{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T07:26:46Z","timestamp":1791617206270,"version":"4.3.4"},"reference-count":52,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["FOC"],"published-print":{"date-parts":[[2017,2]]},"abstract":"\n OBJECTIVE<\/jats:title>\n Cervical disc arthroplasty (CDA) has been demonstrated to be an effective treatment modality for single-level cervical radiculopathy or myelopathy. Its advantages over an anterior cervical discectomy and fusion (ACDF) include motion preservation and decreased reoperations at the index and adjacent segments up to 7 years postoperatively. Considering the fact that many patients have multilevel cervical disc degeneration (CDD), the authors performed a systematic review of the clinical studies evaluating patients who underwent multilevel CDA (2 or more levels).<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n A systematic review in the MEDLINE database was performed. Clinical studies including patients who had multilevel CDA were selected and included. Case reports and literature reviews were excluded. Articles were then grouped according to their main study objective: 1) studies comparing multilevel CDA versus ACDF; 2) studies comparing single-level CDA versus multilevel CDA; and 3) multilevel CDA after a previous cervical spine surgery.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n Fourteen articles met all inclusion criteria. The general conclusions were that multilevel CDA was at least as safe and effective as ACDF, with preservation of cervical motion when compared with ACDF and potentially with fewer reoperations expected in most of the studies. Multilevel CDAs are clinically effective as single-level surgeries, with good clinical and radiological outcomes. Some studies reported a higher incidence of heterotopic ossification in multilevel CDA when compared with single-level procedures, but without clinical relevance during the follow-up period. A CDA may be indicated even after a previous cervical surgery in selected cases.<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n The current literature supports the use of multilevel CDA. Caution is necessary regarding the more restrictive indications for CDA when compared with ACDF. Further prospective, controlled, multicenter, and randomized studies not sponsored by the device manufactures are desirable to prove the superiority of CDA surgery over ACDF as the treatment of choice for CDD in selected cases.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2016.10.focus16354","type":"journal-article","created":{"date-parts":[[2017,2,1]],"date-time":"2017-02-01T03:37:43Z","timestamp":1485920263000},"page":"E4","source":"Crossref","is-referenced-by-count":30,"title":["Multilevel cervical arthroplasty: current evidence. A systematic review"],"prefix":"10.3171","volume":"42","author":[{"given":"Andrei F.","family":"Joaquim","sequence":"first","affiliation":[{"name":"Department of Neurology, Discipline of Neurosurgery, State University of Campinas (UNICAMP), Campinas, S\u00e3o Paulo, Brazil; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"K. Daniel","family":"Riew","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Columbia University, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1-focus16354","series-title":"Med Devices (Auckl)","first-page":"397","article-title":"The Mobi-C cervical disc for one-level and two-level cervical disc replacement: a review of the literature","volume":"7","author":"Alvin","year":"2014"},{"key":"b2-focus16354","series-title":"Spine (Phila Pa 1976)","first-page":"759","article-title":"Comparison of clinical outcomes of 1- and 2-level total disc replacement: four-year results from a prospective, randomized, controlled, multicenter IDE clinical trial","volume":"40","author":"Bae","year":"2015"},{"issue":"5","key":"b3-focus16354","series-title":"Neurosurg Focus","first-page":"E19","article-title":"Multilevel cervical arthroplasty with artificial disc replacement","volume":"28","author":"Cardoso","year":"2010"},{"key":"b4-focus16354","series-title":"Int Orthop","first-page":"1347","article-title":"Fusion versus Bryan Cervical Disc in two-level cervical disc disease: a prospective, randomised study","volume":"33","author":"Cheng","year":"2009"},{"key":"b5-focus16354","series-title":"Spine (Phila Pa 1976)","first-page":"1769","article-title":"Biomechanical analysis of the range of motion after placement of a two-level cervical ProDisc-C versus hybrid construct","volume":"35","author":"Cho","year":"2010"},{"key":"b6-focus16354","series-title":"Spine J","first-page":"341","article-title":"Biomechanical comparison of single- and two-level cervical arthroplasty versus arthrodesis: effect on adjacent-level spinal kinematics","volume":"10","author":"Cunningham","year":"2010"},{"key":"b7-focus16354","series-title":"J Neurosurg Spine","first-page":"15","article-title":"Two-level total disc replacement with Mobi-C cervical artificial disc versus anterior discectomy and fusion: a prospective, randomized, controlled multicenter clinical trial with 4-year follow-up results","volume":"22","author":"Davis","year":"2015"},{"key":"b8-focus16354","series-title":"Eur Spine J","first-page":"627","article-title":"Differences between arthroplasty and anterior cervical fusion in