Return to Activity Following Cervical Disc Arthroplasty

Cervical spondylosis is primarily treated with the gold standard anterior cervical discectomy and fusion (ACDF),[1-3] but over the past decade, cervical disc arthroplasty (CDA) has gained popularity as an anterior alternative.[4] CDA can achieve symptomatic relief for 1- to 2-level mild-to-moderate degeneration while maintaining disc height, preserving motion, and reducing adjacent segment loading.[5-6] Importantly, CDA has demonstrated similar or earlier unrestricted return to activities (RTA) in the early postoperative period compared to ACDF, but the current body of evidence is still in its early stages.[7] Young, active patients would likely desire and benefit from earlier RTA and the retained range of motion (ROM),[4,8] and spine surgeons should endeavor to elucidate the RTA timeline when recommending CDA. In the present article, we aim to clarify RTA as it relates to work, sports, and multi-level constructs in order to assist the spine surgeon in properly counseling arthroplasty candidates on postoperative outcomes.

Return to Work

As CDA continues to grow in its clinical applicability, most cases are being performed in patients from 40-54 years old.[9] Many patients within this age demographic find themselves in the middle of their working careers. As such, the ability to return to work (RTW) represents a critical indicator of surgical success for both patients and surgeons alike. Several randomized controlled trials have characterized RTW timelines for CDA and ACDF. Heller et al found significantly different median RTW intervals of 48 and 61 days for CDA with BRYAN Cervical Discs (Medtronic, Minneapolis, MN) and ACDF groups, respectively.[10] Similarly, Cheng et al found that patients undergoing CDA with the BRYAN implant returned to work sooner after surgery compared to the ACDF group (20 vs 84 days).[11] Mummaneni et al compared outcomes between CDA with the PRESTIGE Cervical Disc System (Medtronic, Minneapolis MN) and ACDF and found that patients in the CDA group returned to work 16 days sooner than those in the ACDF group (45 vs 61 days), but this finding was not statistically significant.[12] The authors of these 3 studies suggested this difference may be due to better functional and neurological outcomes, retained preoperative ROM, and fewer adverse events in the early postoperative period. Differences in RTW for all subsequent timepoints through 120 months after surgery were not significant.[10,13,14]

Several retrospective studies have reported significant differences in RTW metrics between CDA and ACDF. Badve et al found that 49.2% of patients undergoing CDA with BRYAN implants returned to work by 6 weeks after the operation compared to 39.4% for the ACDF group, with similar rates between groups at 6 months and 2 years.[15]

Subramanian et al reported 90.9% of CDA patients returned to work in 14 days while 85.7% of ACDF patients returned to work in 16 days. The authors further noted that occupation intensity was associated with decreased odds of RTW by 15 days.[7] When comparing outcomes of CDA in the ambulatory and hospital settings, Gornet et al found no significant differences in RTW timelines for patients between the ambulatory surgical center, hospital outpatient, and hospital inpatient settings.[16]

Receiving workers’ compensation benefits has been found to be associated with inferior outcomes following spine surgery.[17-19] In the context of CDA, Gornet et al reported that patients receiving workers’ compensation required significantly more time to return to work compared to controls (145.2 vs 61.9 days), which may have been due to self-reported physical demands of the respective jobs.[20] Steinmetz et al performed a subgroup analysis of workers’ compensation patients and reported that those undergoing CDA returned to work more quickly on average than those undergoing ACDF (101 vs 222 days), though the difference was not statistically significant. The difference in average RTW may have been due to decreased neck disability.[21]

Return to Sports

The merits of CDA are distinguishable not only in the general population but also in athletes with the objective of returning to sports. For both noncompetitive and competitive athletes, return to sports (RTS) is considered a subjective measure that hinges upon personal goals and expectations.[22] Nevertheless, postoperative recovery time, preserved ROM, and success in returning to athletics are critical considerations for athletes undergoing surgery to address cervical pathology.[23] Reinke et al found that athletes undergoing single-level CDA for disc herniation demonstrated no significant difference in pre-herniation and postoperative modified Tegner activity scores. Hence, these athletes were all able to return to athletics at a near-identical intensity compared to before injury.[24] In a systematic review of athletes undergoing CDA, Reiter et al found that all patients successfully RTS, on average restarting training and competition after 10.1 weeks and 30.5 weeks, respectively. These findings indicate a comparable or quicker RTS when compared to ACDF, posterior fusion, or nonsurgical management.[25] Like athletes, active-duty military personnel face rigorous physical demands and vertebral stresses. Consequently, examining CDA outcomes in this population could be useful in optimizing treatment for athletes.[25] Tumialán et al found that military personnel undergoing CDA returned to duty on average 6.2 weeks sooner than military personnel undergoing ACDF (10.3 vs 16.5 weeks, p = 0.008).[26]

