History of Trauma Preceding Cervical Disc Replacement Leads to Worse Postoperative Patient Reported Outcomes: A Matched Cohort Analysis

Abstract

Study Design

Single-center retrospective cohort study.

Objectives

To investigate whether a history of minor cervical trauma is associated with worse postoperative outcomes following CDR.

Methods

Patients who underwent primary one- or two-level CDR from 2017 to 2023 by multiple surgeons at a single institution were included. Minor cervical trauma was defined as an event likely to affect the cervical spine but not requiring immediate surgical intervention. Trauma patients were matched 1:3 to controls based on age, sex, number of operated levels, and surgeon. PROMs at early (2–12 weeks) and late (6–24 months) timepoints, along with perioperative variables, were compared.

Results

Of 308 CDR patients, 43 had a history of minor cervical trauma. After matching, the trauma (n = 43) and non-trauma (n = 129) cohorts were demographically similar. The trauma group had significantly worse NDI (early: 33.6 vs. 22.5, P = .005; late: 28.4 vs. 19.1, P = .023), SF-12 PCS, SF-12 MCS, and PROMIS-PF scores. No differences were found in operative time, blood loss, length of stay, or complication rates.

Conclusions

Minor cervical trauma is associated with significantly worse postoperative disability and physical function following CDR, despite similar perioperative courses and complication rates.

Keywords

cervical disc replacement trauma whiplash patient-reported outcomes postoperative recover

Introduction

Cervical spine trauma is a common antecedent to chronic neck pain and disability, with motor vehicle collisions (whiplash injuries) being a predominant cause. Epidemiologic studies indicate that nearly half of individuals who sustain a whiplash injury develop persistent neck symptoms that can last for years.^1,2 Many patients with chronic whiplash exhibit features of central sensitization. This is often accompanied by psychosocial factors, such as post-traumatic stress, which may amplify pain perception and hinder recovery.^3,4 Standard therapies, like education, advice and exercise, often yield only modest improvements in whiplash-associated disorder (WAD), suggesting that conventional approaches do not fully address the underlying pathophysiology.⁴ In cases with refractory symptoms following standard therapies, there are post-traumatic cervical symptoms necessitating surgical intervention as a means to alleviate pain and dysfunction.⁵

Despite the high prevalence and socioeconomic impact of post-traumatic neck pain,⁶ most research to date on minor cervical trauma has focused on non-operative management, rather than outcomes after surgical interventions. Thus, there is a gap in the literature regarding the impact of prior minor cervical spine trauma on surgical results. While cervical total disc replacement (CDR) has been established as a surgical treatment for symptomatic cervical disc disease as an alternative to anterior cervical discectomy and fusion (ACDF),⁷ it is unknown whether patients with a history of cervical trauma derive the same benefit from CDR as those with purely degenerative neck conditions.

Given the unique pathophysiologic sequelae of trauma, it is plausible that prior minor trauma could adversely affect postoperative outcomes. Therefore, this study was designed to examine whether a history of trauma preceding CDR is associated with worse postoperative patient-reported outcomes. We hypothesized that patients with minor cervical trauma would experience less favorable improvements after CDR compared to a non-trauma cohort.

Methods

Patient Population

This is a retrospective review of prospectively collected data of consecutive patients who underwent primary, one- or two-level CDR performed by multiple surgeons at a single academic institution from 2017-2025. Medical records were reviewed to identify a history of trauma defined as a documented traumatic inciting event temporally associated with the onset of persistent cervical and/or radicular symptoms. Trauma mechanisms included low- to moderate-energy motor vehicle collisions, bicycle or pedestrian-related accidents, falls, or direct blunt trauma to the head or neck. Chart review included detailed review of clinical notes and keyword searches for “trauma,” “accident,” “fall,” and “motor vehicle accident (MVA).” Cases with trauma mechanisms unlikely to impact the cervical spine or those requiring immediate operative intervention were excluded.

Surgical Indications

The primary indications for surgery were imaging-confirmed structural pathologies associated with radiculopathy or myelopathy, including degenerative disc disease/spondylosis, herniated nucleus pulposus, and central or foraminal stenosis. Isolated axial neck pain or whiplash-associated disorder without neurologic compression was not considered an indication for CDR at our institution, and no patients underwent surgery solely for post-traumatic neck pain.

Patient Characteristics and Postoperative Outcomes

For baseline patient characteristics, age, body mass index (BMI), sex, age-adjusted Charlson comorbidity index (CCI age), American Society of Anesthesiologists (ASA) score, and medical comorbidities were analyzed. Hospital course was analyzed for primary surgeon, estimated blood loss (EBL), operative time, number of operated levels, length of stay (LOS), and postoperative day (POD) discharge.

