Neurosurgical focus · 2026
Total disc replacement versus lumbar interbody fusion for degenerative disc disease: a meta-analysis of randomized controlled trials.
СтатьяМетаанализСистематический обзорСравнительное исследованиеНазвание и аннотация: Перевод в очереди
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Patel Shaan, Mendonca Angelette, Nischal Shiva A, Kale Kush M, Hines Kevin, Heller Joshua, Jallo Jack, Harrop James S, Prasad Srinivas K
Аннотация
OBJECTIVE: Lumbar total disc replacement (TDR) was developed as a motion-preserving alternative to interbody fusion (IBF) for degenerative disc disease (DDD), yet comparative benefits remain debated. This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to compare clinical, perioperative, and durability-related outcomes between lumbar TDR and IBF.
METHODS: The PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception to December 30, 2025, for RCTs comparing lumbar TDR with IBF (including anterior and posterior fusion approaches) in adults with DDD. Primary outcomes were overall complications, reoperations, and trial-defined overall success. Secondary outcomes included pain, disability, quality of life, perioperative metrics, pseudarthrosis, adjacent segment disease (ASD), device-related complications, and patient satisfaction outcomes. Random-effects meta-analyses were conducted throughout. Risk of bias was assessed using Cochrane's risk-of-bias tool 2, and certainty of evidence evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.
RESULTS: Thirteen RCTs comprising 2349 patients (1549 with TDR, 800 with IBF) with a mean follow-up 44 months were included. TDR was associated with a significantly lower risk of overall complications (31.4% vs 35.4%, risk ratio [RR] 0.75, 95% confidence interval [CI] 0.61-0.93; p < 0.01) and reoperation (6.1% vs 11.9%, RR 0.48, 95% CI 0.34-0.69; p < 0.0001). Risk of ASD (3.7% vs 8.3%, RR 0.41, 95% CI 0.23-0.75; p < 0.01) and pseudarthrosis (0.1% vs 6.5%, RR 0.07, 95% CI 0.02-0.25; p < 0.0001) were lower following TDR. Pain and disability outcomes favored TDR at early and intermediate follow-ups but converged with fusion outcomes by 5 years. Operative time and blood loss did not differ significantly between approaches, while hospital length of stay showed a borderline reduction favoring TDR (mean difference -0.53 days, 95% CI -1.06 to 0.00 days; p = 0.05). Long-term patient satisfaction and return-to-work outcomes were comparable, but narcotic use at the last follow-up was significantly lower following TDR (38.6% vs 55.7%, RR 0.68, 95% CI 0.58-0.81; p < 0.0001). Overall risk of bias across trials was moderate, and certainty of evidence for primary outcomes was graded as moderate, with downgrading primarily driven by risk of bias and heterogeneity.
CONCLUSIONS: In carefully selected patients undergoing surgery for lumbar DDD, TDR lowers overall complications and reoperation risk compared with IBF, driven by reductions in pseudarthrosis and ASD, while achieving comparable long-term patient-reported outcomes. The principal advantage of arthroplasty appears to be mechanical durability and reduced revision burden rather than sustained superiority in conventional functional scores. Systematic review registration no.: CRD420251271692 (https://www.crd.york.ac.uk/prospero/).
METHODS: The PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception to December 30, 2025, for RCTs comparing lumbar TDR with IBF (including anterior and posterior fusion approaches) in adults with DDD. Primary outcomes were overall complications, reoperations, and trial-defined overall success. Secondary outcomes included pain, disability, quality of life, perioperative metrics, pseudarthrosis, adjacent segment disease (ASD), device-related complications, and patient satisfaction outcomes. Random-effects meta-analyses were conducted throughout. Risk of bias was assessed using Cochrane's risk-of-bias tool 2, and certainty of evidence evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.
RESULTS: Thirteen RCTs comprising 2349 patients (1549 with TDR, 800 with IBF) with a mean follow-up 44 months were included. TDR was associated with a significantly lower risk of overall complications (31.4% vs 35.4%, risk ratio [RR] 0.75, 95% confidence interval [CI] 0.61-0.93; p < 0.01) and reoperation (6.1% vs 11.9%, RR 0.48, 95% CI 0.34-0.69; p < 0.0001). Risk of ASD (3.7% vs 8.3%, RR 0.41, 95% CI 0.23-0.75; p < 0.01) and pseudarthrosis (0.1% vs 6.5%, RR 0.07, 95% CI 0.02-0.25; p < 0.0001) were lower following TDR. Pain and disability outcomes favored TDR at early and intermediate follow-ups but converged with fusion outcomes by 5 years. Operative time and blood loss did not differ significantly between approaches, while hospital length of stay showed a borderline reduction favoring TDR (mean difference -0.53 days, 95% CI -1.06 to 0.00 days; p = 0.05). Long-term patient satisfaction and return-to-work outcomes were comparable, but narcotic use at the last follow-up was significantly lower following TDR (38.6% vs 55.7%, RR 0.68, 95% CI 0.58-0.81; p < 0.0001). Overall risk of bias across trials was moderate, and certainty of evidence for primary outcomes was graded as moderate, with downgrading primarily driven by risk of bias and heterogeneity.
CONCLUSIONS: In carefully selected patients undergoing surgery for lumbar DDD, TDR lowers overall complications and reoperation risk compared with IBF, driven by reductions in pseudarthrosis and ASD, while achieving comparable long-term patient-reported outcomes. The principal advantage of arthroplasty appears to be mechanical durability and reduced revision burden rather than sustained superiority in conventional functional scores. Systematic review registration no.: CRD420251271692 (https://www.crd.york.ac.uk/prospero/).