Single or double‐level anterior interbody fusion techniques for cervical degenerative disc disease

Wilco Jacobs; Paul C Willems; Jacques van Limbeek; Ronald Bartels; Paul Pavlov; Patricia G Anderson; F Cumhur Oner

doi:10.1002/14651858.CD004958.pub2

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Figure 1

Summary of risks of bias

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Figure 2

Forest plot of comparison: 1 Discectomy alone vs bone graft, outcome: 1.8 No Fusion.

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Figure 3

Forest plot of comparison: 12.1 complications.

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Figure 4

Forest plot of comparison: 2 Discectomy alone vs cage, outcome: 2.6 Pain not relieved at 2 years.

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Figure 5

Forest plot of comparison: 5 Iliac crest autograft vs cage, outcome: 5.8 Odom's criteria.

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Analysis 1.1

Comparison 1 Discectomy alone vs human bone graft, Outcome 1 Hospital stay.

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Analysis 1.2

Comparison 1 Discectomy alone vs human bone graft, Outcome 2 Operation time.

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Analysis 1.3

Comparison 1 Discectomy alone vs human bone graft, Outcome 3 Blood loss.

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Analysis 1.4

Comparison 1 Discectomy alone vs human bone graft, Outcome 4 Pain not relieved at 5 weeks.

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Analysis 1.5

Comparison 1 Discectomy alone vs human bone graft, Outcome 5 Odom's criteria.

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Analysis 1.6

Comparison 1 Discectomy alone vs human bone graft, Outcome 6 Not Returned to work at 5 weeks.

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Analysis 1.7

Comparison 1 Discectomy alone vs human bone graft, Outcome 7 Not Returned to work at 10 weeks.

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Analysis 1.8

Comparison 1 Discectomy alone vs human bone graft, Outcome 8 No Fusion.

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Analysis 1.9

Comparison 1 Discectomy alone vs human bone graft, Outcome 9 Alignment.

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Analysis 2.1

Comparison 2 Discectomy alone vs cage or cement, Outcome 1 Operation time.

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Analysis 2.2

Comparison 2 Discectomy alone vs cage or cement, Outcome 2 Blood loss.

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Analysis 2.3

Comparison 2 Discectomy alone vs cage or cement, Outcome 3 Length of stay.

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Analysis 2.4

Comparison 2 Discectomy alone vs cage or cement, Outcome 4 Recovery.

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Analysis 2.5

Comparison 2 Discectomy alone vs cage or cement, Outcome 5 Neck pain not relieved at 6 weeks.

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Analysis 2.6

Comparison 2 Discectomy alone vs cage or cement, Outcome 6 Neck pain not relieved at 2 years.

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Analysis 2.7

Comparison 2 Discectomy alone vs cage or cement, Outcome 7 VAS Arm pain 24 months.

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Analysis 2.8

Comparison 2 Discectomy alone vs cage or cement, Outcome 8 VAS Neck pain 24 months.

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Analysis 2.9

Comparison 2 Discectomy alone vs cage or cement, Outcome 9 NASS pain 24 months.

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Analysis 2.10

Comparison 2 Discectomy alone vs cage or cement, Outcome 10 NASS neurology 24 months.

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Analysis 2.11

Comparison 2 Discectomy alone vs cage or cement, Outcome 11 No Fusion.

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Study	Group	Excellent	Good	Fair	Poor
Discectomy alone vs cage
Barlocher 2002	Discectomy	25			8
Barlocher 2002	Cage	34			2
Discectomy alone vs PMMA
Barlocher 2002	Discectomy	25			8
Barlocher 2002	PMMA	21			3

Analysis 2.12

Comparison 2 Discectomy alone vs cage or cement, Outcome 12 Odom's criteria.

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Analysis 3.1

Comparison 3 Discectomy alone vs human bone graft with plates, Outcome 1 VAS Arm pain.

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Analysis 3.2

Comparison 3 Discectomy alone vs human bone graft with plates, Outcome 2 VAS neck pain.

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Analysis 3.3

Comparison 3 Discectomy alone vs human bone graft with plates, Outcome 3 Disc height.

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Analysis 3.4

Comparison 3 Discectomy alone vs human bone graft with plates, Outcome 4 Odoms criteria.

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Analysis 3.5

Comparison 3 Discectomy alone vs human bone graft with plates, Outcome 5 Fusion.

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Analysis 4.1

Comparison 4 Iliac crest autograft vs human allograft or bone substitute, Outcome 1 headache.

