Anterior cervical discectomy and fusion or Cervical artificial disc replacement

Ross Hauser, MD.

In this article, we will discuss the challenges patients may face after cervical artificial disc replacement.

We generally see three types of patients when the subject is artificial disc replacement surgery.

  • We see patients who underwent surgery with less than beneficial results, still have a lot of pain or adjacent segment problems, and are looking to avoid another or revision surgery
  • We see patients who underwent successful surgery but still have some pain and limitations that continue to hinder them.
  • We see patients who are trying to avoid the surgery altogether.

Many people have had successful cervical artificial disc replacement surgery and are happy people. These are typically not the patients that seek our help.

Article outline:

  • “I had two consultations for surgery”
  • Artificial Disc Replacement – Who is it best for? Who is not a candidate?
  • “Cervical disc arthroplasty is an effective surgical technique for optimizing clinical outcomes and radiological results.”
    • Anterior cervical discectomy and arthroplasty (replacement) to anterior cervical discectomy and fusion discectomy. One-level surgery, which is better?
    • Anterior cervical discectomy and fusion, cervical disc replacement, and posterior cervical foraminotomy.
  • A comparison of surgical techniques – fusion vs. disc replacement – is about motion.
  • “The complications after total disc replacement surgery are thought to be caused by inadequate natural movement restoration.”
  • A successful disc replacement surgery, but, have remaining symptoms.
  • Returning to work after surgery.
  • The number of people who get cervical fusion surgery when the cervical disc replacement fails.
    • Repeat anterior cervical discectomy and fusion or repeat cervical artificial disc group can be performed.
    • The hybrid fusion disc replacement surgery option is for patients who are not good candidates for disc replacement.
    • Cervical disc replacement may not recreate the normal range of cervical spine motion. This may cause problems down the road.
  • Anterior bone boss following cervical disc replacement is characteristic of increased cervical lordosis.
    • Heterotopic ossification is a common complication.
    • Heterotopic ossification- the growth of bone in the tendons, muscles, and soft tissue after cervical disc replacement.
  • A weakness in their ability to “hold their head up.”
  • Neck pain after C5-C6 disc replacement surgery.
  • Surgeons ask: “Are Controversial Issues in Cervical Total Disc Replacement Resolved or Unresolved?”
  • Surgery for Cervical Discogenic Syndrome – only as last resort?
    • Complications in neck surgery.
  • Cervical spinal alignment and curvature after disc replacement surgery.
  • The importance of the cervical spine curve in alleviating pain.
  • Surgical treatments for Cervical Instability – the disc may not be the problem causing pain, loss of cervical curvature, and loss of range of motion.
  • CREEP – cervical degenerative ligament disease – why neck surgery fails.
  • Range of motion issues are in the ligaments.
  • Patients suffer because cervical ligament laxity is a mystery.
  • Treating cervical ligaments – published research from Caring Medical.
  • Stabilizing the unstable neck – the case for treating ligaments with Prolotherapy.

“I had two consultations for surgery”

This is the type of story patients share with us. They tell us about cortisone or cervical steroid injections in their neck as a last attempt to avoid surgery following many months or years of typical home remedies including stretching, yoga, and traction. Someone pushing forward with these remedies and treatments has hope that these therapies will help them avoid surgery in the near future. There is a clear desire on these people’s parts to avoid surgery and they have not reached the stage of “I am just getting the surgery and will try to be done with this.” They will also tell us about multi-segment degenerative disc disease and cervical disc bulging, maybe from C3 – C7 or C2 – C5. They tell us about the surgeon who reviewed their MRI and that doctor’s suggestion of surgery because of developing bone spurs. Then they will tell us about a second opinion they got.

  • In one opinion, traditional cervical fusion with multi-level disc replacement would be suggested.
  • In another opinion, from a minimally invasive cervical spine specialist, the suggestion was laser surgery to burn away the bulging areas compressing the nerves. No fusion, no disc replacement but no guarantee that this surgery would prevent the need for cervical fusion later. This may often lead people to question the benefit of laser spine surgery and go ahead with artificial disc/fusion surgery.

Artificial Disc Replacement – Who is it best for? Who is not a candidate?

As a compromise between stability and motion, laminoplasty and artificial disc replacement is done with ever-increasing frequency. Cervical laminoplasty involves cutting the lamina on both sides to make a bone flap which is propped open using small wedges or pieces of bone to enlarge the spinal canal space. Artificial disc replacements and laminoplasties have the advantage of providing some stability while preserving about 80% or so of the normal motion. Unfortunately with both, the biomechanics of the spine are still altered in the adjacent segments and there are still people who do not do well after these procedures.

In a cervical artificial disc replacement surgery, the herniated or damaged disc between the vertebrae is removed. As opposed to a fusion surgery where bone and graft are inserted into the void created by the disc removal and then the vertebrae of the cervical spine are held together with rods and screws, the artificial disc replacement surgery inserts a ball and socket joint apparatus. The idea is that this ball and joint can do the job of a natural disc by maintaining disc height and preventing the vertebrae from rubbing against each other, reducing compression on the nerves, and maintaining mobility in the cervical spine and a proper range of motion.

As a lesser procedure to bone graft, surgeons hope that they can complete the procedure within 2 hours, have the patient go home the next day, and have them return to a normal lifestyle within 2 months.

The benefits of spinal fusion in discussions between surgeons are

  • Patients can move right away and do not need to wear a neck brace.
  • Faster recovery.
  • Better long-term relief than cervical spinal fusion.
  • Restored range of motion is very close to the range of motion of a healthy disc.

However,

  • Cervical disc replacement may not be the best option for people with significant spinal degeneration, multilevel herniation, loss of natural spinal curve, or people with spinal cord compression. They, according to surgeon comparisons would benefit most from spinal fusion.

It is clear from multiple scientific reviews that cervical fusions, total disc replacements, laminoplasty, and laminectomy all alter spinal biomechanics, which promotes adjacent segment degeneration. Cervical fusions and total disc replacements transfer forces to the adjacent vertebral segments increasing disc and facet pressure, which can lead to cervical instability in those segments and to long-term adjacent segment degenerative disease. Laminoplasties also are associated with adjacent segment degenerative disease. When instability or fusion is present, destructive joint forces are transferred to adjacent vertebral segments.

“Cervical disc replacement is an effective surgical technique for optimizing clinical outcomes and radiological results.”

Many people do have a successful surgery, this is why the optimism in some research.

In January 2022, surgeons at the Yonsei University School of Medicine published their findings on their evaluation of radiological and clinical outcomes in patients undergoing cervical disc arthroplasty for cervical degenerative disc disease. (1)

Summary highlights:

  • A total of 125 patients who were treated with cervical disc arthroplasty were assessed.
  • The average follow-up after surgery was 38 months.
  • Radiographic images demonstrated mobility at both the index and adjacent levels, with no signs of hypermobility at an adjacent level.
  • There was a non-significant loss of cervical global motion and range of motion (ROM) of the functional spinal unit at the operating level, as well as the upper and lower adjacent disc levels, compared to preoperative status.
  • Patients experienced a 29.60% incidence of heterotrophic ossification and a 3.20% reoperation rate due to cervical instability, implant subsidence, or osteolysis.

Conclusion: “Cervical disc arthroplasty is an effective surgical technique for optimizing clinical outcomes and radiological results. In particular, the preservation of cervical range of motion with an artificial prosthesis at adjacent and index levels and improvement in cervical global alignment could reduce revision rates due to adjacent segment degeneration.”

The debate in the medical community is whether or not artificial disc replacement is superior to the more traditional cervical fusion.

In January 2024, Indiana University School of Medicine doctors lead research (2) into a twenty year follow up comparison study into the clinical outcomes of anterior cervical discectomy and fusion (ACDF) and cervical disk replacement.

Forty-seven patients with single-level cervical radiculopathy were randomized to either cervical disk replacement or ACDF for a Food and Drug Administration Investigational Device Exemption trial. At 20 years, patient-reported outcomes, including visual analog scales (VAS) for neck and arm pain, neck disability index (NDI), and reoperation rates, were analyzed.

At 20 years follow up with 91.3% of patients reporting.

  • The anterior cervical discectomy and fusion (ACDF) and cervical disk replacement both showed significantly better neck disability index (showing better function), VAS arm pain, and VAS neck pain scores at 20 years versus preoperative scores.
  • Comparing cervical disk replacement versus ACDF, there was no difference at 20 years in the average scores for neck disability index,  VAS arm pain or  VAS neck pain.
  • There was a significant difference between cervical disk replacement versus ACDF groups in the change in VAS neck pain score between 10 and 20 years Reoperations were reported in 41.7% of ACDF patients and 10.0% of CDA patients.

