association (JOA) scores, neck disability index (NDI) scores, cervical curvature
index (CCI) scores, range of motion (ROM), adjacent segmental degeneration (ASD) rates, heterotopic ossification
rates, and overall curative effects (satisfactory rates of Odom’s criteria) were compared between the two groups
before the operation and at 2 weeks, 3 months, 1 year, and 3 years after the operation. Results: There were no
significant differences in operative times and hospitalization times between the two groups (both P > 0.05). Blood
loss in group B was significantly higher than that in group A (P < 0.05). VAS scores, JOA scores, and NDI scores of the
two groups were improved after the operation (all P < 0.05). VAS scores, JOA scores, and NDI scores at 3 months, 1
year, and 3 years after the operation in the two groups were improved, compared with those in the 2 weeks after the
operation (all P < 0.05). VAS scores, JOA scores, and NDI scores at 3 months, 1 year, and 3 years after the operation
showed no significant differences (all P > 0.05). There were no significant differences in VAS scores, JOA scores, NDI
scores, and satisfactory rates of Odom’s criteria between the two groups before or after the operation (all P > 0.05).
Levels of CCI and ROM in group A were significantly higher than those before the operation (both P < 0.05). Levels
in group B were lower than those before the operation (both P < 0.05). Rates of ASD and re-operations in group B
were significantly higher than those in group A (both P < 0.05). The rate of heterotopic ossification in group A was
significantly higher than that in group B (P < 0.05). Conclusion: ACDR for cervical spondylotic myelopathy provides
good curative effects, compared with traditional ACDF. It also preserves or even improves movement of the cervical
vertebra, greatly reducing re-operation rates. However, heterotopic ossification rates are significantly elevated. Thus,
additional studies are required to improve this problem.

Keywords: Cervical spondylotic myelopathy, artificial cervical disc replacement, intervertebral disc decompression
and fusion

Introduction dylotic myelopathy [2]. Each type of cervical

spondylosis has a specific clinical manifesta-
Due to changes in living and working habits, tion that can only be distinguished by imaging
incidence rates of spondylosis have shown an examinations. Treatment of cervical spondylo-
increasing trend in recent years. The average sis usually involves physical therapeutics, med-
age of incidence has trended younger, becom- ication, and surgical treatment [3, 4]. Physical
ing a significant disease affecting both work therapeutics includes physiotherapy, cervical
and life [1]. Cervical spondylosis can be divided traction, and exercise therapy. However, cervi-
into cervical spondylotic radiculopathy, verte- cal traction should be used cautiously in cervi-
bral artery type of cervical spondylosis, sympa- cal spondylotic myelopathy, avoiding injuries to
thetic cervical spondylosis, and cervical spon- the spinal cord. Medication is mainly a symp-
 Comparative study regarding treatment of cervical spondylotic myelopathy

