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A Bibliometric Analysis of the Top 100 Cited Articles in Anterior Cervical Discectomy and Fusion

Authors Wang X, Lin Y, Wang Q, Gao L, Feng F 

Received 22 May 2022

Accepted for publication 23 September 2022

Published 11 October 2022 Volume 2022:15 Pages 3137—3156

DOI https://doi.org/10.2147/JPR.S375720

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 4

Editor who approved publication: Dr Krishnan Chakravarthy



Xun Wang,1 Yanze Lin,1 Qiongtai Wang,1 Liqing Gao,1 Fabo Feng2

1Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, People’s Republic of China; 2Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, People’s Republic of China

Correspondence: Fabo Feng, Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, People’s Republic of China, Email [email protected]

Study design: A bibliometric analysis.
Objective: To identify and analyze the top 100 cited articles in anterior cervical discectomy and fusion.
Summary of Background Data: Anterior cervical discectomy and fusion (ACDF) is one of the most routine surgical procedures in spine surgery. Many surgeons and academics have researched ACDF thoroughly and published numerous articles. However, there is no relevant bibliometric analysis. Therefore, our study aims to identify and analyze the top 100 cited articles in ACDF to identify the research trends.
Methods: We searched the Web of Science (WOS) Core Collection database with restrictions and identified the top 100 cited publications in ACDF for analysis.
Results: The citation counts of the top 100 cited publications ranged from 37 to 361 (mean 67.42). All studies were published between 2008 and 2019, with 2013 and 2015 the most prolific years. The journals Spine and Journal of Neurosurgery-Spine provided the majority of the articles. Overall, the 100 articles came from 12 countries, with the United States being the top producer, followed by China and South Korea. The most frequent keywords were “spine”, “anterior cervical discectomy and fusion”, “interbody fusion”, ‘arthrodesis’, “follow-up”, “decompression”, and “ACDF”.
Conclusion: ACDF has been regarded as a classical gold standard in anterior cervical surgery, and the emergence of new surgical procedures has not affected its status. Cervical disc arthroplasty still needs further research and development. As the first bibliometric analysis of ACDF, this bibliometric study is meant to provide guidance for clinicians and scholars to research the development trend of this field.

Keywords: anterior cervical discectomy and fusion, ACDF, citation analysis, bibliometric, Web of Science, VOSviewer

Introduction

Compared with the lumbar sacral or thoracic spine, anterior access to the cervical is very typical.1–3 Since the introduction of anterior cervical discectomy and fusion (ACDF) in the 1950s, it has been commonly used for treating cervical spine diseases due to its superior clinical efficacy and credible safety4 and has become one of the most common surgical procedures in spine surgery.5,6 The procedure involves the removal of the diseased disc and the implantation of autogenous or allograft implants to restore the stability of the operative vertebral body and achieve direct anterior decompression.7 Indications for ACDF include cervical degenerative disc disease (CDDD), cervical spinal stenosis, and partial ossification of the posterior longitudinal ligament (OPLL).8–10 In recent years, cervical disc arthroplasty (CDA), endoscopic spine surgery (ESS), and other procedures have developed rapidly and have been used to treat cervical spine diseases. CDA preserves the operating segment’s range of motion and reduces the occurrence of adjacent segment degeneration (ASD).11 ESS is considered a safe and effective alternative for cervical spine diseases in the future due to minor tissue damage and fewer complications.12 However, whether CDA and ESS will affect the development trend of ACDF is still unknown.

There are many clinicians and scholars who study ACDF procedure worldwide and have published a large number of valuable reference articles. In recent years, with the rise of surgical methods such as CDA and cervical endoscopic surgery, as well as the development of precision medicine and rehabilitation medicine, the development trend of ACDF may also change. However, to the best of our knowledge, no scholar has conducted a comprehensive analysis of ACDF to identify the most influential research in this field. Therefore, our study is meant to define and analyze the list of top 100 cited papers in ACDF, summarize the research types, identify the research trend in this field, and analyze whether the emergence of new technologies will impact the status of ACDF as the gold standard.

Bibliometrics analysis is the qualitative and quantitative evaluation of research in a specific field by applying multiple methods, which have been commonly used in spine surgery. The number of citations for each article is one of the indicators to evaluate the value of the article. A high citation number means more scholars’ recognition and greater contribution to the field’s development. To our knowledge, this study is the first bibliometric analysis of ACDF. We analyzed research trends based on the most influential articles in ACDF in our study.

