Hybrid surgery: a comparison of early postoperative outcomes between anterior cervical discectomy and fusion and cervical disc arthroplasty

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  • 1 Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota;
  • | 2 Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota;
  • | 3 Mayo Clinic Alix School of Medicine, Rochester, Minnesota; and
  • | 4 Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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OBJECTIVE

Hybrid surgery (HS) is the combination of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) at different levels in the same operation. The aim of this study was to investigate perioperative variables, 30-day postoperative outcomes, and complications of HS in comparison with those of CDA and ACDF.

METHODS

The authors queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry for patients who underwent multilevel primary HS, CDA, and ACDF for degenerative disc disease from 2015 to 2019. The authors compared these three operations in terms of 30-day postoperative outcomes, specifically readmission and reoperation rates, discharge destination, and complications.

RESULTS

This analysis included 439 patients who underwent HS, 976 patients who underwent CDA, and 27,460 patients who underwent ACDF. Patients in the HS and CDA groups were younger, had fewer comorbidities, and myelopathy was less often the indication for surgery compared with patients who underwent ACDF. For the HS group, the unplanned readmission rate was 0.7%, index surgery–related reoperation rate was 0.3%, and nonroutine discharge rate was 2.1%. Major and minor complications were also rare, with rates of 0.2% for each. The mean length of stay in the HS group was 1.5 days. The association of HS with better outcomes in univariate analysis was not evident after adjustment for confounding factors.

CONCLUSIONS

The authors found that HS was noninferior to ACDF and CDA in terms of early postoperative outcomes among patients treated for degenerative disc disease.

ABBREVIATIONS

ACCF = anterior cervical corpectomy and fusion; ACDF = anterior cervical discectomy and fusion; ACS-NSQIP = American College of Surgeons National Surgical Quality Improvement Program; ASA = American Society of Anesthesiologists Physical Status Classification System; ASD = adjacent-segment disease; CDA = cervical disc arthroplasty; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; CPT = Current Procedural Terminology; DDD = degenerative disc disease; DVT = deep venous thrombosis; HO = heterotopic ossification; HS = hybrid surgery; ICD-10 = International Classification of Diseases, Tenth Revision; LOS = length of stay; ROM = range of motion; SSI = surgical site infection; VA = Veterans Affairs.

OBJECTIVE

Hybrid surgery (HS) is the combination of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) at different levels in the same operation. The aim of this study was to investigate perioperative variables, 30-day postoperative outcomes, and complications of HS in comparison with those of CDA and ACDF.

METHODS

The authors queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry for patients who underwent multilevel primary HS, CDA, and ACDF for degenerative disc disease from 2015 to 2019. The authors compared these three operations in terms of 30-day postoperative outcomes, specifically readmission and reoperation rates, discharge destination, and complications.

RESULTS

This analysis included 439 patients who underwent HS, 976 patients who underwent CDA, and 27,460 patients who underwent ACDF. Patients in the HS and CDA groups were younger, had fewer comorbidities, and myelopathy was less often the indication for surgery compared with patients who underwent ACDF. For the HS group, the unplanned readmission rate was 0.7%, index surgery–related reoperation rate was 0.3%, and nonroutine discharge rate was 2.1%. Major and minor complications were also rare, with rates of 0.2% for each. The mean length of stay in the HS group was 1.5 days. The association of HS with better outcomes in univariate analysis was not evident after adjustment for confounding factors.

CONCLUSIONS

The authors found that HS was noninferior to ACDF and CDA in terms of early postoperative outcomes among patients treated for degenerative disc disease.

In Brief

The objective of this paper was to investigate the perioperative complications of hybrid surgery (HS) compared with those of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA). The results indicated that HS is noninferior to ACDF and CDA in terms of early postoperative outcomes among patients treated for degenerative disc disease. This study adds to the evidence that equitable outcomes can be achieved after all three procedures if patients are selected appropriately.

Anterior cervical discectomy and fusion (ACDF) is a well-established treatment modality for degenerative disc disease (DDD) of the cervical spine, with patient satisfaction rates as high as 87%.1–3 However, limitations such as reduction in range of motion (ROM)4–6 and potential adjacent-segment disease (ASD) have inspired the development of motion-preserving techniques, such as cervical disc arthroplasty (CDA).7–9 The noninferiority of CDA to ACDF in terms of overall success has been documented repeatedly in randomized controlled trials.10–12 Nevertheless, CDA has not been definitively proven to decrease ASD compared with ACDF,13,14 it is often complicated by heterotopic ossification (HO),15 and it has several contraindications such as use at levels above C3 and for posterior element disease according to the US FDA.16

Hybrid surgery (HS) is a multidisciplinary surgical model in which CDA and ACDF are performed at different levels in the same operation. This technique enables tailored management of each disc level, such as preservation of disc height and ROM in one level but fusion in another.17–19 However, there is a scarcity of data to confirm the safety and effectiveness of HS compared with ACDF and CDA in the early postoperative period. To date, published studies report outcomes of relatively small cohorts, the level of evidence is low, and there is significant heterogeneity among results.20

In this study, we used the national multicenter American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry. Our aim was to describe the real-world status quo of HS in the management of DDD, and to illustrate a safety profile of HS in comparison with established operations.

Methods

Data Source

The ACS-NSQIP registry was built in the early 1990s, in response to public concerns regarding the quality of surgical care at Veterans Affairs (VA) hospitals; its purpose was to facilitate measurable improvement of care at 44 pilot VA hospitals. From 1991 to 2006, perioperative mortality at VA hospitals decreased by 43%.21 Currently, over 700 private and public hospitals participate in ACS-NSQIP. The registry contains 275 variables, including baseline patient characteristics, operative details, and 30-day postoperative complications. Data registration is performed by trained abstractors, and the overall disagreement rate is as low as 2%.22 The appropriateness of the 30-day milestone is well documented in surgical outcomes research, because most surgery-related complications present within this period.23,24

All patient data were de-identified; hence, this study was exempt from approval by our Institutional Review Board.