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Analysis 4.2

Comparison 4 Iliac crest autograft vs human allograft or bone substitute, Outcome 2 Sensory function.

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Analysis 4.3

Comparison 4 Iliac crest autograft vs human allograft or bone substitute, Outcome 3 Muscle power.

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Analysis 4.4

Comparison 4 Iliac crest autograft vs human allograft or bone substitute, Outcome 4 Odoms criteria.

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Analysis 5.1

Comparison 5 Iliac crest autograft vs cage, Outcome 1 Operation time.

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Analysis 5.2

Comparison 5 Iliac crest autograft vs cage, Outcome 2 Blood loss.

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Analysis 5.3

Comparison 5 Iliac crest autograft vs cage, Outcome 3 Hospital stay.

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Analysis 5.4

Comparison 5 Iliac crest autograft vs cage, Outcome 4 VAS Neck Pain.

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Analysis 5.5

Comparison 5 Iliac crest autograft vs cage, Outcome 5 VAS Arm pain.

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Analysis 5.6

Comparison 5 Iliac crest autograft vs cage, Outcome 6 Neck Disability Index (NDI).

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Analysis 5.7

Comparison 5 Iliac crest autograft vs cage, Outcome 7 JOA.

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Analysis 5.8

Comparison 5 Iliac crest autograft vs cage, Outcome 8 Odom's criteria.

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Analysis 5.9

Comparison 5 Iliac crest autograft vs cage, Outcome 9 SF‐36 Physical.

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Analysis 5.10

Comparison 5 Iliac crest autograft vs cage, Outcome 10 SF‐36 Mental.

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Analysis 5.11

Comparison 5 Iliac crest autograft vs cage, Outcome 11 Satisfaction.

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Analysis 5.12

Comparison 5 Iliac crest autograft vs cage, Outcome 12 Foraminal height.

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Analysis 5.13

Comparison 5 Iliac crest autograft vs cage, Outcome 13 Interspace height.

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Analysis 5.14

Comparison 5 Iliac crest autograft vs cage, Outcome 14 Cobb angle.

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Analysis 5.15

Comparison 5 Iliac crest autograft vs cage, Outcome 15 No Fusion.

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Analysis 6.1

Comparison 6 Iliac crest autograft vs iliac crest autograft with plates, Outcome 1 Clinical outcome.

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Analysis 6.2

Comparison 6 Iliac crest autograft vs iliac crest autograft with plates, Outcome 2 No Fusion.

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Analysis 7.1

Comparison 7 Different types of autograft, Outcome 1 Fusion.

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Analysis 9.1

Comparison 9 Other comparisons between different types of instrumentation, Outcome 1 Odom's criteria.

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Analysis 10.1

Comparison 10 PMMA vs cage, Outcome 1 Operation time.

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Analysis 10.2

Comparison 10 PMMA vs cage, Outcome 2 Odoms criteria.

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Analysis 10.3

Comparison 10 PMMA vs cage, Outcome 3 No Fusion.

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Analysis 11.1

Comparison 11 Cage vs cage and plate, Outcome 1 Neck pain.

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Analysis 11.2

Comparison 11 Cage vs cage and plate, Outcome 2 Arm pain.

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Analysis 11.3

Comparison 11 Cage vs cage and plate, Outcome 3 JOA.

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Analysis 11.4

Comparison 11 Cage vs cage and plate, Outcome 4 Segmental lordosis.

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Analysis 12.1

Comparison 12 Complications, Outcome 1 complications.

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Table 1. Definitions

Term	Definition
Spondylosis	Degenerative disease of the spine associated with degeneration of the intervertebral discs and bone deformations
Radiculopathy	Symptoms, like pain and muscle weakness, arising from compression of the nerve roots
Myelopathy	Symptoms, like difficulty in walking, muscle weakness, imbalance, arising from compression of the spinal cord
Herniated disc	Bulging of the intervertebral disc, often causing pressure on the nerves that have their origin in the spinal canal
Spondylotic myelopathy	Dysfunction of the spinal cord due to direct compression by, for example, decreased size of the spinal canal, disc herniation or bone deformations.
Autograft	Implant material derived from the same individual, usually from the iliac crest, where a piece of bone cn be excised with cortical bone on three sides. Another option is to use bone from the vertebral bodies.
Allograft	Implant material from any other source than the same individual, usually obtained from another human and stored and treated in a bone bank. For example, a ring from a femoral bone can be used.

