A Meta-Analysis of Cost-Effectiveness in Cervical Degenerative Disc Disease Treated With Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion

Abstract

Cervical degenerative disc disease (DDD) occurs when there is deterioration of the intervertebral discs in the cervical spine and can cause extreme pain and disability. Cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) are the two prominent surgical treatment options. There are a few meta-analyses that examine the cost-effectiveness of these two methods. This meta-analysis study seeks to provide a thorough overview of cost-effectiveness and postoperative complications between CDA and ACDF in the treatment of cervical DDD. Publication search was carried out on PubMed and Embase up until March 2025. Comparison studies that included the two treatment methods of interest and reported a cost analysis with complication metrics were included in this meta-analysis. Review Manager 5.4. was utilized for statistical analyses, and a p value ≤ 0.05 was considered statistically significant. Thirteen studies were included. Regarding the cost analysis, there was a significant difference in initial cost in favor of ACDF compared to CDA. As for the outcome metrics, there was a significant difference in reoperation as well as DVT/PE rates in favor of CDA. There was a significant difference in mean operative time in favor of ACDF. No other significant differences were found. ACDF appears to be a cost-effective option, while CDA offers advantages in certain complication metrics. Additional studies investigating the relationship between treatment costs and complications should be completed in order to solidify the superior treatment method for cervical DDD.

Keywords

anterior cervical discectomy and fusion / cervical degenerative disc disease / cervical disc arthroplasty / complications / cost / degenerative cervical disc disease / disc replacement

References

[1] J. Fakhoury and T. J. Dowling, Cervical Degenerative Disc Disease (StatPearls, 2025).

[2] F. Awawdeh, A. Salam, and V. Soti, “Efficacy of Anterior Cervical Discectomy and Fusion Versus Cervical Disc Arthroplasty in the Treatment of Cervical Degenerative Disc Disease, Radiculopathy, and Myelopathy: A Systematic Review,” Cureus 16, no. 11 (2024): e74418, https://doi.org/10.7759/cureus.74418.

[3] B. A. Frost, S. Camarero-Espinosa, and E. J. Foster, “Materials for the Spine: Anatomy, Problems, and Solutions,” Materials (Basel) 12, no. 2 (2019): 253, https://doi.org/10.3390/ma12020253.

[4] F. Wang, F. Cai, R. Shi, X. H. Wang, and X. T. Wu, “Aging and Age Related Stresses: A Senescence Mechanism of Intervertebral Disc Degeneration,” Osteoarthritis and Cartilage 24, no. 3 (2016): 398–408, https://doi.org/10.1016/j.joca.2015.09.019.

[5] N. Kos, L. Gradisnik, and T. Velnar, “A Brief Review of the Degenerative Intervertebral Disc Disease,” Medieval Archaeology 73, no. 6 (2019): 421–424, https://doi.org/10.5455/medarh.2019.73.421-424.

[6] J. Plener, C. Ammendolia, and S. Hogg-Johnson, “Nonoperative Management of Degenerative Cervical Radiculopathy: Protocol of a Systematic Review,” Journal of the Canadian Chiropractic Association 66, no. 1 (2022): 74–84.

[7] B. Karasin and M. Grzelak, “Anterior Cervical Discectomy and Fusion: A Surgical Intervention for Treating Cervical Disc Disease,” AORN Journal 113, no. 3 (2021): 237–251, https://doi.org/10.1002/aorn.13329.

[8] K. Shafi, A. G. Kim, and S. Qureshi, “Cervical Disk Arthroplasty: Surgical Technique,” Clinical Spine Surgery 35, no. 10 (2022): 436–439, https://doi.org/10.1097/BSD.0000000000001406.

[9] A. Mahamid, D. Maman, D. Fishman, et al., “Comparative Analysis of Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion: Trends, Demographics, and Clinical Outcomes in a Nationwide Inpatient Sample,” Journal of Clinical Medicine 14, no. 18 (2025): 6559, https://doi.org/10.3390/jcm14186559.

[10] A. K. Miller, P. Zakko, D. K. Park, et al., “Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion: An Analysis of the Michigan Spine Surgery Improvement Collaborative Database,” Spine Journal 24, no. 5 (2024): 791–799, https://doi.org/10.1016/j.spinee.2023.12.004.