Researcher’s conclusions: Both cervical disk replacement and ACDF are effective in treating cervical radiculopathy with sustained symptom improvement at 20 years. Cervical disk replacement demonstrates lower reoperation rates than ACDF.  The symptomatic nonunion rate of ACDF was 4.2% at 20 years.

A December 2023 paper in the Journal of neurosurgery. Spine, (35) compared single-level cervical disc arthroplasty for reoperation rates against single-level anterior cervical discectomy and fusion. This was a study of more than 148,000 patients.

  • Anterior cervical discectomy and fusion had:
    • higher rates of 90-day adverse events (18.4% vs 14.6%)
    • higher rates of hospital readmission at 90 days (11.5% vs 9.7%)
  • Longer term reoperation rates saw at an average 4.3 years of follow-up, 5.0% of ACDF patients and 5.4% of cervical disc arthroplasty patients underwent reoperation.
  • 10-year reoperation-free survival rate was worse for cervical disc arthroplasty than ACDF (91.0% (success rate) vs 92.0% (success rate) ), as was the rate of reintervention-free survival (81.2% vs 82.0%).
    • Reintervention includes the use of injectables for pain relief.

Conclusions: “Single-level cervical disc arthroplasty was associated with a similar rate of reoperation and higher rate of subsequent injections when compared with a matched cohort that underwent single-level ACDF. Cervical disc arthroplasty was associated with lower rates of 90-day adverse events and readmissions.”

The clinical outcomes in patients with significant cervical spondylosis

A March 2022 paper in the journal Clinical Spine Surgery (3) compared the clinical outcomes in patients with significant cervical spondylosis treated with cervical disc replacement compared with anterior cervical discectomy and fusion. This is what the authors wrote: “As cervical disc replacement utilization has increased over the past decade, recent studies have investigated the outcomes of cervical disc replacement in patients with more significant spondylotic changes and demonstrated improved postoperative patient-reported outcomes.”The study compared patients who underwent one-level or two-level cervical disc replacement or anterior cervical discectomy and fusion with significant cervical spondylosis. A total of 66 patients were included in the present study, of which 35 (53%) were treated with cervical disc replacement and 31 (47%) with anterior cervical discectomy. At the final follow-up, there was no significant difference in the outcomes between the two groups and both groups demonstrated significant improvement.

However, one question that had not been answered previously and one that should be considered important to the patients was which surgery had a better outcome, cervical disc replacement compared or anterior cervical discectomy, and fusion? Let’s look further at the research.

The clinical outcomes in patients with giant cervical disc herniation

A September 2023 paper in the Journal of orthopaedic surgery and research (36) assessed the feasibility for anterior cervical discectomy and fusion for the treatment of giant cervical disc herniation. A total of 23 patients were included in the study. The patients were followed up for 12 to 18 months. Significant pain and functional improvements were seen within three days after surgery. “The results indicate that this approach can be used to safely remove herniated disc fragments, effectively relieve compression of the spinal cord, and improve neurological function.”

Are 80 year-old at great risk of surgical complication than 60 year olds?

A September 2023 paper (x)  lead by doctors at the Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York followed ACDF patients for eleven years to assess if old age of the patient created more risks for complications. To perform this assessment risk changes among elderly groups such as the difference between elderly (60+) and octogenarian (80+) patients were analyzed. What the researchers found was that “Octogenarian patients do not face much riskier outcomes following elective ACDF procedures than do younger elderly patients. Age alone should not be used to screen patients for ACDF.”

Anterior cervical discectomy and fusion or repeat cervical artificial disc

A September 2023 paper in the Spine Journal (4) comes to us from the University of Helsinki and Department of Neurosurgery. In this paper the doctors compared outcomes for Anterior cervical discectomy and fusion for cervical radiculopathy to total disc replacement /cervical disc arthroplasty (joint replacement). As discussed these procedures became popular as Anterior cervical discectomy and fusion has been implicated in “(accelerating) the degeneration of the adjacent cervical discs, which causes so-called adjacent segment disease.” The doctors noted that “the rationale is that a synthetic disc prosthesis may preserve motion at the operated level, which is expected to lead to reduced stress on the other cervical levels and thus decrease the risk of developing adjacent cervical discs.” In this study, the doctors sought to add to the knowledge pool of the long-term outcomes of these procedures.”

Learning points:

  • Thirty eight patients who underwent total disc replacement due to degenerative cervical disease at Helsinki University Hospital between 2006 and 2012 were compared to patients who underwent Anterior cervical discectomy and fusion during this period (76 patients) for degenerative disc disease.
  • First comparisons compared the need for revision or re-operation surgery.
  • Second examinations included:
    • Severity or relief of neck symptoms (pain and function scores),
    • health-related quality of life,
    • satisfaction with the surgery,
    • radiological outcomes , and
    • employment status.

Results: The total rate of reoperations and further cervical surgeries during the follow-up of average of 14 years was:

  • Seven patients out of 38 (18%) in the total disc replacement group and
  • Six patient out of 76 (8%) in the Anterior cervical discectomy and fusion group.
  • Total disc replacement patients were re-operated earlier, and the 5-year reoperation rate was significantly higher in the total disc replacement group (11% vs. 1.3%.
    • None of the total disc replacement patients underwent further cervical surgery more than six years after index surgery, whereas 5/6 (83%) of the re-operated ACDF patients were re-operated after that time.
  • There were no significant differences in pain and disability index scores between the patient groups.
  • The employment rate and health-related quality of life were slightly higher in the total disc replacement group, but the differences were statistically non-significant.

The researchers concluded, that in long-term outcomes there were not much differences but did note: “total disc replacement patients were reoperated earlier, and the 5-year reoperation rate was significantly higher in the total disc replacement group”

Anterior cervical discectomy and arthroplasty (replacement) to anterior cervical discectomy and fusion discectomy. One-level surgery, which is better?

  • Anterior cervical discectomy and arthroplasty (replacement).  Surgery from the front that removes the disc and replaces it with an artificial disc.
  • Anterior cervical discectomy and fusion. Surgery from the front that uses bones and metal to fuse the vertebrae together to limit motion. In Discectomy the disc is removed and replaced by boney fragments.

In January 2022 a team of researchers from leading neurosurgery university medical centers in the Netherlands with analysis help from Brigham and Women’s Hospital, and Harvard Medical School (5) examined data from 251 patients who were included in two randomized, double-blinded clinical trials comparing clinical results of anterior cervical discectomy and arthroplasty (replacement) to anterior cervical discectomy and fusion, and anterior cervical discectomy, for single-level disc herniation.

The study aimed to investigate whether the anterior cervical discectomy and arthroplasty procedure offer superior clinical results 2 years after surgery, to either anterior cervical discectomy and fusion or anterior cervical discectomy without instrumentation, in the entire group of patients or in a particular subgroup of patients.

Results: “After combining data from two Randomized Controlled Trials it can be concluded that there is no clinical benefit for anterior cervical discectomy and arthroplasty when compared with anterior cervical discectomy and fusion or anterior cervical discectomy two years after surgery. Preliminary subgroup analysis indicated outcomes were similar between treatment groups, and that no subgroup could be appointed that benefited more from either anterior cervical discectomy, anterior cervical discectomy, and fusion, or anterior cervical discectomy and arthroplasty ”

Less lower dysphagia (swallowing)/dysphonia(speaking) problems seen in artificial cervical disc replacement groups

A July 2022 comparison study in the journal International orthopedics (6) found that better overall success, neurological success, and improved NDI (Neck Disability Index score) success rates were found in the artificial cervical disc replacement group in all follow-up periods of this study, with lower dysphagia (swallowing)/dysphonia(speaking) problems during short-term follow-up. The researchers also suggested that lower adjacent segment disease was found in the artificial cervical disc replacement group during long-term follow-up and overall analysis, with lower reoperation rates in all follow-up periods.

The complication rate of one surgery versus the other is about the same

A June 2020 comparison study in the journal Orthopaedic surgery (7) compared the efficacy and safety of the postoperative long-term effect of the treatment of single-level cervical spondylosis through anterior cervical discectomy and fusion (ACDF) and artificial cervical disc replacement (ACDR).

