Multiple-level (≥ 3) cervical artificial disc replacement: illustrative case and systematic review of the literature

Cervical artificial disc replacement (C-ADR) has been shown to have potential advantages over anterior cervical discectomy and fusion for certain indications. However, currently published data have been extrapolated from the postoperative outcomes of C-ADR at 1 or 2 levels, and there is no extensive literature regarding patients who have had multilevel (≥ 3 levels) C-ADR. The aim of this paper was to characterize how patients who have undergone multilevel C-ADR procedures fare in terms of their outcomes and complications. In addition, the authors present an illustrative case of a patient who underwent a 3-level C-ADR for technical discussion.

The authors performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. They queried two databases, PubMed and MEDLINE, in August 2025. While screening, the authors sought to identify all primary, peer-reviewed studies that included patients who have undergone multilevel C-ADR, with postoperative patient-reported outcomes including preservation of range in motion and complications.

Across 5 studies evaluating 3- and 4-level C-ADR, patients demonstrated substantial and durable improvements in pain, disability, and quality of life. Neck and arm visual analog scale scores decreased by > 50%, with parallel reductions in Neck Disability Index scores and sustained benefits reported up to 7 years. Importantly, these multilevel C-ADR procedures preserved both segmental and global cervical range of motion, contrasting with near-complete loss of motion after fusion, and no cases of symptomatic adjacent segment degeneration requiring reoperation were reported. Complication rates were low and primarily transient, with reoperation required in only 0%-2% of cases. The illustrative case reinforced these findings, demonstrating full neurological recovery, early return to activity, and durable implant stability following a 3-level C-ADR procedure.

Three- and 4-level C-ADR appears to be a safe and effective motion-preserving alternative to fusion that provides durable pain relief, functional recovery, and high patient satisfaction, with low complication and revision rates for appropriately selected patients. Overall, these outcomes are in line with prior published outcomes for FDA-approved 1- and 2-level C-ADR.