[11] D. Moher, A. Liberati, J. Tetzlaff, D. G. Altman, and Group P, “Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement,” PLoS Medicine 6, no. 7 (2009): e1000097, https://doi.org/10.1371/journal.pmed.1000097.

[12] J. S. Kim, J. Dowdell, Z. B. Cheung, et al., “The Seven-Year Cost-Effectiveness of Anterior Cervical Discectomy and Fusion Versus Cervical Disc Arthroplasty: A Markov Analysis,” Spine (Phila Pa 1976) 43, no. 22 (2018): 1543–1551, https://doi.org/10.1097/BRS.0000000000002665.

[13] S. J. McAnany, R. K. Merrill, S. C. Overley, J. S. Kim, R. L. Brochin, and S. A. Qureshi, “Investigating the 7-Year Cost-Effectiveness of Single-Level Cervical Disc Replacement Compared to Anterior Cervical Discectomy and Fusion,” Global Spine Journal 8, no. 1 (2018): 32–39, https://doi.org/10.1177/2192568217726283.

[14] K. Radcliff, J. Lerner, C. Yang, T. Bernard, and J. E. Zigler, “Seven-Year Cost-Effectiveness of ProDisc-C Total Disc Replacement: Results From Investigational Device Exemption and Post-Approval Studies,” Journal of Neurosurgery. Spine 24, no. 5 (2016): 760–768, https://doi.org/10.3171/2015.10.SPINE15505.

[15] J. P. Higgins, D. G. Altman, P. C. Gotzsche, et al., “The Cochrane Collaboration's Tool for Assessing Risk of Bias in Randomised Trials,” BMJ 343 (2011): d5928, https://doi.org/10.1136/bmj.d5928.

[16] G. S. B. Wells, D. O'Connell, J. Peterson, et al., The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomized Studies in Meta- Analyses (Department of Epidemiology and Community Medicine, University of Ottawa, 2021).

[17] M. S. Hisey, J. E. Zigler, R. Jackson, et al., “Prospective, Randomized Comparison of One-Level Mobi-C Cervical Total Disc Replacement vs. Anterior Cervical Discectomy and Fusion: Results at 5-Year Follow-Up,” International Journal of Spine Surgery 10 (2016): 10, https://doi.org/10.14444/3010.

[18] D. Murrey, M. Janssen, R. Delamarter, et al., “Results of the Prospective, Randomized, Controlled Multicenter Food and Drug Administration Investigational Device Exemption Study of the ProDisc-C Total Disc Replacement Versus Anterior Discectomy and Fusion for the Treatment of 1-Level Symptomatic Cervical Disc Disease,” Spine Journal 9, no. 4 (2009): 275–286, https://doi.org/10.1016/j.spinee.2008.05.006.

[19] M. F. Gornet, J. K. Burkus, M. E. Shaffrey, P. J. Argires, H. Nian, and F. E. Harrell, “Cervical Disc Arthroplasty With PRESTIGE LP Disc Versus Anterior Cervical Discectomy and Fusion: A Prospective, Multicenter Investigational Device Exemption Study,” Journal of Neurosurgery. Spine 23, no. 5 (2015): 558–573, https://doi.org/10.3171/2015.1.SPINE14589.

[20] M. C. Weinstein, J. E. Siegel, M. R. Gold, M. S. Kamlet, and L. B. Russell, “Recommendations of the Panel on Cost-Effectiveness in Health and Medicine,” Journal of the American Medical Association 276, no. 15 (1996): 1253–1258.

[21] J. P. T. Higgins, T. Li, and J. J. Deeks, “Chapter 6: Choosing Effect Measures and Computing Estimates of Effect [Last Updated August 2023],” in Cochrane Handbook for Systematic Reviews of Interventions Version 6.5, ed. J. P. T. Higgins, J. Thomas, J. Chandler, et al. (Cochrane, 2024), www.training.cochrane.org/handbook.

[22] C. Kumar, N. Dietz, M. Sharma, D. Wang, B. Ugiliweneza, and M. Boakye, “Long-Term Comparison of Health Care Utilization and Reoperation Rates in Patients Undergoing Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disc Disease,” World Neurosurgery 134 (2020): e855–e865, https://doi.org/10.1016/j.wneu.2019.11.012.

