Reasons for Selecting ACDF Over Total Disc Replacement in Cervical Spine Surgery

ISASS19 Meeting Highlight

Peer Reviewed

The most common reasons for choosing anterior cervical discectomy and fusion (ACDF) over cervical total disc replacement in a consecutive series of patients undergoing cervical spine surgery was related to factors that may compromise stability of the operated segment and/or disc replacement functionality, explained Dr. Richard Guyer at the International Society for the Advancement of Spine Surgery (ISASS) 19th Annual Conference held April 3 to 5, 2019 in Anaheim, CA.

“The results of cervical disc replacement have been consistently reported to be similar or superior to ACDF in appropriately selected patients even out to 10 years,” said spine surgeon Richard D. Guyer, MD, who is Co-Founder of the Texas Back Institute (TBI) and Co-Director of TBI’s Center for Disc Replacement in Plano, TX. “We believe it is a very exciting time, because there is no better data in all of spine surgery than we find in cervical arthroplasty.”

cervical spine superimposed on woman's neckThe results of cervical disc replacement have been consistently reported to be similar or superior to ACDF. Photo Source:

Dr. Guyer and colleagues investigated the reasons why three surgeons specializing in total disc replacement performed ACDF in a consecutive series of 464 patients undergoing cervical spine surgery during a 5-year period. Of this group, 356 patients (76.7%) underwent total disc replacement and 108 patients (23.3%) underwent ACDF.

For each ACDF performed, the researchers recorded the primary reason for not performing artificial disc replacement and classified these reasons into categories, including kyphosis/scoliosis, insurance (denial/non-coverage; Medicare), and anatomical. Examples of anatomical factors include excessive spondylosis, severe spondylosis with little or no segmental ablation, facet arthropathy, and severe neural foraminal stenosis that could not be adequately decompressed while maintaining the structural integrity of the endplate for cervical disc replacement support.

Anatomic Factors Are Top Reasons for Choosing ACDF

The most common reasons for performing ACDF over cervical total disc replacement were anatomical factors (n=64;13.8%), followed by insurance issues (n=17; 3.23%), and deformity/kyphosis (n=13; 2.8%). In addition, 3 patients had pseudo-repair (prior ACDF), 2 had osteoporosis, 2 patients had high heterotopic ossification risk, and one patient each had the following factors: nickel allergy, trauma with posterior element fractures, disc replacement removal, concern about artifact on future imaging, benign osteoblastic bone, and lack of adequate surgical approach for artificial disc implantation.

Case Study of Cervical Radiculopathy

Dr. Guyer discussed a case involving a 56-year-old woman who had a 6-month history of numbness, pain, and weakness radiating from her shoulder into her right hand with C6 radiculopathy found on electromyography. The patient failed to respond to physical therapy, injections, and medications.

“She had foraminal stenosis that was quite severe, and it was felt that the surgeons could not get adequate decompression in order to maintain the disc replacement,” and ACDF was performed instead, Dr. Guyer explained. In this case, ACDF was successful with the patient reporting neck and arm pain scores of 0 by 6-week follow-up.

Older Age and Multiple-Level Surgery Linked to ACDF

The mean age of patients who underwent ACDF was significantly older than that in the disc replacement group (55.3 versus 46.7 years; P<0.01). In addition, a greater proportion of patients requiring 1-level surgery underwent artificial disc replacement compared with ACDF (60.8% versus 43.5%; P<0.05). In contrast, gender was not linked to the type of surgery performed, with 40% to 44% of women undergoing disc replacement and ACDF, respectively.

The series included two patients with planned total disc replacements that were converted intraoperatively to ACDF for the following reasons:

  • Poor vertebral body endplate quality that would not have adequately supported the endplate of the prosthesis
  • Beveled anterior-inferior body creating a high risk of migration

An additional patient underwent reoperation with fusion at the index level of disc replacement at 2 weeks postoperatively because of severe pain resulting from persistent osteophytes.


“The most common reason for not performing cervical total disc replacement was related to the fact that it may compromise the stability of the operated segment and of the disc replacement function,” Dr. Guyer concluded. “The low rate of total disc replacement intraoperative conversions and index level reoperations support that the indications applied in the series were appropriate.”

“Older age and greater number of operated levels may be related to uncommon factors leading to ACDF rather than total disc replacement,” Dr. Guyer said. “Primarily, these factors were related to osteophytes and severely degenerative facet joints/severe stenosis that could not be adequately decompressed and still maintain enough support for the end plates. These factors and cervical deformity/kyphosis were most likely to occur in the older patient population prior to multilevel anterior cervical fusions.”

“This study found that many patients are good candidates for cervical total disc replacement,” Dr. Guyer told attendees. “In fact, in our skewed population, which is understandable because we specialize in disc replacement, 77% of patients did undergo disc replacement. However, even among total disc replacement specialists, ACDF may still be preferred in some patients in whom it is prudent not to take undue risk with an implant.”

Dr. Guyer has received royalties from ATEC Spine; has received stock/options from Spinal Kinetics and Spinal Ventures; has served as a consultant or on the Scientific Advisory Board for K2M, Aesculap, Safe Orthopaedics, and Orthofix; and as a speaker/faculty for K2M and Paradigm Spine.

Updated on: 05/17/19
Continue Reading
Low Reoperation Rate After Cervical Total Disc Replacement With ProDisc-C
Richard D. Guyer, MD
Chairman, TBIRF
Texas Back Institute

Get new patient cases delivered to your inbox

Sign up for our healthcare professional eNewsletter, SpineMonitor.
Sign Up!