tomatic treatment for pain or inflammation ca- eases; (2) Patients with severe osteoporosis
used by cervical vertebral compression. Surgi- or softening and obvious fracture defects; (3)
cal treatment is optional if conditions permit Patients with cervical spinal canal stenosis,
for patients experiencing ineffective results cervical tumor, infections, or deformities; and
through physiotherapy and medication. The (4) Patients with a history of cervical spondylo-
current study examines surgical treatment of sis surgery.
cervical spondylotic myelopathy. Cervical spon-
dylotic myelopathy can cause spinal cord inju- The current study was approved by the Medi-
ries after compression of the spinal cord. Cli- cal Ethics Committee of HwaMei Hospital,
nical symptoms are obvious and muscle st- University of Chinese Academy of Sciences. All
rength changes are likely to occur. Operation patients were informed of possible treatment
treatment is an effective method in relieving risks and other treatment options if results
compression issues. Anterior cervical decom- were not satisfactory. Informed consent was
pression and fusion (ACDF) is the classical obtained from all patients.
procedure for treatment of cervical spondylo-
tic myelopathy. Its clinical effects are also sa- Research subjects
tisfactory. However, as time goes on after the
Sixty patients were divided into two groups,
operation, the operation procedure can influ-
according to the random number table method,
ence the range of motion of the cervical verte-
with 30 patients in each group. Group A includ-
bra. Degeneration of the adjacent vertebral
ed artificial cervical disc replacement (ACDR)
body will also occur, often requiring a second-
patients. Group B included ACDF patients.
ary operation [5-7]. Therefore, a new surgical
method is necessary to solve the situation. Treatment methods
Artificial cervical disc replacement (ACDR) is a
new surgical procedure, developed in recent Group A [10]: Patients were placed in the supi-
years. Compared with ACDF, ACDR is a non- ne position. After general anesthesia, they we-
fusion operation, replacing the diseased disc re given pillows under the head, neck, and
with an artificial disc. It can preserve the mo- shoulders, enabling a moderate extension of
tion of the vertebral body. However, long-term the neck. After disinfection and towel laying, a
effects and possible side effects require fur- transverse incision of the right neck was taken.
ther study. The current study compares the The operative incision was exposed layer by
effects of ACDF and ACDR in the treatment of layer. Thus, the anterior edge of the vertebral
cervical spondylotic myelopathy, aiming to dis- body was completely exposed. Next, the loca-
cover a better treatment method. tion needle was implanted. The diseased inter-
vertebral discs and median lines were identi-
Materials and methods
fied via imaging. The prospective replacement
General materials segment was exposed. The bone and fibrous
rings in intervertebral space and adjacent ver-
From January 1, 2015, to December 31, 2017, tebral body hyperplasia were then removed
60 patients with single segment cervical spon- and replaced. The posterior longitudinal liga-
dylotic myelopathy, admitted to HwaMei Hos- ment without obvious degeneration was re-
pital, University of Chinese Academy of Sci- served, as far as possible. Spinal cord com-
ences, were selected. pression was completely relieved. After con-
firming the size and position of the prosthesis,
Inclusion criteria [8]: (1) Patients diagnosed a suitable type of Bryan prosthesis was insert-
with cervical spondylotic myelopathy; (2) Single- ed. Drainage tubes were placed and the inci-
level cervical spondylosis with lesion segments sion was closed layer by layer. The patients
located in C3-C7; (3) Patients with no signifi- were sent back to the ward, after awakening,
cant improvement or aggravation of the condi- under the protection of cervical gear.
tion after 3 months of non-operative treatment;
and (4) Ages ranged from 18 to 70 years. Group B [11]: Patients were placed in the
supine position. After general anesthesia, they
Exclusion criteria: (1) Patients with significant were given pillows under the head, neck, and
cardiovascular and other important organ dis- shoulders, enabling a moderate extension of

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 Comparative study regarding treatment of cervical spondylotic myelopathy

the neck. Anterior and right transverse inci- posterior lower angle of C7 was measured on
sions of neck were taken, layer by layer. The X-ray lateral images as a denominator. Vertical
anterior edge of the vertebral body was ex- distances between the posterior inferior angle
posed. The location needle was implanted. The of C3, C4, C5, and C6 to posterior lower angle
lesion segment was located by imaging. Os- of C2 and C7 were recorded as a1, a2, a3, and
teophytes and calcification of the diseased a4, respectively. CCI = (a1 + a2 + a3 + a4)/A *
vertebral space were completely removed for 100%.
full decompression. Next, the endplate of the
upper and lower vertebrae was grinded, aiming Range of motion (ROM) [16]: ROM includes the
to facilitate postoperative fusion. Autogenous sum of angles between the superior endplate
iliac bone and vertebral body fragments were on the upper vertebral body and the inferior
implanted into the intervertebral space. They endplate on the inferior vertebral body of the
were fixed with plates and screws at the anteri- operative segment via X-rays of cervical hyper-
or edge of the vertebral body. When the posi- flexion and hyperextension. When ROM < 3°, it
tion was satisfactory, negative pressure drain- is obviously lost. ROM was compared before
age tubes were placed. The incision was closed and after the operation, determining the effects
layer by layer. The patients were sent back to of surgery on cervical spine mobility.
the ward, after awakening, under the protection
Satisfactory Rate of Odom’s criteria: Overall
of cervical gear.
curative effects of the patients were evaluat-
Postoperative management: The two groups of ed during the follow-up period, divided into 4
patients were fixed for at least 4 weeks after grades. Excellent: Complete remission of all
the operation. Proper rehabilitation exercise preoperative symptoms; Good: Preoperative
was carried out under the fixation of neck sup- symptoms were obviously relieved and daily
port. Neck exercises were gradually strength- activities and work were not affected; Fair:
ened after the neck support was removed. Preoperative symptoms were partially relieved,
Postoperative antibiotics were used for 3 days, but daily activities were significantly limited;
preventing postoperative infections. Analgesic Poor: No change or a deterioration of preope-
drugs were used if the patient had a severe rative symptoms. Satisfactory rate of Odom’s
pain within 3 days after the operation. criteria = Odom’s Standard excellent and good
cases/Total number * 100%.
Therapeutic evaluation
Adjacent Segment Degeneration Rate (ASD): In-
The following indexes were evaluated before tervertebral disc degeneration, herniation, spi-
the operation, 2 weeks after the operation, 3 nal stenosis, spondylolisthesis, or instability wi-
months after the operation, 1 year after the th or without symptoms in adjacent segments
operation, and 3 years after the operation: indicate degeneration of adjacent segments.