Inclusion and Exclusion Criteria

We queried the ACS-NSQIP registry from September 1, 2015, to December 31, 2019, for cases registered under Current Procedural Terminology (CPT) codes for ACDF (22551, 22554, and 63075) and CDA (22856) (Fig. 1). Subsequently, we excluded patients with 373 International Classification of Diseases, Tenth Revision (ICD-10), codes relevant to tumor, trauma, and infection because these pathological entities were beyond the scope of this study. We also excluded revision operations on the basis of the CPT codes (Table 1). We identified 132 CPT codes for ineligible operations, and we excluded 10,011 patients on the basis of these CPT codes. The two most common procedures that led to patient exclusion were anterior cervical corpectomy and fusion (ACCF) (n = 5566) and combined anteroposterior arthrodesis (n = 2401). This process yielded a total of 51,450 patients who underwent anterior arthrodesis and/or arthroplasty for degenerative disease of the cervical spine. Our next step was to exclude single-level surgical procedures and thereby homogenize our groups for comparison because, by definition, HS involves multiple levels. Our final cohort consisted of patients with CPT codes for only ACDF (ACDF group), CPT codes for only CDA (CDA group), and CPT codes for both ACDF and CDA (HS group). This study included all primary multilevel ACDF, CDA, and HS operations for DDD registered in ACS-NSQIP from 2015 to 2019.

FIG. 1.
FIG. 1.

Flowchart of cohort formation based on the inclusion and exclusion criteria. Some patients had more than one reason for exclusion.

TABLE 1.

CPT codes for ACDF, CDA, ACCF, posterior arthrodesis, and revision operations

Procedure or IndicationCPT Code
ACDF22551, 22554, 63075
CDA22856
Revision op22830, 22849, 22850, 22852, 22855, 22861, 22864, 0095T
ACCF63081, 63082, 22854
Posterior arthrodesis22590, 22600, 22614, 22840, 22841, 22842, 22843, 22844
Radiculopathy*M47.2, M47.20, M47.22, M47.23, M50.1, M50.10, M50.11, M50.12, M50.121, M50.122, M50.123, M50.13, M54.1, M54.10, M54.12, M54.13
Myelopathy*G99.2, M47.1, M47.10, M47.12, M47.13, M50.0, M50.00, M50.01, M50.02, M50.020, M50.021, M50.022, M50.023, M50.03

ICD-10 diagnostic codes as an indication for surgery are shown.

Endpoints

The primary endpoints of interest were unplanned readmission, reoperation related to index surgery, and major and minor complications within 30 days after surgery. Major complications included deep venous thrombosis (DVT) requiring therapy, pulmonary embolism, cardiac arrest requiring cardiopulmonary resuscitation, myocardial infarction, stroke/cerebrovascular accident, progressive renal insufficiency, acute renal failure, deep incisional surgical site infection (SSI), organ/space SSI, sepsis/septic shock, unplanned intubation, failure to wean from mechanical ventilation after 48 hours, and bleeding requiring transfusion. Minor complications included superficial incisional SSI, pneumonia, urinary tract infection, and wound dehiscence.25

The secondary endpoints were length of stay (LOS), nonroutine discharge, operative time, and all-cause mortality within 30 days. Home and facility that was home were considered routine discharge destinations; the remaining options were considered nonroutine, and included rehabilitation facility, hospice, separate acute care facility, skilled care facility that was not home, unskilled facility that was not home, and multilevel senior community.

Covariates

Covariates of interest were age, sex, BMI, race, ethnicity, inpatient versus outpatient status on admission, smoking status, comorbidities, indication for surgery, functional status, and physical status according to the American Society of Anesthesiologists Physical Status Classification System (ASA).26 Comorbidities included diabetes mellitus, hypertension, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), renal insufficiency requiring dialysis, disorders for which chronic immunosuppression was indicated, and bleeding disorders. To determine the indication for surgery, we used 16 ICD-10 diagnosis codes associated with radiculopathy and 14 ICD-10 codes associated with myelopathy (Table 1); the remaining patients were categorized with other degenerative indications.

Statistical Analysis

For univariate analysis of HS, CDA, and ACDF, we used chi-square analysis for categorical variables and ANOVA for continuous variables with Bonferroni correction for groups. To adjust for potential confounding factors when comparing the three groups, we performed multivariable analysis for all major and minor endpoints. We also performed multivariable linear regression for LOS in the HS group. All statistical analyses were performed using R version 4.0.2 (R Foundation for Statistical Computing) and the rms package.

Results

Cohort

We identified 64,594 patients who underwent ACDF, CDA, or HS between 2015 and 2019. After applying the exclusion criteria, we included 28,875 patients in our cohort (Fig. 1). The majority (n = 27,460) underwent ACDF, 976 patients underwent CDA, and 439 underwent HS.

Patient Demographic Characteristics and Comorbidities

Patient characteristics are presented in Table 2. Patients who underwent HS were on average younger than the total cohort (49.4 years vs 55.8 years), had fewer comorbidities, and were more likely to be male and African American. Patients who underwent HS and those who underwent CDA had similar ASA status, and patients who underwent HS had lower ASA status than patients who underwent ACDF. Radiculopathy as an indication for surgery was more prevalent in the HS group than the total cohort (36.9% vs 29.4%), contrary to myelopathy (14.6% vs 19.2%).

TABLE 2.

