Implant Research Core, School of Biomedical Science, Engineering, and Health Systems, Drexel University, Philadelphia, PA, USA.
The Disc Replacement Center, Salt Lake City, UT, USA.
Eur Spine J. 2024 Aug;33(8):2969-2981. doi: 10.1007/s00586-024-08407-2. Epub 2024 Jul 16.
Cervical total disc replacement (cTDR) has been established as an alternative treatment for degenerative cervical radiculopathy and myelopathy. While the rate of complications for cTDR is reasonably low, recent studies have focused on bone loss after cTDR. The purpose of this work is to develop a clinical management plan for cTDR patients with evidence of bone loss. To guide our recommendations, we undertook a review of the literature and aimed to determine: (1) how bone loss was identified/imaged, (2) whether pre- or intraoperative assessments of infection or histology were performed, and (3) what decision-making and revision strategies were employed.
We performed a search of the literature according to PRISMA guidelines. Included studies reported the clinical performance of cTDR and identified instances of cervical bone loss.
Eleven case studies and 20 cohort studies were reviewed, representing 2073 patients with 821 reported cases of bone loss. Bone loss was typically identified on radiographs during routine follow-up or by computed tomography (CT) for patients presenting with symptoms. Assessments of infection as well as histological and/or explant assessment were sporadically reported. Across all reviewed studies, multiple mechanisms of bone loss were suspected, and severity and progression varied greatly. Many patients were reportedly asymptomatic, but others experienced symptoms like progressive pain and paresthesia.
Our findings demonstrate a critical gap in the literature regarding the optimal management of patients with bone loss following cTDR, and treatment recommendations based on our review are impractical given the limited amount and quality evidence available. However, based on the authors' extensive clinical experience, close follow-up of specific radiographic observations and serial radiographs to assess the progression/severity of bone loss and implant changes are recommended. CT findings can be used for clinical decision-making and further follow-up care. The pattern and rate of progression of bone loss, in concert with patient symptomatology, should determine whether non-operative or surgical intervention is indicated. Future studies involving implant retrieval, histopathological, and microbiological analysis for patients undergoing cTDR revision for bone loss are needed.
颈椎间盘置换术（cTDR）已被确立为治疗退行性颈椎神经根病和颈椎病的一种替代方法。虽然 cTDR 的并发症发生率相当低，但最近的研究集中在 cTDR 后的骨丢失上。本研究的目的是为 cTDR 患者制定一种针对骨丢失的临床管理方案。为了指导我们的建议，我们对文献进行了回顾，并旨在确定：（1）如何识别/成像骨丢失，（2）是否进行了感染或组织学的术前或术中评估，以及（3）采用了哪些决策和修正策略。
我们按照 PRISMA 指南对文献进行了搜索。纳入的研究报告了 cTDR 的临床结果，并确定了颈椎骨丢失的病例。
共回顾了 11 项病例研究和 20 项队列研究，共 2073 例患者，821 例报告有骨丢失病例。骨丢失通常是在常规随访时通过 X 线片或因症状出现而行 CT 检查时发现的。感染评估以及组织学和/或植入物评估的报道较为零星。在所有回顾的研究中，怀疑有多种机制导致骨丢失，其严重程度和进展情况差异很大。许多患者无症状，但也有患者出现进行性疼痛和感觉异常等症状。
我们的研究结果表明，在 cTDR 后发生骨丢失的患者的最佳管理方面，文献中存在一个关键的空白，而且由于现有证据数量有限且质量不高，基于我们的综述提出的治疗建议不切实际。然而，根据作者的丰富临床经验，建议密切关注特定的影像学观察结果，并进行连续的 X 线片检查以评估骨丢失和植入物变化的进展/严重程度。CT 结果可用于临床决策和进一步的随访护理。骨丢失的进展模式和速度，结合患者的症状，应决定是否需要非手术或手术干预。需要开展涉及植入物取出、组织病理学和微生物学分析的研究，以便为接受 cTDR 翻修以治疗骨丢失的患者提供参考。