Visual analogue scores (VAS): A 10 cm horizon- Ectopic Ossification [17]: Appearance of bone
tal line was drawn on paper, with 0 on one end tissue in soft tissues can be judged by the
and 10 on the other. Patients marked pain patient’s positive and lateral X-rays. These can
scores on the line according to the degree of be divided into 5 grades, according to severity:
pain. Higher scores indicate more severe pain. Grade 0: No ossification; Grade I: Ossification
has not entered into the intervertebral space;
Japanese Orthopedic Association (JOA) scores Grade II: Ossification has entered the interver-
[12, 13]: There are 17 points in this score. tebral space; Grade III: Further aggravation of
Higher scores indicate better spinal functional ossification may affect intervertebral space
recovery. activity; Grade IV: A bone bridge has been
formed with segmental mobility < 3°.
Neck disability index (NDI) scores [14, 15]:
There are 10 items with 50 points. Higher Re-operation rates: This refers to the probabili-
scores indicate more severe dysfunction. ty of re-operations in the two groups of patients
during the observation period: (number of re-
Cervical curvature index (CCI): Straight distan- operation/number of observers) * 100%. When
ce A from the posterior lower angle of C2 to the the cervical vertebra was completely inactivat-

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 Comparative study regarding treatment of cervical spondylotic myelopathy

Table 1. Comparison of general materials the operation in both groups (all P < 0.05). VAS,
Group A Group B JOA, and NDI scores of the two groups at 3
P months, 1 year, and 3 years after the operation
(n = 30) (n = 30)
Sex 0.657 were improved, compared with those at 2
weeks after the operation (all P < 0.05). There
Male 18 20
were no significant differences in VAS, JOA, and
Female 12 10
NDI scores at 3 months, 1 year, and 3 years
Age (year) 48.5 ± 4.6 46.8 ± 6.0 0.474
after the operation (all P > 0.05). See Tables
Operative segment 0.386 3-5.
C3-C4 4 3
C4-C5 3 6 Comparison of CCI and ROM between the two
C5-C6 12 9 groups
C6-C7 11 12
Note: Group A, artificial disc replacement group; group B,
Levels of CCI and ROM after the operation in
anterior cervical discectomy and fusion group. group A were significantly higher than those
before the operation (both P < 0.05). Levels of
CCI and ROM in group B were significantly lower
ed and mobility was less than 3°, it was ne- than those before the operation (both P < 0.05).
cessary to re-operate. ACDF or ACDR was See Figures 1, 2.
adopted according to patient choice and spe-
cific conditions. Comparison of satisfactory rates of Odom’s,
ASD, heterotopic ossification, and re-operation
Statistical analysis rates between the two groups
SPSS17.0 software was used for data analysis.
_ There were no significant differences in satis-
Measurement data are expressed as x ± sd. factory rates of Odom’s criteria in the two
Independent sample t-tests were used for com- groups (all P > 0.05). ASD and incidence rates
parisons between groups. Paired sample t-tests of re-operations in group B were significantly
were used for intra-group comparisons. Enu- higher (all P < 0.05). Rates of heterotopic ossi-
meration data are expressed as χ2. P < 0.05 fication in group A were also significantly higher
indicates statistical significance. (all P < 0.05). See Tables 6-8.
Results Discussion
Comparison of general materials of the sub- Since the development of ACDF, it has gradual-
jects ly developed into the classical method of tre-
atment of cervical spondylosis. However, more
There were no significant differences in age,
and more problems have been found with this
sex, and operative segments between the two
method. One study confirmed that cervical
groups (all P > 0.05). See Table 1.
fusion after ACDF can significantly affect the
Comparison of operations between the two motion of the cervical spine, even if cervical
groups mobility will be completely lost and need for a
second operation. This can significantly affect
There were no significant differences in opera- patient quality of life [18]. Therefore, the ap-
tion times and hospitalization times between pearance of an artificial intervertebral disc pro-
the two groups (both P > 0.05). Blood loss in vides a new method of treating cervical spon-
group B was significantly higher than that in dylosis. The current study examined the effica-
group A (P < 0.05). See Table 2. cy of ACDR with traditional ACDF, as surgical
methods for cervical spondylotic myelopathy.
Comparison of VAS, JOA, and NID scores be-
tween the two groups According to present results, there were no
significant differences between CDR and ACDF
There were no differences in preoperative in operative times and hospitalization times.
scores between the two groups (all P > 0.05). However, blood loss of ACDR was significantly
VAS, JOA, and NDI scores were improved after less than that in ACDF. Blood loss has an impor-