Patient-reported outcome measures (PROMs) were analyzed for Neck Disability Index (NDI), visual analogue pain scale for neck and arm (VAS neck and VAS arm), Short Form 12 Physical Component Score and Mental Component Score (SF-12 PCS and SF-12 MCS), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), and Global Rating of Change (GRC). All PROMs data were collected preoperatively and at 6 follow-up time points (2 weeks, 6 weeks, 12 weeks, 6 months, 1 year, 2 years). Means were calculated for all values at 2 weeks, 6 weeks, and 12 weeks to create an “early” time point and at 6 months, 1 year, and 2 years to create a “late” time point.

Postoperative complications, readmissions, and reoperations were analyzed during the index hospitalization, within 90 days, and greater than 90 days.

Data Management

Data was collected and managed using REDCap (Research Electronic Data Capture) hosted at Weill Cornell Medicine Clinical and Translational Science Center supported by the National Center For Advancing Translational Science of the National Institute of Health under award number: UL1 TR002384.^8,9 REDCap is a secure, HIPAA-compliant web-based software platform designed to support data capture and data management for research studies.

Statistical Analysis

Comparisons of categorical variables were performed with Chi-square or Fisher exact tests when applicable, and continuous variable comparisons were performed with two-sample T-tests for means and Mann-Whitney U tests for medians. A 1:3, propensity-score, nearest-neighbor match was used to match patients with a history of trauma to those without. Propensity scores were calculated based on age, sex, number of operated levels, and primary surgeon based on the univariate analysis before matching and clinical relevance. Surgeon was included to account for different practices in collection of medical history. The cohorts were compared via demographics, hospital course, postoperative course, and postoperative PROMs. Statistical significance was set at P < .05. Statistical analysis was performed using MATLAB (The MathWorks Inc Released 2023. MATLAB for Macintosh, Version R2023a. Natick, Massachusetts: The Mathworks Inc).

Results

Patient Characteristics

A total of 308 patients underwent primary, one- or two-level CDR with 8 fellowship-trained surgeons. Of those, 43 (14.0%) patients reported a history of minor cervical trauma to their operation, while 265 (86.0%) did not. Pre-match comparisons showed no significant differences in demographics, comorbidities, and number of operated levels except frequency distribution of primary surgeon (P < .001) (Table 1).

Table 1.

Pre-Matching Demographics & Comorbidities

Variable	Trauma history	No trauma history	P-value
N	43	265	—
Age	43.1 ± 9.8	43.2 ± 8.8	.969
BMI	27.2 ± 4.2	26.6 ± 4.8	.416
Sex			.429
Female	19 (44.2)	90 (34.0)
Male	24 (55.8)	175 (66.0)
Race			.935
White or Caucasian	37 (86.0)	212 (80.0)
Black or African American	2 (4.7)	7 (2.6)
Asian	1 (2.3)	17 (6.4)
Mixed race	0 (0.0)	1 (0.4)
Other	2 (4.7)	16 (6.0)
Patient declined	1 (2.3)	12 (4.5)
Ethnicity			.955
Not Hispanic or Latino	39 (90.7)	246 (92.8)
Hispanic or Latino	3 (7.0)	13 (4.9)
Patient refused/Unknown	1 (2.3)	6 (2.3)
CCI age	0.4 ± 0.7	0.5 ± 1.0	.582
ASA			.646
I	11 (25.6)	46 (17.4)
II	31 (72.1)	212 (80.0)
III	1 (2.3)	7 (2.6)
Uncomplicated DM	1 (2.3)	6 (2.3)	1.000
Complicated DM	0 (0.0)	0 (0.0)	1.000
HTN	6 (14.0)	35 (13.2)	.991
Peripheral neuropathy	1 (2.3)	5 (1.9)	.598
Current smoker	5 (11.6)	23 (8.7)	.566
Former smoker	7 (16.3)	47 (17.7)	.998
Number of levels			.407
One-level	23 (53.5)	170 (64.2)
Two-level	20 (46.5)	95 (35.8)
Primary surgeon			<.001
Surgeon 1	7 (16.3)	119 (44.9)
Surgeon 2	0 (0.0)	35 (13.2)
Surgeon 3	0 (0.0)	4 (1.5)
Surgeon 4	27 (62.8)	60 (22.6)
Surgeon 5	0 (0.0)	6 (2.3)
Surgeon 6	1 (2.3)	7 (2.6)
Surgeon 7	7 (16.3)	26 (9.8)
Surgeon 8	1 (2.3)	8 (3.0)

BMI, body mass index; CCI age, Charlson comorbidity index age adjusted; ASA, American society of anesthesiologists; DM, diabetes mellitus; HTN, hypertension; DOS, date of surgery.

