Cervical Intervertebral Disc Degeneration – Surgical Treatment Indications and Options

Authors: P. Suchomel
Authors‘ workplace: Neurochirurgické oddělení, Neurocentrum, Krajská nemocnice Liberec a. s.
Published in: Cesk Slov Neurol N 2008; 71/104(3): 246-261
Category: Minimonography


There are a growing number of patients presenting with complaints related to pain in the cervical spine. In order to discover the underlying causes, both the acquired clinical knowledge and a number of modern examination methods are utilised. Usually, the cause resides in a degenerative disease, and if the patient is not affected by a significant or progressing neurological deficit, conservative therapy should be applied. In the opposite case, or if conservative therapy proves ineffective, surgery is considered as a therapeutic option. The objective of the overview article is to describe pathological conditions related to cervical intervertebral disc degeneration, to systematize their morphological diagnosis and to provide the reader with clear guidelines for the selection of patients who could benefit from surgical intervention. The subsequent section pursues the objective of describing, in simple terms, current methods of surgical treatment of cervical intervertebral space. Each of the procedures described therein has its strong and weak points. None of the methods described is endorsed by the necessary body of evidence in relevant literature and similar results can be expected from the application of any one of them. However, the basic prerequisites are correct indication based on the harmony of clinical and morphological findings and excellence of surgical technique. Of equal importance is long-term follow-up of patients and standardized evaluation of the results of the surgeons' efforts. The doctor sending his or her patient for surgery should always know what the results of the surgery team have been, and should be in permanent contact with them. Experience in performing similar procedures and adequate equipment of the centre should be another criterion for successful cooperation. The Czech Spine Surgery Society JEP monitors on a long-term basis the parametres of the different spine surgery centres and classifies their performance. For better orientation among spine surgery centres, the referring neurologist, orthopaedist or rehabilitation specialist can use the database of approved spine surgery centres published at www.spine.cz on an annual basis.

Key words:
cervical spine – degenerative disease – cervical spine surgery – discectomy


1. Boos N, Weissbach S, Rohrbach M, Weiler C, Spratt KF, Nerlich AG. Classification of age related changes in lumbar intervertebral discs. Spine 2002; 27(23): 2631–2644.

2. Benoist M. Natural history of the aging spine. Eur Spine J 2003; 12(Suppl 2): S86–S89.

3. Urban J. The physiology of the intervertebral disc. In: Gunzburg R, Szpalski M (Eds). Lumbar disc herniation. Philadelphia: Lippincot Williams and Wilkins 2001: 22–31.

4. Holm SH. Nutritional and pathophysiologic aspects of the lumbar intervertebral disc. In: Wiesel SW, Weinstein JN, Herkowitz H et al (Eds). The lumbar spine. Philadelphia: WB Saunders 1996: 285–310.

5. Bogduk N, Windsor M, Inglis A. The inervation of the cervical intervertebral discs. Spine 1988; 13(1): 2–8.

6. Lukáš R, Barsa P, Suchomel P. Diskogenní bolest a její chirurgická léčba arthroplastikou. Acta Spondylologica 2004; 3(1): 9–17.

7. Kadaňka Z, Mareš M, Bednařík J, Smrčka V, Krbec M, Stejskal L et al. Approaches to spondylotic cervical myelopathy: conservative versus surgical results in a 3-year follow-up study. Spine 2002; 27(20): 2205–2210.

8. Lohnert J, Látal J. Cervikálna spondylotická myelopatia. Bratislavské Lek Listy 1999; 96: 395–400.

9. Benzel EC, Lancon J, Kesterson L, Hadden T. Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy. J Spinal Disord 1991; 4(3): 286–295.

10. Herdmann J, Linzbach M, Krzan M, Dvorak J, Bock WJ. The European myelopathy score. Advances in Neurosurgery 1994; 22: 266–268.

11. Rogers C, Joshi A, Dreyfuss P. Cervical instrinsic disc pain and radiculopathy. In: Malanga GA (Ed). Cervical Flexion-Extension Injuries. 2nd ed. Hanley and Belfus (State of the art reviews 1998): 323–356.

12. Schellhas KP, Smith MD, Cooper RG, Pollei SR. Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine 1996; (21)3: 300–312.

13. Pracyk JB, Traynelis VC. Treatment of the painful motion segment: cervical arthroplasty. Spine 2005; 30(Suppl 16): S23–S32.