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 Comparative study regarding treatment of cervical spondylotic myelopathy

Table 2. Comparison of the operation between the two groups ACDF in this respect. The-
Group A Group B P re are many criteria used
in evaluating the curative
Operation time (min) 128.54 ± 32.31 132.67 ± 29.82 0.546
effects of cervical spon-
Blood loss (mL) 236.76 ± 41.95 328.88 ± 46.17 0.021
dylosis surgery. Several
Hospitalization time (d) 10.75 ± 3.31 11.23 ± 3.08 0.757 representative indicators
Note: Group A, artificial disc replacement group; group B, anterior cervical discectomy were selected for the cur-
and fusion group.
rent study. VAS, JOA, and
NID scores of the two sur-
Table 3. Comparison of VAS scores between the two groups gical methods were im-
Group A Group B t P
proved after the opera-
tion compared, with scor-
Before operation 7.54 ± 1.44 7.33 ± 1.61 5.773 0.643
es before the operation.
2 weeks after operation 3.12 ± 0.87*** 3.54 ± 0.53*** 6.358 0.497
There were no significant
3 months after operation 1.27 ± 0.31#,*** 1.44 ± 0.28#,*** 4.553 0.783 differences in satisfacto-
1 year after operation 1.36 ± 0.26#,*** 1.33 ± 0.38#,*** 5.587 0.618 ry rates of Odom’s crite-
3 years after operation 1.29 ± 0.41#,*** 1.31 ± 0.37#,*** 4.525 0.796 ria between the two gr-
Note: VAS, visual analogue score; group A, artificial disc replacement group; group B, an- oups after the operation,
terior cervical discectomy and fusion group. Compared with 2 weeks after the operation, indicating no significant
#
P < 0.05; compared with before the operation, ***P < 0.001.
differences in the impro-
vement of pain and the
Table 4. Comparison of JOA scores between the two groups recovery of spinal cord
function between the two
Group A Group B t/χ 2
P
kinds of surgical meth-
Before operation 7.38 ± 2.41 7.49 ± 2.39 5.653 0.685
ods. Results showed that
2 weeks after operation 11.66 ± 1.98** 11.23 ± 1.64** 4.543 0.734 ACDR could produce the
3 months after operation 15.23 ± 0.85##,*** 14.98 ± 1.12#,*** 3.654 0.796 same therapeutic effect
1 year after operation 14.76 ± 1.23#,*** 15.11 ± 0.68##,*** 6.346 0.528 as ACDF. According to re-
3 years after operation 15.42 ± 0.46 ##,***
14.59 ± 1.22 #,***
5.355 0.691 sults, CCI and ROM we-
Note: JOA, Japanese Orthopedic Association; group A, artificial disc replacement group; re significantly decreas-
group B, anterior cervical discectomy and fusion group. Compared with 2 weeks after the ed and incidence of ASD
operation, #P < 0.05; Compared with 2 weeks after the operation, ##P < 0.01; compared was significantly increa-
with before operation, **P < 0.01; compared with before the operation, ***P < 0.001.
sed after ACDF. There we-
re 8 patients that need-
Table 5. Comparison of NID scores between the two groups ed to undergo seconda-
ry surgeries during the
Group A Group B t/χ2 P
follow-up period of three
Before operation 38.63 ± 5.77 37.47 ± 6.86 4.142 0.754
years. After ACDR, CCI
2 weeks after operation 24.56 ± 4.18** 26.22 ± 4.27** 5.235 0.681 and ROM were slightly hi-
3 months after operation 7.23 ± 3.19###,*** 8.35 ± 3.07##,*** 4.654 0.718 gher than those before
1 year after operation 6.96 ± 3.21###,*** 7.28 ± 2.53###,*** 5.483 0.669 operation. Incidence of
3 years after operation 7.11 ± 3.73##,*** 6.89 ± 2.53###,*** 6.245 0.514 ASD was only 10% after
Note: NDI, neck disability index; group A, artificial disc replacement group; group B, an- 3 years. This method co-
terior cervical discectomy and fusion group. Compared with 2 weeks after the operation, uld retain or even improve
##
P < 0.01; Compared with 2 weeks after the operation, ###P < 0.001; compared with cervical spine movement,
before the operation, **P < 0.01; compared with before the operation, ***P < 0.001.
improving the quality of
life of the patients. ACDR
tant effect on the recovery and prognosis, was obviously superior to ACDF. After 3 years of
especially in elderly or infirm patients. An in- follow-ups for 30 patients, no displacement,
crease of blood loss during the operation will sinking, or rejection of artificial intervertebral
significantly affect hemodynamic changes and discs occurred. However, one of the most im-
lead to fluctuation of blood pressure during the portant postoperative complications after AC-
operation. This will affect the prognosis of the DR is ectopic ossification. The pathogenesis
patients. Therefore, blood loss should be re- of heterotopic ossification is complex. Thus far,
duced as much as possible. ACDR is superior to there are no definite conclusions. Some studi-