  • In this study, 113 patients were divided into two groups depending on the operation anterior cervical discectomy and fusion (ACDF) and artificial cervical disc replacement (ACDR). These patients were followed up for eight years (96 months). In both groups pain and disability scores improved In the last follow-up visit, six patients (12.77%) in the ACDR group and 18 patients (27.27%) in the ACDF suffered from adjacent segment degeneration (ASD). The researchers also noted: “The general complication rate in the replacement group and fusion group was 38.31% and 37.88%, respectively, but the difference between the two groups was not statistically significant. Overall, the surgical effectiveness and related complication rate of single-level cervical spondylosis after an anterior cervical approach operation was superior in the artificial cervical disc replacement group when compared to the anterior cervical discectomy and fusion group.

Still a question of long-term results

A January 2022 study from the Rothman Institute at Thomas Jefferson University published in the journal World Neurosurgery (8) also assessed rates of adjacent segment degeneration, adjacent segment disease, and reoperation rates as a result of adjacent segment pathology in patients who have undergone anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty. This study concluded that cervical disc arthroplasty results in significantly lower adjacent segment degeneration, adjacent segment disease, and reoperation rates. Although cervical disc arthroplasty may be a viable alternative to ACDF, further long-term studies are warranted to ensure consistency and establish the longevity of our findings.

Anterior cervical discectomy and fusion, cervical disc replacement, and posterior cervical foraminotomy

A September 2019 study in the journal World Neurosurgery (9) “evaluated clinical and radiologic results as well as biomechanical changes after anterior cervical discectomy and fusion, cervical disc replacement, and posterior cervical foraminotomy. (a minimally invasive surgical procedure performed from the back) and/or discectomy in individuals with unilateral single-level cervical radiculopathy.

  • A total of 97 patients received surgical treatment for unilateral intolerable radiculopathy.
  • Clinical outcomes included pain scores for neck and arm pain, neck disability scores, and modified Odom’s criteria (A scoring system to assess the outcome of the cervical surgery.)
  • Also measured were the cervical spine range of motion for the whole cervical (C-ROM), operated segment (S-ROM), and upper and lower adjacent segments.

RESULTS:

  • A total of:
    • 55 anterior cervical discectomy and fusion,
    • 21 cervical disc replacements, and
    • 21 posterior cervical foraminotomies were performed.
  • Clinical improvement in neck disability and pain was significant after surgery; however, there was no statistical significance among the groups.
  • Satisfaction rate
    • posterior cervical foraminotomy (76.2%)
    • anterior cervical discectomy and fusion (90.9%) and
    • cervical disc replacement (90.5%) without statistical difference.
  • Range of motion was reported as only slightly better in the cervical disc replacements and posterior cervical foraminotomy groups, without statistical significance. The complete range of motion significantly increased in cervical disc replacement, and slightly increased in the posterior cervical foraminotomy group as compared to the results of the anterior cervical discectomy and fusion group, where the cervical range of motion decreased.

Comparatively:

  • Anterior cervical discectomy and fusion provide the lowest reoperation rate.
  • Cervical disc replacement is effective in ameliorating the cervical range of motion.
  • Posterior cervical foraminotomy has a greater probability of reoperation; however, the range of motion after surgery is better than with anterior cervical discectomy.

Yet within the medical community is a debate about what is considered successful cervical artificial disc replacement, when cervical artificial disc replacement should be chosen over anterior cervical discectomy with fusion, and when patients should reconsider the surgical recommendation.

A comparison of surgical techniques – fusion vs. disc replacement – is about motion

If you have been recommended for a disc replacement fusion surgery, one of the main aspects of this recommendation is your need to have some type of movement in your neck and that you are a candidate for this type of surgery.

We are going to explore a June 2020 study from the Department of Neurosurgery, Medical College of Wisconsin. It was published in the Journal of the Mechanical Behavior of Biomedical Materials. (10) Let’s let the surgeons explain the differences and comparisons between anterior cervical discectomy and fusion and cervical disc arthroplasty or replacement:

“Surgical treatment for spinal disorders, such as cervical disc herniation and spondylosis, includes the removal of the intervertebral disc and replacement of biological or artificial materials. In the former case, a bone graft is used to fill the space, and this conventional procedure is termed anterior cervical discectomy and fusion. The latter surgery is termed artificial disc replacement or cervical disc arthroplasty. Surgeries are most commonly performed at one or two levels.”

Range of motion and anterior and posterior load sharing

The question that these researchers were asking in this study was to determine the external (range of motion, ROM) and internal (anterior and posterior load sharing) responses of the spines with one-level and two-level surgeries in both models (anterior cervical discectomy and fusion and cervical disc arthroplasty/replacement).

“Results for both one-level and two-level surgeries showed that anterior cervical discectomy and fusion decreases the range of motion at the index level (the surgery segments or levels), while cervical disc arthroplasty/replacement increases motions compared to the intact normal spine.

The ROM, anterior column load (pressure on the front-facing part of the cervical vertebrae), and  posterior column load (pressure on the rear part of the cervical vertebrae) increased at both adjacent levels for the anterior cervical discectomy and fusion while cervical disc arthroplasty/replacement showed a decrease.”

Suspected facet joint disease after surgery

“Although two-level surgeries resulted in increased these biomechanical variables, greater changes to adjacent segment biomechanics in anterior cervical discectomy and fusion may accelerate adjacent segment disease. Decreased ROM and lower load sharing in cervical disc arthroplasty/replacement may limit adjacent segment effects such as accelerated degeneration. Their increased posterior load sharing, however, may need additional attention for patients with suspected facet joint disease.”

So to recap. The benefit of cervical disc arthroplasty/replacement surgery is a better range of motion and less risk of Cervical adjacent segment disease, as compared to traditional cervical spine fusion. However, cervical disc arthroplasty/replacement surgery may accelerate facet joint disease. Let’s again refer to the research above. “Cervical disc replacement may not recreate a normal range of cervical spine motion.” Just having more range of motion is not beneficial if it is creating a hypermobile situation that is causing the development of osteoarthritis and bone spurs.

“The complications after total disc replacement surgery are thought to be caused by inadequate natural movement restoration.”

In research from the Department of Orthopedic Surgery, Newton-Wellesley Hospital/Harvard Medical School, published in the Journal of Orthopaedic Translation, July 2019, (11) doctors wrote: “The subaxial cervical spine (C3, C4, C5, C6, C7) is the most mobile region of the cervical spine, allowing positioning of the head in a multitude of positions for various activities of daily living. As the discs degenerate, the relationship between alteration in kinematics (natural motion), resting alignment, and symptom development are not clear.”

(Explanatory note: As cervical degenerative disease occurs, it is not clear what causes the development of the person’s pain challenges or what causes one person to have symptoms of cervical spine degenerative disease, and why another person with a similar degenerative disease will have no symptoms.)

  • The research continues: “Surgical treatment of disc degeneration not responding to conservative measures with anterior cervical discectomy with fusion has been the gold standard although concern remains regarding the development of adjacent segment disease. Although total disc replacement (TDR) and other motion-preserving technologies are becoming popular alternatives that are capable of restoring the cervical spine motion, recent follow-up studies indicated that symptomatic adjacent segment degeneration is not eliminated and reoperation rates of approximately 9% were reported at 24 months after surgery. The complications after total disc replacement surgery are thought to be caused by the inadequate restoration of the in vivo (within) intervertebral kinematics of the affected segments.” (Note: How the c3-c7 segment moves after surgery).

Again, what the research suggests is that:

  • For some patients, symptomatic adjacent segment degeneration is not eliminated and reoperation rates of approximately 9% were reported 24 months after surgery.
  • The complications after total disc replacement surgery are thought to be caused by inadequate natural movement restoration

Returning to the research:

  • “Simply understanding ranges of motion (ROMs) does not capture the quality of normal cervical motion, nor does it allow appreciation for the change in the quality of motion associated with disease development and restoration of quality motion through surgical treatment.”

The researchers of this study concluded that: “the subaxial cervical intervertebral center of rotation (the place where the vertebra anchors itself to support rotation) and range of motions were segment level- and neck motion-dependent. (Each vertebra had its own unique rotation and motions and fusing or replacing one or multiple segments will impact other non-surgical treated segments). This may help to improve the artificial disc design as well as a surgical technique by which the neck functional motion is restored following the cervical arthroplasty.”

In other words, there is a concern that cervical spine disc replacement surgery does not restore the normal motion of the cervical spine in some patients and that this lack of normal motion can cause post-surgical complications and complaints. Doctors should look for ways to make the neck move more naturally. If they can, the better the chance the surgery, or any treatment will have for achieving better success.

A successful disc replacement surgery, but I have remaining symptoms

This is an email we received. It is reflective of many. This email has been edited for clarity.