Demographic characteristics and comorbidities

CharacteristicACDF (n = 27,460)CDA (n = 976)HS (n = 439)Total (n = 28,875)p Value
Age, yrs56.2 (11.2)48.6 (10.3)49.4 (10.5)55.8 (11.3)<0.001
Female sex13,813 (50.3)456 (46.7)191 (43.5)14,460 (50.1)0.004
BMI30.530 (6.9)30.004 (6.6)30.050 (6.5)30.505 (6.8)0.046
Race<0.001
White21,726 (79.1)779 (79.8)318 (72.4)22,823 (79.0)
African American3,011 (11.0)73 (7.5)55 (12.5)3,139 (10.9)
American Indian or Alaska Native159 (0.6)6 (0.6)2 (0.5)167 (0.6)
Asian430 (1.6)25 (2.6)16 (3.6)471 (1.6)
Native Hawaiian or Pacific Islander70 (0.3)5 (0.5)1 (0.2)76 (0.3)
Hispanic ethnicity1,415 (5.2)52 (5.3)27 (6.2)1,494 (5.2)0.054
Smoking6,984 (25.4)215 (22.0)111 (25.3)7,310 (25.3)0.112
Comorbidities
Diabetes mellitus4,713 (17.2)103 (10.6)55 (12.5)4,871 (16.9)<0.001
Hypertension13,268 (48.3)292 (29.9)138 (31.4)13,698 (47.4)<0.001
CHF83 (0.3)1 (0.1)3 (0.7)87 (0.3)0.362
COPD1,299 (4.7)26 (2.7)12 (2.7)1,337 (4.6)0.004
Renal insufficiency requiring dialysis73 (0.3)0 (0.0)1 (0.2)74 (0.3)0.540
Chronic immunosuppression981 (3.6)21 (2.2)14 (3.2)1,016 (3.5)0.112
Bleeding disorder338 (1.2)9 (0.9)3 (0.7)350 (1.2)0.816
Radiculopathy vs myelopathy<0.001
Radiculopathy7,907 (28.8)426 (43.6)162 (36.9)8,495 (29.4)
Myelopathy5,366 (19.5)123 (12.6)64 (14.6)5,553 (19.2)
Other degenerative indication14,187 (51.7)427 (43.8)213 (48.5)14,827 (51.3)
Functional status0.048
Independent26,909 (98.0)964 (98.8)432 (98.4)28,305 (98.0)
Partially dependent395 (1.4)3 (0.3)5 (1.1)403 (1.4)
Totally dependent29 (0.1)0 (0.0)0 (0.0)29 (0.1)
ASA class<0.001
I (no disturbance)722 (2.6)84 (8.6)30 (6.8)836 (2.9)
II (mild disturbance)13,772 (50.2)626 (64.1)285 (64.9)14,683 (50.9)
III (severe disturbance)12,433 (45.3)263 (26.9)117 (26.7)12,813 (44.4)
IV (life-threatening)514 (1.9)2 (0.2)7 (1.6)523 (1.8)
V (moribund)1 (<0.1)0 (0.0)0 (0.0)1 (<0.1)

Values are shown as number (percent) or mean (SD) unless indicated otherwise. Boldface type indicates statistical significance (p < 0.05).

The CDA and HS groups were quite similar in terms of most baseline patient characteristics, but the mean values of the cohort were skewed toward the values of the ACDF cohort owing to sample size.

Operative Variables and Perioperative Outcomes

The majority (61%) of the patients in the HS group were registered as inpatients on admission (Table 3). The mean number of levels treated in the HS group was 2.57, with 54 surgical procedures (12.3%) involving 4 or more levels. The mean operative time was 133.6 minutes in the total cohort and 146.1 minutes in the HS group. The mean LOS in the HS group was 1.54 days, and the CDA group had significantly shorter LOS than the rest of the cohort.

TABLE 3.

Operative variables and perioperative outcomes

CharacteristicACDF (n = 27,460)CDA (n = 976)HS (n = 439)Total (n = 28,875)p Value
Inpatient17,143 (62.4)439 (45.0)271 (61.7)17,853 (61.8)<0.001
Levels treated2.500 (0.9)2.047 (0.3)2.572 (0.8)2.485 (0.9)<0.001
218,316 (66.7)942 (96.5)256 (58.3)19,514 (67.6)<0.001
36,252 (22.8)24 (2.5)129 (29.4)6,405 (22.2)
42,010 (7.3)8 (0.8)44 (10.0)2,062 (7.1)
>4882 (3.2)2 (0.2)10 (2.3)894 (3.1)
Op time, mins133.476 (62.8)131.944 (50.7)146.130 (63.0)133.616 (62.5)<0.001
LOS, days1.677 (4.4)0.954 (4.8)1.540 (2.9)1.651 (4.4)<0.001
Deaths61 (0.2)0 (0.0)0 (0.0)61 (0.2)0.207
Unplanned readmission825 (3.0)17 (1.7)3 (0.7)845 (2.9)0.01
Readmission related to index op660 (2.4)13 (1.3)3 (0.7)676 (2.3)0.012
POD of readmission10.791 (8.0)7.706 (6.7)9.667 (2.1)10.727 (8.0)0.282
Reop related to index op279 (1.3)4 (0.6)1 (0.3)284 (1.3)0.058
POD of reop9.485 (8.2)14.250 (5.4)1.000 (NA)9.517 (8.2)0.023
Discharge destination0.002
Home26,006 (94.9)961 (98.6)429 (97.7)27,396 (95.0)
Facility that was home128 (0.5)0 (0.0)0 (0.0)128 (0.4)
Rehab667 (2.4)5 (0.5)4 (0.9)676 (2.3)
Hospice4 (<0.1)0 (0.0)0 (0.0)4 (<0.1)
Multilevel senior community1 (<0.1)0 (0.0)0 (0.0)1 (<0.1)
Separate acute care facility57 (0.2)1 (0.1)0 (0.0)58 (0.2)
Skilled care, not home527 (1.9)8 (0.8)5 (1.2)540 (1.9)
Unskilled facility, not home12 (<0.1)0 (0.0)0 (0.0)12 (<0.1)
Unknown8 (<0.1)0 (0.0)0 (0.0)8 (<0.1)
Nonroutine discharge1,268 (4.6)14 (1.4)9 (2.1)1,291 (4.5)0.001

NA = not applicable; POD = postoperative day.

Values are shown as number (percent) or mean (SD) unless indicated otherwise. Boldface type indicates statistical significance (p < 0.05).