14. Schofferman J, Garges K, Goldwaithe N, Koestler M, Libby E. Upper cervical anterior discectomy and fusion improves discogenic cervical headaches. Spine 2002; 27(20): 2240–2244.

15. Wachli B, Dvorak J, Grob D. Cervical spine disorders and headaches. 21st Meeting of CSRS, New York 1993.

16. MacNab I. Symptoms in cervical disc degeneration. In: Cervical Spine research Society Editorial Committee (Ed). The Cervical Spine. 2nd ed. Philadelphia: JB Lippincott 1989: 599–606.

17. Abumi K, Manabu I, Kaneda K. Surgical treatment of cervical destructive spondylarthropathy (DSA). Spine 2000; 25(22): 2899–2905.

18. Friedenberg ZB, Miller VT. Degenerative disc disease in cervical spine. J Bone Joint Surg Am 1963; 45: 1171–1178.

19. Schlamann M, Reischke L, Klassen D, Maderwald S, Böhner V, Kollia K et al. Dynamic magnetic resonance imaging of the cervical spine using the NeuroSwing System. Spine 2007; 32(21): 2398–2401.

20. Lindblom K. Diagnostic puncture of intervertebral disks in sciatica. Acta Orthop Scand 1948; 17: 231–239.

21. Smith G. The normal cervical diskogram; with clinical observations. Am J Roentgenol Radium Ther Nucl Med 1959; 81(6): 1006–1010.

22. Smith G, Nichols PJ. The technique of cervical discography. Radiology 1957; 68: 718–720.

23. Cloward RB. Cervical discography: technique, indications and use in the diagnosis of cervical ruptured disks. Am J Roentgenol 1958; 79(4): 563–564.

24. Cloward RB. Cervical discography: a contribution to the aethiology and mechanism of neck, shoulder and arm pain. Ann Surg 1959; 150: 1052-1064.

25. Hadra BE. Wiring of the spinous process in injury and Pot´s disease. Trans Am Orthop Assoc 1981; 4: 206.

26. Walton GL, Paul WE. Contribution to the study of spinal surgery: One successful and one unsuccessful operation for the removal of the tumor. Boston Med Surg J 1905; 153: 114–117.

27. Elsberg CA. The extradural ventral chondromas, their favorite sites, the spinal cord and root symptoms they produce, and their surgical treatment. Bull Neurol Inst NY 1931; 1: 350–388.

28. Spurling RG, Segerberg LH. Lateral intervertebral disc lesionsin the lower cervical region. J Am Med Assoc 1953; 151(5): 354–359.

29. Bailey RW, Badgley CE. Stabilization of the cervical spine by anterior fusion. J Bone Joint Surg Am 1960; 42-A: 565–594.

30. Robinson RA, Smith GW. Anterolateral cervical disc removal and interbody fusion for cervical disc syndrome. Bull Johns Hopkins Hosp 1955; 96: 223–224.

31. Cloward RB. The treatment of ruptured intervertebral discs by vertebral body fusion. Indications, operative technique, aftercare. J Neurosurg 1953; 10(2): 154–168.

32. Ann HS, Simpson JM, Glover JM, Stephan J. Comparison between allografts plus demineralised bone matrix versus autograft. Spine 1995; 20(20): 2211–2216.

33. Bishop RC, Moore KA, Hadley MN. Anterior cervical interbody fusion using autogenic and allogenic bone graft substrate: a prospective comparative analysis. J Neurosurg 1996; 85: 206–210.

34. Brown CW, Orme TJ, Richardson HD. The rate of pseudoartrosis in patients who are smokers and patients who are not smokers: a comparison study. Spine 1986; 11: 942–943.

35. Floyd T, Ohnmeiss D. A meta-analysis of autograft versus allograft in anterior cervical spine fusion. Eur Spine J 2000; 9(5): 398–403.

36. Martin GJ jr, Haid RW jr, MacMillan M, Rodts GE jr, Berkman R. Anterior cervical discectomy with freeze-dried fibula allograft. Overview of 317 cases and literature review. Spine 1999; 24(9): 852–858.

37. Suchomel P, Barsa P, Buchvald P, Svobodník A, Vaničková E. Autologous versus allogenic bone grafts in instrumented anterior cervical discectomy and fusion: a prospective study with respect to a bone union pattern. Eur Spine J 2004; 13(6): 510–515.

38. Erbe EM, Marx JG, Clineff TD, Bellincampi LD. Potential of an ultraporous beta-tricalcium phosphate synthetis cancelous bone void filler and bone marrow aspirate composite graft. Eur Spine J 2001; 10(Suppl 2): S141–S146.