 “I had cervical disc replacement at  C4-5, C6-7 for severe neck pain and numbness of the left thumb and pointer finger. I have been recovering and doing physical therapy yet my neck is still very stiff and depending on the day or movement pain still radiates down my shoulders to my fingers. I’ve seen several doctors and feel that I’m not getting any help. I have several other symptoms I feel related to my neck. My spinal cord was pinched for several years. At times I have POTS-like symptoms, depending on the position of my neck it changes my sinuses and breathing. Constant headache above the left eye and pressure around the eye, bright lights, and sudden movements cause head pressure. I also get very lightheaded just when standing or driving which is very scary. I feel something isn’t right with my atlas. It worsens as the day goes on or if I don’t lay down periodically.”

Is this reflective of a successful procedure? Let’s look at more research.

About 1 in 50 need the disc replacement removed

A January 2021 study in the Global Spine Journal (12) examined the outcomes of 3,350 people who had elective primary Anterior Cervical Disc Arthroplasty surgery between  2008 – 2017.

  • Of the 3,350 patients, 69 patients had revision surgery requiring the removal of the disc replacement.
  • The most common reasons for revision surgery included cervical spondylosis or continued cervical spine degenerative disease (59.4%) and mechanical complications(27.5%).
  • After the removal of the disc replacement, common procedures performed included anterior cervical fusion with or without decompression(69.6%), combined anterior/posterior fusion/decompression (11.6%), and replacement of the disc replacement (7.2%).
  • Patients requiring revision surgery for mechanical complications or those who underwent a combined surgical approach were at significantly higher risk for subsequent short-term complications.

A successful fusion surgery, but I have remaining symptoms

What constitutes a successful fusion surgery? For most people it is a noticeable difference in quality of life. In May 2023, surgeons in Sweden published their findings in the journal BMC musculoskeletal disorders (37) of patient reported outcomes with an up to twenty year follow up in fifty patients.

Here are some of the summary highlights:

  • Two surgical procedures were compared: the Cloward Procedure and the carbon fiber fusion cage. There was no significant differences reported between the two procedures.
  • On average, patients reported bot pain and disability remained improved during this 20-year period.
    • 71% of participants had a clinically relevant improvements in pain compared to 41% in disability, and 88% were improved according to in global outcome ratings (overall health assessment).
  • People continued to have improvement in pain well after 10 years following the surgery, however disability did not share that same result.
    • The researchers noted this might be due to participants with pain who continue to live their lives in a somewhat limited way (they reduced their pain by altering their movements), thus reducing the mechanical strain on the neck, but with a consequent impact on daily life.
    • Most participants were also retired from work, possibly reducing the strain on the neck, and subsequently their pain ratings.
    • A few participants had additional surgeries and this may have altered the group means to the better.

Returning to work

Research led by the Department of Neurosurgery, St. Olav’s University Hospital, and the Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology investigated the likely outcomes for returning to work following cervical radiculopathy surgery. This research appeared in a February 2023 study in the journal Spine (13)

In this study, approximately half of the patients returned to work within four months, and the positive trend continued throughout the first year, by which 66.9% of the patients had returned to work. By the third year after surgery, the number of people working three years later was about equal to the number of people who were working before the surgery. People who took fewer sick days pre-surgery tended to have better success returning to work after surgery. The doctors here did note: “Although we observed a substantial improvement in disability and pain after surgery in all groups, the rate of return-to-work among the same population was disproportionally lower than expected from the clinical improvement.” Having more trouble returning to work was seen in female patients more so than men.

The number of people who get cervical fusion surgery when the cervical disc replacement fails

A March 2021 paper in the journal Neurospine (14) comes from researchers at the Department of Neurosurgery, the University of Campinas in Brazil, and the Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian. The researchers here reviewed previously published studies on the outcomes and need for revision surgeries at the index (or primary)  level after cervical disc arthroplasty failure. The minimum follow-up for these studies was 5 years.

  • Results: From a total of 4,087 patients, 161 patients required reoperation at the index level.
  • A total of 170 surgeries were performed, as some patients required multiple surgeries.
  • The most common secondary procedures were anterior cervical discectomy and fusion (ACDF) (68%, 61 patients) and posterior cervical fusion (15.5%, 14 patients), followed by other reoperation (13.3%, 12 patients). The associated outcomes for those who required revision surgery were rarely mentioned in the included literature. (The researchers noted the lack of long-term follow-up on the outcomes of the patients needing revision surgery).

The long-term revision rate at the index level of failed cervical disc arthroplasty surgery was 3.9%, with a minimum 5-year follow-up. Anterior cervical discectomy and fusion was the most commonly performed procedure to salvage a failed cervical disc arthroplasty. Some patients who required a new surgery after cervical disc arthroplasty failure may require a more extensive salvage procedure and even subsequent surgeries.

Repeat anterior cervical discectomy and fusion or repeat cervical artificial disc group can be performed

A 2021 paper (15) from surgeons at the Chang Gung Memorial Hospital at Keelung, Department of Orthopedic Surgery in Taiwan analyzed 3,957 patients who had a disc replacement surgery of which 182 underwent revision/removal of the artificial disc and 3,775 underwent revision or removal of fusion.

  • Up to 4.6% of patients in the repeat anterior cervical discectomy and fusion group had a complication, compared to 0.5% in the cervical artificial disc group.
  • The 30-day readmission rate was found to be similar between the two groups (repeat-anterior cervical discectomy and fusion 3.8% vs. repeat-cervical artificial disc group, 2.2%.
  • Similarly, the 30-day reoperation rate was also not found to be different between the two groups (repeat-anterior cervical discectomy and fusion, 3.9% vs. repeat-cervical artificial disc group, 2.7%).
  • On multivariable analysis, removal or revision of anterior cervical discectomy and fusion was found to be only significantly associated with an increased risk of 30-day complications.

Conclusion: Repeat anterior cervical discectomy and fusion or repeat cervical artificial disc group can be performed safely and are associated with optimal 30-day outcomes, comparable to those of index procedures. However, patients undergoing revision anterior cervical discectomy and fusion may be slightly more likely to have complications than those undergoing revision cervical artificial disc group.

The hybrid fusion disc replacement surgery option for patients who are not good candidates for disc replacement

An October 2021 study in the Global Spine Journal (16) comes from The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center doctors. Here they write: “Although cervical disc arthroplasty has become a well-established and effective treatment for symptomatic cervical degeneration, many patients with the multilevel disease are not good candidates for cervical disc arthroplasty at all levels. For such patients, a hybrid surgery-a combination of adjacent anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty-may be more appropriate.” The researchers noted that the hybrid surgery of adjacent anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty is somewhat novel and there is not much by way of patient outcomes following the procedure. In this paper questions about the short-term morbidity profile of the hybrid surgery, differences in operative duration, length of hospital stay, and readmission and reoperation rates were gathered and compared to a 2-level ACDF alone, patient group.

In this study, 390 patients undergoing hybrid surgery were followed.

  • Two-level procedures were the most common (74.9%).
  • Patients undergoing hybrid surgery were more likely to be younger, male, and have fewer comorbidities.
  • There were no differences between hybrid surgery and 2-level ACDF in rates of any postoperative complication, transfusion, readmissions, and operative duration. However, hybrid surgery had a decreased length of hospital stay (one-half day on average), relative to a 2-level ACDF.
  • Hybrid surgery patients had low rates of reoperation (1.28%).

If you can make the neck move more naturally, the better the chance treatment will have in achieving success.

One of the controversial issues surrounding cervical neck surgery is the movement and range of motion, or lack thereof, of the cervical spine following neck surgery. Even in artificial disc surgery, there is a question as to how much, natural movement can be restored. In the above research and the research below, a key benefit is the improved range of motion with a disc replacement.

Cervical disc replacement may not recreate the normal range of cervical spine motion. This may cause problems down the road.

As we will see in the research below, one of the given benefits discussed with surgical candidates for cervical disc replacement is a better range of motion in the neck compared to the traditional fusion. We will explore just how much better it is or is not in the surgical studies we are presenting here.

One of the problems that patients seek to solve with a cervical disc replacement is the abnormal motion that they are already suffering from in their neck which is causing them many challenges. They have hope that surgery will remedy this problem. For some people, this may be a false hope.

Significant posterior bone spur at C6 vertebra shortly after a C5-C6 disc replacement surgery

The caption of the below image reads Significant posterior bone spur at C6 vertebra shortly after a C5-C6 disc replacement surgery. Unfortunately for this patient, the bone spur formed because of instability after the disc replacement. This bone spur caused impingement of the anterior spinal cord and blocked CSF Cerebrospinal Fluid, causing the need for a spinal fusion.