two-level cervical degenerative disc disease","volume":"23","author":"Fay","year":"2014"},{"key":"b9-focus16354","series-title":"J Neurosurg Spine","first-page":"261","article-title":"A clinical analysis of 4- and 6-year follow-up results after cervical disc replacement surgery using the Bryan Cervical Disc Prosthesis","volume":"12","author":"Goffin","year":"2010"},{"key":"b10-focus16354","series-title":"Eur Spine J","first-page":"1417","article-title":"Comparison between single- and multilevel patients: clinical and radiological outcomes 2 years after cervical disc replacement","volume":"20","author":"Huppert","year":"2011"},{"key":"b11-focus16354","series-title":"J Korean Neurosurg Soc","first-page":"532","article-title":"Surgical outcome of cervical arthroplasty using Bryan\u00ae","volume":"46","author":"Kim","year":"2009"},{"key":"b12-focus16354","series-title":"Eur Spine J","first-page":"218","article-title":"Comparison of radiographic changes after ACDF versus Bryan disc arthroplasty in single and bi-level cases","volume":"18","author":"Kim","year":"2009"},{"key":"b13-focus16354","series-title":"Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi","first-page":"383","article-title":"[Two-level cervical artificial disc replacement combined with nearby segments fused for multilevel disc herniations.]","volume":"20","author":"Liu","year":"2006"},{"key":"b14-focus16354","series-title":"Spine (Phila Pa 1976)","first-page":"1359","article-title":"Kinematics of cervical total disc replacement adjacent to a two-level, straight versus lordotic fusion","volume":"36","author":"Martin","year":"2011"},{"key":"b15-focus16354","series-title":"Curr Opin Rheumatol","first-page":"127","article-title":"Heterotopic bone formation after joint replacement","volume":"11","author":"Nilsson","year":"1999"},{"key":"b16-focus16354","series-title":"Spine (Phila Pa 1976)","first-page":"1337","article-title":"Superiority of multilevel cervical arthroplasty outcomes versus single-level outcomes: 229 consecutive PCM prostheses","volume":"32","author":"Pimenta","year":"2007"},{"key":"b17-focus16354","series-title":"J Neurosurg Spine","first-page":"213","article-title":"Five-year clinical results of cervical total disc replacement compared with anterior discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease: a prospective, randomized, controlled, multicenter investigational device exemption clinical trial","volume":"25","author":"Radcliff","year":"2016"},{"issue":"196","key":"b18-focus16354","series-title":"Clin Orthop Relat Res","first-page":"217","article-title":"Prophylactic indomethacin for the prevention of heterotopic bone formation following total hip arthroplasty","author":"Ritter","year":"1985"},{"issue":"3","key":"b19-focus16354","series-title":"Neurosurg Focus","first-page":"E10","article-title":"Long-term outcome after implantation of the Prestige I disc in an end-stage indication: 4-year results from a pilot study","volume":"17","author":"Robertson","year":"2004"},{"key":"b20-focus16354","series-title":"Clin Spine Surg","first-page":"E522","article-title":"Feasibility and biomechanics of multilevel arthroplasty and combined cervical arthrodesis and arthroplasty","volume":"29","author":"Safavi-Abbasi","year":"2016"},{"key":"b21-focus16354","series-title":"J Clin Neurosci","first-page":"412","article-title":"Two-level artificial disc placement for spondylotic cervical myelopathy","volume":"11","author":"Sekhon","year":"2004"},{"key":"b22-focus16354","series-title":"J Neurosurg Spine","first-page":"335","article-title":"Cervical arthroplasty after previous surgery: results of treating 24 discs in 15 patients","volume":"3","author":"Sekhon","year":"2005"},{"key":"b23-focus16354","series-title":"J Neurosurg Spine","first-page":"457","article-title":"Heterotopic ossification after cervical total disc replacement: determination by CT and effects on clinical outcomes","volume":"14","author":"Tu","year":"2011"},{"key":"b24-focus16354","series-title":"Spine (Phila Pa 1976)","first-page":"E1251","article-title":"Multilevel arthroplasty for cervical spondylosis: more heterotopic ossification at 3 years of follow-up","volume":"37","author":"Wu","year":"2012"},{"key":"b25-focus16354","series-title":"Eur Spine J","first-page":"101","article-title":"Multilevel cervical disc arthroplasty (CDA) versus single-level CDA for the treatment of cervical disc diseases: a meta-analysis","volume":"24","author":"Zhao","year":"2015"},{"key":"b26-focus16354","series-title":"Spine (Phila Pa 1976)","first-page":"111","article-title":"Application of cervical arthroplasty with Bryan cervical disc: 10-year follow-up results in China","volume":"41","author":"Zhao","year":"2016"},{"key":"b1-focus16354","series-title":"Med Devices (Auckl)","first-page":"397","article-title":"The Mobi-C cervical disc for one-level and two-level cervical disc replacement: a review of the literature","volume":"7","author":"Alvin","year":"2014"},{"key":"b2-focus16354","series-title":"Spine (Phila Pa 1976)","first-page":"759","article-title":"Comparison of clinical outcomes of 1- and 2-level total disc replacement: four-year results from a prospective, randomized, controlled, multicenter IDE clinical trial","volume":"40","author":"Bae","year":"2015"},{"issue":"5","key":"b3-focus16354","series-title":"Neurosurg