39. Khan SN, Sandhu HS, Parvataneni HK, Girardi FP, Cammisa FP jr. Bone graft substitutes in spine surgery. Bull Hosp Jt Dis 2000; 59(1): 5–10.

40. Marchesi DG. Spinal fusions: bone and bone substitutes. Eur Spine J 2000; 9(5): 372–378.

41. Rudinský B, Hill R, Koleják K. Anterior cervical interbody fusion with bioceramic cages: initial experience. In: Kaech DL, Jinkins JR (Eds). Spinal restabilisation procedures. Elsevier 2002: 249–256.

42. Orozco Delcios R, Llovet Tapies J. Osteosyntesis en lac fractures de raquis cervical. Revista Otop Traumatol 1977; 14: 285–288.

43. Brantigan JW, Steffee AD, Geiger JM. A carbon fiber implant to aid interbody lumbar fusion: mechanical testing. Spine 1991; 16(Suppl 6): S227–S282.

44. Matgé G, Leclercq TA. Rationale for interbody fusion with threaded titanium cages at cervical and lumbar levels. Results of 357 cases. Acta Neurochir (Wien) 2000; 142(4): 425–434.

45. Ray CD. Spinal interbody fusion: a review featuring new generation technigues. Neurosurg Q 1997; 7(2): 135–156.

46. Suchomel P, Barsa P. Náhrada krční meziobratlové ploténky vložkou Cespace bez použití kosti či její náhrady. Prospektivní studie. Acta Spondylologica 2004; 3(1): 5–9.

47. Goffin J, Casey A, Ker P, Liebig K, Lind B, Logroscino C et al. Preliminary Clinical Experience with the Bryan Cervical Disc Prosthesis. Neurosurgery 2002; 51(3): 840–847.

48. Kulkarni V, Rajshekhar V, Raghuram L. Accelerated spondylotic changes adjacent to the fused segment following central cervical corpectomy: magnetic resonance imaging study evidence. J Neurosurg Spine 2004; 100: 2–6.

49. Hilibrand AS, Robbins M. Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? Spine J 2004; 4(Suppl 6): 190S–194S.

50. Bertagnoli R, Duggal N, Pickett GE, Wigfield CC, Gill SS, Karg A et al. Cervical Total Disc Replacement. Part Two. Clinical Results. Orthop Clin North Am 2005; 36(3): 355–362.

51. Bertagnoli R, Yue JJ, Pfeiffer F, Fenk-Mayer A, Lawrence JP, Kershaw T et al. Early results after ProDisc-C cervical disc replacement. J Neurosurg Spine 2005; 2(4): 403–410.

52. Coric D, Finger F, Boltes P. Prospective randomized controlled study of the Bryan Cervical Disc: early clinical results from a single investigational site. J Neurosurg Spine 2006; 4(1): 31–35.

53. Pimenta L, McAfee P, Cappuccino A, Kellera FP, Link HD. Clinical experience with the new artificial cervical PCM (Cervitech) Disc Spine J 2004; 4(Suppl 6): 315S–321S.

54. Singh K, Vaccaro AR, Albert TJ. Assessing the potential impact of total disc arthroplasty on surgeon practice patterns in North America. Spine J 2004; 4(Suppl 6): 195S–201S.

55. Clarke MJ, Ecker RD, Krauss WE, McClelland RL, Dekutoski MB. Same-segment and adjacent-segment disease following posterior cervical foraminotomy. J Neurosurg Spine 2007; 6(1): 5–9.

56. Gala VC, O'Toole JE, Voyadzis JM, Fessler RG. Posterior minimally invasive approaches for the cervical spine. Orthop Clin North Am 2007; 38(3): 339–349.

57. Ruetten S, Komp M, Merk H, Godolias G. A new full-endoscopic technique for cervical posterior foraminotomy in the treatment of lateral disc herniations using 6.9-mm endoscopes: prospective 2-year results of 87 patients. Minim Invasive Neurosurg 2007; 50(4): 219–226.

58. Dowd GC, Wirth FP. Anterior cervical discectomy: is fusion necessary? J Neurosurg 1999; 90(Suppl 1): 8–12.

59. Hirsch C. Cervical disc rupture: diagnosis and therapy. Acta Orthop Scan 1960; 30: 172–186.

60. Savolainen S, Rinne J, Hernesniemi J. A prospective randomised study of anterior single level cervical disc operations with long-term follow-up: Surgical fusion is unnecessary. Neurosurgery 1998; 43(1): 51–55.