Anterior bone boss following cervical disc replacement is characteristic of increased cervical lordosis

A July 2022 paper in the journal World Neurosurgery (17) discusses how anterior bone boss following cervical disc replacement is characteristic of increased cervical lordosis (excessive curvature in the neck-forward head type posture). Here is what this team of neurosurgeons wrote:

“Although cervical disc arthroplasty has reportedly been associated with similarly low incidences of complications to anterior cervical discectomy and fusion, the phenomenon of anterior bone loss is unique to cervical disc arthroplasty and has only recently gained notice.”

In investigating the anterior bone loss phenomenon, these researchers looked at patients who received cervical disc arthroplasty for herniated disc or spondylosis.

  • A total of 41 patients were analyzed with an average follow-up of 24.1 months.
  • All patients (41 of 41 = 100%) had bone loss of various degrees, with grade 3 anterior bone loss the most common (30 of 41 = 73.1%). In this instance, the researchers described grade 3 as bone loss significant enough at the front of the vertebrae that the disc replacement became exposed).
  • More than half of the patients (26 of 41, 63.4%) in the series suffered from cervical lordosis.

Heterotopic ossification is a common complication

Heterotopic ossification is abnormal bone growth that can occur weeks after surgery. The bone grows within the cervical muscles and soft tissues including the cervical spine ligaments.

A November 2021 study in the Journal of Orthopaedic Surgery and Research (18) explains the concerns of some doctors: “Heterotopic ossification is a common complication after cervical disc replacement. Biomechanical factors including endplate coverage and intervertebral disc height change may be related to Heterotopic ossification formation. However, there is a dearth of quantitative analysis for endplate coverage, intervertebral height change, and their combined effects on Heterotopic ossification.”

What the researchers are suggesting is that the artificial disc did not provide ample coverage of the cervical vertebrae endplates. This possible degenerative wear condition may be causing changes to the disc height and instability. Where there is instability, there is typically bone overgrowth.

Here is what the researchers discussed: “Patients who underwent single-level or two-level cervical disc replacement with Prestige-LP ( a specific artificial disc were retrospectively (post-surgery) reviewed.

  • A total of 138 patients with 174 surgical segments were evaluated.
  • Both the prosthesis-endplate depth ratio and post-operative disc height change were predictive factors for heterotopic ossification formation.
  • Conclusions: “Inadequate endplate coverage and excessive change of intervertebral height are both potential risk factors for heterotopic ossification after cervical disc replacement. Endplate coverage of less than 93.8% of intervertebral height change of more than 1.8 mm would increase the risk of heterotopic ossification. (Comment it would not take much to cause complication). The combination of these two factors may exacerbate the non-uniform distribution of stress in the bone-implant interface and promote heterotopic ossification development.”

An October 2021 paper comes to us from the Department of Neurological Surgery, Washington University School of Medicine. It was published in the journal Neurosurgery clinics of North America. (19) This paper offers suggestions on the type of patients cervical artificial disc replacement may be most successful for.  Here is what the authors wrote:

  • “Cervical total disc replacement has a unique set of complications compared to anterior cervical discectomy and fusion proper patient selection and astute surgical technique can minimize the complication rate. As seen in other joint replacement procedures, heterotopic ossification and osteolysis (scar tissue formation) are common in cervical artificial disc replacement. Most of the time it is not symptomatic and only needs to be observed. Revision should be considered for complications that cause symptomatology. Oftentimes, revision motion-sparing procedures (ie, revision cervical artificial disc replacement or posterior foraminotomy) can be performed, however, revision fusion may be the best option in some cases.”

Heterotopic ossification- the growth of bone in the tendons, muscles, and soft tissue after cervical disc replacement

Heterotopic ossification is the unnatural formation of bone in the tendons, muscles, and other soft tissue. Speculation in the medical community is that the acquired form of heterotopic ossification can occur when a muscle is injured. Muscle is injured during surgery. Let’s look at the research:

Doctors wrote in the journal Medicine – (20)

  • The occurrence of Heterotopic ossification is an inevitable postoperative complication after cervical artificial disc replacement and can decrease the range of motion at the segment where the disc was replaced. This they note is “contrary to the fundamental goal of an artificial disc.”
  • Previous studies reported various results on the occurrence of Heterotopic ossification.
    • One study they cite reports 17.8% of Heterotopic ossification occurrence in studied patients at 12 months of follow-up
    • Another cited study reported that 78.6% of patients exhibited Heterotopic ossification at an average follow-up period of 43.4 months.
  • In this study, the results of Heterotopic ossification and severe Heterotopic ossification were grouped into different subgroups, and the pooled data showed that the prevalence of Heterotopic ossification after cervical artificial disc replacement was:
    • within 1 to 2 years after surgery = 38% with a condition of severe Heterotopic ossification reported in 10.9%
    • within 2 to 5 years after surgery, and = 52.6 with a condition of severe Heterotopic ossification reported in 22.2%
    • within 5 to 10 years after surgery = 53.6% with a condition of severe Heterotopic ossification reported in 47.5%

What causes this?

Doctors at the Spine Institute of Louisiana wrote in a June 2018 study in the International Journal of Spine Surgery (21) that it is difficult to understand why Heterotopic ossification happens.

  • Heterotopic ossification is a known risk following cervical total disc replacement surgery, but the cause and effect of Heterotopic ossification are not well understood. Reported Heterotopic ossification rates vary, (as in the research documented above)  and few studies are specifically designed to report Heterotopic ossification.
  • The findings (of this study) are limited for clinical decision-making because we cannot yet make causal inferences (a conclusion as to cause. The researchers concluded it happens, but they are not sure why it happens. Other researchers have pointed out that even if Heterotopic ossification occurs, many times it is asymptomatic and does not bother that patient at all.)
  • The rates of Heterotopic ossification were shown to progress over time, warranting further research into the relationship between Heterotopic ossification and inflammatory response.
  • There remains a paucity of literature analyzing potential surgical techniques and implant-specific causes of Heterotopic ossification following cervical total disc replacement surgery. Further analysis needs to be conducted to understand the significance and relationship between each of these possible predictors, and other potential predictors, such as adjacent-level degeneration, sagittal alignment, and operative levels.
  • Although spine surgeons have traditionally referred to Heterotopic ossification as clinically relevant (symptomatic) and nonrelevant (asymptomatic), this nomenclature (classification) appears to be founded on Range of Motion and does not impact clinical outcomes. Based on this analysis, the largest to date, it seems clear that Heterotopic ossification terminology should be more accurately defined as motion-restricting and non–motion-restricting.

We would like to point out that the possible causation is adjacent-level degeneration and possible problems with the cervical neck sagittal alignment. The cervical spine’s natural alignment or curve.

Adjacent segment degeneration was not merely a natural progression but with the pathological (disease-causing) process such as heterotopic ossification.”

A November 2023 twelve-year follow-up study in the European Spine Journal (22) looked at changes in adjacent segment degeneration (ASD) after cervical total disc replacement (CTDR) and identified the risk factors for adjacent segment degeneration (ASD).

Seventy-five 75 patients underwent cervical total disc replacement from February 2004 to December 2012, with a follow-up of an average of about 12.5 years.

  • Postoperative adjacent segment degeneration increased at 6 months and especially between 6 months to 2 years.
  • The majority of adjacent segments were C4/5 (33.6%) and C6/7 (34.2%), and adjacent segment degeneration of C5/6 had the highest incidence (61.5%).
  • The complications were implant migration, subsidence, and heterotopic ossification.

Conclusions: “After over 12-year follow-up of cervical total disc replacement, the occurrence of adjacent segment degeneration and heterotopic ossification had temporal synchronization (they occurred spontaneously and simultaneously). Adjacent segment degeneration was not merely a natural progression but with the pathological (disease-causing) process such as heterotopic ossification.”

What are we seeing in this image?

Below we see an image of a neck with a series of disc replacements. As we note in the image caption: Artificial joint replacement parts, in the case of this article, artificial discs, are stiff and rigid. In the supportive research noted in this image, these stiff and rigid parts are up to 500 times stronger than osteoarthritic cartilage. While the disc replacement is much stronger than the remaining natural structures, this imbalance can cause a structural breakdown in the neck. Maybe not enough to warrant a revision surgery, but a significant impact on neck pain and structure is just the same.

The imbalance of artificial components and surviving elements in the neck can cause daily joint forces to be transmitted to these weaker areas of the periarticular (the soft tissue surrounding the cervical spine) structures. This can cause the accelerated breakdown of this soft tissue and lead to neck pain and neck instability.

