cervical disc arthroplasty

[bedrock]

I'd like to hear everyones thoughts about contemporary cervical disc arthroplasty.

I'm not a fan of lumbar disc replacement as the physics are different and it seems like lumbar disc arthroplasties always fail, either initially or within a few years.

Initially cervical disc arthroplasties were a mixed bag, but supposedly in well chosen patients with newer disc hardware/surgical techniques have better outcomes?

I met with several spine surgeons in LA who offered cervical arthroplasties and sung their praises, but then again, everyone in LA lies about everything.

I'd like to hear everyones thoughts pro and con for cervical disc arthoplasties?

And which patients are even a candidate? I know they are inappropriate for true instability, patient with autoimmune disease, and for more than 2 levels, but that is all I know.

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[TIVAndy]

Outcomes seem decent from what ive seen. I did see a complication of artificial disc slipping out towards canal and pt had to fuse it. I think the surgeon who placed it didnt screw in the disc properly

 

[epidural man]

Every patient I have taken care of that then went on to get the disc replacement have told me “I can’t believe I waited so long”

I’ve been impressed with them.

 

[BobBarker]

I would get one. Mobi C.

 

[bedrock]

I would get one. Mobi C.

There are like 10 brands of cervical discs.

How did you settle on that one?

 

[BobBarker]

Surgeons seem very comfortable
With it and I haven’t seen any failures in my practice. Competing reps even say it is good.

 

[Baron Samedi]

Have one. Would recommend. Super easy recovery, full ROM.

 

[RoloTomassi]

Pros- preserved ROM, less adjacent segment disease, shorter recovery, can always do a revision ACDF if it falls

Cons- migration, subsidence, failure

Patients generally need to be younger, as they can't have too much disc height loss, osteophytes, loss of lordosis, or osteoporosis

 

[MitchLevi]

One of our spine surgeons has one and he spends his weekends racing cars.

 

[bedrock]

Pros- preserved ROM, less adjacent segment disease, shorter recovery, can always do a revision ACDF if it falls

Cons- migration, subsidence, failure

Patients generally need to be younger, as they can't have too much disc height loss, osteophytes, loss of lordosis, or osteoporosis

Have one. Would recommend. Super easy recovery, full ROM.

Baron, Is the recovery quicker than ACDF?

Rolo,
Any idea on the failure rate compared to ACDF?

I have seen data on adajacent segment degeneration. It appears better than ACDF but not amazingly so. About 10% less adjacent segment wear.

Can you tell me what are the selection criteria for cervical disc arthoplasty?

 

[RoloTomassi]

Baron, Is the recovery quicker than ACDF?

Rolo,
Any idea on the failure rate compared to ACDF?

I have seen data on adajacent segment degeneration. It appears better than ACDF but not amazingly so. About 10% less adjacent segment wear.

Can you tell me what are the selection criteria for cervical disc arthoplasty?

I think reoperation rate is a little higher than ACDF, but not a lot. In general, the benefits aren't huge. ACDF is a tried and true technique and most patients do very well without issues other than adjacent disease, which like you said, isn't that much worse than ADR.

I forgot to mention HO. Happens pretty commonly but clinical significance is variable.

 

[Baron Samedi]

Baron, Is the recovery quicker than ACDF?

Rolo,
Any idea on the failure rate compared to ACDF?

I have seen data on adajacent segment degeneration. It appears better than ACDF but not amazingly so. About 10% less adjacent segment wear.

Can you tell me what are the selection criteria for cervical disc arthoplasty?

I'm an n=1 study, but I had a super easy recovery. Took zero opioids after PACU discharge, didn't require a brace or anything, and was basically pain free POD 2.

 

[clubdeac]

I'm an n=1 study, but I had a super easy recovery. Took zero opioids after PACU discharge, didn't require a brace or anything, and was basically pain free POD 2.

that's amazing. What symptoms were you having and what did your MRI look like if you don't mind me asking. I injured my neck 10 years ago lifting weights and then again doing cross fit last year. Haven't been the same since despite daily PT, various topicals, oral NSAIDs, and dry needling. Wearing lead > 4 hrs is debilitating

 

[SSdoc33]

that's amazing. What symptoms were you having and what did your MRI look like if you don't mind me asking. I injured my neck 10 years ago lifting weights and then again doing cross fit last year. Haven't been the same since despite daily PT, various topicals, oral NSAIDs, and dry needling. Wearing lead > 4 hrs is debilitating

still should have radicular pain for the surgery.