Materials and Methods

Search Strategy

We thoroughly searched the WOS Core Collection database to ascertain the top 100 cited articles in ACDF published between 1985 and 2022 on JAN 22, 2022. The specific search strategies are as follows: using CNKI (China national knowledge infrastructure) to identify keywords and synonyms: “anterior cervical discectomy and fusion”, “anterior cervical discectomy with fusion” and “ACDF”. Then, search the WOS Core Collection database with the keywords and synonyms identified. Select “Article” or “Review” publications published in English between 1985 and 2022.

The query is as follows: (((TI=(anterior cervical discectomy with fusion OR anterior cervical discectomy and fusion OR ACDF)) AND DT=(Article OR Review)) AND LA=(English)) AND PY=(1985–2022). A total of 890 articles were searched. All articles were arranged from most to least cited. The top 100 were exported, with title, author, citation number, country, journal, year of publication, and article number noted for further analysis.

Data Analysis

According to the title and abstract, each publication was allocated to a study type and grouped into diagnostic, therapeutic, prognostic, economic, systemic, or non-systemic reviews. The data was analyzed using VOSviewer and Microsoft Excel 2019. VOSviewer is a Java-based software that can analyze and visualize bibliometrics data. We used VOSviewer to build visual co-occurrence networks of the author, keyword, and year of publication. We used Microsoft Excel 2019 to convert data from the WOS Core Collection database into tables and figures.

Result

Basic Characteristics

A total of 890 ACDF-related publications were retrieved and ranked in descending order according to citation frequency. We selected the top 100 articles and marked them from No.1 to 100 (Table 1).6,9,13–110 The citations of the top 100 papers were between 37 and 361 times, with 6742 total and 67.42 mean. Among the articles,

Results of the prospective, randomized, controlled multicenter Food and Drug Administration investigational, device exemption study of the ProDisc-C total disc replacement versus anterior discectomy and fusion for the treatment of 1-level symptomatic cervical disc disease

Table 1 The Top 100 Cited Publications in ACDF

by Murrey, D et al was the highest cited article.

There were seventeen systematic reviews, nine non-systematic reviews, and seventy-four primary studies among the top 100 publications.

Distribution of Publication Years

All studies were published between 2008 to 2019. From 2013 to 2015, 42 highly cited articles were published, which was the most active period. The most productive year was 2013 (17 publications), followed by 2015 (14 publications) (Figure 1). The earliest article was “Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis” by Ying, Z et al in Feb 2008. The latest article was “Machine learning for prediction of sustained opioid prescription after anterior cervical discectomy and fusion” published in 2019 by Karhade, AV et al

Figure 1 Total number of articles published per year.

Distribution of Authors

In terms of the number of author publications, there are 89 first authors among the top 100 articles and ten first authors with more than two articles. With three articles (No.30, 52, 74 in Table 1), Lied, B was considered the most prolific first author, and the other nine authors contributed two articles per person (Table 2).

Table 2 Authors with More Than Two Articles

VOSviewer’s Density Visualization function visualizes the co-author relations between all authors by clustering them (Figure 2). Phillips FM, McAfee PC, Howell KM, and five other authors were part of the primary cluster. Anderson PA and three additional authors formed another significant cluster.

Figure 2 VOSviewer density visualization shows co-authorship and clusters among all authors in the top 100 cited articles.

Distribution of Country/Region and Institution

We identified 81 institutions based on correspondence addresses, and 15 institutions had repeatedly published articles (Table 3). The top three institutions were Rush Univ, USA, Carolina Neurosurg & Spine Associates, USA, and Soochow Univ, China, with three publications each. In terms of countries and regions, twelve different countries and regions contributed to the top 100 articles, among which the United States, with 65 articles, contributed 60.2% of all articles and 66.5% of total citations, followed by China (17 articles) and Korea (8 articles) (Figure 3). Moreover, all articles from North America were contributed by the United States, with 65 articles and 4671 citations. China, Korea, and Japan are the primary sources of Asian articles, with 27 articles and 1537 citations in total. Articles from Europe were composed of seven countries (Norway, United Kingdom, Germany, Italy, Netherlands, Denmark, and Switzerland), with 12 articles and 595 citations. Oceania had only four articles (216 citations) published by Australia. Yet, no publications from South America and Africa were included (Figure 4).

Table 3 Institutions with More Than Two Articles

Figure 3 Articles published by each country.

Figure 4 Map of worldwide research productivity.