Below we see an image of a neck with a series of disc replacements. As we note in the image caption: Artificial joint replacement parts, of in the case of this article, artificial discs, are stiff and rigid. In the supportive research noted in this image, these stiff and rigid parts are up to 500 times stronger than osteoarthritic cartilage. While the disc replacement is much stronger than the remaining natural structures, this imbalance can cause structural breakdown in the neck. Maybe not enough to warrant a revision surgery, but a significant impact to neck pain and structure just the same.

Before we go further, let’s understand again that there are many people who get great benefits from cervical artificial disc replacement surgery. There are a lot of people who do well with the “hybrid” surgery of anterior cervical discectomy with fusion plus cervical artificial disc replacement surgery when multiple areas of the cervical spine are causing them pain. The people who have successful surgery are, however, not typically the patients that we see in our office. But we do see a lot post-surgery:

  • We see patients with new pain issues following the surgery that was supposed to resolve their old pain issues.
  • We see patients who feel that their cervical spine could be stronger and more stable following the surgery.

Generally, people who have had a successful cervical artificial disc replacement surgery will report problem situations like this:

  • I feel great, the nerve pain is much less. I do have spasms in my neck and shoulders. I cannot resume my old activities yet and it is somewhat frustrating. I have been in Physical Therapy for 6 months. I may need more surgery because the other discs are now showing compression. I am looking for other options moving forward.

Or,

  • I decided on hybrid surgery. I had C6/C7 fused with anterior cervical discectomy with fusion (ACDF). My surgeon recommended that to preserve a range of motion I get the artificial discs at C4 and C5. The surgery went well, I take muscle relaxants mostly, and painkillers sometimes. However, my neck does not feel strong and there is a concern that I may need more surgery.

A weakness in their ability to “hold their head up.”

The reason that these people come to our office is that they are exploring regenerative medicine treatments that may help them avoid further surgery by strengthening their cervical spine by way of addressing cervical ligament damage and weakness. We will discuss this below. They may also be in our office looking for ways to strengthen their cervical spine even after successful surgery but they feel something is not right. Some of these patients, recognize a weakness in their ability to “hold their head up.”

In this video, Ross Hauser explains how even after disc replacement surgery, cervical spine instability is not only present but has been made worse.

Again, let’s point out that many people get significant benefits from cervical disc replacement. These are the people we do not see in our office. We see the people who had disc replacement and continued or worsening problems.

A summary transcript and explanatory notes are below the video.

I’m seeing a lot more disc replacement patients with continued neck problems

  • We are seeing a lot more disc replacement patients because of the popularity of the surgery. Surgeons are using disc replacement as an alternative to cervical fusion surgery.

The belief is that disc replacement can provide stability as well as a more natural motion. For some people, this did not work out.

    • Some doctors believe that cervical disc replacement will be a better choice of surgery because they believe that the problem is from severe disc degeneration and what we’re finding is that, unfortunately, after they put in the disc replacement some of the time that area of the disc replacement doesn’t stabilize. What does this mean?
      • When a disc replacement is performed, the surgeons have to move or stretch the cervical spine ligaments. Sometimes after the surgery, those ligaments don’t tighten back up. This is why some people who had a disc replacement come in and feel just as bad or even worse after the surgery

At 1:10 of the video, Dr. Hauser shows on a Digital Motion X-ray (DMX) how one patient continued to suffer from cervical spine instability 

What is Dr. Hauser demonstrating with the tongue depressor?

In the video, (1:40) the patient with the disc replacement is moving their head forward. The DMX image is stopped so the cervical spine instability can be demonstrated.

  • When a person moves their head forward, the cervical vertebrae should line up in an anatomically correct position. In this case, the patient’s vertebrae do not line up.
  • Dr. Hauser uses the tongue depressor to show that the vertebrae do not line up in a straight line, it is a crooked line with space gaps – an unnatural distance or space between the vertebrae

DMX image of what Dr. Hauser is showing with the tongue depressor: (Note the bottom vertebrae, that is where the disc replacement is)

The person in this DMX image did not have the disc replacement that long ago. So the cervical spine instability see at C2 C3 C4 C5 C6 has probably been there for some time. This is why disc replacement at C6 did not help their neck problems at C2-C5

  • The person in this DMX image did not have the disc replacement that long ago. So the cervical spine instability seen at C2 C3 C4 C5 C6 has probably been there for some time. This is why disc replacement at C6 did not help their neck problems at C2-C5

Neck pain after C5-C6 disc replacement surgery
An introductory video discussion with Ross Hauser, MD

In this video, Ross Hauser, MD, explains pain after disc replacement surgery. These are the learning points:

  • The patients we see come in with cervical spine instability after cervical neck disc replacement.
  • Demonstrating from a still image from a patient’s Digital Motion X-ray – a situation of offset cervical vertebrae is shown.
  • In a situation of offset vertebrae, the cervical ligaments that hold the vertebrae are so loose and weak that the vertebrae float away from each other. In this video, the situation is demonstrated with problems at C5 – C6 following a disc replacement.
  • The patient suffered from symptoms of clicking, grinding, and muscle tension. The muscle tension is created to help protect the spinal cord from the floating instability of C5-C6.
  • The case documented in this video is very severe instability. If the patient’s muscles did not “clamp down,” on the unstable area, each time the patient looked down, the vertebrae would be pressing into the spinal cord and the nerves that pass through C5-C6.
  • Prolotherapy injections which are explained below, help tighten and strengthen the spinal ligaments. In this patient’s case, 6 – 8 treatments may be required.


Surgeons ask: “Are Controversial Issues in Cervical Total Disc Replacement Resolved or Unresolved?”

In the February 2018 issue of the Asian Spine Journal, (23) Neurologists in Korea published these findings in their paper: Are Controversial Issues in Cervical Total Disc Replacement Resolved or Unresolved?: A Review of Literature and Recent Updates.

Here are the summary findings and learning points:

  • Since the launch of cervical total disc replacement in the early 2000s, many clinical studies have reported better outcomes of cervical total disc replacement compared to those of anterior cervical discectomy and fusion.
  • However, cervical total disc replacement is still a new and innovative procedure with limited indications for clinical application in spinal surgery, particularly, for young patients presenting with soft disc herniation with radiculopathy and/or myelopathy.
  • In addition, some controversial issues related to the assessment of clinical outcomes of cervical total disc replacement remain unresolved.
  • These issues, including surgical outcomes, adjacent segment degeneration, heterotopic ossification, wear debris and tissue reaction, and multilevel total disc replacement and hybrid surgeries are common concerns of spine surgeons and need to be resolved. Among them, the effect of cervical total disc replacement on patient outcomes and adjacent segment disease is theoretically and clinically important; however, this issue remains disputable.

A September 2023 study in the Spine Journal (24) wrote: ” While cervical disc replacement (CDR) has been emerging as a reliable and efficacious treatment option for degenerative cervical spine pathology, not all patients undergoing cervical disc replacement (CDR) will achieve minimal clinically important difference (MCID) in patient-reported outcome measures (PROMs) post-operatively-risk factors for failure to achieve MCID in PROMs following cervical disc replacement (CDR) have not been established.”

In this paper, the researchers wanted to help establish certain risk factors that doctors could look for in helping to identify which patients may not benefit from cervical disc replacement. Failure to be of benefit was seen in the patient not achieving minimal clinically important difference from pre to post-surgery for pain, function, disability, and quality of life as measured through various standardized scoring systems.

  • A total of 154 patients were included and the majority of patients achieved minimal clinically important differences in pain, function, disability, and quality of life.
  • For those where surgery did not offer a minimum change in symptoms, these were seen as risk factors:
    • Predominant neck pain.
    • Myelopathy.
    • Anxiety was identified as a risk factor
    •  Cervical disc replacement (CDR) at levels C5-C7 was identified as a risk factor for failure to achieve minimal clinically important difference in disability for the late postoperative period.

Surgery for Cervical Discogenic Syndrome – only as a last resort?

Let’s start here with a 1995 paper (25) and bring the research currently to 2022. In 1995 the suggestion of sending people to surgery for cervical disc causing pain or cervical discogenic syndrome was somewhat controversial. In this 1995 paper Dr. Bruce S. Senter an orthopedic surgeon wrote: “In patients with persistent pain of the neck, head, shoulder, and periscapular area, the diagnosis of cervical discogenic syndrome should be considered. The intervertebral disc can be a source of persistent pain and the severity of the symptoms should dictate the treatment. Surgical intervention should only be considered as a last resort in someone with significant pain who has failed prolonged conservative therapy. The success of the surgical treatment of this entity is most closely linked to adequate patient selection and rigorous patient preparation.”

In the medical publication STAT PEARLS (26) housed at the National Center for Biotechnology Information, U.S. National Library of Medicine a 2022 update on treatment and patient selection is given with similarities in the message.