Statistics are summarized as mean ± SD. All categorical variables reported as N (%). Significant P-values (P < .05) are bolded.

Propensity score matching extracted 43 patients with trauma history and 129 without. The frequency distribution of primary surgeon was similar between matched cohorts (P = .463) with other comparisons remaining well-matched. Mean age was 43.1 ± 9.8 vs 42.9 ± 9.4 years, mean BMI was 27.2 ± 4.2 vs 26.1 ± 4.1 kg/m², and most patients were male (55.8% vs 69.0%). Mean CCI age was 0.4 ± 0.7 vs 0.6 ± 1.1, and the majority of both cohorts were ASA II (72.1% vs 82.9%) (Table 2).

Table 2.

After-Matching Demographics & Comorbidities

Variable	Trauma history	No trauma history	P-value
N	43	129	—
Age	43.1 ± 9.8	42.9 ± 9.4	.922
BMI	27.2 ± 4.2	26.1 ± 4.1	.123
Sex			.289
Female	19 (44.2)	40 (31.0)
Male	24 (55.8)	89 (69.0)
Race			.790
White or Caucasian	37 (86.0)	103 (79.8)
Black or African American	2 (4.7)	3 (2.3)
Asian	1 (2.3)	13 (10.0)
Mixed race	0 (0.0)	1 (0.8)
Other	2 (4.7)	6 (4.7)
Patient declined	1 (2.3)	3 (2.3)
Ethnicity			.789
Not Hispanic or Latino	39 (90.7)	122 (94.6)
Hispanic or Latino	3 (7.0)	6 (4.7)
Patient refused/unknown	1 (2.3)	1 (0.8)
CCI age	0.4 ± 0.7	0.6 ± 1.1	.412
ASA			.646
I	11 (25.6)	19 (14.7)
II	31 (72.1)	107 (82.9)
III	1 (2.3)	3 (2.3)
Uncomplicated DM	1 (2.3)	4 (3.1)	1.000
Complicated DM	0 (0.0)	0 (0.0)	1.000
HTN	6 (14.0)	17 (13.1)	.992
Peripheral neuropathy	1 (2.3)	2 (1.6)	1.000
Current smoker	5 (11.6)	11 (8.5)	.551
Former smoker	7 (16.3)	22 (17.1)	.997
Number of levels			.614
One-level	23 (53.5)	80 (62.0)
Two-level	20 (46.5)	49 (38.0)
Primary surgeon			.463
Surgeon 1	7 (16.3)	21 (16.3)
Surgeon 2	0 (0.0)	6 (4.7)
Surgeon 3	0 (0.0)	4 (3.1)
Surgeon 4	27 (62.8)	60 (46.5)
Surgeon 5	0 (0.0)	6 (4.7)
Surgeon 6	1 (2.3)	7 (5.4)
Surgeon 7	7 (16.3)	22 (17.1)
Surgeon 8	1 (2.3)	3 (2.3)

BMI, body mass index; CCI age, Charlson comorbidity index age adjusted; ASA, American society of anesthesiologists; DM, diabetes mellitus; HTN, hypertension; DOS, date of surgery.

Statistics are summarized as mean ± SD. All categorical variables reported as N (%). Significant P-values (P < .05) are bolded.

Hospital Course

EBL, operative time, and LOS were not significantly different between the cohorts (trauma: 39.6 ± 23.6 mL, 115.8 ± 39.0 min, 25.0 ± 10.0 h; no trauma: 36.4 ± 21.2 mL, 114.3 ± 41.3 min, 21.9 ± 11.3 h; all P > .05). POD of discharge was also not significantly different overall (trauma: 1.0 ± 0.4 vs no trauma: 0.9 ± 0.7, P = .257), but a significantly greater portion of patients without a trauma history were discharged on the same day (7.0% vs 20.9%, P = .038). Discharge on POD 1 (81.4% vs 69.0%, P = .116), POD 2 (11.6% vs 8.5%, P = .551), and POD ≥ 3 (0% vs 1.6%, P = 1.000) was similar between the cohorts (Table 3).

Table 3.

Surgical Outcomes

Variable	Trauma history	No trauma history	P-value
EBL (ml)	39.6 ± 23.6	36.4 ± 21.2	.420
Operative time (min)	115.8 ± 39.0	114.3 ± 41.3	.835
LOS (hours)	25.0 ± 10.0	21.9 ± 11.3	.113
POD discharge	1.0 ± 0.4	0.9 ± 0.7	.257
Same day	3 (7.0)	27 (20.9)	.038
POD 1	35 (81.4)	89 (69.0)	.116
POD 2	5 (11.6)	11 (8.5)	.551
POD 3	0 (0.0)	1 (0.8)	1.000
POD >3	0 (0.0)	1 (0.8)	1.000

EBL, estimated blood loss; LOS, length of stay; POD, postoperative day.