Distribution of Publication Journals

The top 100 articles retrieved in our study were from 21 different journals (Table 4), and the top three journals account for 51% of all articles. Spine ranked first with 24 articles, followed by Journal of Neurosurgery-Spine (15 articles) and Spine Journal (12 articles) (Figure 5). Unsurprisingly, Spine has an absolute advantage in the total number of citations (1434 times). However, the journal with the highest average citations was Journal of Bone And Joint Surgery-American Volume (100.5 times), followed by Spine Journal (93.5 times) and Journal of Neurosurgery-Spine (81.5 times).

Table 4 The Total Amount of Articles in Each Journal

Figure 5 The number of articles published in each journal.

Distribution of Article Types and Keywords

Categorizing all the articles, we found that “therapeutic” (n=65) was the most common type, followed by systemic reviews (n=17), non-systemic reviews (n=9), and “prognostic” (n=9) (Table 5).

Table 5 Categorizing by Article Types

The co-occurrence network analysis function of VOSviewer was used to analyze the keywords with a minimum frequency of eight. The 33 high-frequency keywords were divided into “procedure”, “disease and symptoms”, and “prognosis” (Figure 6). Overall, the most frequent keyword was “spine” (38), followed by “anterior cervical discectomy and fusion” (36), “interbody fusion” (34), “arthrodesis” (32), “follow-up” (26), “decompression” (23), and “ACDF” (22).

Figure 6 (A) Network visualization map showed clustering of high-frequency keywords. (B) Network visualization map showed the variation trend of high-frequency keywords over time. The colors were determined based on the mean year the keywords appear in the articles.

Discussion

ACDF represents one of the most popular procedures in spine surgery.111,112 In 1958, Smith and Robinson firstly described the application of anterior cervical approach as the therapeutic of spine disorders.113 Since then, with numerous modifications introduced by surgeons, ACDF has been considered a gold standard for cervical spondylosis, and the number of related publications has steadily increased. As far as we know, no scholar has conducted a comprehensive analysis of ACDF to define the most significant studies. Our article is the first to analyze ACDF by bibliometric analysis.

According to our study, the publications related to ACDF showed a steady increasing trend before 2013, while the number of articles published in 2013 increased by 240% compared with 2012. From 2013 to 2019, 62% of highly cited articles were published in the seven years. This trend indicated that ACDF research had attracted more attention in recent years, which may relate to an increased risk of cervical spondylosis caused by the aging population and lousy lifestyle such as using smartphones for a long time.114 The earliest article in our study was published by Ying, Z et al on February 1, 2008, and the most cited one was published by Murrey, D et al in April 2009. ACDF was initially described in 1958, and Cloward used Wiltberger’s lumbar interbody dowel fusion procedure on the cervical spine in November of the same year.4 To date, ACDF has long been considered the initial and gold standard of anterior cervical surgery.115–117 Interestingly, Ying, Z et al creatively described the application of ACDF in treating spondylolisthesis of the axis. They believed ACDF might be a feasible surgical procedure for unstable traumatic spondylolisthesis of the axis (TSA),100 which provided a reference for applying ACDF in treating other cervical spine diseases. The surgical procedure of ACDF has been unchanged for more than 60 years, recognizing its reliability and effectiveness. However, more trials and innovations are necessary to push it forward.117

In terms of national publications, the United States dominates with 65% of the total (Figure 3). This might be due to the following reasons: As previously mentioned, the ACDF was first described and modified by American scholars. Among the first ten articles in the top 100, nine articles were published by institutions in the United States. Moreover, in the United States, ACDF is the most routinely performed cervical spine procedure, with more than 500,000 ACDF procedures performed between 1990 to 1999 alone. The clinical outcomes of most cases were good or excellent.111 According to a recent study, 1,212,475 ACDFs were performed in the United States between 2004 and 2014, accounting for more than 80% of cervical spine procedures.118 The United States still dominated the institution publications: 11 of the 15 most productive institutions were affiliated to the United States (Table 3), explaining why the United States leads the world in total publications.