“There are many approaches to the management of cervical discogenic pain syndrome, which are dependent on the cause, severity, and clinical presentation. The initial approach is always aggressive nonsurgical treatment. This includes the use of NSAIDs, partial rest, proper posture, and body mechanics, along with home-based exercise programs. Spontaneous recovery is usually common within the first few weeks. Physical therapy should be focused on maintaining proper posture and body ergonomics. . . In some cases, patients with cervical discogenic pain syndrome may require cervical epidural injections or nerve root blocks to facilitate their participation in physical therapy. These interventions should be used as an adjunct to therapy and are not usually effective alone.

Patients who do not respond to appropriate conservative therapies and have persistent radicular pain, progressive neurologic deficits, motor weakness, or signs of cord compression may consider surgical intervention. Patients with discogenic neck pain can potentially benefit from anterior cervical discectomy and fusion surgery.”

Complications in neck surgery.

It is likely that you are like many people. You want someone experienced in the challenges you are facing to help you. This would be especially true in choosing a surgeon. Many people ask their surgeon, “How many of these surgeries have you done?” It is human nature to feel better when the surgeon reports more rather than less.

A February 2021 study published in Surgical Neurology International (27) examined the experience of cervical spine surgery as being a factor in reduced complication rates. What the study found was the experience of the surgeon did not matter. This study is here in this article not to question the surgeon’s experience, but because it gives the most recent list of complications and rates. The complications were examined for anterior cervical discectomy without fusion, anterior cervical discectomy and fusion, and anterior cervical disc arthroplasty and noted as:

  1. Dysphagia (swallowing difficulties).
  2. Dysphonia (difficulty speaking)
  3. Unintended durotomy (puncture of dura matter).
  4. Hyposthenia (extreme neck weakness)
  5. Hypoesthesia (Strange sensations to the sense of touch, numbness)
  6. Hematoma
  7. Horner’s syndrome (constriction of the pupil caused by injury to the facial nerves)

A February 2023 paper in the journal Spine (28) led by researchers at the Loma Linda University Medical Center compared the pre-surgery problems of patients with complications and reoperation rates after anterior cervical discectomy and fusion (ACDF), cervical disk arthroplasty (CDA), and posterior cervical foraminotomy (PCF) in patients being treated with cervical radiculopathy. The study assessed outcomes in 507 patients who underwent anterior cervical discectomy and fusion (ACDF), 507 underwent cervical disk arthroplasty (CDA), and 507 underwent posterior cervical foraminotomy (PCF).

  • Surgical site infection rates were highest after posterior cervical foraminotomy (PCF) (2.17%) compared with anterior cervical discectomy and fusion (ACDF) (0.20%) and CDA (0.59%) at 30 days and three months.
  • New-onset cervicalgia was highest following anterior cervical discectomy and fusion (ACDF) (34.32%) and lowest after posterior cervical foraminotomy (PCF) (22.88%) at three and six months respectively.
  • Revision surgeries were highest among those who underwent cervical disk arthroplasty (CDA) (6.90%) versus anterior cervical discectomy and fusion (ACDF) (3.16%) and posterior cervical foraminotomy (PCF) (3.55%) at six months.
  • Limb paralysis was significantly higher after posterior cervical foraminotomy (PCF) compared with cervical disk arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) at six months.

Injury to the vagus nerve

Please see my article, Inappropriate Sinus Tachycardia – Elevated heart rate and the vagus nerve, for a more detailed discussion of this topic.

In December 2023, doctors from the Department of Neurosurgery, St Luke’s University Health Network reported a case history of vagus nerve damage from anterior cervical discectomy and fusion (ACDF) in the North American Spine Society journal. (29) Here is a summary of the paper’s authors.

“The surgical approach of an anterior cervical discectomy and fusion (ACDF) navigates many important neurologic and vascular structures in the neck. More frequently reported complications are dysphagia (swallowing difficulties), postoperative hematoma, cerebrospinal fluid leaks, and dysphonia issues with the voice).”

This case report details an anterior cervical discectomy and fusion (ACDF) in a 49-year-old woman. She had previously been diagnosed with fibromyalgia and rheumatoid arthritis with acute worsening of chronic neck pain and radicular symptoms. She complained of decreased strength and dexterity. Her symptoms were affecting her sleep and daily routines.

She decided on surgery and underwent an ACDF of levels C4–C7.

Following the surgery she had the common issues of postoperative pain, muscle spasm, and swallowing discomfort, which all improved significantly a few days after. “However, she experienced periodic episodes of sustained sinus tachycardia ranging from heart rates in the 100 to 110 seconds while resting and with spikes up to 150 seconds with exertion prompting a cardiology consult.” Nothing could be found and the women went home with scheduled cardiology and neurosurgery visits.

After a few months of continued rapid heart rate episodes; “The patient underwent a vagus nerve ultrasound demonstrated a thickened and hypoechoic vagus nerve one inch inferior to the skin incision. . . .The findings suggest neuropathy perhaps due to local scar tissue formation.” At this point, because of the vagus nerve injury, the patient’s tachycardia was managed with beta-blockers.

The neck just decided to fuse itself following a disc replacement

Spontaneous fusion is considered a somewhat rare phenomenon following a cervical disc replacement. But it happens. The point that we stress in our patients is that the neck is always trying to stabilize itself. One way it does this is by the formation of bone spurs. Here in this patient, a patient who had cervical disc replacement, his neck decided that the disc replacement was not providing enough stability so the neck fused over it.

Let’s take a look at a case history presented in June 2020 in the Journal of Pain Research (30) by the attending physicians of a patient whose neck decided to fuse itself.

A 63-year-old man presented to the case authors with a 6-month history of progressive neck pain and developed left C-7 radiculopathy 4 years ago. Magnetic resonance imaging revealed disc herniation at the C6–C7 levels resulting in compression of the left C-7 nerve root.

The patient underwent cervical disc replacement at the C6–C7 levels. He failed to follow up regularly as recommended postoperatively because he was completely free from the pain in his neck and left upper limb.

Four years later, he was readmitted with a 2-month history of occasional neck stiffness. Plain radiographs indicated complete radiographic fusion of the C6–C7 levels with trabecular bone bridging surrounding the cervical disc prosthesis, and dynamic imaging showed no motion.

He was seen at regular follow-up visits for up to 60 months without special treatment, as his symptoms of neck stiffness were minor and his symptoms have not worsened since then.

Here again, we have a successful cervical disc replacement. The patient developed fusion and lost range of motion but had no significant pain. His body decided to just fuse itself and save him from another procedure.

In this video, Danielle R. Steilen-Matias, MMS, PA-C explains the challenges of adjacent segment disease

Summary transcript

  • We often get calls from patients who already had a cervical spine fusion or neck fusion surgery and are still suffering from the symptoms that sent them to the surgery in the first place, or, from patients for whom the cervical fusion helped initially, but the pain relief did not last and any relief was temporary.
  • Some patients did not have a full understanding of what the fusion outcome will be. The segment that is fused does not move. Yet the patient still has to do their best to have normal neck movement. They have to move their head. They want to look down and look up and move their heads in a normal way.
  • When you have had a neck segment fused, the segments above and below the fusion have to take on the extra stress of providing as normal neck movement as possible and they are overworked and develop adjacent segment disease, a rapid deterioration of the cervical spine.

A case presented

  • A female patient came in whom I treated. She had undergone two cervical fusions into the lower cervical spine.  We did a DMX or digital motion x-ray which is explained and illustrated below to look at how unstable her neck was and we could see that the segment above her fusion was unnaturally moving all over the place. She had fusion surgery 8 years ago, so this constant strain and degenerative wear and tear condition have been going on for some time. When she came in for her treatments, the symptoms she described were similar to the symptoms she had experienced 8 years prior that led to her initial fusion surgery. A lot of neck pain, muscle tightness from muscle spasms, and pain running down her arm from the vertebrae pinching on the cervical nerves.
  • In her case, we determined that she would likely respond very favorably to Prolotherapy injections to stabilize the segment of her cervical spine instability.

Cervical spinal alignment and curvature after disc replacement surgery

Let’s point out again that people can have good success with cervical disc replacement. In some instances, documented in the studies we will cite below, the disc replacement helped restore, in part, the natural alignment of the neck. In others, the artificial disc caused an unnatural curve and alignment in the neck that caused complications.