[23] “ U.S. Bureau of Labor Statistics CPI Inflation Calculator,” https://www.bls.gov/data/inflation_calculator.htm.

[24] “ Currency Exchange Converter,” https://www.exchange-rates.org/.

[25] J. J. Deeks, J. P. T. Higgins, D. G. Altman, J. E. McKenzie, and A. A. Veroniki, “Chapter 10: Analysing Data and Undertaking Meta-Analyses [Last Updated November 2024],” in Cochrane Handbook for Systematic Reviews of Interventions Version 6.5, ed. J. P. T. Higgins, J. Thomas, J. Chandler, et al. (Cochrane, 2024), www.training.cochrane.org/handbook.

[26] A. K. Bhadra, A. S. Raman, A. T. Casey, and R. J. Crawford, “Single-Level Cervical Radiculopathy: Clinical Outcome and Cost-Effectiveness of Four Techniques of Anterior Cervical Discectomy and Fusion and Disc Arthroplasty,” European Spine Journal 18, no. 2 (2009): 232–237, https://doi.org/10.1007/s00586-008-0866-8.

[27] J. M. Heijdra Suasnabar, C. L. A. Vleggeert-Lankamp, C. M. W. Goedmakers, F. de Vries, M. P. Arts, and M. E. van den Akker-van Marle, “Cost Effectiveness of Implanting a Prosthesis After Anterior Cervical Discectomy for Radiculopathy: Results of the NECK Randomized Controlled Trial,” Spine Journal 23, no. 6 (2023): 851–858, https://doi.org/10.1016/j.spinee.2023.02.003.

[28] A. Leibold, S. Glener, A. Sarikonda, et al., “What Is the True Cost of Motion Preservation? A Time-Driven Activity-Based Cost Analysis of Anterior Cervical Discectomy and Fusion Versus Disc Replacement,” World Neurosurgery 192 (2024): e506–e512, https://doi.org/10.1016/j.wneu.2024.10.010.

[29] D. Z. Nin, Y. W. Chen, D. H. Kim, et al., “Health Care Costs Following Anterior Cervical Discectomy and Fusion or Cervical Disc Arthroplasty,” Spine (Phila Pa 1976) 49, no. 8 (2024): 530–535, https://doi.org/10.1097/BRS.0000000000004917.

[30] R. S. Nunna, J. S. Ryoo, P. B. Ostrov, et al., “Single-Level Cervical Disc Replacement (CDR) Versus Anterior Cervical Discectomy and Fusion (ACDF): A Nationwide Matched Analysis of Complications, 30- and 90-Day Readmission Rates, and Cost,” World Neurosurgery: X 21 (2024): 100242, https://doi.org/10.1016/j.wnsx.2023.100242.

[31] P. B. Ostrov, A. K. Reddy, J. S. Ryoo, M. Behbahani, and A. I. Mehta, “Anterior Cervical Discectomy and Fusion Versus Cervical Disc Arthroplasty: A Comparison of National Trends and Outcomes,” World Neurosurgery 160 (2022): e96–e110, https://doi.org/10.1016/j.wneu.2021.12.099.

[32] K. Radcliff, J. Zigler, and J. Zigler, “Costs of Cervical Disc Replacement Versus Anterior Cervical Discectomy and Fusion for Treatment of Single-Level Cervical Disc Disease: An Analysis of the Blue Health Intelligence Database for Acute and Long-Term Costs and Complications,” Spine (Phila Pa 1976) 40, no. 8 (2015): 521–529, https://doi.org/10.1097/BRS.0000000000000822.

[33] P. P. Ratnasamy, M. J. Gouzoulis, S. S. Jabbouri, A. G. Varthi, and J. N. Grauer, “Outcomes Following Two-Level Cervical Disc Arthroplasty Relative to Two-Level Anterior Cervical Discectomy,” Spine (Phila Pa 1976) 50, no. 8 (2025): 548–554, https://doi.org/10.1097/BRS.0000000000005131.