Statistics are summarized as mean ± SD. All categorical variables reported as N (%). Significant P-values (P < .05) are bolded.

Patient-Reported Outcome Measures (PROMs)

Preoperatively, no significant differences were found between the trauma and no-trauma cohorts, though SF-12 PCS (35.0 ± 10.5 vs 39.3 ± 8.9, P = .061) and PROMIS-PF (37.9 ± 8.2 vs 42.9 ± 7.5, P = .071) neared significance.

At the early time point, trauma patients had significantly greater disability as measured by the NDI (29.6 ± 16.7 vs 20.5 ± 15.5, P = .005), greater arm pain via VAS arm (2.7 ± 2.8 vs 1.7 ± 2.3, P = .044), and worse physical and mental status via SF-12 PCS (36.4 ± 7.9 vs 43.1 ± 8.4, P = .001), SF-12 MCS (45.8 ± 11.5 vs 53.1 ± 8.0, P = .001), and PROMIS-PF (42.2 ± 10.0 vs 49.4 ± 8.4, P = .021). VAS neck (3.4 ± 2.3 vs 2.7 ± 2.4, P = .169) and GRC (4.7 ± 0.7 vs 4.5 ± 0.8, P = .064) were not significantly different.

At the late time point, trauma patients continued to report worse NDI (21.0 ± 22.8 vs 13.3 ± 16.3, P = .049), SF-12 PCS (39.3 ± 12.0 vs 48.3 ± 9.1, P = .002), SF-12 MCS (45.3 ± 13.1 vs 51.4 ± 8.2, P = .027), and PROMIS-PF (41.3 ± 8.3 vs 54.6 ± 9.0, P = .001). VAS neck (2.5 ± 2.1 vs 1.8 ± 2.1, P = .140) was not significantly different, but GRC compared to pre-op remained worse (4.2 ± 0.9 vs 4.8 ± 0.4, P = 0.009) (Table 4).

Table 4.

PROMs Comparison Within Matched Cohort

Variable	Trauma history	No trauma history	P-value
NDI
Preoperative	46.2 ± 22.6	40.3 ± 17.7	.121
Early	29.6 ± 16.7	20.5 ± 15.5	.005
Late	21.0 ± 22.8	13.3 ± 13.6	.049
VAS neck
Preoperative	6.7 ± 2.9	5.9 ± 2.9	.152
Early	3.4 ± 2.3	2.7 ± 2.4	.169
Late	2.5 ± 2.1	1.8 ± 2.1	.141
VAS arm
Preoperative	6.3 ± 2.9	5.6 ± 3.1	.247
Early	2.7 ± 2.8	1.7 ± 2.3	.044
Late	1.7 ± 2.2	1.2 ± 1.8	.307
SF-12 PCS
Preoperative	35.0 ± 10.5	39.3 ± 8.9	.061
Early	36.4 ± 7.9	43.1 ± 8.4	.001
Late	39.3 ± 12.0	48.3 ± 9.1	.002
SF-12 MCS
Preoperative	39.8 ± 11.7	43.6 ± 11.1	.172
Early	45.8 ± 11.5	53.1 ± 8.0	.001
Late	45.3 ± 13.1	51.4 ± 8.2	.027
PROMIS-PF
Preoperative	37.9 ± 8.2	42.9 ± 7.5	.071
Early	42.2 ± 10.0	49.4 ± 8.4	.021
Late	41.3 ± 8.3	54.6 ± 9.0	.001
GRC - preoperative
Early	4.7 ± 0.7	4.5 ± 0.8	.653
Late	4.2 ± 0.9	4.8 ± 0.4	.009

PROMs, patient-reported outcome measures; NDI, neck disability index; VAS neck, visual analogue pain scale for neck; VAS arm, visual analogue pain scale for arm; SF-12 PCS, short form 12 physical component score; SF-12 MCS, short form 12 mental component score; PROMIS-PF, patient-reported outcomes measurement information system physical function; GRC, global rating of change (compared to preoperative timepoint).

Statistics are summarized as mean ± SD. Significant P-values (P < .05) are bolded.

Subgroup Analysis Stratified by Surgical Levels

One-Level CDR

Preoperatively, trauma patients had significantly worse SF-12 PCS (32.4 ± 10.4 vs 39.3 ± 9.1, P = .026), while SF-12 MCS neared significance (37.7 ± 10.9 vs 44.4 ± 11.4, P = .071).