61. Lee JY, Löhr M, Impekoven P, Koebke J, Ernestus RI, Ebel H et al. Small keyhole transuncal foraminotomy for unilateral cervical radiculopathy. Acta Neurochir (Wien) 2006; 148(9): 951–958.

62. Cağlar YS, Bozkurt M, Kahilogullari G, Tuna H, Bakir A, Torun F et al. Keyhole approach for posterior cervical discectomy: experience on 84 patients. Minim Invasive Neurosurg 2007; 50(1): 7–11.

63. Bohlman HH, Emerz SE, Goodfellow DB, Jones PK. Robinson Anterior Cervical Discectomy and Arthrodesis for Cervical Radiculopathy. J Bone Joint Surg Am 1993; 75(9): 1298–1307.

64. Gore DR. The arthrodesis rate in multilevel anterior cervical fusions using autogenous fibula. Spine 2001; 26(11): 1259–1263.

65. Whitecloud 3rd TS, La Rocca H. Fibular strut graft in reconstructive surgery of the cervical spine. Spine 1976; 1: 33–43.

66. Gore DR. Technique of cervical interbody fusion. Clin Orthop 1984; 188: 191–195.

67. Graham JJ. Complications of cervical spine surgery.A five-year report on a survey of the membership of the cervical spine research society by the morbidity and mortality committee. Spine 1989; 14: 1046–1050.

68. Barsa P, Suchomel P. Organické materiály v přední krční diskektomii a fúzi. Acta Spondylologica 2002; 1(2): 123–129.

69. Zdeblick TA, Ducker TB. The use of freeze-dried allograft bone for anterior cervical fusions. Spine 1991; 16(7): 726–729.

70. Tomford WW. Transmission of disease through transplantation of musculoskeletal allografts. J Bone Joint Surg Am 1995; 77(11): 1742–1754.

71. Barsa P, Suchomel P, Buchvald P, Kolářová E, Svobodník A. Je víceetážová instrumentovaná přední krční fúze rizikovým faktorem vzniku kostního spojení? (prospektivní studie s minimální délkou sledování 3 roky). Acta Chir Orthop Traumatol Cech 2004; 71(3): 137–141.

72. Epstein NE. Dynamic anterior cervical plates for multilevel anterior corpectomy and fusion with simultaneous posterior wiring and fusion: efficacy and outcomes. Spinal Cord 2006; 44(7): 432–439.

73. Stulik J, Pitzen TR, Chrobok J, Ruffing S, Drumm J, Sova L et al. Fusion and failure following anterior cervical plating with dynamic or rigid plates: 6-months results of a multi-centric, prospective, randomized, controlled study. Eur Spine J 2007; 16(10): 1689–1694.

74. Barsa P, Suchomel P, Buchvald P, Lukáš R, Vaníčková E. Jsou šrouby při přední krční fúzi s bikortikální fixací skutečně bikortikálně zavedeny? Retrospektivní studie. Acta Chir Orthop Traumatol Cech 2002; 69: 35–38.

75. Bagby GW. Arthrodesis by the distraction-compression using a stainless steel implant. Orthopedics 1988; 11(9): 931–934.

76. Kuslich SD. The treatment of chronic discogenic low back pain by the Bagby and Kuslich method of interbody fusion. In: Szpalski M, Gunzburg R, Spengler DM et al (Eds). Instrumented fusion of the degenerative lumbar spine: State of the art, questions and controversies. Philadelphia: Lippincott-Raven 1996: 233–248.

77. Barsa P, Suchomel P. Factors affecting sagittal malalignment due to cage subsidence in standalone cage assisted anterior cervical fusion. Eur Spine J 2007; 16(9): 1395–1400.

78. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am 1999; 81(4): 519–528.

79. DiAngelo DJ, Foley KT. An improved biomechanical testing protocol for evaluating spinal arthroplasty and motion preservation devices in a multilevel human cadaveric cervical model. Neurosurg Focus 2004; 17(3): E4.

80. DiAngelo DJ, Foley KT, Morrow BR, Schwab JS, Song J, German JW et al. In vitro biomechanics of cervical disc arthroplasty with the Prodisc-C total disc implant. Neurosurg Focus 2004; 17(3): E7.

81. Maiman DJ, Kumaresan S, Yoganandan N, Pintar FA. Biomechanical effect of anterior cervical spine fusion on adjacent segments. Biomed Mater Eng 1999; 9(1): 27–38.