Table 1. Definitions

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Table 2. Assessment of clinical relevance

Study	Clinical relevance	Patient description	Intervention description	Outcome measures	Effect size	Benefits/harms
Abd‐Alrahman 1999		Yes	Yes	No	No	Unsure
Barlocher 2002	Yes	Unsure	Yes	Yes	No	Yes
Baskin 2003		Yes	Unsure	Yes	Unsure	Unsure
Celik 2007	No	No	No	No	No	No
Dai 2008	Unsure	Yes	Yes	Yes	No	No
Dowd 1999		No	Yes	Yes	Unsure	Unsure
Feiz‐Erfan 2007	No	No	No	Yes	Yes	Unsure
Fernandez‐Fairen 2008	Yes	Yes	Yes	Yes	Yes	No
Hacker 2000		Yes	Yes	Yes	No	Unsure
Hauerberg 2008	Yes	Yes	Yes	No	No	No
Lind 2007	No	No	No	No	No	No
Lofgren 2000		Yes	Yes	Yes	No	Unsure
Lofgren 2010	Yes	Yes	Yes	Yes	No	No
Madawi 1996		Unsure	Unsure	No	No	Unsure
Martins 1976		Yes	Yes	No	No	Unsure
McConnel 2003		Unsure	Yes	No	No	Unsure
McGuire 1994		Yes	Unsure	No	Unsure	No
Nabhan 2007	No	No	Yes	No	No	No
Nunley 2009	Yes	Yes	Yes	No	No	No
Oktenoglu 2007	No	Yes	yes	No	No	No
Pan 2005	Unsure	Yes	Yes	Yes	Unsure	Yes
Porras‐Estrada 2004	No	Yes	Yes	No	Yes	Unsure
Rosenorn 1983		Yes	Yes	No	Yes	Yes
Ruetten 2009	Yes	Yes	Yes	Yes	No	No
Ryu 2006	Yes	Yes	Yes	Yes	No	No
Savolainen 1998		Yes	Yes	No	No	Unsure
Schroder 2007	No	No	No	No	Yes	Yes
Stulik 2007	No	Yes	No	No	No	Unsure
Thome 2006	Yes	No	Yes	Yes	Unsure	Unsure
van den Bent 1996		Yes	Yes	No	No	No
Vavruch 2002		Yes	Yes	Yes	No	Unsure
Xie 2007	No	Yes	Yes	Yes	No	No
Zoega 2000		Yes	Yes	Yes	No	Unsure

Table 2. Assessment of clinical relevance

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Comparison 1. Discectomy alone vs human bone graft

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Hospital stay Show forest plot	4	300	Std. Mean Difference (IV, Random, 95% CI)	‐0.48 [‐1.01, 0.05]

2 Operation time Show forest plot	3	237	Mean Difference (IV, Random, 95% CI)	‐23.71 [‐33.21, ‐14.21]

3 Blood loss Show forest plot	1	63	Mean Difference (IV, Random, 95% CI)	‐21.0 [‐28.68, ‐13.32]

4 Pain not relieved at 5 weeks Show forest plot	1	84	Risk Ratio (M‐H, Random, 95% CI)	0.83 [0.20, 3.46]

5 Odom's criteria Show forest plot	2	149	Risk Ratio (M‐H, Random, 95% CI)	0.95 [0.82, 1.10]

6 Not Returned to work at 5 weeks Show forest plot	2	144	Risk Ratio (M‐H, Random, 95% CI)	1.26 [1.02, 1.54]

7 Not Returned to work at 10 weeks Show forest plot	2	128	Risk Ratio (M‐H, Random, 95% CI)	1.44 [0.77, 2.69]

8 No Fusion Show forest plot	5	303	Risk Ratio (M‐H, Random, 95% CI)	0.22 [0.10, 0.49]

9 Alignment Show forest plot	2	75	Risk Ratio (M‐H, Random, 95% CI)	0.34 [0.07, 1.56]

Comparison 1. Discectomy alone vs human bone graft

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Comparison 2. Discectomy alone vs cage or cement

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Operation time Show forest plot	3	334	Mean Difference (IV, Random, 95% CI)	8.74 [‐8.21, 25.69]

1.1 Discectomy alone vs cage	3	275	Mean Difference (IV, Random, 95% CI)	9.49 [‐13.66, 32.64]
1.2 Discectomy alone vs PMMA	1	59	Mean Difference (IV, Random, 95% CI)	6.40 [0.53, 12.27]
2 Blood loss Show forest plot	1	128	Mean Difference (IV, Random, 95% CI)	11.32 [6.27, 16.36]