id probably opt for a cerv disc replacement if i had the choice. if >50 or so, then probably an ACDF.

this was the whole discussion around jack eichel and the buffalo sabres

Insight on Eichel's side of neck surgery debate with Sabres

Buffalo prefers fusion (ACDF), while Eichel wants to undergo disc replacement surgery.

nhl.nbcsports.com

 

[Baron Samedi]

that's amazing. What symptoms were you having and what did your MRI look like if you don't mind me asking. I injured my neck 10 years ago lifting weights and then again doing cross fit last year. Haven't been the same since despite daily PT, various topicals, oral NSAIDs, and dry needling. Wearing lead > 4 hrs is debilitating

Sorry for low quality MRI pic. I had rapidly progressive weakness over two days, urgent surgery. Strength is no where what it used to be as I had pretty significant axonal loss but I'm back to lifting weights, albeit nothing too crazy anymore.

 

[SSdoc33]

Sorry for low quality MRI pic. I had rapidly progressive weakness over two days, urgent surgery. Strength is no where what it used to be as I had pretty significant axonal loss but I'm back to lifting weights, albeit nothing too crazy anymore.

ugh. that sucks.

spasticity?

it is pretty amazing that you were able to get a urgent disc replacement. id say 95% of surgeons would just do an ACDF in your case

 

[Baron Samedi]

ugh. that sucks.

spasticity?

it is pretty amazing that you were able to get a urgent disc replacement. id say 95% of surgeons would just do an ACDF in your case

Thankfully it was a pure radic with no myelopathic symptoms. Did have pretty profound atrophy but nowadays its hardly noticeable(esp with the layer of dad bod fat I've added).

Only reason I got the CDR is because I knew the surgeon. It happened during my fellowship year and I got treated at the same hospital where I worked.

 

[SSdoc33]

Thankfully it was a pure radic with no myelopathic symptoms. Did have pretty profound atrophy but nowadays its hardly noticeable(esp with the layer of dad bod fat I've added).

Only reason I got the CDR is because I knew the surgeon. It happened during my fellowship year and I got treated at the same hospital where I worked.

i guess if i saw the axials, i prob wouldnt have been as concerned. big benefit to knowing the right people

 

[DrMDAware]

I'm an n=1 study, but I had a super easy recovery. Took zero opioids after PACU discharge, didn't require a brace or anything, and was basically pain free POD 2.

With a stim on day 3?

 

[clubdeac]

Thankfully it was a pure radic with no myelopathic symptoms. Did have pretty profound atrophy but nowadays its hardly noticeable(esp with the layer of dad bod fat I've added).

Only reason I got the CDR is because I knew the surgeon. It happened during my fellowship year and I got treated at the same hospital where I worked.

damn man sorry to hear that but glad you're doing well. Now I'm curious. What led to the herniation and how man years out from surgery are you? No neck pain at all? Asking for a friend

 

[Baron Samedi]

damn man sorry to hear that but glad you're doing well. Now I'm curious. What led to the herniation and how man years out from surgery are you? No neck pain at all? Asking for a friend

I was sitting at a meeting when it happened. No real inciting event. I was big into weightlifting which probably contributed.

Surgery was in 2018. No neck pain at all. Still quite a bit weaker than I was pre-injury but I've shifted my fitness goals so it's not as impactful.

 

[clubdeac]

I was sitting at a meeting when it happened. No real inciting event. I was big into weightlifting which probably contributed.

Surgery was in 2018. No neck pain at all. Still quite a bit weaker than I was pre-injury but I've shifted my fitness goals so it's not as impactful.

Yeah I used to lift all the time. 80# dumb bell military press with poor form destroyed my neck. Wish I knew then what I know now

 

[epidural man]

Sorry for low quality MRI pic. I had rapidly progressive weakness over two days, urgent surgery. Strength is no where what it used to be as I had pretty significant axonal loss but I'm back to lifting weights, albeit nothing too crazy anymore.