The 30-day readmission rates for the HS, CDA, and ACDF groups were 0.7% (n = 3), 1.7% (n = 17), and 3% (n = 825), respectively. Only 1 patient (0.3%) underwent a reoperation in the HS group, and the rates of reoperation did not differ between groups. Mortality was minimal in all groups. The vast majority of patients who underwent HS were discharged to home (n = 429 [97.7%]), 4 patients were discharged to a rehabilitation center, and 5 patients were discharged to a skilled care facility. The rates of nonroutine discharge destination were statistically and significantly different among groups (2.1% for the HS group, 1.4% for the CDA group, and 4.6% for the ACDF group).

Postoperative Complications

In the HS group, 1 case (0.2%) was complicated by superficial incisional SSI, and others were complicated by DVT (n = 1) and pulmonary embolism (n = 1) (Table 4). Overall, the minor complication rates were different between groups (0.2% for the HS group, 0.7% for the CDA group, and 1.4% for the ACDF group; p = 0.023). Major complication rates showed a similar pattern (0.2%, 0.4%, and 1.5%, respectively; p = 0.001).

TABLE 4.

Postoperative complications

ComplicationACDF (n = 27,460)CDA (n = 976)HS (n = 439)Total (n = 28,875)p Value
Overall SSI131 (0.5)2 (0.2)1 (0.2)134 (0.5)0.359
Minor complications384 (1.4)7 (0.7)1 (0.2)392 (1.4)0.023
Superficial incisional SSI75 (0.3)2 (0.2)1 (0.2)78 (0.3)0.908
Pneumonia178 (0.6)2 (0.2)0 (0.0)180 (0.6)0.055
Urinary tract infection137 (0.5)3 (0.3)0 (0.0)140 (0.5)0.236
Wound disruption8 (<0.1)0 (0.0)0 (0.0)8 (<0.1)0.814
Major complications424 (1.5)4 (0.4)1 (0.2)429 (1.5)0.001
DVT requiring therapy79 (0.3)0 (0.0)1 (0.2)80 (0.3)0.239
Pulmonary embolism65 (0.2)0 (0.0)1 (0.2)66 (0.2)0.314
Cardiac arrest requiring CPR34 (0.1)0 (0.0)0 (0.0)34 (0.1)0.416
Myocardial infarction37 (0.1)2 (0.2)0 (0.0)39 (0.1)0.623
Stroke/CVA25 (0.1)1 (0.1)0 (0.0)26 (0.1)0.812
Progressive renal insufficiency9 (<0.1)0 (0.0)0 (0.0)9 (0.0)0.793
Acute renal failure11 (<0.1)0 (0.0)0 (0.0)11 (<0.1)0.753
Deep incisional SSI29 (0.1)0 (0.0)0 (0.0)29 (0.1)0.473
Organ/space SSI28 (0.1)0 (0.0)0 (0.0)28 (0.1)0.486
Sepsis/septic shock66 (0.2)1 (0.1)0 (0.0)67 (0.2)
Unplanned intubation131 (0.5)2 (0.2)0 (0.0)133 (0.5)0.167
On ventilator >48 hrs93 (0.3)0 (0.0)0 (0.0)93 (0.3)0.090
Intraop/postop transfusion50 (0.2)0 (0.0)0 (0.0)50 (0.2)0.275

CPR = cardiopulmonary resuscitation; CVA = cerebrovascular accident.

Values are shown as number (percent) unless indicated otherwise. Boldface type indicates statistical significance (p < 0.05).

Multivariable Analysis

After adjustment for the potentially confounding covariates mentioned in the Methods, HS performed noninferiorly to ACDF and CDA in terms of the unplanned readmission rate (Fig. 2), index surgery–related reoperation rate (Supplemental Fig. 1A), nonroutine discharge destination rate (Fig. 3), and major and minor complication rates (Fig. 4 and Supplemental Fig. 1B). In fact, the odds ratios (ORs) of the HS group compared with the ACDF group were < 1 for all these analyses—0.33, 0.31, 0.61, 0.23, and 0.24, respectively—and less than the ORs of CDA compared with ACDF, but without reaching statistical significance.

FIG. 2.
FIG. 2.

Multivariable logistic regression analysis of the rate of 30-day unplanned readmission. Comparisons between HS, CDA, and ACDF are indicated by red boxes. ORs and 95% CIs are presented. Figure is available in color online only.

FIG. 3.
FIG. 3.

Multivariable logistic regression analysis of the rate of nonroutine discharge. Comparisons between HS, CDA, and ACDF are indicated in red boxes. ORs and 95% CIs are presented. Figure is available in color online only.

FIG. 4.
FIG. 4.

Multivariable logistic regression analysis of the rate of major complications within 30 days. Comparisons between HS, CDA, and ACDF are indicated in red boxes. ORs and 95% CIs are presented. Figure is available in color online only.

The most common covariates associated with readmission, reoperation, nonroutine discharge, and complications for the overall cohort were increased age, smoking, comorbidities, dependent functional status, ASA class III–IV, and myelopathy as an indication for surgery, whereas radiculopathy was a protective factor.

HS (OR 17.3. 95% CI 11.4–23.2) and CDA (OR 11.9, 95% CI 8–15.9) were associated with longer operative time than ACDF in multivariable analysis (Supplemental Fig. 2A); no statistically significant difference emerged between the former two. In the overall cohort, number of levels treated, ASA class III–IV, and myelopathy as an indication for surgery were among the covariates associated with increased duration of operation.

CDA was associated with shorter hospitalization than ACDF; however, HS was noninferior to both (Supplemental Fig. 2B). Factors associated with increased LOS were, among others, African American race, dependent functional status, comorbidities, and myelopathy as an indication for surgery.

In a linear regression analysis of LOS of only the HS group, age and history of CHF were associated with increased LOS, contrary to patients who were labeled as outpatients on admission (Supplemental Fig. 2C).