2.1 Discectomy alone vs cage	1	69	Mean Difference (IV, Random, 95% CI)	13.10 [6.61, 19.59]
2.2 Discectomy alone vs PMMA	1	59	Mean Difference (IV, Random, 95% CI)	8.60 [0.58, 16.62]
3 Length of stay Show forest plot	1	118	Mean Difference (IV, Random, 95% CI)	‐0.70 [‐1.30, ‐0.09]

3.1 Discectomy alone vs cage	1	59	Mean Difference (IV, Random, 95% CI)	‐0.60 [‐1.43, 0.23]
3.2 Discectomy alone vs PMMA	1	59	Mean Difference (IV, Random, 95% CI)	‐0.80 [‐1.67, 0.07]
4 Recovery Show forest plot	1	79	Risk Ratio (M‐H, Random, 95% CI)	1.12 [0.91, 1.38]

4.1 Discectomy alone vs cages	1	79	Risk Ratio (M‐H, Random, 95% CI)	1.12 [0.91, 1.38]
5 Neck pain not relieved at 6 weeks Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

5.1 Discectomy alone vs cement	2	140	Risk Ratio (M‐H, Random, 95% CI)	0.75 [0.21, 2.66]
6 Neck pain not relieved at 2 years Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

6.1 Discectomy alone vs cement	2	135	Risk Ratio (M‐H, Random, 95% CI)	1.05 [0.69, 1.61]
7 VAS Arm pain 24 months Show forest plot	1	103	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

7.1 Discectomy alone versus cage	1	103	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
8 VAS Neck pain 24 months Show forest plot	1	103	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

8.1 Discectomy alone versus cage	1	103	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
9 NASS pain 24 months Show forest plot	1	103	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

9.1 Discectomy alone vs cage	1	103	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
10 NASS neurology 24 months Show forest plot	1	103	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

10.1 Discectomy alone versus cage	1	103	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
11 No Fusion Show forest plot	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

11.1 Discectomy alone vs cement	2	131	Risk Ratio (M‐H, Random, 95% CI)	4.75 [0.58, 38.67]
11.2 Discectomy alone vs cage	3	250	Risk Ratio (M‐H, Random, 95% CI)	0.65 [0.09, 4.42]
12 Odom's criteria Show forest plot			Other data	No numeric data

12.1 Discectomy alone vs cage			Other data	No numeric data
12.2 Discectomy alone vs PMMA			Other data	No numeric data

Comparison 2. Discectomy alone vs cage or cement

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Comparison 3. Discectomy alone vs human bone graft with plates

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 VAS Arm pain Show forest plot	1	20	Mean Difference (IV, Random, 95% CI)	‐0.16 [‐0.85, 0.53]

2 VAS neck pain Show forest plot	1	20	Mean Difference (IV, Random, 95% CI)	‐0.81 [‐1.42, ‐0.20]

3 Disc height Show forest plot	1	20	Mean Difference (IV, Random, 95% CI)	1.33 [0.57, 2.09]

4 Odoms criteria Show forest plot	1	60	Risk Ratio (M‐H, Random, 95% CI)	0.96 [0.71, 1.28]

5 Fusion Show forest plot	2	76	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.96, 1.27]

Comparison 3. Discectomy alone vs human bone graft with plates

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Comparison 4. Iliac crest autograft vs human allograft or bone substitute

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 headache Show forest plot	1	27	Mean Difference (IV, Random, 95% CI)	18.0 [4.77, 31.23]

2 Sensory function Show forest plot	1	27	Mean Difference (IV, Random, 95% CI)	15.0 [2.07, 27.93]

3 Muscle power Show forest plot	1	27	Mean Difference (IV, Random, 95% CI)	27.0 [11.48, 42.52]

4 Odoms criteria Show forest plot	1	115	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.77, 1.15]

Comparison 4. Iliac crest autograft vs human allograft or bone substitute

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Comparison 5. Iliac crest autograft vs cage

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Operation time Show forest plot	3	200	Mean Difference (IV, Random, 95% CI)	‐13.21 [‐29.99, 3.57]

