1. O P O L E
Department of Neurosurgery – State Medical Center
OPOLE - POLAND
POLAND
Early experiences and technical remarks on five different cervical arthroplasty systems. Dariusz Latka, MD PhD, Tomasz Krzeszowiec, MD, Boguslaw Maj, MD
Mister chairman, ladies and gentelmen. I’ve got the great honour to present you the paper on cervical arthroplasty coming from the small 40-bed neurosurgical department in the district hospital in Opole…….
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

2. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
OPOLE, POLAND
POLAND
Department of Neurosurgery
State Medical Center
……….beautiful historic city, south of Poland.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

3. Author Disclosure Information
O P O L E
POLAND
D. Latka, MD PhD
Medronic*; Synthes*; Johnson & Johnson*;
T. Krzeszowiec, MD
B.Maj, MD
Disclousure information….
* Grants/Research Support/Other Financial or Material Support
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

4. CERVICAL ARTHROPLASTY = the most expensive way to fuse ?????
O P O L E
POLAND
CERVICAL ARTHROPLASTY = the most expensive way to fuse ?????
My neurosurgery teacher when he’s learned that I’ve started cervical arthroplasty program in my Department told me that arthroplasty is the most expensive way to fuse.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

5. What for? The begining of our arthroplasty experience – Dec 2003
O P O L E
What for?
SYDNEY 2001
POLAND
In december twenty O three we also have been full of frightens.
But our nowadays experience indicates that the aim of arthroplasty surely is not the effect shown on this movie, but my boss opinion is not longer true.
The begining of our arthroplasty experience – Dec 2003
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

6. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
What for?
O P O L E
POLAND
The incidence of symptomatic adjacent segment degeneration requiring further surgery following cervical fusion is estimated as high as 3% per level/per year
1,5yr postop
The incidence of symptomatic adjacent segment degeneration requiring surgery following cervical
fusion is estimated as high as 3% per level/per year. That is the real reason for looking for the alternative to this
procedure. Cervical arthroplasty should help to avoid overload of adjacent segments and its degeneration.
Cervical arthroplasty should help to avoid overload of adjacent segments.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

7. Barriers Cost of the implant Difficulty of implantation
O P O L E
POLAND
Cost of the implant
Difficulty of implantation
The main barrier in wider use of arthroplasty is the price of an implant, especially in Polish, rather poor medical care system. The price of the prothesis in Poland can be 10 times bigger than the price of simple cage used for standard fusion.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

8. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
POLAND
We’ve started our experince with arthroplasty with Bryan disc protheis.
It wasn,t really the piece of cake procedure. The preparation of the prothesis nest was very complicated, unpleasant for the neurosurgeon forced to to something blindly, only under X- ray control. So it isn’t strange that the procedure required the intensive preoperation training. We weren’t enthusiastic and have limited our experience only to three cases.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

9. Barriers Difficulty of implantation Price DISCOVER PRESTIGE PRODISC C
O P O L E
Barriers
POLAND
Price
BRYAN ACCEL
PRESTIGE
PRODISC C
DISCOVER
Difficulty of implantation
The recent years brought the more simple systems of arthroplasty, what allows us to cancel this second barrier.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

10. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
Aim of the study
POLAND
Presentation of five different arthroplasty systems used in Opole
Own rules of patients’ qualification to this procedure
Early radiological and clinical outcomes
Four different cervical disc replacement systems have been employed in Opole. In the present study we discuss the intraoperative technical problems, retrospectively review our own rules of patient qualification to this procedure, and perform the early radiological and clinical outcome evaluation.
BRYAN ACCEL
PRESTIGE
PRODISC
DISCOVER
ACTIVE C
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

11. Material 7 years DEC 2003 – NOV 2010 858 anterior cervical procedures
O P O L E
119 patients underwent a total of 127 cervical disc replacements
POLAND
BRYAN ACCEL
PRESTIGE
PRODISC
DISCOVER
ACTIVE C
population
7 years
DEC 2003 – NOV 2010
858 anterior cervical procedures
During the past seven years the group of 119 patients underwent a total of 127 cervical disc replacements from among almost six hundred operated on due to cervical disc disease.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

12. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
BRYAN ACCEL
POLAND
The new modern Bryan implantation technique is more user friendly than the former one and it allows far more vision control. The necessity of angle measurements is still time consuming, but the main advantyge of this system is the lentiform shape of the prothesis remaining the most physiological situation after surgery.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

13. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
PRESTIGE
POLAND
The Prestige LP prothesis, the system we are most familiar with, is a complete two element metal construction allowing most physiological movement including not only AP and latral bendings but also the anterior translation. It is very easy to implant. The only disadvantage is the necessity of the railways’ preparation with so called railway cutter, which can sometimes convert the bloodless operative field into more bloody one. No one likes it.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

14. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
PRODISC
POLAND
The Prodisc C prothesis is being settled in almost the same manner. Although it is a three element construction it is applicated in one piece like the cage. The disadvantages are: deep railways for anchors wchich can weaken the structure of vertebral bodies, the lack of translation in movement and the plastic element of unknown mechanical durability.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

15. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
Discover
POLAND
The Discover is a construction very similar to Prodisc, but with no neccesity to cut anything for anchors in the neighbouring bodies. The only disadvantage is the need of severe distraction while inserting it.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

16. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
Active C
POLAND
The AciveC is a construction very similar to Prodisc, but with double and smaller anchors in one of the the neighbouring bodies, and pinssimillar to Discover in another. It gives easier possibilities to multilevel arthtoplasies.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

17. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
Number of surgical steps 9 6 7 5
Mean sugery time
1h 50’
1h 05’
1h 15’
1h 10’
1h12’
Mean number of intraoperative X-ray expositons 8 3 4
POLAND
BRYAN
ACCEL
PRESTIGE
PRODISC
DISCOVER
ACTIVE C
According to our experienece the arthroplasty in all systems are comparably easy to perform, maybe except Bryan Accel, easier than in previous version but still demanding.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

18. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010α
O P O L E
BRYAN ACCEL
POLAND
PRESTIGE α α
The early radiological evaluation confirms the maintenance of motion in every employed system and in every case of our series.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

19. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E α
PRODISC
POLAND
DISCOVER α
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

20. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
Early clinical outcome (according to ODOMS criteria) (n=119):
POLAND 44 60 15
Early clinical results were comparable to good outcomes attained by fusion procedures according to ODOMS criteria…..
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

21. ……… and in pre- and postoperative neck disability index evaluation.
O P O L E
POLAND
Neck Disability Index (NDI) in arthroplasty group N=119
……… and in pre- and postoperative neck disability index evaluation.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

22. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
Dynamic of cervical arthroplasties per year number (percentage of all anterior cervical discsectomies)
POLAND
We can notice the rapidly growing mumber of arthroplasty in compare to fusion in our department.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

23. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
POLAND
Age structure
The key to solve this mistery are of course the indications. Even the simple analysis of mean age of patients indicates the widening of indications.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

24. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
O P O L E
IDEAL CERVICAL ARTHROPLASTY CANDIDATE
young
active
no major changes on adjacent levels
no instabillity
persistent mobility of operated segments on X-rays
POLAND
On the beginning we supposed that the ideal candidate to arthroplasty should be like this lady: young active with no major changes on adjacent levels, no instability and with persistent mobility of operated segments on functional radiograms.
The only doubt concerns this last parameter. The lack of mobility on preoperative radiograms can be the matter of muscle constriction in acute phase of cervical syndrome. ?
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

25. Intraoperative evaluation of segments’ mobility persistance
O P O L E
Intraoperative evaluation of segments’ mobility persistance
POLAND
We decided to qualify patients to the arthroplasty basing on intraoperative mobility evaluation, like in this case.
So our early experience indicates us the possibility of arthroplasty in patients with no mobility of the sick segment in preoperative radiograms. The more important for us is the intraoperative mobility.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

26. Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
Conclusions
O P O L E
POLAND
Cervical arthroplasty with Bryan, Prodisc C, Discover, ActiveC and Prestige LP is a safe and effective treatment option as demonstrated by clinical and radiological result.
Our early results let us hope that combining of anterior cervical decompression with arthroplasty could
advantage in quicker convalescence without the need for plating and fusion, bone grafting or cervical
immobilization in a collar.
The long term benefits of cervical arthroplasty remain to be seen.
Arthroplasty with all introduced systems is a safe and effective treatment option as demonstrated by clinical and radiological results.
Our early results let us hope that combining of anterior cervical decompression with arthroplasty could
advantage in quicker convalescence without the need for plating and fusion, bone grafting or cervical
immobilization in a collar.
The long term benefits of cervical arthroplasty remain to be seen.
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.

27. İlginiz için teşekkür ederim
O P O L E
POLAND
İlginiz için teşekkür ederim
Fuse or not to fuse…
Spine Experts Group Annual Meeting 2010, Istanbul Dec 2-3, 2010
XIV World Congress of Neurological Surgery. Boston, MA, USA. Aug 30-Sep 04 ,2009.