Heterotopic ossification and radiographic adjacent-segment disease after cervical disc arthroplasty

Presented at the 2019 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

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OBJECTIVE

Cervical disc arthroplasty (CDA) is an accepted motion-sparing technique associated with favorable patient outcomes. However, heterotopic ossification (HO) and adjacent-segment degeneration are poorly understood adverse events that can be observed after CDA. The purpose of this study was to retrospectively examine 1) the effect of the residual exposed endplate (REE) on HO, and 2) identify risk factors predicting radiographic adjacent-segment disease (rASD) in a consecutive cohort of CDA patients.

METHODS

A retrospective cohort study was performed on consecutive adult patients (≥ 18 years) who underwent 1- or 2-level CDA at the University of Calgary between 2002 and 2015 with > 1-year follow-up. REE was calculated by subtracting the anteroposterior (AP) diameter of the arthroplasty device from the native AP endplate diameter measured on lateral radiographs. HO was graded using the McAfee classification (low grade, 0–2; high grade, 3 and 4). Change in AP endplate diameter over time was measured at the index and adjacent levels to indicate progressive rASD.

RESULTS

Forty-five patients (58 levels) underwent CDA during the study period. The mean age was 46 years (SD 10 years). Twenty-six patients (58%) were male. The median follow-up was 29 months (IQR 42 months). Thirty-three patients (73%) underwent 1-level CDA. High-grade HO developed at 19 levels (33%). The mean REE was 2.4 mm in the high-grade HO group and 1.6 mm in the low-grade HO group (p = 0.02). On multivariable analysis, patients with REE > 2 mm had a 4.5-times-higher odds of developing high-grade HO (p = 0.02) than patients with REE ≤ 2 mm. No significant relationship was observed between the type of artificial disc and the development of high-grade HO (p = 0.1). RASD was more likely to develop in the lower cervical spine (p = 0.001) and increased with time (p < 0.001). The presence of an artificial disc was highly protective against degenerative changes at the index level of operation (p < 0.001) but did not influence degeneration in the adjacent segments.

CONCLUSIONS

In patients undergoing CDA, high-grade HO was predicted by REE. Therefore, maximizing the implant-endplate interface may help to reduce high-grade HO and preserve motion. RASD increases in an obligatory manner following CDA and is highly linked to specific levels (e.g., C6–7) rather than the presence or absence of an adjacent arthroplasty device. The presence of an artificial disc is, however, protective against further degenerative change at the index level of operation.

ABBREVIATIONS ACDF = anterior cervical discectomy and fusion; AP = anteroposterior; ASD = adjacent-segment disease; CDA = cervical disc arthroplasty; HO = heterotopic ossification; NSAID = nonsteroidal antiinflammatory drug; rASD = radiographic ASD; REE = residual exposed endplate; ROM = range of motion.
Article Information

Contributor Notes

Correspondence R. John Hurlbert: University of Arizona, Tucson, AZ. rjhurlbert@surgery.arizona.edu.INCLUDE WHEN CITING Published online August 2, 2019; DOI: 10.3171/2019.5.SPINE19257.Disclosures Dr. Jacobs: consultant for Medtronic and Stryker.
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References
  • 1

    Buchowski JMAnderson PASekhon LRiew KD: Cervical disc arthroplasty compared with arthrodesis for the treatment of myelopathy. Surgical technique. J Bone Joint Surg Am 91 (Suppl 2):2232322009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Chen JWang XBai WShen XYuan W: Prevalence of heterotopic ossification after cervical total disc arthroplasty: a meta-analysis. Eur Spine J 21:6746802012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Cho HJShin MHHuh JWRyu KSPark CK: Heterotopic ossification following cervical total disc replacement: iatrogenic or constitutional? Korean J Spine 9:2092142012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Gornet MFBurkus JKShaffrey MENian HHarrell FE Jr: Cervical disc arthroplasty with Prestige LP disc versus anterior cervical discectomy and fusion: seven-year outcomes. Int J Spine Surg 10:242016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Hadley MN: The real value of cervical arthroplasty? J Neurosurg Spine 15:3453472011

  • 6

    Hilibrand ASCarlson GDPalumbo MAJones PKBohlman HH: Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am 81:5195281999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Hilibrand ASRobbins M: Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? Spine J 4 (6 Suppl):190S194S2004