[34] D. Warren, T. Andres, C. Hoelscher, P. Ricart-Hoffiz, J. Bendo, and J. Goldstein, “Cost-Utility Analysis Modeling at 2-Year Follow-Up for Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion: A Single-Center Contribution to the Randomized Controlled Trial,” International Journal of Spine Surgery 7 (2013): e58–e66, https://doi.org/10.1016/j.ijsp.2013.05.001.

[35] V. Goz, B. I. Martin, C. J. Donnally, et al., “Potential Selection Bias in Observational Studies Comparing Cervical Disc Arthroplasty to Anterior Cervical Discectomy and Fusion,” Spine (Phila Pa 1976) 45, no. 14 (2020): 960–967, https://doi.org/10.1097/BRS.0000000000003427.

[36] J. D. Ament, Z. Yang, P. Nunley, M. B. Stone, D. Lee, and K. D. Kim, “Cost Utility Analysis of the Cervical Artificial Disc vs Fusion for the Treatment of 2-Level Symptomatic Degenerative Disc Disease: 5-Year Follow-Up,” Neurosurgery 79, no. 1 (2016): 135–145, https://doi.org/10.1227/NEU.0000000000001208.

[37] O. Maayan, K. Shafi, and S. Qureshi, “Update on Design and Biomechanics of Cervical Disc Arthroplasty,” Seminars in Spine Surgery 35, no. 1 (2023): 101009, https://doi.org/10.1016/j.semss.2023.101009.

[38] Y. Lu, S. J. McAnany, A. C. Hecht, S. K. Cho, and S. A. Qureshi, “Utilization Trends of Cervical Artificial Disc Replacement After FDA Approval Compared With Anterior Cervical Fusion: Adoption of New Technology,” Spine (Phila Pa 1976) 39, no. 3 (2014): 249–255, https://doi.org/10.1097/BRS.0000000000000113.

[39] S. A. Qureshi, S. McAnany, V. Goz, S. M. Koehler, and A. C. Hecht, “Cost-Effectiveness Analysis: Comparing Single-Level Cervical Disc Replacement and Single-Level Anterior Cervical Discectomy and Fusion: Clinical Article,” Journal of Neurosurgery. Spine 19, no. 5 (2013): 546–554, https://doi.org/10.3171/2013.8.SPINE12623.

[40] C. Saifi, A. W. Fein, A. Cazzulino, et al., “Trends in Resource Utilization and Rate of Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion Throughout the United States From 2006 to 2013,” Spine Journal 18, no. 6 (2018): 1022–1029, https://doi.org/10.1016/j.spinee.2017.10.072.

[41] B. Wiedenhofer, J. Nacke, M. Stephan, W. Richter, C. Carstens, and M. Eichler, “Is Total Disk Replacement a Cost-Effective Treatment for Cervical Degenerative Disk Disease?,” Clinical Spine Surgery 30, no. 5 (2017): E530–E534, https://doi.org/10.1097/BSD.0000000000000189.

[42] J. D. Ament, Z. Yang, P. Nunley, M. B. Stone, and K. D. Kim, “Cost-Effectiveness of Cervical Total Disc Replacement vs Fusion for the Treatment of 2-Level Symptomatic Degenerative Disc Disease,” JAMA Surgery 149, no. 12 (2014): 1231–1239, https://doi.org/10.1001/jamasurg.2014.716.

[43] S. C. Overley, S. J. McAnany, R. L. Brochin, J. S. Kim, R. K. Merrill, and S. A. Qureshi, “The 5-Year Cost-Effectiveness of Two-Level Anterior Cervical Discectomy and Fusion or Cervical Disc Replacement: A Markov Analysis,” Spine Journal 18, no. 1 (2018): 63–71, https://doi.org/10.1016/j.spinee.2017.06.036.

[44] S. J. McAnany, S. Overley, E. O. Baird, et al., “The 5-Year Cost-Effectiveness of Anterior Cervical Discectomy and Fusion and Cervical Disc Replacement: A Markov Analysis,” Spine (Phila Pa 1976) 39, no. 23 (2014): 1924–1933, https://doi.org/10.1097/BRS.0000000000000562.

[45] A. Ghori, J. F. Konopka, H. Makanji, T. D. Cha, and C. M. Bono, “Long Term Societal Costs of Anterior Discectomy and Fusion (ACDF) Versus Cervical Disc Arthroplasty (CDA) for Treatment of Cervical Radiculopathy,” International Journal of Spine Surgery 10 (2016): 1, https://doi.org/10.14444/3001.