Discussion

In this study, we used a national multicenter registry to better understand differences in patient characteristics and outcomes among ACDF, CDA, and HS. In terms of patient characteristics, we found that patients who underwent CDA and HS were more likely to be younger. This is consistent with the previously published literature, including one study of a Medicare database that found that more than half of the patients who underwent CDA nationally were younger than 65 years.27 Additionally, we found that patients who underwent HS and CDA tended to be healthier, in that they were more likely to have ASA class I or II and less likely to have multiple comorbidities. We did not resolve any differences in patient mix between HS and CDA. Hence, we have provided evidence that centers offering CDA or HS may select for a younger, healthier population than those who undergo ACDF, thereby making it crucial to adjust for these factors in comparative effectiveness studies.

We identified several other important differences in surgical approach and patient mix between the ACDF, CDA, and HS cohorts, including levels treated and indications for surgery. As expected on the basis of the US FDA guidelines, CDA was rarely used for patients with more than 2-level disease.26 In fact, we found that only 3.5% of patients in our cohort who underwent CDA had more than 2 levels treated compared with 33.3% of those who underwent ACDF and 32.4% of those who underwent HS. Additionally, we found that radiculopathy was a more common indication for surgery in the HS cohort (36.9%) compared with the overall cohort (29.4%); the opposite was true for myelopathy (14.6% and 19.2%, respectively). These results further point to differences in patient selection and surgical technique that must be accounted for when comparing outcomes between these procedures.

Our investigation of 30-day readmission rates across these procedures revealed that readmission rates were highest in the ACDF (3%) and lowest in the HS (0.7%) cohorts on univariate analysis. However, with adjustment for potential confounding variables, this difference was not statistically significant. This finding can likely be explained by the differences in patient mix that we observed between groups. Given that patients who undergo HS and CDA are more likely to be younger and with a lower ASA class, they are less likely to have a readmission within 30 days. In contrast, 30-day reoperations were rare and there was no statistically significant difference between groups. This implies that 30-day readmissions after either HS, CDA, or ACDF are likely to be medical in nature and not require reoperation.

Adjusting for confounding variables, we found that the type of surgery received (HS, CDA, or ACDF) was not associated with greater odds of either major or minor complications. The most common minor postoperative complication in our cohort was pneumonia (180 patients [0.6%]), whereas the most common major postoperative complication was unplanned intubation (133 [0.5%]). Additionally, after analysis of routine versus nonroutine discharge, we found that type of surgery was not associated with greater odds of nonroutine discharge. Because neither HS nor CDA was associated with greater odds of postoperative complications or nonroutine discharge compared with ACDF after adjustment for risk factors, this study adds to the evidence that equitable outcomes can be achieved after all three procedures if patients are selected appropriately.

Indeed, some previous studies corroborate our findings related to postoperative outcomes. Similar to our study, a meta-analysis of 861 patients from 17 studies found no difference in postoperative complications between ACDF and HS.29 In one single-center study of 37 patients with congenital cervical stenosis, Chang et al. reported that the HS and ACDF groups did not differ in terms of early postoperative outcomes; however, this conclusion was limited by the small patient sample size.30 On the other hand, some studies reported relatively high rates of early minor complications after HS, especially hematomas requiring surgical drainage and wound-related adverse events.31,32 In our cohort of 439 patients, only 1 patient presented with superficial SSI in the early postoperative period, and there were no reoperations for hematoma drainage.

It is important to note that there is a need for additional study of long-term outcomes after ACDF, CDA, and HS in large patient samples. Cardoso et al. presented a single-center cohort of 31 patients who underwent 2- or 3-level HS and found no evidence of HO, ASD, or hardware complications at a mean follow-up of 18 months.33 Nevertheless, this study provided no comparison of outcomes with other surgical modalities. An interesting finding of this study was the high rate of transient dysphagia and hoarseness (25.8%); this could be attributed to the use of PRESTIGE ST, which was a relatively bulky device that is not available in the US market anymore.12 Some recent studies have found no evidence that either CDA or HS is superior to ACDF for both maintaining ROM and reducing incidence of ASD on long-term follow-up.29,34–36 For example, one study found that CDA was associated with significant rates of HO, which can limit ROM over the long term.37 In contrast, one meta-analysis of eight prospective randomized controlled trials found that CDA was superior to ACDF in terms of several long-term outcomes, including patient satisfaction, adjacent-segment degeneration, and need for a second procedure.38 Also, Chang et al. found that HS was associated with a significantly greater ROM than ACDF (10.7° vs 2.2°, p < 0.001) at 2 years after surgery.30 Employing a different hybrid model, Kan et al. suggested that the combination of ACCF with arthroplasty at noncontiguous levels may be associated with lower ASD rates than ACCF and ACDF.39 Hence, the current evidence is mixed and more data from large multicenter, prospective studies are needed to clarify how ACDF, CDA, and HS compare in terms of these long-term clinical outcomes.

Overall, our study using a nationally derived cohort of patients who underwent ACDF, CDA, or HS adds to the evidence that HS is noninferior in terms of short-term perioperative outcomes to other approaches for the treatment of DDD. Further investigation is needed to determine whether this result remains valid for long-term outcomes.

Limitations

The most prominent limitation of this study is the short follow-up duration. Some early-onset complications after spine surgery may present outside the 30-day window provided by the ACS-NSQIP registry. Additionally, no conclusions can be drawn from this study regarding the long-term noninferiority of HS compared with ACDF and CDA for parameters such as ASD, HO, and equipment failure.

There are several other limitations to the present findings that are similar to those of other national registry studies.40 To begin with, utilizing observational data to compare different treatment modalities is liable to the effect of unaccounted confounders that influence decision-making.41 Selecting a surgical technique is a relatively individualized process, and several parameters influence the final decision. In addition, our ability to resolve the different procedures is limited by the sensitivity of the CPT codes, and coding practices may vary among the centers that contribute to the ACS-NSQIP registry. For instance, 12.3% of HS procedures included in this study were performed on 4 or more levels; this could be partially attributed to data contamination. Furthermore, we were limited to studying the perioperative outcomes available in the ACS-NSQIP registry, such as nonroutine discharge, 30-day readmission rate, etc., and thus we were unable to capture long-term outcomes. Also, we were unable to account for clustering of outcomes because the hospitals that contribute to the ACS-NSQIP registry are de-identified. Lastly, there may be limited external validity of our study for centers that are unlike most academic medical centers that contribute to the ACS-NSQIP registry.