At early follow-up, trauma patients had worse NDI (30.9 ± 19.0 vs 19.5 ± 16.7, P = .013), VAS arm (3.1 ± 3.1 vs 1.6 ± 2.4, P = .049), SF-12 PCS (37.6 ± 9.1 vs 43.6 ± 8.2, P = .025), and SF-12 MCS (46.4 ± 11.6 vs 53.6 ± 8.2, P = .011). PROMIS-PF (43.4 ± 11.1 vs 50.2 ± 8.1, P = .073) neared significance. VAS neck (3.6 ± 2.5 vs 2.7 ± 2.5, P = .177) was not significantly different.

At the late time point, trauma patients had worse NDI (24.7 ± 23.9 vs 12.7 ± 13.4, P = .028), SF-12 PCS (38.1 ± 12.1 vs 48.7 ± 9.8, P = .011), SF-12 MCS (45.2 ± 10.3 vs 52.4 ± 8.5, P = .042), PROMIS-PF (39.2 ± 8.9 vs 57.4 ± 10.0, P = .002), and GRC (4.3 ± 0.6 vs 4.8 ± 0.4, P = .043). VAS neck and arm were not significantly different (Supplemental Table 1).

Two-Level CDR

At early follow-up, trauma patients had worse SF-12 PCS (34.0 ± 4.0 vs 42.3 ± 8.7, P = .019) and SF-12 MCS (44.7 ± 12.1 vs 52.3 ± 7.9, P = .047). NDI, VAS scores, PROMIS-PF, and GRC were not significantly different.

At late time points, SF-12 PCS (40.6 ± 12.7 vs 47.7 ± 8.0, P = .086) and GRC (4.0 ± 1.4 vs 4.8 ± 0.4, P = .076) neared significance (Supplemental Table 2).

Postoperative Complications, Readmissions, and Reoperations

Number of postoperative complications, readmissions, and reoperations during the index hospitalization, within 90 days postoperatively, and greater than 90 days postoperatively can be seen in Table 5. No nonoperative readmissions occurred, and no significant differences were found between the 2 cohorts at any time point or overall.

Table 5.

Postoperative Complications and Reoperations in Matched Cohort

Variable	Trauma history	No trauma history	P-value
Complications
During index hospitalization	2 (4.7)	6 (4.7)	1.000
Within 90 days	2 (4.7)	8 (6.2)	1.000
Greater than 90 days	5 (11.6)	7 (5.4)	.178
Reoperations
During index hospitalization	0 (0.0)	0 (0.0)	1.000
Within 90 days	0 (0.0)	0 (0.0)	1.000
Greater than 90 days	1 (2.3)	1 (0.8)	.439
Total complications	9 (20.9)	21 (16.3)	.486
Total reoperations	1 (2.3)	1 (0.8)	.439

No nonoperative readmissions occurred. All categorical variables reported as N (%). Significant P-values (P < .05) are bolded.

During the index hospitalization, complications occurred in 4.7% in both cohorts (P = 1.000). Within 90 days, complications were reported in 2 trauma patients (4.7%) and 8 no-trauma patients (6.2%) (P = 1.000). At greater than 90 days, complications occurred in 5 trauma patients (11.6%) compared to 7 no-trauma patients (5.4%) (P = .178). Total complication rates were 20.9% in the trauma group vs 16.3% in the no-trauma group (P = .486).

Reoperation rates were low across all intervals. No reoperations occurred during the index hospitalization or within 90 days in either cohort. Only one reoperation (2.3%) occurred in the trauma group after 90 days, compared to one reoperation (0.8%) in the no-trauma group (P = .439).

For the trauma history cohort, all complications were new-onset radiculopathies except for one case of dysphagia. The single reoperation was a revision for implant migration. For the no trauma history cohort, all complications were new-onset radiculopathies except for one airway complication, 3 cases of odynophagia, and one case of dysphagia. The single reoperation was similarly a revision for implant migration.

Discussion

In this matched cohort analysis, we found that a history of cervical trauma preceding CDR was associated with significantly worse postoperative patient-reported outcomes. Patients who had sustained minor cervical trauma had higher levels of neck pain and disability following CDR than those without a trauma history. Perioperative factors, including the indications for surgery, the levels operated, and the rate of surgical complications, were comparable between the trauma and no-trauma cohorts, which suggests that the observed outcome differences were not due to disparities in the surgery itself. Instead, the findings point to the lasting impact of pre-existing trauma on recovery, even when structural disc pathology is treated with a technically successful CDR, patients with prior cervical injuries achieve less improvement in axial neck pain and disability, despite comparable relief of radicular symptoms. This aligns with clinical experience and reinforces that trauma can impart long-term changes to the cervical spine and nervous system that may limit the maximal benefit obtained from surgical intervention.