82. Dmitriev AE, Cunningham BW, Hu N, Sell G, Vigna F, McAfee PC. Adjacent level intradiscal pressure and segmental kinematics following a cervical total disc arthroplasty: an in vitro human cadaveric model. Spine 2005; 30(10): 1165–1172.

83. Le H, Thongtrangan I, Kim DH. Historical review of cervical arthroplasty. Neurosurg Focus 2004; 17(3): E1.

84. Cummins BH, Robertson JT, Gill SS. Surgical experience with an implanted artificial cervical joint. J Neurosurg 1998; 88(6): 943–948.

85. Wigfield CC, Gill SS, Nelson RJ, Metcalf NH, Robertson JT. The New Frenchay Artificial Cervical Join. Spine 2002; 27(22): 2446–2452.

86. Smith HE, Wimberley DW, Vaccaro AR. Cervical arthroplasty: material properties. Neurosurg Focus 2004; 17(3): E3.

87. Goffin J, Van Calenbergh F, van Loon J, Casey A, Kehr P, Liebig K et al. Intermediate follow-up after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis: single-level and bi-level.. Spine 2003; 28(24): 2673–2678.

88. McAfee PC, Cunningham B, Dmitriev A, Hu N, Woo Kim S, Cappuccino A et al. Cervical disc replacement-porous coated motion prosthesis: a comparative biomechanical analysis showing the key role of the posterior longitudinal ligament. Spine 2003; 28(20): S176–S185.

89. Pickett GE, Mitsis DK, Sekhon LH, Sears WR, Duggal N. Effects of a cervical disc prosthesis on segmental and cervical spine alignment. Neurosurg Focus 2004; 17(3): E5.

90. Mehren C, Suchomel P, Grochulla F, Barsa P, Sourkova P, Hradil J et al. Heterotopic ossification in total cervical artificial disc replacement. Spine 2006; 31(24): 2802–2806.

91. Barsa P, Pešánová H, Suchomel P. Rehabilitační a režimové vedení pacientů po náhradě krční meziobratlové ploténky a intervertebrální déze. Rehabilitace a fyzikální lékařství 2004; 11(3): 122–127.

92. Pickett GE, Rouleau JP, Duggal N. Kinematic analysis of the cervical spine following implantation of an artificial cervical disc. Spine 2005; 30(17): 1949–1954.

93. Pickett GE, Sekhon LH, Sears WR, Duggal N. Complications with cervical arthroplasty. J Neurosurg Spine 2006; 4(2): 98–105.

94. Shim ChS, Shin HD, Lee SH. Posterior avulsion fracture at adjacent vertebral body during cervical disc replacement with ProDisc-C: a case report.. J Spinal Disord Tech 2007; 20(6): 468–472.

95. McAfee PC, Cunningham BW, Devine J, Williams E, Yu-Yahiro J. Classification of heterotopic ossification (HO) in artificial disc replacement. J Spinal Disord Tech 2003; 16(4): 384–389.

96. Leung C, Casey AT, Goffin J, Kehr P, Liebig K, Lind B et al. Clinical significance of heterotopic ossification in cervical disc replacement: a prospective multicenter clinical trial. Neurosurgery 2005; 57(4): 759–763.

97. Parkinson JF, Sekhon LHS. Cervical arthroplasty complicated by delayed spontaneous vision. J Neurosurg Spine 2005; 2(3): 377–380.

98. Robertson JT, Papadopoulos SM, Traynelis VC. Assessment of adjacent-segment disease in patients treated with cervical fusion or arthroplasty: a prospective 2-year study. J Neurosurg Spine 2005; 3(6): 417–423.

99. Mummaneni PV, Haid RW. The future in the care of the cervical spine: interbody vision and arthroplasty. J Neurosurg Spine 2004; 1(2): 155–159.

100. Porchet F, Metcalf NH. Clinical outcomes with the Prestige II cervical disc: preliminary results from a prospective randomized clinical trial. Neurosurg Focus 2004; 17(3): E6.

101. Sasso RC, Smucker JD, Hacker RJ, Heller JG. Clinical outcomes of BRYAN cervical disc arthroplasty: a prospective, randomized, controlled, multicenter trial with 24-month follow-up. J Spinal Disord Tech 2007; 20(7): 481–491.

102. Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther 1991; 14(7): 409–415.

Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 3

2008 Issue 3

Most read in this issue

This topic is also in:

Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account