STUDY RATIONALE AND CONTEXT
Patients with cervical radiculopathy due to single-level degenerative disc disease who fail to improve with nonoperative therapy are candidates for anterior decompression and reconstruction with either an arthrodesis or arthroplasty. Both procedures require minimal hospitalization and are highly effective in relieving pain and improving neurological function. These patients are usually in the middle of their working careers. The ability to return to work and the speed with which this occurs are important to the individual being treated and also to society. Arthrodesis and arthroplasty differ in that one treatment eliminates motion at a cervical spinal segment while the other preserves it. This fundamental difference may impact postoperative function in terms of activity level, which ultimately could facilitate or hinder the ability to return to work.
RESULTS
We identified eight reports that met our inclusion criteria, which included information on return to work. From a total of 295 citations retrieved, 46 reports were selected for full-text review ([Fig 1]). Of these, eight met the inclusion criteria, four of which described the same study at different follow-up points ([Table 1]). Seven article representing four randomized controlled trials (CoE II) and four artificial discs are critically summarized: Bryan® Cervical Disc: US [1], [2] and China [3], Prestige® ST [4], [5], ProDisc-C [6], and Kineflex|C [7]. In addition, we summarized a secondary analysis of data from the U. Bryan® and Prestige® RCTs that focused on a subset of patients who were covered by workers’ compensation [8].
Further details on the class of evidence rating and additional data for these studies can be found in the Web Appendix at www.aospine.org/ebsj.
Percentage of patients working at follow-up (
[Tables 2], [3]
)
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In two studies [2], [4], the overall proportion of patients who were working increased postoperatively approximately 10%–12% (from 65% preoperatively to 75% at 24 months). Larger improvements were evident among workers’ compensation patients (from 36%–63%) [8], and a third study [6] reported no preoperative or postoperative differences in work status.
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At 24 months postoperatively, there was no significant difference in work status between disc replacement and fusion patients across three trials.
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Work status less than 24 months after surgery was reported in only one study [2], and suggested that disc replacement patients were more likely than fusion patients to be working 6 weeks after surgery. This difference was more pronounced in workers’ compensation patients [8].
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Patients covered by workers’ compensation appeared to be less likely to be working at all time points; however, no direct statistical comparisons of these patients-to-patients with other insurance were reported.
Time returning to work postoperatively (
[Fig 2]
)
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Patients who received disc replacement began working sooner after surgery than patients who received fusion with statistical significance reported in two studies.
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After controlling for gender, study, and preoperative work status, the difference between treatments for median time to work return among worker’s compensation participants did not reach statistical significance. Among patients who were covered by workers’ compensation, those who were working at the time of surgery returned to work sooner than did patients in the full sample of the worker’s compensation patients. No direct comparison of workmen’s compensation patients-to-other patients was reported.
Differential effects of C-ADR/ACDF on return to work
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No studies examined differential work-related outcomes by gender, smoking status, litigation, or any characteristic other than workers’ compensation.
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No direct comparisons of worker’s compensation patients-to-patients with other insurance were possible. The pattern of findings for workers’ compensation patients, however, was similar to that of patients in general: earlier return to work with disc replacement compared with fusion and no significant group differences in work status after 6 months.
Activity levels
Fig 1
Results of literature search.
Table 1
Characteristics of studies comparing cervical artificial disc replacement (C-ADR) with anterior cervical discectomy and fusion (ACDF).
*RCT indicates randomized controlled trial; NR, not reported; and N/A, not applicable.
Table 2
Percentage of patients working at follow-up.*
*C-ADR indicates total disc replacement; ACDF, anterior cervical discectomy and fusion; WC, workers’ compensation; and NR, not reported.
†
P < .05.
‡
P < .10.
Fig 2
Median number of days from surgery to return to work. C-ADR indicates total disc replacement; ACDF, anterior cervical discectomy and fusion.
* Workers’ compensation patients only; controlling for gender, study, and preoperative work status.
† Workers’ compensation patients who had been working at the time of surgery.
CLINICAL GUIDELINES
No clinical guidelines specific to the focus of this topic were found. General clinical guidelines related to C-ADR are summarized elsewhere in this issue.
DISCUSSION
This analysis of the data demonstrated that patients treated with disc replacement tended to return to work more quickly than those receiving fusion, but that overall return to work in the two groups was equivalent at 2 years. Both therapies have been shown to be safe and effective; therefore, it is expected that most patients will be able to resume normal productive lives.
The C-ADR patients tended to return to work sooner than fusion patients and the reasons for this are unclear. There are several potential explanations. The first is either patient or surgeon bias since neither group was blinded. At the time of enrollment for each of the studies, C-ADR had not been approved in the United States, and it could be presumed that the primary patient motivation to enter one of the studies was to obtain a C-ADR. This high level of interest could have led to a placebo effect in those receiving the C-ADR. Additionally, surgeons may have been more willing to release patients to work if they received a C-ADR. Finally, it may be that there is period during which the patient adjusts to the loss of a motion segment which is associated with increased discomfort, particularly with activity. Such an adjustment would not occur with C-ADR and if real, could account for the difference in early return to work.
Conclusions from this review are limited by the following:
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Follow-up rates in the Prestige study were low; however, these low rates were due to the publication of articles before all patients had reached the follow-up window. Follow-up rates at 4 years were also fairly low (75%) in the FDA Bryan trial; however, in both of these studies loss to follow-up was equivalent across treatment groups.
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Questions about return to work were assessed with patient self-report and apparently not validated with work records.
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No definition was provided of self-reported “return to work” (eg, how the question was asked, whether part-time work was included).
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The measures do not reflect return to work per se, as “return to work” assumes that patients were working before surgery. The proportions of people who are working do not reflect individual change from preoperative to postoperative, only group percentages at the various time points. These percentages were not broken down by the work status of the patient before surgery, and included patients who were working postoperatively as well as those who were not working. Therefore, this measure does not accurately reflect return to work but rather work status at the time of follow-up in the study population.
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No direct comparison of patients with workers’ compensation versus patients with other kinds of insurance was reported in a secondary analysis of the Bryan and Prestige trials. Workers’ compensation patients comprised only about 10% of patients in those two trials, so that it is likely that the percentages reported in [Table 2] for the full sample would be close to the percentages for the nonworkers’ compensation sample. If that is the case, then indirect comparisons of the workers’ compensation patients with the full sample would approximate differences between patients with and without workers’ compensation.
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Only the published articles from the Bryan trial [1], [2] provided data on working status less than 2 years after surgery. Measures from earlier time points were collected in the Prestige trial and analyzed by Steinmetz et al [8], but they are not reported in the main articles from the Prestige study [4], [5].
EVIDENCE SUMMARY
Table 3
Working and activity level.