Our results corroborate and extend the existing literature on cervical trauma and post-traumatic neck disorders. It is well documented that a substantial fraction of whiplash patients continue to experience pain, functional limitations, and reduced quality of life long after the acute injury phase.^1,2 Prior studies of conservative management have shown that individuals with a history of neck trauma often have worse outcomes or slower recovery than those with non-traumatic neck pain, likely due to the complex biomechanical and neurological sequelae of injury.^4,10,11 However, there has been little research into how such pre-injury factors affect surgical results. To our knowledge, this study is among the first to demonstrate that prior minor cervical trauma can negatively influence PROMs after CDR. For example, in the realm of whiplash-associated disorders, higher initial pain intensity and the presence of post-traumatic stress symptoms have been identified as predictors of persisting pain and disability.¹² Such factors may also be at play in the surgical population, patients in the trauma group might have had more extensive soft-tissue damage, adverse psychosocial profiles, or central pain amplification that blunted the impact of surgical pain relief.

The inferior postoperative outcomes observed in the trauma cohort may instead reflect differences in pain perception or psychological status. These mechanisms are increasingly recognized as important contributors to chronic pain and disability, particularly following traumatic events. Importantly, arm pain improved similarly in both trauma and non-trauma cohorts, supporting the effectiveness of CDR for radiculopathy, whereas axial neck pain and disability persisted to a greater degree in the trauma group.

Neuroplastic and psychosocial factors likely further explain the outcome disparity. Trauma, especially whiplash, is known to induce central sensitization, wherein the spinal cord and brain amplifies pain signals from the cervical region.³ Patients with chronic WAD often exhibit lowered pain thresholds and heightened sensitivity (hyperalgesia) not only in the neck but also in remote body regions, reflecting an injury-triggered augmentation of pain processing.^13-15 This state of sensitization could plausibly reduce the effectiveness of surgery, even after successful decompression or motion restoration at the operated level, the patient’s central nervous system may continue to generate pain disproportionate to any remaining nociception. Furthermore, psychological distress associated with the traumatic event can influence recovery. Post-traumatic stress disorder (PTSD) symptoms are common after serious accidents and have been linked to worse outcomes in chronic neck pain.¹⁰ It is possible that patients in the trauma cohort had higher prevalence of PTSD or catastrophizing, which may have adversely affected their pain perception, adherence to rehabilitation, or overall satisfaction. We did not specifically assess central sensitization or formal psychological diagnoses in our cohort; however, the significantly lower SF-12 MCS scores in the trauma group at both early (45.8 ± 11.5 vs 53.1 ± 8.0, P = .001) and late (45.3 ± 13.1 vs 51.4 ± 8.2, P = .027) postoperative timepoints suggest a persistent difference in mental health status. These findings support the notion that psychological burden, potentially including post-traumatic stress, anxiety, or depressive symptoms, may have contributed to poorer perceived recovery in the trauma group, aligning with prior research on the role of mental health and central sensitization in chronic pain syndromes.

Additionally, external factors such as litigation, compensation claims, or other secondary gain mechanisms may influence symptom reporting and recovery following trauma. Prior work in whiplash-associated disorders has shown that medico-legal involvement can amplify psychological distress and pain behavior. For example, symptom persistence has been strongly linked to compensation structures, with outcomes worsening in tort-based systems compared to non-tort environments.¹⁶ Compensation claims have also been associated with higher pain reporting, delayed recovery, and greater psychological distress, with psychological distress acting as a mediator of this relationship.^17,18 Because our study did not collect data on compensation or legal involvement, we could not directly assess this effect, but it remains an important consideration when interpreting PROM differences.

