Disc Replacement Adjacent to Cervical Fusion A Biomechanical Comparison of Hybrid Construct Versus Two-Level Fusion

Study Design. A cadaveric biomechanical study. Objective. To investigate the biomechanical behavior of the cervical spine after cervical total disc replacement (TDR) adjacent to a fusion as compared to a two-level fusion. Summary of Background Data. There are concerns regarding the biomechanical effects of cervical fusion on the mobile motion segments. Although previous biomechanical studies have demonstrated that cervical disc replacement normalizes adjacent segment motion, there is a little information regarding the function of a cervical disc replacement adjacent to an anterior cervical decompression and fusion, a potentially common clinical application. Methods. Nine cadaveric cervical spines (C3-T1, age: 60.2 +/- 3.5 years) were tested under load-and displacement-control testing. After intact testing, a simulated fusion was performed at C4-C5, followed by C6-C7. The simulated fusion was then reversed, and the response of TDR at C5-C6 was measured. A hybrid construct was then tested with the TDR either below or above a single-level fusion and contrasted with a simulated two-level fusion (C4-C6 and C5-C7). Results. The external fixator device used to simulate fusion significantly reduced range of motion (ROM) at C4-C5 and C6-C7 by 74.7 +/- 8.1% and 78.1 +/- 11.5%, respectively (P < 0.05). Removal of the fusion construct restored the motion response of the spinal segments to their intact state. Arthroplasty performed at C5-C6 using the porous-coated motion disc prosthesis maintained the total flexion-extension ROM to the level of the intact controls when used as a stand-alone procedure or when implanted adjacent to a single-level fusion (P > 0.05). The location of the single-level fusion, whether above or below the arthroplasty, did not significantly affect the motion response of the arthroplasty in the hybrid construct. Performing a two-level fusion significantly increased the motion demands on the nonoperated segments as compared to a hybrid TDR-plus fusion construct when the spine was required to reach the same motion end points. The spine with a hybrid construct required significantly less extension moment than the spine with a two-level fusion to reach the same extension end point. Conclusion. The porous-coated motion cervical prosthesis restored the ROM of the treated level to the intact state. When the porous-coated motion prosthesis was used in a hybrid construct, the TDR response was not adversely affected. A hybrid construct seems to offer significant biomechanical advantages over two-level fusion in terms of reducing compensatory adjacent-level hypermobility and also loads required to achieve a predetermined ROM.