Comparing the Effectiveness and Safety of Anterior Cervical Discectomy and Fusion with Four Different Fixation Systems: A Systematic Review and Network Meta-analysis

Jin Xiao2, #, Hui Yu3, #, Jianfeng Sun1, Yuxuan Deng4, Yang Zhao5, Rui Gao5, #, Xian Li1, *
1 Department of Orthopedic and Trauma Surgery, Xiyuan Hospital, China Academy of Chinese Medical Science, Beijing 100091, China
2 Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
3 Guangzhou Key Laboratory of Spine Disease Prevention and Treatment, Department of Orthopaedic Surgery,The Third Affiliated Hospital, Guangzhou Medical University, Guangzhou 510150, China
4 Department of Dermatology and Allergy, and Christine Kühne-Center for Allergy Research and Education, University Hospital of Bonn, Bonn D-53127, Germany
5 Institute of Clinical Pharmacology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, China

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© 2023 Xiao et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Orthopedic and Trauma Surgery, Xiyuan Hospital, China Academy of Chinese Medical Science, Beijing 100091, China; E-mail:
#These authors equally contributed



Anterior cervical discectomy and fusion (ACDF) is the classic procedure for the treatment of degenerative cervical myelopathy (DCM). Cage with plate (CP), polyetheretherketone cage alone (PCA), ROI-C and Zero-P are the most widely used fixation systems in ACDF. However, there is insufficient evidence to determine the optimal system for ACDF.


A comprehensive analysis to show which of the CP, PCA, ROI-C and Zero-P after ACDF has the best clinical efficacy and the most reliable safety.


We searched the Embase, Pubmed, and Cochrane library up to the date of February 13th, 2021. Studies included relevant randomized controlled trials (RCTs) and cohort studies with a comparison of different fixation systems among CP, PCA, ROI-C and Zero-P were identified.


We screened 43 trials eligible, including 3045 patients. No significant differences were found in the NDI score. PCA has shown a significantly less recovery of cervical lordosis than CP and Zero-P. For the non-fusion rate, PCA was significantly higher than CP. PCA had a significantly higher subsidence rate than CP and Zero-P, and ROI-C was also significantly higher than CP. For the incidence of complications, CP was significantly higher than the others. The surface under the cumulative ranking curves (SUCRA) for NDI score improvement was: SSC, PCA, and CP. ROI-C, Zero-P, PCA, and CP; for cervical lordosis recovery: CP, Zero-P, ROI-C, and PCA; for non-fusion rate: PCA, Zero-P, ROI-C, and CP; for subsidence rate: PCA, ROI-C, Zero-P, and CP; for complications: CP, PCA, ROI-C, and Zero-P.


Despite the third-ranking spectrums of fusion rate, Zero-P still could be recommended for its second-ranking spectrums of the NDI score improvement efficacy, cervical lordosis recovery, and reduction of subsidence rate, with the least ranking of complications.


The number of PROSPERO is CRD42021230735 (

Keywords: ACDF, Internal fixation system , Degenerative cervical myelopathy , Network meta-analysis , Anterior cervical discectomy, NDI score.