Maintenance of cervical ROM is impactful in return to athletics since athletes’ cervical spines tend to experience greater physical loading than the general population; as such, ROM limitations may substantially decrease performance.[23,27] For ROM preservation, CDA appears to be the optimal motion-sparing treatment modality.[28] In contrast to patients undergoing ACDF, patients undergoing CDA have been found to demonstrate significantly greater improvements in cervical ROM (+5.9° vs -0.8° in ACDF patients).[29]

Chang et al reported that loss of ROM at the operative level in ACDF patients results in compensation throughout the unfused cervical spine to maintain gross cervical mobility. In contrast, CDA patients maintained a physiologic distribution of ROM at 12-month follow-up, potentially reducing the risk of adjacent segment degeneration when compared to ACDF.[30] Considering that CDA is a relatively newer surgical treatment for cervical pathology, further research regarding long-term performance is warranted in physically active populations.[31] Nonetheless, current evidence regarding the clinical and biomechanical advantages of CDA in athletes is encouraging.

Return to Activities for Multilevel Constructs

In patients with multi-level degeneration otherwise without contraindications, a multi-level CDA may be performed. Generally, these are 2-level procedures, though procedures involving more than 2 levels have been performed as well.[11,32,33] In the study by Cheng et al, including 2- and 3-level CDAs, the author reported significantly earlier RTW for the CDA group compared to ACDF (20 vs 84 days).[11] Huppert et al compared RTW status in a cohort of patients on preoperative sick leave and received either 1-level or 2-level CDA. At 2 years, 46% of the 2-level CDA group returned to work with 21% remaining on sick leave, while 70% of the 1-level returned and only 13% stayed on sick leave. The average time to return was longer for the 2-level group, though it was not statistically significant (7.5 vs. 4.8 months, p = 0.079). Of note, the 2-level group had a significantly longer preoperative sick leave period at baseline (15.6 vs. 7.0 months), which may have impacted return to work. At 2-year follow-up, both groups’ return to work statuses improved significantly compared to preoperatively.[34] In a young military population with high activity demand, Zarkadis et al found that 12 of 18 patients undergoing 2-level CDA were able to return to duty in 9.6 ± 11.7 weeks. All patients who returned were able to resume their previous roles with significant improvement in their pain scores compared to preoperatively. Six of the 18 did not return to duty and were medically retired.[35]

At times, a CDA may be utilized in combination with an ACDF to produce a hybrid construct (eg, CDA at 1 level and ACDF at another a level). Cody et al investigated the RTA status of a mixed cohort of 1-level CDAs, 2-level CDAs, and multi-level hybrids. They found that 96.0% of the 2-level contiguous CDAs and 90.6% of the 2-level hybrids returned to activities and experienced complete symptomatic relief. In contrast, patients receiving 3-level hybrids fared worse as only 72.2% returned to activities with 77.8% experiencing complete symptomatic relief. The authors attributed this difference to higher preoperative symptom severity than the 2-level groups with 27.8% vs 10% experiencing myelopathic symptoms, respectively. The study noted an average follow-up of approximately 11 months. 36 Though the literature on RTA for multi-level CDA constructs is limited, the impact of sparing ROM and fairly maintained natural forces on RTA appear to remain for constructs greater than 1 level.

Conclusion

Patients with degenerative cervical disease who are candidates for CDA would benefit from understanding their timeline for RTA, especially since these patients are often younger and more active. Returning to work and sports appears to be in greater proportion and at earlier time points for CDA compared to ACDF. Although further studies are needed to understand RTA in CDA, especially in higher-activity populations and multi-level constructs, CDA is a promising intervention for patients to return to their normal daily activities.

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Authors: Chad Z. Simon, BS

Eric Mai, BS

Cole Kwas, BA

Tomoyuki Asada, MD

Sheeraz A. Qureshi, MD, MBA

From the Hospital for Special Surgery in New York, New York.