This study has several limitations. First, as a retrospective review of an observational dataset, it is subject to inherent biases in selection and data collection. Although we employed rigorous matching to ensure the trauma and control groups had similar baseline characteristics, there may have been unmeasured confounders such as the severity of the prior trauma and comprehensive assessment of psychological factors. Second, the definition of “trauma” was based on chart review and patient-reported history, which may have introduced variability. The mechanism and severity of injury (eg, high-energy vs low-energy trauma), presence of whiplash-type mechanisms, or soft tissue involvement such as muscle edema or posterior ligamentous complex (PLC) injury were not consistently available or defined. Therefore, the biological extent of trauma exposure across the cohort remains unclear. Third, we did not assess or include the time interval between trauma and surgery and symptom duration, which may be a relevant factor influencing recovery. Chronic post-traumatic changes likely differ from more recent injuries, and this variability could have affected the outcomes. Fourth, our follow-up interval, while sufficient to detect differences in early postoperative PROMs, may not capture longer-term outcome convergence or divergence between groups. Fifth, all surgeries were performed at a single institution by a limited number of surgeons, which may limit generalizability. However, including multiple surgeons and consistency in surgical technique can also be viewed as a strength, as it reduces variability in operative factors. Lastly, our outcome measures focused on patient-reported pain and function; we did not include objective measures of muscle health or imaging beyond the treated level postoperatively. Incorporating such data could help clarify the mechanisms behind the outcome differences observed. Despite these limitations, the study offers valuable insight into how trauma history may influence surgical recovery in a real-world clinical population.

Conclusions

This matched cohort analysis demonstrates that patients with a prior history of cervical trauma experience significantly worse postoperative PROMs following CDR, despite having similar preoperative scores, surgical parameters, and complication rates compared to those without trauma. The observed differences, particularly in disability, physical and mental health scores, and perceived recovery, were most prominent among patients undergoing single-level CDR and may reflect persistent effects of trauma on pain processing, psychosocial factors, and recovery of axial neck pain. These findings highlight the need to account for trauma history in preoperative counseling and patient selection. Future prospective studies incorporating muscle functionality assessment and long-term follow-up are warranted to further elucidate the mechanisms and optimize surgical outcomes in this unique patient population.

Supplemental Material

Supplemental Material - History of Trauma Preceding Cervical Disc Replacement Leads to Worse Postoperative Patient Reported Outcomes: A Matched Cohort Analysis

Supplemental Material for History of Trauma Preceding Cervical Disc Replacement Leads to Worse Postoperative Patient Reported Outcomes: A Matched Cohort Analysis by Sereen Halayqeh, Chad Z. Simon, Annika Bay, Eric Mai, Cole T. Kwas, Tomoyuki Asada, Andrea Pezzi, Adrian T. H. Lui, Atahan Durbas, Olivia C. Tuma, Nicholas J. Giattino, Anthony R. Lewis, James E. Dowdell, Kyle W. Morse, James Farmer, Russel C. Huang, Todd J. Albert, Han Jo Kim, Sheeraz A. Qureshi and Sravisht Iyer in Global Spine Journal.

Supplemental Material

Supplemental Material - History of Trauma Preceding Cervical Disc Replacement Leads to Worse Postoperative Patient Reported Outcomes: A Matched Cohort Analysis

Footnotes

ORCID iDs

Sereen Halayqeh

Adrian T. H. Lui

Kyle W. Morse

Sheeraz A. Qureshi

Sravisht Iyer

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: No direct funding was received for this study. However, the study used REDCap (Research Electronic Data Capture) hosted at Weill Cornell Medicine Clinical and Translational Science Center supported by the National Center for Advancing Translational Science of the National Institute of Health (NIH) under award number: UL1 TR002384.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Sheeraz Qureshi has the following disclosures: AMOpportunities: Other financial or material support; Annals of Translational Medicine: Editorial or governing board; Association of Bone and Joint Surgeons: Board or committee member; Cervical Spine Research Society: Board or committee member; Contemporary Spine Surgery: Editorial or governing board; Globus Medical: IP royalties; Paid consultant; Paid presenter or speaker; Hospital Special Surgery Journal: Editorial or governing board; HS2, LLC: Stock or stock Options; International Society for the Advancement of Spine Surgery (ISASS) - Program Committee member: Board or committee member; Lifelink.com: Other financial or material support; Lumbar Spine Research Society: Board or committee member; Minimally Invasive Spine Study Group: Board or committee member; North American Spine Society: Board or committee member; Simplify Medical, Inc.: Other financial or material support; Society of Minimally Invasive Spine Surgery (SMISS) - Program Committee member: Board or committee member; Spinal Simplicity: Other financial or material support; SpineGuard, Inc.: Paid consultant; Stryker: IP royalties; Paid consultant; Surgalign: Paid consultant; Tissue Differentiation Intelligence: Stock or stock Options; Viseon, Inc.: Paid consultant; Research support; Clinical Spine Surgery: Editorial or governing board. Sravisht Iyer has the following disclosures: Globus Medical: Paid presenter or speaker; Stryker: Paid presenter or speaker; Vertebral Columns/International Society for the Advancement of Spine Surgery (ISASS): Editorial or governing board; HS2, LLC: Ownership/Equity/Investment; Innovasis: Research Support (either personally or through institution). State: - HS2, LLC Innovasis HSS ASC Development Network, LLC Globus Medical, Inc. SpineGuard, Inc. Joint Effort Administrative Services Organization Intrinsic Therapeutics. James Dowdell has the following disclosures: Globus Medical, Inc.: Honoraria; Expert Institute: Law Firm; Consultant; Providence Medical Technology, Inc.: Consultant; Joint Effort Administrative Services Organization: Ownership Interest; CME Outfitters: Honoraria; Stryker: Sponsored Travel; Consultant; HSS ASC Development Network, LLC: Ownership Interest; JEC: Consultant; HS2, LLC: Ownership Interest; BICMD, Inc.: Consultant. Han Jo Kim has the following disclosures: Grant: ISSGF; Royalties: Zimmerbiomet, K2M Stryker, Acuity Surgical; Consulting: Nuvasive; Scientific Advisory Board/ Other Office, Vivex Biology, Aspen Medical; Fellowship Support: AO Spine.