OH wow this reminds me of a colleague -

While I was in Ass-crackistan, our CT surgeon (sent as a general surgeon in case you were wondering what the hell a CT surgeon was doing there) started complaining of bilateral UE numbness in his hands (non-dermatomal) and loss of fine motor skills. He brought this suturing thing to help him practice suturing very small things so he wouldn't loose skill. He was getting very frustrated with the loss of this ability - and watching him play soccer would have been very funny (as he was clearly having coordination issues with his feet) if it wasn't so concerning.

I asked my ortho - 'have you ever heard of a central disc causing equal bilateral symptoms like his, with some upper motor neuron symptoms?" He confirmed that he hadn't ever heard of that.

Given this, we were very concerned (meaning this was sounding more and more like a debilitating spinal cord disorder that is career ending).

He (and like all of use would probably do) ignored these symptoms for as long as he could and pretended it would get better - but eventually, we said - Dude, we are sorry but we need to get you out of here to get evaluated.

By the way, he was having a great time doing general surgery cases that he hadn't done for years -but that has nothing to do with the story....just thought it was interesting and cool for him.

Also, it should be noted that he had landed on his head (up-side-down) during the worthless role-over training everyone does before going into the country. HIs neck hurt for a bit, but that was it.

Anyway, after an MRI - he was found to have a very LARGE central herniation - exactly in the middle...crazy I thought.

After surgery, all his symptoms resolved.

 

[bedrock]

Really appreciate everyone’s thoughts. I need to recalibrate my brain on this as my early surgical partner gave me an imbalanced perspective on the outcomes of cervical disc replacement. I will certainly be more open to that in the future.


To finish this conversation, I’d like to hear everyone’s thoughts on contemporary lumbar disc replacement. I rarely see it done these days and have seen plenty of lumbar disc arthroplasty failures in clinic 10 years ago.

Id like to hear everyone’s thoughts on contemporary lumbar disc arthroplasty?

 

[Doctodd]

I’d get a cervical before a lumbar any day

 

[RoloTomassi]

Surgeons love to put stuff in people. If most are gun shy about LDR I think that says a lot. Revisions can be a nightmare.

 

[Ducttape]

would not recommend lumbar disc replacement. what recent data i see is not positive, and neither are my discussions with the spine surgeons.

people seem to do better with most types of cervical vs lumbar spine surgery...

 

[MaximusD]

Id just like to add on to this old thread as both a pain doc and someone who just underwent two-level mobi-C, the data isn’t even close at 7–10 years between fusion and ADR in terms of reoperation rate, particularly at adjacent segments.

Quick graphical representation (this is not my work, citation is included).

Mobi-C 10 year primary study:

https://www.researchgate.net/profil...-Clinical-Trial.pdf?origin=publication_detail

Will try to parse out the data on here but there have been similar reduction in neck and arm pain and disability scores but a significant reduction in index level and adjacent level reoperation rates when compared to ACDF. Improvements in disability scores and pain scores have been maintained at 10 years.

There are artificial discs with lower rates of heterotopic ossification which appears to occur in 30-40% of mobi-C ACDR patients. Most of these studies required patients to avoid NSAIDs and it looks like NSAID prophylaxis can reduce HO rates by 50-75% and keep motion limiting HO rates <5-10% depending on the disc.

 

[MaximusD]

Thought this was illustrative of the significant delayed differences at 5-10 years in severe adjacent segment disease.

 

[clubdeac]

Id just like to add on to this old thread as both a pain doc and someone who just underwent two-level mobi-C, the data isn’t even close at 7–10 years between fusion and ADR in terms of reoperation rate, particularly at adjacent segments.

Quick graphical representation (this is not my work, citation is included).

View attachment 376831

Mobi-C 10 year primary study:

https://www.researchgate.net/profil...-Clinical-Trial.pdf?origin=publication_detail

Will try to parse out the data on here but there have been similar reduction in neck and arm pain and disability scores but a significant reduction in index level and adjacent level reoperation rates when compared to ACDF. Improvements in disability scores and pain scores have been maintained at 10 years.

There are artificial discs with lower rates of heterotopic ossification which appears to occur in 30-40% of mobi-C ACDR patients. Most of these studies required patients to avoid NSAIDs and it looks like NSAID prophylaxis can reduce HO rates by 50-75% and keep motion limiting HO rates <5-10% depending on the disc.

great data. how was the recovery personally? Is this covered by most insurance? and do you need to stay on NSAIDs indefinitely to prevent HO or just during the healing process?