الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Background: Cervical disc herniation is a common cause of neck pain in adults. The severity of the disease can range from mild to severe. The prevalence of cervical disc herniation increases with age for both men and women and is most common in people in their 3rd to 5th decades of life. It occurs more frequently in females, accounting for more than 60% of cases. For both sexes, the most frequently diagnosed patients were in the age group of 51 to 60.
Anterior cervical discectomy and fusion (ACDF) was considered the ―gold standard‖ for management of cervical disc herniation. But in recent years, radiographic and clinical studies have shown that as time passes, the segments adjacent to the fused spinal segments become occasionally degenerated or unstable.
ACDF involves removing the problematic disc completely and replacing it with a bone graft (or bone graft substitute) to allow the adjacent vertebrae to eventually fuse together. One of the main limitations of the ACDF surgery, is that it alters the original mechanical behavior of the spine at the expense of the activity of the fusion segment; and this leads to the changes of adjacent vertebral stress distribution and the movement patterns, resulting in biomechanical changes including stress concentration of adjacent segments, compensatory increase in activity, and even instability.
Objectives: To perform a systematic review and meta- analysis comparing the total disk replacement (TDR) with anterior cervical discectomy and fusion (ACDF) in cervical disk herniation patients with regards to clinical, radiological, biomechanical factors and patient outcomes.
Materials and Methods: We followed the PRISMA statement guidelines Moher et al. (64) during this systematic review and meta-analysis preparation and performed all steps according to the Cochrane handbook of systematic reviews of intervention (65). We searched PubMed, Scopus, Cochrane, and WOS, Embase, and Science Direct till July 2021 using relevant keywords. We used the relevant keywords for searching databases including ―total disc replacement‖ AND ―Anterior cervical discectomy and fusion‖ Or ―Cervical herniation‖.
We included studies that followed the following criteria:
(1) Adult patients above 18 years old (2) Double arm designs
(3) Studies designs are limited to randomized control trial (RCT) to obtain high-quality evidence (4) English studies (5) Outcomes either clinical or radiological are acceptable. We excluded conference abstracts or unpublished data, studies written in a language other than English, in-vitro studies, and duplicated articles by the same author unless those with longer follow-ups studies.
We evaluated the included studies using the Cochrane risk of bias assessment tool Green et al. (66), which included the
following risks: selection bias ”through random sequence generation and allocation concealment,” selective reporting, attrition bias, performance bias through blinding of participants, and personnel, detection bias through blinding of outcome assessment. Each bias domain is recorded as one of the following: low risk, high risk, or unclear risk.
We use Review Manager software (RevMan version 5.4). Regarding the study outcomes, risk ratio (RR) with 95% confidence interval (CI) was used for dichotomous variables, while the mean difference (MD) and 95% CI were presented for continuous variables. Cochrane’s P values and I2 were tested to examine heterogeneity among the studies.
Results: Ten studies were included qualitatively and nine studies were included quantitatively. We found that the overall SALDRS rate of the TDR group was significantly lower than that of the ACDF group after a minimum follow-up period with a P-value of 0.0001. Also, regarding a longer follow-up of 4-5 years in terms of SLDRS rate, we found a significant positive result towards the TDR compared to ACDF (P = 0.006). Longer follow-up of seven years and nine years postoperatively showed also a significant favorable effect of TDR over ACDF with P- value of 0.01 and 0.02 respectively.
Regarding the postoperative patient’s satisfaction, we found a favorable effect of TDR over ACDF with increased satisfaction rate in patients underwent TDR (P = 0.0001). In terms of Neck
disability index (NDI), there was no significant difference between either TDR or ACDF postoperatively (P = 0.81). Dysphagia also showed no significant difference between both TDR and ACDF postoperatively with a P value of 0.11. Also, postoperative major complication showed no significant difference between both TDR and ACDF postoperatively with P value of 0.13. On the other hand, regarding the postoperative subsequent surgical intervention, we found a significant difference between both groups favoring TDR over ACDF (P < 0.00001).
Pain score of the neck and the arm _ assessed by VAS score_, there was no significant difference between both groups of TDR and ACDF in either arm or neck pain with P- values of 0.79, 0.40 respectively. The analysis of SF-36 questionnaire showed a significant difference in physical functioning (P = 0.0002). However, no significant difference was detected regarding the mental component of SF-36 (P = 32).