Data Availability Statement

The data supporting this study are not publicly available. However, they can be made available upon reasonable request from the corresponding author.*

IRB Approval

Hospital for Special Surgery IRB (approval number 2018-1142).

Supplemental Material

Supplemental material for this article is available online.

References

Elliott

Pedler

Kenardy

Galloway

Jull

Sterling

. The temporal development of fatty infiltrates in the neck muscles following whiplash injury: an association with pain and posttraumatic stress. PLoS One. 2011;6(6):e21194.

Krogh

Kasch

. Whiplash injury results in sustained impairments of cervical muscle function: a one-year prospective, controlled study. J Rehabil Med. 2018;50(6):548-555.

Freeman

Nystrom

Centeno

. Chronic whiplash and central sensitization; an evaluation of the role of a myofascial trigger points in pain modulation. J Brachial Plexus Peripher Nerve Inj. 2009;4:2.

de Zoete

RMJ

Coppieters

Farrell

. Editorial: whiplash-associated disorder-advances in pathophysiology, patient assessment and clinical management. Front in Pain Res (Lausanne, Switzerland). 2022;3:1071810.

Chang

Huang

, et al. Cervical arthroplasty for traumatic disc herniation: an age- and sex-matched comparison with anterior cervical discectomy and fusion. BMC Muscoskelet Disord. 2015;16:228.

Freeman

Croft

Rossignol

Centeno

Elkins

. Chronic neck pain and whiplash: a case-control study of the relationship between acute whiplash injuries and chronic neck pain. Pain Res Manag. 2006;11(2):79-83.

Chang

Huang

Mummaneni

. The option of motion preservation in cervical spondylosis: cervical disc arthroplasty update. Neurospine. 2018;15(4):296-305.

Harris

Taylor

Minor

, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inf. 2019;95:103208.

Harris

Taylor

Thielke

Payne

Gonzalez

Conde

. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 2009;42(2):377-381.

10.

Sterling

Smeets

Keijzers

Warren

Kenardy

. Physiotherapist-delivered stress inoculation training integrated with exercise versus physiotherapy exercise alone for acute whiplash-associated disorder (StressModex): a randomised controlled trial of a combined psychological/physical intervention. Br J Sports Med. 2019;53(19):1240-1247.

11.

Andersen

Ravn

Carstensen

Ørnbøl

Frostholm

Kasch

. Posttraumatic stress symptoms and pain sensitization after whiplash injury: a longitudinal cohort study with quantitative sensory testing. Front in Pain Res (Lausanne, Switzerland). 2022;3:908048.

12.

Sterling

Jull

Kenardy

. Physical and psychological factors maintain long-term predictive capacity post-whiplash injury. Pain. 2006;122(1–2):102-108.

13.

Koelbaek Johansen

Graven-Nielsen

Schou Olesen

Arendt-Nielsen

. Generalised muscular hyperalgesia in chronic whiplash syndrome. Pain. 1999;83(2):229-234.

14.

Sterling

Jull

Vicenzino

Kenardy

. Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery. Pain. 2003;104(3):509-517.

15.

Banic

Petersen-Felix

Andersen

, et al. Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia. Pain. 2004;107(1–2):7-15.

16.

Cassidy

Carroll

Côté

Lemstra

Berglund

Nygren

. Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. N Engl J Med. 2000;342(16):1179-1186.

17.

Murgatroyd

Harris

Tran

Cameron

. The association between seeking financial compensation and injury recovery following motor vehicle related orthopaedic trauma. BMC Muscoskelet Disord. 2016;17:282.

18.

Wadhwa

Taouk

Spittal

King

. Workplace injury compensation and mental health and self-harm outcomes: a systematic review. New Solut. 2024;34(2):71-82.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.21 MB