In terms of research topic and hotspot, we found the top four high-frequency keywords were “spine”, “anterior cervical discectomy and fusion”, “interbody fusion”, and “arthrodesis”. Meanwhile, through the analysis of the title and abstract, we found that the procedures comparison (n=36) was the most common topic type, especially ACDF versus CDA (n=28). Therefore, we concluded that the comparison between ACDF and CDA was a contemporary research hotspot in cervical surgery and had received significant attention. The articles by Murrey, D et al with the most total cited and the highest average number of citations and their latest publication on cervical surgery were reviews involving the ACDF versus CDA. ACDF is regarded as the standard surgical procedure for CDDD.119 However, in addition to the common complications of ACDF, there are rare but disastrous complications, such as esophageal tear, pharyngeal perforation, and even expectoration of the entire ACDF construct.120 Moreover, several publications showed that changes in the biomechanical of adjacent segments after ACDF may result in adjacent segment degeneration (ASD).121 CDA was introduced to protect spinal biomechanics and reduce the incidence of ASD.122 In 1966, Fernstrom introduced the concept of CDA.123 Limited by the technology available at the time, the initial device was a ball bearing implanted in the lumbar disc space. After more than 50 years of development, the artificial discs used in the clinic have the characteristics of bionic, stable, and shock absorption.124 Nine artificial discs have received US FDA approval: Prestige ST, Prestige LP, Prodisc-C, Bryan, Secure-C, PCM, Mobi-C, M6-C, and Simplify.125 Compared with ACDF, CDA was superior or equivalent in terms of length of stay (LOS), clinical indicators, range of motion (ROM) of the cervical spine, adverse events, and reoperation rates.29,97,109,126 Although CDA has some advantages over ACDF in surgical outcomes, the indications of CDA are relatively narrow, the procedure is more complex,117,119 and the financial requirements of patients are higher,127 all of which limit the application of CDA in the clinic. Some scholars believe that postoperative complications of CDA, such as heterotopic ossification (HO), osteolysis, and aseptic loosening caused by abrasion, spontaneous fusion, and postoperative hematoma, are also one of the factors limiting its wide application.125,128 Since Food and Drug Administration (FDA) approved CDA in 2007, the growth rate of CDA has reached a steady-state, about twice that of ACDF.129 In a recent investigation by Comron Saifi et al, in the United States alone, approximately 132,000 ACDFs are performed each year compared to only 1600 CDAs, with a ratio of 81:1.51 Junbo He et al analyzed the top 100 cited publications on anterior cervical surgery and found that 80% of the publications were related to ACDF.117 As a representative of minimally invasive spine surgeries (MISS), endoscopic spine surgery is expected to become the mainstream direction of spine surgery due to its characteristics of fewer complications and minor tissue damage.130 However, the immaturity of the technique and the long learning cycle deter most spinal surgeons. ACDF is still the gold standard procedure for CDDD.11,130,131

Concerning research trends, CDA and artificial disc have been the research hotspots in recent years (Figure 6). Despite advances in artificial discs in the material, design, and manufacturing technology, wear remains the most influential factor in prosthesis implantation success.132 Aseptic loosening propagated by implant wear is the primary reason for implant failure and reoperation. Meanwhile, debris from wear induces an inflammatory response at the surgical level, leading to pain in the area surrounding the prosthesis.124 Researchers argued that disc neovascularization is the cornerstone of new-onset pain, and more investigations into this factor should be increased over the next five years.133

As a bibliometric to analyze the top 100 cited articles, our study has the following limitations: firstly, all the articles were published between 2008 to 2019. Like other bibliometric studies, “cumulative effect” is inevitable in our study, which means the earlier articles may have more citations. In contrast, the high-quality articles published recently may not be included due to the low citation.134,135 Secondly, we only retrieved English publications from the WOS, which might have omitted high-impact articles from other databases or languages. Finally, citation numbers may not be the sole standard to measure the quality and influence of an article. Other factors should be taken into account comprehensively in the future.

Conclusion

This bibliometric study identified the top 100 cited publications in ACDF, demonstrated the significance of ACDF in spine surgery, and identified the most prominent authors, institutions, countries, and journals. Generally, as the birthplace of ACDF, the United States is the country with the most thorough research in the world and has made outstanding contributions to the development of ACDF. CDA, as an alternative procedure for ACDF, has many limitations and needs further research for improvement. Endoscopic spine surgery is limited in clinical due to its immaturity and long learning period. Therefore, ACDF is still the gold treatment for cervical disc degeneration disease, the emergence of new procedures has not affected its position. As the first bibliometric analysis of ACDF, our study is expected to provide effective guidance for surgeons and researchers to familiarize the most influential publications in this field.

Data Sharing Statement

Research data supporting this publication are available from the Web of Science at located at www.webofknowledge.com.

Ethical Approval

The authors confirmed that no ethical approval is required.

Device Status/Drug Statement

The manuscript submitted does not contain information about medical device(s)/drug(s).

Funding

This research was supported in part by the Natural Science Foundation of Zhejiang Province under grant number LQ19H160014.

Disclosure

The authors have no competing interests to declare that are relevant to the content of this article.

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