10601 Int J Clin Exp Med 2019;12(8):10597-10604

 Comparative study regarding treatment of cervical spondylotic myelopathy

inflammation of surrounding
muscles caused by intraoper-
ative traction [19, 20]. Ectopic
ossification may be charac-
terized by joint swelling and
pain in the early stages, limit-
ed movement, or even a com-
plete loss of activity in the late
stages. This may result in the
need for a second operation
[21]. Present results showed
that the heterotopic ossifica-
tion rate in the ACDR group
was significantly higher than
that in the ACDF group. In one
case, a complete osseous bri-
dge was formed and cervical
Figure 1. Comparison of CCI between the two groups. CCI, cervical curva- movement was almost com-
ture index; group A, artificial disc replacement group; group B, anterior cervi- pletely lost, requiring a seco-
cal discectomy and fusion group. Compared with before the operation, ★P nd operation. Although a small
< 0.05; compared with before the operation, ★★P < 0.01; compared with
before the operation, ★★★P < 0.001; compared with group A, ☆P < 0.05;
part of the remaining patients
compared with group A, ☆☆P < 0.01; compared with group A, ☆☆☆P < 0.001. developed heterotopic ossifi-
cation, it did not affect normal
life and did not require a sec-
ond surgery. However, some
studies have confirmed that
the rate of heterotopic ossifi-
cation after artificial cervical
disc replacement can reach
as high as 60% [22, 23]. Stu-
dies have shown that inci-
dence rates of heterotopic os-
sification with different types
of prostheses are also differ-
ent. Bryan prostheses have
the lowest incidence of het-
erotopic ossification, with a 3-
year incidence of about 22%
[24, 25]. This study confirmed
that the heterotopic ossifica-
tion rate of Bryan prosthesis
was 43.3%. However, because
study times were short and
the numbers of cases were
Figure 2. Comparison of ROM between the two groups. ROM, range of mo- few, the accuracy of incide-
tion; group A, artificial disc replacement group; group B, anterior cervical dis- nce should be further inves-
cectomy and fusion group. Compared with before the operation, ★P < 0.05; tigated.
compared with before the operation, ★★P < 0.01; compared with before the
operation, ★★★P < 0.001; compared with group A, ☆☆P < 0.01; compared In conclusion, although the ra-
with group A, ☆☆☆P < 0.001.
te of heterotopic ossification
of ACDR was significantly high-
es have suggested that it is related to incom- er, incidence of re-operations was only 3.3%.
plete removal of osteophytes, unsuitable pros- This rate was significantly lower than that of
thesis, unclean bone fragments, incomplete ACDF. There were no other significant differ-
suction of bleeding during the operation, or ences between ACDR and ACDF. Thus, both are

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 Comparative study regarding treatment of cervical spondylotic myelopathy

Table 6. Comparison of satisfactory rates of Odom’s crite- Address correspondence to: Qingjiang
ria between the two groups (%) Pang, Department of Orthopedics, Hwa
Group A Group B t/χ2 P Mei Hospital, University of Chinese Aca-
demy of Sciences, No.41 Xibei Street,
2 weeks after operation 79.6 76.7 4.567 0.857
Haishu District, Ningbo 315010, Zhe-
3 months after operation 86.5 83.3 5.644 0.685
jiang Province, China. Tel: +86-0574-
1 year after operation 91.8 93.6 4.268 0.884 83870248; Fax: +86-0574-83870248;
3 years after operation 97.4 96.7 6.246 0.613 E-mail: [email protected]
Note: Group A, artificial disc replacement group; group B, anterior cervical
discectomy and fusion group. References

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Table 7. Comparison of ASD rates between the two groups Zhou Y, Huang K, Wang J and Teng
Group A Group B t/χ2 P H. Cervical spondylotic myelopathy
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3 years after operation 10 30 38.543 < 0.001 rol Neurosurg 2018; 175: 34-39.
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Note: Group A, artificial disc replacement group; group B, anterior cervical
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