What is hybrid cervical spine surgery?

What is Hybrid Cervical Spine Surgery?

Hybrid cervical spine surgery is a technique that combines anterior cervical discectomy and fusion (ACDF) at one or more levels with cervical disc arthroplasty (artificial disc replacement) at other levels in the same patient, or combines anterior cervical corpectomy and fusion (ACCF) with ACDF, allowing for tailored treatment of multilevel cervical pathology. 1, 2, 3

Two Main Types of Hybrid Surgery

Type 1: ACDF Combined with Cervical Disc Arthroplasty

• This approach fuses diseased segments that require stabilization while preserving motion at other affected levels using an artificial disc 2, 3
• Most commonly used in 2-level or 3-level cervical degenerative disc disease 4, 2
• The artificial disc component maintains cervical range of motion while the fusion component provides stability where needed 2, 3

Type 2: ACCF Combined with ACDF

• This technique combines vertebral body removal (corpectomy) with disc removal (discectomy) at different levels in the same patient 1, 3
• Used when multilevel cervical spondylotic myelopathy involves both disc-level pathology and stenosis posterior to the vertebral body or acute kyphotic deformity 1
• Particularly applicable when multilevel ACDF alone is not feasible due to anatomical constraints 1

Clinical Rationale and Advantages

The hybrid technique addresses the limitations of performing only multi-level fusion or only multi-level arthroplasty by allowing surgeons to match the specific reconstruction method to each individual spinal level's pathology. 1, 5

Advantages Over Multi-Level Fusion Alone

• Preserves overall cervical spine range of motion better than multi-level ACDF 4, 2
• May reduce adjacent segment degeneration at skip levels (non-operated levels between operated levels) compared to complete fusion 3
• In the ACCF + ACDF hybrid approach: lower complication rates, lower implant failure/mesh subsidence rates, and less blood loss compared to 2-level corpectomy 1

Advantages Over Multi-Level Arthroplasty Alone

• Provides fusion where instability or severe deformity exists while maintaining motion at more stable levels 2, 3
• Allows treatment of pathology that is not suitable for arthroplasty alone (such as severe facet arthropathy or instability) 1

Clinical Outcomes

• Clinical improvement measured by Japanese Orthopaedic Association (JOA) scores, Neck Disability Index (NDI), and Visual Analog Scale (VAS) scores are comparable between hybrid surgery, multi-level ACDF, and multi-level cervical disc replacement 4, 2
• Cervical range of motion is better preserved with hybrid techniques compared to complete fusion 4, 2
• Fusion rates are comparable to standard ACDF when hybrid techniques are used 4, 1
• No significant increase in surgical complications compared to standard approaches 1, 2

Important Clinical Considerations

When deciding between hybrid surgery and other approaches, the key determining factors are the specific location and nature of pathology at each cervical level, the presence of kyphotic deformity, and whether stenosis exists posterior to the vertebral body. 1

Indications for Hybrid Surgery

• Multilevel cervical spondylotic myelopathy where some levels have primarily disc pathology while others have vertebral body pathology 1, 3
• Noncontiguous multilevel disease (skip lesions) where intervening levels may benefit from motion preservation 3
• Cases where complete fusion would result in excessive loss of cervical motion 2, 5

Technical Considerations

• Anterior plating is typically used with the fusion component to improve fusion rates 6, 1
• The arthroplasty component should be placed at levels with preserved facet joints and no significant instability 3, 5
• In ACCF + ACDF hybrid constructs, the corpectomy is performed where stenosis exists posterior to the vertebral body 1