2 Blood loss Show forest plot	2	120	Mean Difference (IV, Random, 95% CI)	‐8.05 [‐15.30, ‐0.79]

3 Hospital stay Show forest plot	3	211	Mean Difference (IV, Random, 95% CI)	‐0.42 [‐0.84, 0.01]

4 VAS Neck Pain Show forest plot	3	275	Mean Difference (IV, Random, 95% CI)	0.40 [‐0.94, 1.73]

5 VAS Arm pain Show forest plot	2	180	Mean Difference (IV, Random, 95% CI)	‐0.29 [‐0.90, 0.33]

6 Neck Disability Index (NDI) Show forest plot	2	175	Mean Difference (IV, Random, 95% CI)	1.47 [‐5.39, 8.33]

7 JOA Show forest plot	1	100	Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.79, 0.59]

8 Odom's criteria Show forest plot	6	412	Risk Ratio (M‐H, Fixed, 95% CI)	1.11 [0.99, 1.24]

9 SF‐36 Physical Show forest plot	1	54	Mean Difference (IV, Fixed, 95% CI)	2.30 [‐4.57, 9.17]

10 SF‐36 Mental Show forest plot	1	54	Mean Difference (IV, Random, 95% CI)	5.80 [‐1.32, 12.92]

11 Satisfaction Show forest plot	1	488	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.88, 1.08]

12 Foraminal height Show forest plot	1	65	Mean Difference (IV, Random, 95% CI)	1.5 [0.83, 2.17]

13 Interspace height Show forest plot	1	65	Mean Difference (IV, Random, 95% CI)	1.9 [1.17, 2.63]

14 Cobb angle Show forest plot	1	65	Mean Difference (IV, Random, 95% CI)	0.80 [‐0.92, 2.52]

15 No Fusion Show forest plot	5	424	Risk Ratio (M‐H, Random, 95% CI)	1.87 [1.10, 3.17]

Comparison 5. Iliac crest autograft vs cage

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Comparison 6. Iliac crest autograft vs iliac crest autograft with plates

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Clinical outcome Show forest plot	2	104	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.91, 1.41]

2 No Fusion Show forest plot	2	76	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.92, 1.07]

Comparison 6. Iliac crest autograft vs iliac crest autograft with plates

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Comparison 7. Different types of autograft

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Fusion Show forest plot	1	50	Risk Ratio (M‐H, Random, 95% CI)	0.61 [0.32, 1.17]

Comparison 7. Different types of autograft

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Comparison 9. Other comparisons between different types of instrumentation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Odom's criteria Show forest plot	1	107	Risk Ratio (M‐H, Random, 95% CI)	1.09 [0.91, 1.31]

Comparison 9. Other comparisons between different types of instrumentation

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Comparison 10. PMMA vs cage

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Operation time Show forest plot	2	169	Mean Difference (IV, Random, 95% CI)	13.49 [8.23, 18.75]

2 Odoms criteria Show forest plot	2	167	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.85, 1.19]

3 No Fusion Show forest plot	2	167	Risk Ratio (M‐H, Random, 95% CI)	7.25 [0.70, 74.75]

Comparison 10. PMMA vs cage

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Comparison 11. Cage vs cage and plate

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Neck pain Show forest plot	1	37	Mean Difference (IV, Random, 95% CI)	0.30 [0.03, 0.57]

2 Arm pain Show forest plot	1	37	Mean Difference (IV, Random, 95% CI)	‐0.60 [‐0.80, ‐0.40]

3 JOA Show forest plot	1	62	Mean Difference (IV, Random, 95% CI)	0.5 [‐0.65, 1.65]

4 Segmental lordosis Show forest plot	1	62	Mean Difference (IV, Random, 95% CI)	‐0.60 [‐2.95, 1.75]

Comparison 11. Cage vs cage and plate

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Comparison 12. Complications

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 complications Show forest plot	33	2595	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.49, 1.06]

1.1 Discectomy alone versus human bone graft	7	442	Risk Ratio (M‐H, Fixed, 95% CI)	1.56 [0.71, 3.43]
1.2 Discectomy alone vs cage	3	260	Risk Ratio (M‐H, Fixed, 95% CI)	0.18 [0.01, 3.69]
1.3 Discectomy alone vs PMMA	2	140	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.01, 5.03]
1.4 Discectomy alone vs iliac crest autograft with plates	3	111	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.33, 3.21]
1.5 Autograft versus Allograft	4	220	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [0.34, 3.48]
1.6 Autograft vs autograft w cages	7	492	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.12, 0.92]
1.7 Iliac crest autograft vs iliac crest autograft and plates	3	136	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.37, 2.63]
1.8 Different types of autograft	1	46	Risk Ratio (M‐H, Fixed, 95% CI)	0.23 [0.05, 1.08]
1.9 Bone substitute vs bone substitute w cages	1	44	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.76]
1.10 Conservative instrumentation verus innovational instrumentation	10	704	Risk Ratio (M‐H, Fixed, 95% CI)	0.10 [0.01, 1.85]

Comparison 12. Complications

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