[46] M. Singh, B. Chanes, M. Balmaceno-Criss, A. H. Daniels, and A. S. Zhang, “Cervical Disc Arthroplasty Is Safe Across Various Obesity Levels,” Spine Journal 25, no. 4 (2025): 756–762, https://doi.org/10.1016/j.spinee.2024.11.008.

[47] G. Abdelmalek, H. Uppal, D. Coban, et al., “Is Cervical Disc Arthroplasty an Effective Treatment Option for Patients With Cervical Spondylotic Myelopathy? A Matched Cohort Analysis Compared to Anterior Cervical Discectomy and Fusion,” Spine Journal 25 (2024): 921–928, https://doi.org/10.1016/j.spinee.2024.11.003.

[48] T. Loidolt, S. Kurra, K. D. Riew, A. D. Levi, J. Florman, and W. F. Lavelle, “Comparison of Adverse Events Between Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion: A 10-Year Follow-Up,” Spine Journal 21, no. 2 (2021): 253–264, https://doi.org/10.1016/j.spinee.2020.10.013.

[49] P. A. Anderson, R. C. Sasso, and K. D. Riew, “Comparison of Adverse Events Between the Bryan Artificial Cervical Disc and Anterior Cervical Arthrodesis,” Spine (Phila Pa 1976) 33, no. 12 (2008): 1305–1312, https://doi.org/10.1097/BRS.0b013e31817329a1.

[50] A. G. Zavras, J. R. Acosta, K. J. Holmberg, et al., “Effect of Device Constraint: A Comparative Network Meta-Analysis of ACDF and Cervical Disc Arthroplasty,” Spine Journal 24, no. 10 (2024): 1858–1871, https://doi.org/10.1016/j.spinee.2024.05.016.

[51] E. S. Quinto, N. D. Paisner, E. G. Huish, and M. Senegor, “Ten-Year Outcomes of Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion: A Systematic Review With Meta-Analysis,” Spine (Phila Pa 1976) 49, no. 7 (2024): 463–469, https://doi.org/10.1097/BRS.0000000000004887.

[52] G. R. Toci, J. A. Canseco, P. D. Patel, et al., “The Incidence of Adjacent Segment Pathology After Cervical Disc Arthroplasty Compared With Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis of Randomized Clinical Trials,” World Neurosurgery 160 (2022): e537–e548, https://doi.org/10.1016/j.wneu.2022.01.072.

[53] Y. Zhang, N. Lv, F. He, et al., “Comparison of Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion for the Treatment of Cervical Disc Degenerative Diseases on the Basis of More Than 60 Months of Follow-Up: A Systematic Review and Meta-Analysis,” BMC Neurology 20, no. 1 (2020): 143, https://doi.org/10.1186/s12883-020-01717-0.

[54] Q. L. Wang, Z. M. Tu, P. Hu, et al., “Long-Term Results Comparing Cervical Disc Arthroplasty to Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” Orthopaedic Surgery 12, no. 1 (2020): 16–30, https://doi.org/10.1111/os.12585.

[55] R. S. Zhu, S. L. Kan, Z. G. Cao, Z. H. Jiang, X. L. Zhang, and W. Hu, “Secondary Surgery After Cervical Disc Arthroplasty Versus Fusion for Cervical Degenerative Disc Disease: A Meta-Analysis With Trial Sequential Analysis,” Orthopaedic Surgery 10, no. 3 (2018): 181–191, https://doi.org/10.1111/os.12401.

[56] S. L. Kan, Z. F. Yuan, G. Z. Ning, F. F. Liu, J. C. Sun, and S. Q. Feng, “Cervical Disc Arthroplasty for Symptomatic Cervical Disc Disease: Traditional and Bayesian Meta-Analysis With Trial Sequential Analysis,” International Journal of Surgery 35 (2016): 111–119, https://doi.org/10.1016/j.ijsu.2016.09.088.