Conclusions

After adjusting for a variety of clinical factors, we found that HS was noninferior to ACDF and CDA in terms of the 30-day rates of unplanned readmission, reoperation, major and minor complications, and nonroutine discharge for patients with DDD.

Disclosures

Dr. Sebastian is a consultant for DePuy Synthes and CTL Amedica and receives royalties from Jaypee Publishers.

Author Contributions

Conception and design: Michalopoulos, Alvi. Acquisition of data: Bhandarkar, Jarrah, Ghaith. Analysis and interpretation of data: Michalopoulos, Yolcu. Drafting the article: Michalopoulos, Bhandarkar, Jarrah, Yolcu. Critically revising the article: Bydon, Sebastian, Freedman. Statistical analysis: Michalopoulos, Yolcu, Alvi. Study supervision: Bydon.

Supplemental Information

Online-Only Content

Supplemental material is available with the online version of the article.

References

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    Chang HK, Huang WC, Wu JC, Tu TH, Fay LY, Chang PY, et al. Cervical arthroplasty for traumatic disc herniation: an age- and sex-matched comparison with anterior cervical discectomy and fusion. BMC Musculoskelet Disord. 2015;16:228.

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    Vaccaro A, Beutler W, Peppelman W, Marzluff J, Mugglin A, Ramakrishnan PS, et al. Long-term clinical experience with selectively constrained SECURE-C Cervical Artificial Disc for 1-level cervical disc disease: results from seven-year follow-up of a prospective, randomized, controlled investigational device exemption clinical trial. Int J Spine Surg. 2018;12(3):377387.

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    Hisey MS, Bae HW, Davis R, Gaede S, Hoffman G, Kim K, et al. Multi-center, prospective, randomized, controlled investigational device exemption clinical trial comparing Mobi-C Cervical Artificial Disc to anterior discectomy and fusion in the treatment of symptomatic degenerative disc disease in the cervical spine. Int J Spine Surg. 2014;8:7.

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    • Search Google Scholar
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    Jawahar A, Cavanaugh DA, Kerr EJ III, Birdsong EM, Nunley PD. Total disc arthroplasty does not affect the incidence of adjacent segment degeneration in cervical spine: results of 93 patients in three prospective randomized clinical trials. Spine J. 2010;10(12):10431048.

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    • Search Google Scholar
    • Export Citation
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    Zhang Y, Liang C, Tao Y, Zhou X, Li H, Li F, Chen Q. Cervical total disc replacement is superior to anterior cervical decompression and fusion: a meta-analysis of prospective randomized controlled trials. PLoS One. 2015;10(3):e0117826.

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    Wahood W, Yolcu YU, Kerezoudis P, Goyal A, Alvi MA, Freedman BA, Bydon M. Artificial discs in cervical disc replacement: a meta-analysis for comparison of long-term outcomes. World Neurosurg. 2020;134:598613.e5.

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    Premarket Approval (PMA). Mobi-C Cervical Disc Prosthesis (One-Level Indication). Accessed August 18, 2021. https://www.accessdata.fda.gov/cdrh_docs/pdf11/P110002A.pdf

    • Search Google Scholar
    • Export Citation
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    Wong CE, Hu HT, Hsieh MP, Huang KY. Optimization of three-level cervical hybrid surgery to prevent adjacent segment disease: a finite element study. Front Bioeng Biotechnol. 2020;8:154.

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    • Search Google Scholar
    • Export Citation
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    Tu TH, Wu JC, Cheng H, Mummaneni PV. Hybrid cervical disc arthroplasty. Neurosurg Focus. 2017;42(VideoSuppl1):V5.

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    Miller CA, Boulter JH, Coughlin DJ, Rosner MK, Neal CJ, Dirks MS. Return-to-active-duty rates after anterior cervical spine surgery in military pilots. Neurosurg Focus. 2018;45(6):E10.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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    Jia Z, Mo Z, Ding F, He Q, Fan Y, Ruan D. Hybrid surgery for multilevel cervical degenerative disc diseases: a systematic review of biomechanical and clinical evidence. Eur Spine J. 2014;23(8):16191632.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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    Participants. ACS-NSQIP. FACS.org. Accessed August 18, 2021. https://www.facs.org/quality-programs/acs-nsqip/about/participants

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    Surgical Site Infection Event. National Healthcare Safety Network; 2021.Accessed August 18, 2021. https://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf

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    Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):14181428.

  • 25

    Zreik J, Alvi MA, Yolcu YU, Sebastian AS, Freedman BA, Bydon M. Utility of the 5-item modified frailty index for predicting adverse outcomes following elective anterior cervical discectomy and fusion. World Neurosurg. 2021;146:e670e677.

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

    Dripps RD. New classification of physical status. Anesthesiology. 1963;24:111.

  • 27

    Niedzielak TR, Ameri BJ, Emerson B, Vakharia RM, Roche MW, Malloy JP IV. Trends in cervical disc arthroplasty and revisions in the Medicare database. J Spine Surg. 2018;4(3):522528.

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

    Nunley P, Frank K, Stone M. Patient selection in cervical disc arthroplasty. Int J Spine Surg. 2020;14(s2):S29S35.

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    Yang YD, Zhao H, Chai Y, Zhao DY, Duan LJ, Wang HJ, et al. A comparison study between hybrid surgery and anterior cervical discectomy and fusion for the treatment of multilevel cervical spondylosis. Bone Joint J. 2020;102-B(8):981996.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Chang PY, Chang HK, Wu JC, Huang WC, Fay LY, Tu TH, et al. Is cervical disc arthroplasty good for congenital cervical stenosis?. J Neurosurg Spine. 2017;26(5):577585.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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    Hur JW, Ryu KS, Kim JS, Seong JH. Multilevel fusion versus hybrid surgery in three-level cervical disc disease: retrospective matched analysis of clinical and radiologic results in minimum two-year follow-up. Spine J. 2015;15(10):S236S237.