Focus","first-page":"E19","article-title":"Multilevel cervical arthroplasty with artificial disc replacement","volume":"28","author":"Cardoso","year":"2010"},{"key":"b4-focus16354","series-title":"Int Orthop","first-page":"1347","article-title":"Fusion versus Bryan Cervical Disc in two-level cervical disc disease: a prospective, randomised study","volume":"33","author":"Cheng","year":"2009"},{"key":"b5-focus16354","series-title":"Spine (Phila Pa 1976)","first-page":"1769","article-title":"Biomechanical analysis of the range of motion after placement of a two-level cervical ProDisc-C versus hybrid construct","volume":"35","author":"Cho","year":"2010"},{"key":"b6-focus16354","series-title":"Spine J","first-page":"341","article-title":"Biomechanical comparison of single- and two-level cervical arthroplasty versus arthrodesis: effect on adjacent-level spinal kinematics","volume":"10","author":"Cunningham","year":"2010"},{"key":"b7-focus16354","series-title":"J Neurosurg Spine","first-page":"15","article-title":"Two-level total disc replacement with Mobi-C cervical artificial disc versus anterior discectomy and fusion: a prospective, randomized, controlled multicenter clinical trial with 4-year follow-up results","volume":"22","author":"Davis","year":"2015"},{"key":"b8-focus16354","series-title":"Eur Spine J","first-page":"627","article-title":"Differences between arthroplasty and anterior cervical fusion in two-level cervical degenerative disc disease","volume":"23","author":"Fay","year":"2014"},{"key":"b9-focus16354","series-title":"J Neurosurg Spine","first-page":"261","article-title":"A clinical analysis of 4- and 6-year follow-up results after cervical disc replacement surgery using the Bryan Cervical Disc Prosthesis","volume":"12","author":"Goffin","year":"2010"},{"key":"b10-focus16354","series-title":"Eur Spine J","first-page":"1417","article-title":"Comparison between single- and multilevel patients: clinical and radiological outcomes 2 years after cervical disc replacement","volume":"20","author":"Huppert","year":"2011"},{"key":"b11-focus16354","series-title":"J Korean Neurosurg Soc","first-page":"532","article-title":"Surgical outcome of cervical arthroplasty using Bryan\u00ae","volume":"46","author":"Kim","year":"2009"},{"key":"b12-focus16354","series-title":"Eur Spine J","first-page":"218","article-title":"Comparison of radiographic changes after ACDF versus Bryan disc arthroplasty in single and bi-level cases","volume":"18","author":"Kim","year":"2009"},{"key":"b13-focus16354","series-title":"Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi","first-page":"383","article-title":"[Two-level cervical artificial disc replacement combined with nearby segments fused for multilevel disc herniations.]","volume":"20","author":"Liu","year":"2006"},{"key":"b14-focus16354","series-title":"Spine (Phila Pa 1976)","first-page":"1359","article-title":"Kinematics of cervical total disc replacement adjacent to a two-level, straight versus lordotic fusion","volume":"36","author":"Martin","year":"2011"},{"key":"b15-focus16354","series-title":"Curr Opin Rheumatol","first-page":"127","article-title":"Heterotopic bone formation after joint replacement","volume":"11","author":"Nilsson","year":"1999"},{"key":"b16-focus16354","series-title":"Spine (Phila Pa 1976)","first-page":"1337","article-title":"Superiority of multilevel cervical arthroplasty outcomes versus single-level outcomes: 229 consecutive PCM prostheses","volume":"32","author":"Pimenta","year":"2007"},{"key":"b17-focus16354","series-title":"J Neurosurg Spine","first-page":"213","article-title":"Five-year clinical results of cervical total disc replacement compared with anterior discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease: a prospective, randomized, controlled, multicenter investigational device exemption clinical trial","volume":"25","author":"Radcliff","year":"2016"},{"issue":"196","key":"b18-focus16354","series-title":"Clin Orthop Relat Res","first-page":"217","article-title":"Prophylactic indomethacin for the prevention of heterotopic bone formation following total hip arthroplasty","author":"Ritter","year":"1985"},{"issue":"3","key":"b19-focus16354","series-title":"Neurosurg Focus","first-page":"E10","article-title":"Long-term outcome after implantation of the Prestige I disc in an end-stage indication: 4-year results from a pilot study","volume":"17","author":"Robertson","year":"2004"},{"key":"b20-focus16354","series-title":"Clin Spine Surg","first-page":"E522","article-title":"Feasibility and biomechanics of multilevel arthroplasty and combined cervical arthrodesis and arthroplasty","volume":"29","author":"Safavi-Abbasi","year":"2016"},{"key":"b21-focus16354","series-title":"J Clin Neurosci","first-page":"412","article-title":"Two-level artificial disc placement for spondylotic cervical myelopathy","volume":"11","author":"Sekhon","year":"2004"},{"key":"b22-focus16354","series-title":"J Neurosurg 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(Phila Pa 1976)","first-page":"111","article-title":"Application of cervical arthroplasty with Bryan cervical disc: 10-year follow-up results in China","volume":"41","author":"Zhao","year":"2016"}],"container-title":["Neurosurgical 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