[57] S. Zou, J. Gao, B. Xu, X. Lu, Y. Han, and H. Meng, “Anterior Cervical Discectomy and Fusion (ACDF) Versus Cervical Disc Arthroplasty (CDA) for Two Contiguous Levels Cervical Disc Degenerative Disease: A Meta-Analysis of Randomized Controlled Trials,” European Spine Journal 26, no. 4 (2017): 985–997, https://doi.org/10.1007/s00586-016-4655-5.

[58] Y. Zhu, B. Zhang, H. Liu, Y. Wu, and Q. Zhu, “Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion for Incidence of Symptomatic Adjacent Segment Disease: A Meta-Analysis of Prospective Randomized Controlled Trials,” Spine (Phila Pa 1976) 41, no. 19 (2016): 1493–1502, https://doi.org/10.1097/BRS.0000000000001537.

[59] Y. Hu, G. Lv, S. Ren, and D. Johansen, “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 11, no. 2 (2016): e0149312, https://doi.org/10.1371/journal.pone.0149312.

[60] Z. M. Zhong, S. Y. Zhu, J. S. Zhuang, Q. Wu, and J. T. Chen, “Reoperation After Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion: A Meta-Analysis,” Clinical Orthopaedics and Related Research 474, no. 5 (2016): 1307–1316, https://doi.org/10.1007/s11999-016-4707-5.

[61] F. Gao, T. Mao, W. Sun, et al., “An Updated Meta-Analysis Comparing Artificial Cervical Disc Arthroplasty (CDA) Versus Anterior Cervical Discectomy and Fusion (ACDF) for the Treatment of Cervical Degenerative Disc Disease (CDDD),” Spine (Phila Pa 1976) 40, no. 23 (2015): 1816–1823, https://doi.org/10.1097/BRS.0000000000001138.

[62] Q. Yao, F. Liang, Y. Xia, and C. Jia, “A Meta-Analysis Comparing Total Disc Arthroplasty With Anterior Cervical Discectomy and Fusion for the Treatment of Cervical Degenerative Diseases,” Archives of Orthopaedic and Trauma Surgery 136, no. 3 (2016): 297–304, https://doi.org/10.1007/s00402-015-2337-0.

[63] A. M. Wu, H. Xu, K. P. Mullinix, et al., “Minimum 4-Year Outcomes of Cervical Total Disc Arthroplasty Versus Fusion: A Meta-Analysis Based on Prospective Randomized Controlled Trials,” Medicine (Baltimore) 94, no. 15 (2015): e665, https://doi.org/10.1097/MD.0000000000000665.

[64] M. J. Rao, S. P. Nie, B. W. Xiao, G. H. Zhang, X. R. Gan, and S. S. Cao, “Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion for Treatment of Symptomatic Cervical Disc Disease: A Meta-Analysis of Randomized Controlled Trials,” Archives of Orthopaedic and Trauma Surgery 135, no. 1 (2015): 19–28, https://doi.org/10.1007/s00402-014-2122-5.

[65] C. Ren, Y. Song, Y. Xue, and X. Yang, “Mid- To Long-Term Outcomes After Cervical Disc Arthroplasty Compared With Anterior Discectomy and Fusion: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” European Spine Journal 23, no. 5 (2014): 1115–1123, https://doi.org/10.1007/s00586-014-3220-3.

[66] Y. Gao, M. Liu, T. Li, F. Huang, T. Tang, and Z. Xiang, “A Meta-Analysis Comparing the Results of Cervical Disc Arthroplasty With Anterior Cervical Discectomy and Fusion (ACDF) for the Treatment of Symptomatic Cervical Disc Disease,” Journal of Bone and Joint Surgery. American Volume 95, no. 6 (2013): 555–561, https://doi.org/10.2106/JBJS.K.00599.

[67] A. Tuchman, I. Chen, C. T. Walker, L. E. Kanim, H. W. Bae, and D. L. Skaggs, “Is Single-Level Cervical Disc Arthroplasty Associated With a Lower Reoperation Rate Than Anterior Cervical Discectomy and Fusion?,” Journal of Neurosurgery. Spine 40, no. 3 (2024): 282–290, https://doi.org/10.3171/2023.10.SPINE23640.