    • Crossref
    • Search Google Scholar
    • Export Citation
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    Scott-Young M, McEntee L, Rathbone E, Hing W, Nielsen D. Clinical outcomes of cervical hybrid reconstructions: a prospective study. Int J Spine Surg. 2020;14(s2):S57S66.

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    • Search Google Scholar
    • Export Citation
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    Cardoso MJ, Mendelsohn A, Rosner MK. Cervical hybrid arthroplasty with 2 unique fusion techniques. J Neurosurg Spine. 2011;15(1):4854.

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    Brotzki C, Petridis AK, Steiger HJ, Bostelmann T, Bostelmann R. Comparison of different hybrid techniques for the treatment of multilevel cervical degenerative disc disease-analysis of prospectively collected clinical, radiologic, and psychological parameters. World Neurosurg. 2020;140:e112e120.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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    Xu S, Liang Y, Wang J, Yu G, Zhu Z, Liu H. Cervical spine balance of multilevel total disc replacement, hybrid surgery, and anterior cervical discectomy and fusion with a long-term follow-up. Spine (Phila Pa 1976).2020;45(16):E989E998.

    • Crossref
    • Search Google Scholar
    • Export Citation
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    Grasso G, Sallì M, Torregrossa F. Does hybrid surgery improve quality of life in multilevel cervical degenerative disk disease? Five-year follow-up study. World Neurosurg. 2020;140:527533.

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    • Search Google Scholar
    • Export Citation
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    Laratta JL, Shillingford JN, Saifi C, Riew KD. Cervical disc arthroplasty: a comprehensive review of single-level, multilevel, and hybrid procedures. Global Spine J. 2018;8(1):7883.

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    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Hu Y, Lv G, Ren S, Johansen D. Mid- to long-term outcomes of cervical disc arthroplasty versus anterior cervical discectomy and fusion for treatment of symptomatic cervical disc disease: a systematic review and meta-analysis of eight prospective randomized controlled trials. PLoS One. 2016;11(2):e0149312.

    • Crossref
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    • Search Google Scholar
    • Export Citation
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Illustration from Levi and Schwab (pp 653–659). Copyright Roberto Suazo. Published with permission.
  • View in gallery

    Flowchart of cohort formation based on the inclusion and exclusion criteria. Some patients had more than one reason for exclusion.

  • View in gallery

    Multivariable logistic regression analysis of the rate of 30-day unplanned readmission. Comparisons between HS, CDA, and ACDF are indicated by red boxes. ORs and 95% CIs are presented. Figure is available in color online only.

  • View in gallery

    Multivariable logistic regression analysis of the rate of nonroutine discharge. Comparisons between HS, CDA, and ACDF are indicated in red boxes. ORs and 95% CIs are presented. Figure is available in color online only.

  • View in gallery

    Multivariable logistic regression analysis of the rate of major complications within 30 days. Comparisons between HS, CDA, and ACDF are indicated in red boxes. ORs and 95% CIs are presented. Figure is available in color online only.

  • 1

    Wang H, Huang K, Liu H, Meng Y, Wang X, Ding C, et al. Is cervical disc replacement valuable in 3-level hybrid surgery compared with 3-level anterior cervical discectomy and fusion? World Neurosurg. 2021;146:e151e160.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Chang HK, Huang WC, Wu JC, Tu TH, Fay LY, Chang PY, et al. Cervical arthroplasty for traumatic disc herniation: an age- and sex-matched comparison with anterior cervical discectomy and fusion. BMC Musculoskelet Disord. 2015;16:228.

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

    Asher AL, Devin CJ, Kerezoudis P, Nian H, Alvi MA, Khan I, et al. Predictors of patient satisfaction following 1- or 2-level anterior cervical discectomy and fusion: insights from the Quality Outcomes Database. J Neurosurg Spine. 2019;31(9):835843.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Wu XD, Wang XW, Yuan W, Liu Y, Tsai N, Peng YC, et al. The effect of multilevel anterior cervical fusion on neck motion. Eur Spine J. 2012;21(7):13681373.

  • 5

    Limanówka B, Sagan L. Changes in cervical range of motion following anterior cervical discectomy with fusion - preliminary results. Neurol Neurochir Pol. 2020;54(6):568575.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Cui W, Wu B, Liu B, Li D, Wang L, Ma S. Adjacent segment motion following multi-level ACDF: a kinematic and clinical study in patients with zero-profile anchored spacer or plate. Eur Spine J. 2019;28(10):24082416.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Alhashash M, Shousha M, Boehm H. Adjacent segment disease after cervical spine fusion: evaluation of a 70 patient long-term follow-up. Spine (Phila Pa 1976).2018;43(9):605609.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Carrier CS, Bono CM, Lebl DR. Evidence-based analysis of adjacent segment degeneration and disease after ACDF: a systematic review. Spine J. 2013;13(10):13701378.

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

    Zhang J, Meng F, Ding Y, Li J, Han J, Zhang X, et al. Comprehensive analysis of hybrid surgery and anterior cervical discectomy and fusion in cervical diseases: a meta-analysis. Medicine (Baltimore). 2020;99(5):e19055.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Vaccaro A, Beutler W, Peppelman W, Marzluff J, Mugglin A, Ramakrishnan PS, et al. Long-term clinical experience with selectively constrained SECURE-C Cervical Artificial Disc for 1-level cervical disc disease: results from seven-year follow-up of a prospective, randomized, controlled investigational device exemption clinical trial. Int J Spine Surg. 2018;12(3):377387.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Hisey MS, Bae HW, Davis R, Gaede S, Hoffman G, Kim K, et al. Multi-center, prospective, randomized, controlled investigational device exemption clinical trial comparing Mobi-C Cervical Artificial Disc to anterior discectomy and fusion in the treatment of symptomatic degenerative disc disease in the cervical spine. Int J Spine Surg. 2014;8:7.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Mummaneni PV, Burkus JK, Haid RW, Traynelis VC, Zdeblick TA. Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: a randomized controlled clinical trial. J Neurosurg Spine. 2007;6(3):198209.