This is the progression of cervical neck instability. The neck has a natural “backward C” shape. Cervical instability causes a normal lordotic curve to end up as an “S” or “Snake” curve, or cervical dysstructure.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability
While people have good success with cervical disc replacement, in some instances, documented in the studies we will cite in this article, the disc replacement helped restore, in part, the natural alignment of the neck. In others, the artificial disc caused an unnatural curve and alignment in the neck that caused complications. This image helps document the type of changes that can occur in the cervical spine.

In the European Spine Journal (31), medical university researchers in Italy researchers examined alignment at the cervical spine in patients following cervical disc replacement surgery.

Here is what they wrote:

“The alignment at the cervical spine has been considered a determinant of degeneration at the adjacent disc, but this issue in cervical disc replacement surgery is poorly explored and discussed in this patient population. The aim of this systematic review is to compare anterior cervical fusion and total disc replacement in terms of preservation of the overall cervical alignment and complications.”

“In most of the retrieved studies, a tendency towards a more postoperative kyphotic alignment in total disc replacement was reported. The reported mean (average) complication rate was 12.5 % (0% in some research up to 66.2 % in other research). Complications associated with cervical prosthesis included heterotopic ossification, device migration, mechanical instability, failure, implant removal, operations, and revision.

“Even though cervical disc arthroplasty (replacement) leads to similar outcomes compared to arthrodesis (fusion) in the middle-term follow-up, no evidence of the superiority of cervical total disc replacement is available up to date. We understand that the overall cervical alignment after total disc replacement tends towards the loss of lordosis, but only longer follow-up can determine its influence on the clinical results.”


The importance of the cervical spine curve in alleviating pain

  • In this video, Dr. Hauser presents the case of one of our patients who came over from Europe. This case will illustrate how important the cervical curve is.
  • In many patients, we see the destruction of the cervical curve is just as challenging a problem as severe cervical spine instability.
  • This particular patient demonstrated symptoms following an airline flight 2 years ago.
    • Symptoms included Tinnitus, feeling that her head was in a vice, nasal stuffiness, and extreme sensitivity to light.
  • At 1:12 Dr. Hauser demonstrates a still image from the patient’s Digital Motion X-Ray. We see the loss of the cervical curve. This causes pressure and stretching of her spinal cord. This also alters the balance of her head on her neck and distributes the weight of the head in an unnatural manner. Further worsening symptoms. Dr. Hauser points out that the weight of the head will now stretch the cervical spine ligaments causing further cervical spine instability. The patient is in a significant degenerative condition.
  • At 3:07 of the video, you can see the patient’s neck motion under DMX x-ray.
  • The patient has severe cervical instability. The patient will require many Prolotherapy injections and help to correct the loss of her cervical curve.
  • Prolotherapy is an injection therapy given over many sessions. Normally we see patients every 4 to 6 weeks.

Surgical treatments for Cervical Instability – the disc may not be the problem causing pain, loss of cervical curvature, and loss or range of motion

In our practice, we see many patients, not only with neck pain and radiating pain into the back, shoulders, arms, and hands but also with a myriad of symptoms related to cervical neck problems that doctors feel an artificial disc may help remedy, those related to degenerative cervical disc disease including problems of pinched nerves.

cervical degenerative ligament disease
When spinal ligaments are exposed to continued compression or stress, they “Creep.” Creep is a medical condition that results from the deformity or elongation of the ligaments that hold the cervical spinal vertebrae in place. This is cervical neck instability.

CREEP – cervical degenerative ligament disease – why neck surgery fails

Some of the most debilitating conditions attributed to problems in the neck are those due to cervical instability caused by ligament laxity. What does this mean? It means that surgery may not address the problems you are experiencing in your neck.

When spinal ligaments are exposed to continued compression or stress, they “Creep.” Creep is a medical condition that results from the deformity or elongation of the ligaments that hold the cervical spinal vertebrae in place. This is cervical spine instability.

  • The surgery that cuts away the cervical vertebrae bone that is pressing on the nerves – does not correct or prevent CREEP recurrence
  • The surgery that will fuse the cervical vertebrae in place so the vertebrae do not shift out of place and press on the nerves again, MAY NOT be needed at all if CREEP can be repaired and prevented by the use of non-surgical regenerative medicine techniques.
    • Regenerative medicine injection techniques such as Prolotherapy explained below, work on the same understanding as fusion surgery, but with big differences.
    • The regenerative injections repair the ligaments.
    • The injections strengthen the ligaments’ ability to hold the vertebrae in their natural position. Which is what the fusion seeks to do.
    • The big difference is that with fusion surgery you will lose a great amount of ability to turn your head from side to side and up and down. In Regenerative medicine injections the treatment repairs and allows for this natural movement of your head.

Range of motion issues are in the ligaments

A study came out of the University of Waterloo in Canada and was published in the November 2017 edition of the Spine Journal. (32) Briefly here was the problem and the goal of the study:

Loose ligaments are not normal

  • Predicting the physiological (normal) range of motion (ROM) using a finite element (FE) model (a numeric scoring system) of the upper cervical spine requires the incorporation of ligament laxity.
    • COMMENT: The doctors understand that ligament laxity (CREEP) is a problem of stability and instability To come up with a scoring system to define the normal range of neck motion, you need to understand how loose ligaments are not normal.

Patients suffer from big problems caused by little damage to the ligaments

  • The effect of ligament laxity can be observed only on a macro level of joint motion and is lost once ligaments have been dissected and preconditioned for experimental testing.
    • COMMENT: It is hard on any level to accurately determine the amount of ligament damage to the amount of instability because even small injuries or damage, sometimes undetectable, cause big problems. This is what we call cervical ligament microinstability.

Patients suffer because Ligament laxity is a mystery

  • As a result, although ligament laxity values are recognized to exist, specific values are not directly available in the literature for use in finite element models.
    • COMMENT:  Ligament laxity is a mystery, defining it within mathematical equations for the scoring system is difficult. This is why cervical neck pain patients have a difficult time finding the right medical care. Their conditions if based on degenerative ligament disease are a mystery.

Patients suffer because cervical ligament laxity is a mystery


In this video, a demonstration of treatment is given

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

Treating cervical ligaments – published research from Caring Medical

In 2014 headed by Danielle R. Steilen-Matias, PA-C, our Caring Medical team published these findings in The Open Orthopaedics Journal. (33)

The capsular ligaments (the ligaments of the joint capsule) are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Such pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions such as disc herniation, cervical spondylosis, whiplash injury, whiplash-associated disorder, post-concussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome.

When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae.

  • In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.
  • In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain.
  • In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability.

Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.

Stabilizing the unstable neck – the case for treating ligaments with Prolotherapy

Back to our 2014 research headed by Danielle R. Steilen-Matias, PA-C, published in The Open Orthopaedics Journal. Here we outline that the problems of the cervical neck are not always problems of degenerative disc disease but problems of degenerative ligament disease. This explains why traditional treatments focused on the discs will not be successful in the long term.

The use of conventional modalities for chronic neck pain remains debatable, primarily because most treatments have had limited success. We conducted a review of the literature published up to December 2013 on the diagnostic and treatment modalities of disorders related to chronic neck pain and concluded that, despite providing temporary relief of symptoms, these treatments do not address the specific problems of healing and are not likely to offer long-term cures.

The objectives of this study are to provide an overview of chronic neck pain as it relates to cervical instability, to describe the anatomical features of the cervical spine and the impact of capsular ligament laxity, to discuss the disorders causing chronic neck pain and their current treatments, and lastly, to present Prolotherapy as a viable treatment option that heals injured ligaments, restores stability to the spine, and resolves chronic neck pain.

There are a number of treatment modalities for the management of chronic neck pain and cervical instability, including injection therapy, nerve blocks, mobilization, manipulation, alternative medicine, behavioral therapy, fusion, and pharmacologic agents such as NSAIDs and opiates. However, these treatments do not address stabilizing the cervical spine or healing ligament injuries, and thus, do not offer long-term curative options. In fact, cortisone injections are known to inhabit, rather than promote, healing.

Research on 21 patients with cervical instability and chronic neck pain

In our research published in the European Journal of Preventive Medicine, we presented the following findings:

  • Ninety-five percent of patients reported that Prolotherapy met their expectations in regard to pain relief and functionality. Significant reductions in pain at rest, during normal activity, and during exercise were reported.
  • Eighty-six percent of patients reported overall sustained improvement, while 33 percent reported complete functional recovery.
  • Thirty-one percent of patients reported complete relief of all recorded symptoms. No adverse events were reported.

We concluded that statistically significant reductions in pain and functionality, indicate the safety and viability of Prolotherapy for cervical spine instability. (34)

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

Please see related articles:

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your neck pain. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

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This article was updated January 10, 2024

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