[68] Y. Zhu, Z. Tian, B. Zhu, W. Zhang, Y. Li, and Q. Zhu, “Bryan Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion for Treatment of Cervical Disc Diseases: A Meta-Analysis of Prospective, Randomized Controlled Trials,” Spine (Phila Pa 1976) 41, no. 12 (2016): E733–E741, https://doi.org/10.1097/BRS.0000000000001367.

[69] M. Aragones, E. Hevia, and C. Barrios, “Polyurethane on Titanium Unconstrained Disc Arthroplasty Versus Anterior Discectomy and Fusion for the Treatment of Cervical Disc Disease: A Review of Level I-II Randomized Clinical Trials Including Clinical Outcomes,” European Spine Journal 24, no. 12 (2015): 2735–2745, https://doi.org/10.1007/s00586-015-4228-z.

[70] S. A. Badve, J. E. Florman, A. D. Levi, S. Kurra, K. D. Riew, and W. F. Lavelle, “Employment Status for the First Decade Following Randomization to Cervical Disc Arthroplasty Versus Fusion,” Spine (Phila Pa 1976) 45, no. 20 (2020): 1411–1418, https://doi.org/10.1097/BRS.0000000000003565.

[71] A. Perez-Albela, J. E. Nassar, C. Thomson, et al., “Return to Work After Anterior Cervical Disc Replacement vs. Fusion: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” Spine (Phila Pa 1976) 50 (2025): 1110–1119, https://doi.org/10.1097/BRS.0000000000005319.

[72] M. Oglesby, S. J. Fineberg, A. A. Patel, M. A. Pelton, and K. Singh, “The Incidence and Mortality of Thromboembolic Events in Cervical Spine Surgery,” Spine (Phila Pa 1976) 38, no. 9 (2013): E521–E527, https://doi.org/10.1097/BRS.0b013e3182897839.

[73] H. Jiang, Z. Zhu, Y. Qiu, B. Qian, X. Qiu, and M. Ji, “Cervical Disc Arthroplasty Versus Fusion for Single-Level Symptomatic Cervical Disc Disease: A Meta-Analysis of Randomized Controlled Trials,” Archives of Orthopaedic and Trauma Surgery 132, no. 2 (2012): 141–151, https://doi.org/10.1007/s00402-011-1401-7.

[74] Z. M. Zhong, M. Li, Z. M. Han, et al., “Does Cervical Disc Arthroplasty Have Lower Incidence of Dysphagia Than Anterior Cervical Discectomy and Fusion? A Meta-Analysis,” Clinical Neurology and Neurosurgery 146 (2016): 45–51, https://doi.org/10.1016/j.clineuro.2016.04.002.

[75] L. Shangguan, G. Z. Ning, Y. Tang, Z. Wang, Z. J. Luo, and Y. Zhou, “Discover Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion in Symptomatic Cervical Disc Diseases: A Meta-Analysis,” PLoS One 12, no. 3 (2017): e0174822, https://doi.org/10.1371/journal.pone.0174822.

[76] P. V. Rajan, A. K. Emara, M. Ng, D. Grits, D. W. Pelle, and J. W. Savage, “Longer Operative Time Associated With Prolonged Length of Stay, Non-Home Discharge and Transfusion Requirement After Anterior Cervical Discectomy and Fusion: An Analysis of 24,593 Cases,” Spine Journal 21, no. 10 (2021): 1718–1728, https://doi.org/10.1016/j.spinee.2021.04.023.

[77] M. Singh, A. Perez-Albea, I. Shah, M. Jensen, A. H. Daniels, and B. A. Basques, “Three-Level Anterior Cervical Discectomy and Fusion (ACDF) is Associated With Higher Rates of Instrumentation Failure and Shorter Time to Reoperation Than One-Level or Two Level ACDF,” Spine (Phila Pa 1976) (2025), https://doi.org/10.1097/BRS.0000000000005543.

[78] H. W. Mun, J. J. Lee, H. C. Shin, T. H. Kim, S. W. Kim, and J. K. Oh, “Fusion Sequence and Risk Factors for Pseudarthrosis in Multilevel Anterior Cervical Discectomy and Fusion,” Neurosurgery 97, no. 5 (2025): 1153–1161, https://doi.org/10.1227/neu.0000000000003537.

RIGHTS & PERMISSIONS

2026 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.