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

    Jawahar A, Cavanaugh DA, Kerr EJ III, Birdsong EM, Nunley PD. Total disc arthroplasty does not affect the incidence of adjacent segment degeneration in cervical spine: results of 93 patients in three prospective randomized clinical trials. Spine J. 2010;10(12):10431048.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Zhang Y, Liang C, Tao Y, Zhou X, Li H, Li F, Chen Q. Cervical total disc replacement is superior to anterior cervical decompression and fusion: a meta-analysis of prospective randomized controlled trials. PLoS One. 2015;10(3):e0117826.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Wahood W, Yolcu YU, Kerezoudis P, Goyal A, Alvi MA, Freedman BA, Bydon M. Artificial discs in cervical disc replacement: a meta-analysis for comparison of long-term outcomes. World Neurosurg. 2020;134:598613.e5.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Premarket Approval (PMA). Mobi-C Cervical Disc Prosthesis (One-Level Indication). Accessed August 18, 2021. https://www.accessdata.fda.gov/cdrh_docs/pdf11/P110002A.pdf

    • Search Google Scholar
    • Export Citation
  • 17

    Wong CE, Hu HT, Hsieh MP, Huang KY. Optimization of three-level cervical hybrid surgery to prevent adjacent segment disease: a finite element study. Front Bioeng Biotechnol. 2020;8:154.

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

    Tu TH, Wu JC, Cheng H, Mummaneni PV. Hybrid cervical disc arthroplasty. Neurosurg Focus. 2017;42(VideoSuppl1):V5.

  • 19

    Miller CA, Boulter JH, Coughlin DJ, Rosner MK, Neal CJ, Dirks MS. Return-to-active-duty rates after anterior cervical spine surgery in military pilots. Neurosurg Focus. 2018;45(6):E10.

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

    Jia Z, Mo Z, Ding F, He Q, Fan Y, Ruan D. Hybrid surgery for multilevel cervical degenerative disc diseases: a systematic review of biomechanical and clinical evidence. Eur Spine J. 2014;23(8):16191632.

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

    Participants. ACS-NSQIP. FACS.org. Accessed August 18, 2021. https://www.facs.org/quality-programs/acs-nsqip/about/participants

  • 22

    User Guide for the 2018 ACS NSQIP Participant Use Data File (PUF). American College of Surgeons;2019.Accessed August 18, 2021. https://www.facs.org/-/media/files/quality-programs/nsqip/nsqip_puf_userguide_2018.ashx

    • Search Google Scholar
    • Export Citation
  • 23

    Surgical Site Infection Event. National Healthcare Safety Network; 2021.Accessed August 18, 2021. https://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf

    • Search Google Scholar
    • Export Citation
  • 24

    Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):14181428.

  • 25

    Zreik J, Alvi MA, Yolcu YU, Sebastian AS, Freedman BA, Bydon M. Utility of the 5-item modified frailty index for predicting adverse outcomes following elective anterior cervical discectomy and fusion. World Neurosurg. 2021;146:e670e677.

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

    Dripps RD. New classification of physical status. Anesthesiology. 1963;24:111.

  • 27

    Niedzielak TR, Ameri BJ, Emerson B, Vakharia RM, Roche MW, Malloy JP IV. Trends in cervical disc arthroplasty and revisions in the Medicare database. J Spine Surg. 2018;4(3):522528.

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

    Nunley P, Frank K, Stone M. Patient selection in cervical disc arthroplasty. Int J Spine Surg. 2020;14(s2):S29S35.

  • 29

    Yang YD, Zhao H, Chai Y, Zhao DY, Duan LJ, Wang HJ, et al. A comparison study between hybrid surgery and anterior cervical discectomy and fusion for the treatment of multilevel cervical spondylosis. Bone Joint J. 2020;102-B(8):981996.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Chang PY, Chang HK, Wu JC, Huang WC, Fay LY, Tu TH, et al. Is cervical disc arthroplasty good for congenital cervical stenosis?. J Neurosurg Spine. 2017;26(5):577585.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Hur JW, Ryu KS, Kim JS, Seong JH. Multilevel fusion versus hybrid surgery in three-level cervical disc disease: retrospective matched analysis of clinical and radiologic results in minimum two-year follow-up. Spine J. 2015;15(10):S236S237.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32

    Scott-Young M, McEntee L, Rathbone E, Hing W, Nielsen D. Clinical outcomes of cervical hybrid reconstructions: a prospective study. Int J Spine Surg. 2020;14(s2):S57S66.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Cardoso MJ, Mendelsohn A, Rosner MK. Cervical hybrid arthroplasty with 2 unique fusion techniques. J Neurosurg Spine. 2011;15(1):4854.

  • 34

    Brotzki C, Petridis AK, Steiger HJ, Bostelmann T, Bostelmann R. Comparison of different hybrid techniques for the treatment of multilevel cervical degenerative disc disease-analysis of prospectively collected clinical, radiologic, and psychological parameters. World Neurosurg. 2020;140:e112e120.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Xu S, Liang Y, Wang J, Yu G, Zhu Z, Liu H. Cervical spine balance of multilevel total disc replacement, hybrid surgery, and anterior cervical discectomy and fusion with a long-term follow-up. Spine (Phila Pa 1976).2020;45(16):E989E998.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36

    Grasso G, Sallì M, Torregrossa F. Does hybrid surgery improve quality of life in multilevel cervical degenerative disk disease? Five-year follow-up study. World Neurosurg. 2020;140:527533.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Laratta JL, Shillingford JN, Saifi C, Riew KD. Cervical disc arthroplasty: a comprehensive review of single-level, multilevel, and hybrid procedures. Global Spine J. 2018;8(1):7883.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Hu Y, Lv G, Ren S, Johansen D. Mid- to long-term outcomes of cervical disc arthroplasty versus anterior cervical discectomy and fusion for treatment of symptomatic cervical disc disease: a systematic review and meta-analysis of eight prospective randomized controlled trials. PLoS One. 2016;11(2):e0149312.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

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