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Hisey MSZigler JEJackson RNunley PDBae HWKim KD: Prospective, randomized comparison of one-level Mobi-C cervical total disc replacement vs. anterior cervical discectomy and fusion: results at 5-year follow-up. Int J Spine Surg 10:102016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Kim KSHeo DH: Do postoperative biomechanical changes induce heterotopic ossification after cervical arthroplasty?: A 5-year follow-up study. Clin Spine Surg 29:E309E3132016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Lee JHJung TGKim HSJang JSLee SH: Analysis of the incidence and clinical effect of the heterotopic ossification in a single-level cervical artificial disc replacement. Spine J 10:6766822010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Leung CCasey ATGoffin JKehr PLiebig KLind B: Clinical significance of heterotopic ossification in cervical disc replacement: a prospective multicenter clinical trial. Neurosurgery 57:7597632005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Luo JWang HPeng JDeng ZZhang ZLiu S: Rate of adjacent segment degeneration of cervical disc arthroplasty versus fusion meta-analysis of randomized controlled trials. World Neurosurg 113:2252312018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    McAfee PCCunningham BWDevine JWilliams EYu-Yahiro J: Classification of heterotopic ossification (HO) in artificial disk replacement. J Spinal Disord Tech 16:3843892003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Meisel HJJurák LAntinheimo JArregui RBruchmann BČabraja M: Four-year results of a prospective single-arm study on 200 semi-constrained total cervical disc prostheses: clinical and radiographic outcome. J Neurosurg Spine 25:5565652016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Noriega DCRamajo RHSánchez-Lite IToribio BDelen ESahin S: Heterotopic ossification in cervical disk surgery is still a problem. What are the key factors for a solution? World Neurosurg 96:5855902016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Nunley PDCoric DFrank KAStone MB: Cervical disc arthroplasty: current evidence and real-world application. Neurosurgery 83:108711062018

  • 17

    Nunley PDJawahar ACavanaugh DAGordon CRKerr EJ IIIUtter PA: Symptomatic adjacent segment disease after cervical total disc replacement: re-examining the clinical and radiological evidence with established criteria. Spine J 13:5122013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Nunley PDJawahar AKerr EJ IIIGordon CJCavanaugh DABirdsong EM: Factors affecting the incidence of symptomatic adjacent-level disease in cervical spine after total disc arthroplasty: 2- to 4-year follow-up of 3 prospective randomized trials. Spine (Phila Pa 1976) 37:4454512012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Park CKRyu KS: Are controversial issues in cervical total disc replacement resolved or unresolved?: A review of literature and recent updates. Asian Spine J 12:1781922018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Peduzzi PConcato JKemper EHolford TRFeinstein AR: A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 49:137313791996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Quan GMVital JMHansen SPointillart V: Eight-year clinical and radiological follow-up of the Bryan cervical disc arthroplasty. Spine (Phila Pa 1976) 36:6396462011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Radcliff KCoric DAlbert T: Five-year clinical results of cervical total disc replacement compared with anterior discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease: a prospective, randomized, controlled, multicenter investigational device exemption clinical trial. J Neurosurg Spine 25:2132242016

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Rao RDWang MMcGrady LMPerlewitz TJDavid KS: Does anterior plating of the cervical spine predispose to adjacent segment changes? Spine (Phila Pa 1976) 30:278827932005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Ryu KSPark CKJun SCHuh HY: Radiological changes of the operated and adjacent segments following cervical arthroplasty after a minimum 24-month follow-up: comparison between the Bryan and Prodisc-C devices. J Neurosurg Spine 13:2993072010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Sasso WRSmucker JDSasso MPSasso RC: Long-term clinical outcomes of cervical disc arthroplasty: a prospective, randomized, controlled trial. Spine (Phila Pa 1976) 42:2092162017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Wu TKWang BYDeng MDHong YRong XChen H: A comparison of anterior cervical discectomy and fusion combined with cervical disc arthroplasty and cervical disc arthroplasty for the treatment of skip-level cervical degenerative disc disease: a retrospective study. Medicine (Baltimore) 96:e81122017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Xu SLiang YZhu ZQian YLiu H: Adjacent segment degeneration or disease after cervical total disc replacement: a meta-analysis of randomized controlled trials. J Orthop Surg Res 13:2442018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Yang JJYu CHChang BSYeom JSLee JHLee CK: Subsidence and nonunion after anterior cervical interbody fusion using a stand-alone polyetheretherketone (PEEK) cage. Clin Orthop Surg 3:16232011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Zhou FJu KLZhao YZhang FPan SHeller JG: Progressive bone formation after cervical disc replacement: minimum of 5-year follow-up. Spine (Phila Pa 1976) 43:E163E1702018

    • Crossref
    • Search Google Scholar
    • Export Citation
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