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. 2023 Sep 8;102(36):e34984. doi: 10.1097/MD.0000000000034984

Global trends and frontiers of research on total disc replacement: A bibliometric analysis

Yanlei Li a,b, Jinlong Tian a,b, Jiongnan Xu a,c, Meng Ge a,b, Haiyu Shao a,b, Jun Zhang a,b, Tingxiao Zhao a,b, Weibin Wang d,*
PMCID: PMC10489399  PMID: 37682143

Abstract

With the increased risk of complications associated with traditional spinal fusion for the treatment of degenerative disc disease, total disc replacement (TDR) has received increasing attention in recent years. Despite the rapid development of its related research fields, its research status and the hotspot analysis are still unclear. Our goal was to identify and analyze the global research trends on TDR using bibliometric tools. All TDR data were obtained from the WoSCC. The information of research field was collected, including title, author, institutions, journals, countries, references, total citations, and years of publication for further analysis. From 1993 to 2022, a total of 1167 articles and 11,348 references were included in this field. These publications are mainly from 53 countries/regions and 174 journals, led by the United States and China. According to the citation report, the US was absolutely in the leading position in this research field. The most contribution institution and author were Sichuan University and Liu H. Spine and European Spine Journal were the most active journal on TDR research, with 205 and 118 articles. Meanwhile, they were also the most frequently cited journals. The “bone loss,” “cervical arthroplasty,” “hybrid surgery” were the most frequently cited areas of TDR research. Meanwhile, the latest research hotspots and directions were “cervical disc arthroplasty,” “7 year follow up,” “heterotopic ossification.” The scientific research on TDR has increased considerably in recent years. This study clarifies the current research status and future development trends in order to guide clinicians and researchers in the field of TDR. It can be inferred that cervical disc arthroplasty and bone loss will be the research focus in the future.

Keywords: bibliometric analysis, cervical disc arthroplasty, CiteSpace, research trends, total disc replacement, VOSviewer

1. Introduction

In the past few decades, the number of patients with degenerative disc disease (DDD) has increased rapidly. It is often described as the deterioration and symptoms of one or more discs, with the lumbar and cervical discs most commonly affected.[1] Pain in the low back, neck and arms is a common symptom of DDD in the lumbar and cervical spine.[2] According to reports, the lifetime incidence of low back pain ranges from 58% to 84%, with a peak incidence around the age of 40.[3–5] Similarly, the lifetime incidence of DDD in neck-related pain is >65%.[6] The process of DDD can lead to abnormal motion and biomechanical instability of the spinal segment through a series of changes, including disc dehydration, annular tears, and loss of disc height or collapse.[7,8] In addition, it seriously affects the quality of life of patients, is a main cause of global disability and brings a huge socio-economic burden to society.[9]

For a long time, spinal fusion has been considered as the surgical gold standard of failed conservative treatment for degenerative disc disease.[10,11] However, traditional spinal fusion increases the risk of adjacent segment disease and loss of spinal motion.[11,12] It is estimated that approximately 20% to 30% of patients with DDD do not respond to non-surgical treatment and other conservative options.[13] Meanwhile, total disc replacement (TDR), which can combat these complications, is gaining popularity.[14] Hence, TDR has attracted widespread attention and a large number of related literature has been published. However, the overall research on TDR is still uncertain, posing a comprehensive analytical challenge.

Bibliometrics, first defined by Alan Pritchard[15] in 1969, is a scientific tool that uses mathematical and statistical methods to quantitatively analyze a field of study.[16,17] Through quantitative analysis of published articles, it can measure the contribution of authors, journals, institutions or countries in a field of research, and identify current research trends and hotspots.[18,19] Moreover, bibliometric analysis can also discover valuable information hidden in the data and display it intuitively by the visualization.[20] Therefore, we aim to identify and analyze TDR research trends and hotspots, and provide relevant information to relevant researchers.

2. Materials and methods

2.1. Search strategy

All articles in this study were sourced from the web of science core collection (WoSCC) databases on August 15, 2022. The main information of the papers was downloaded, including titles, abstracts, authors, journals, institutions, countries, keywords, and reference records. The following search strategy was used: Topic = (“total disk replacement” OR “artificial disc replacement” OR “intervertebral disc arthroplasty” OR “spine arthroplasty” OR“disc replacement, total” OR “replacement, total disc” OR “arthroplasty, replacement, disk” OR “disk replacement, total” OR “replacement, total disk” OR “artificial disk replacement” OR “disk replacement, artificial” OR “replacement, artificial disk” OR “total disc arthroplasty” OR “arthroplasty, total disc” OR “total disk arthroplasty” OR “arthroplasty, total disk” OR “disk arthroplasty, total” OR “arthroplasty, replacement, disc” OR “artificial disc replacement” OR “disc replacement, artificial” OR “replacement, artificial disc”) OR Topic = (“cervical disc arthroplasty” OR “cervical disc replacement” OR “cervical disc prostheses” OR “lumbar disc arthroplasty” OR “lumbar disc replacement” OR “lumbar disc prostheses”) AND Language = English AND Time span = 1993 to 2022. In order to obtain an accurate and comprehensive research data, the specific method is shown in Figure 1.

Figure 1.

Figure 1.

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Flowchart of total disc replacement (TDR) screening process.

2.2. Tools

CiteSpace, VOSviewer, and Excel software were used to analyze the data. CiteSpace is an effective visualization tool that enables the analysis of literature data. It facilitates the identification of connections between documents, examination of research hotspots and trends, and exploration of disciplinary development. On the other hand, VOSviewer assists researchers in swiftly locating and comprehending the present state and dynamics of relevant research fields within extensive literature collections. The Excel software was used to identify various details of the publication, including titles, authors, journals, institutions, countries, reference records, year of publication, journal impact factors, citation reports, and the number of published articles.

2.3. Data extraction

According to the search strategy, the relevant data were independently extracted and organized by 2 researchers, which discussed the disagreements until they achieved a consensus. All data were obtained from the core collection database of Web of Science, and the useful information on TDR was extracted and analyzed by using CiteSpace, VOSviewer, and Excel software.

3. Result

3.1. Publication trend

A total of 3056 publications regarding TDR were identified in the WoSCC databases. After manual screening, a total of 1167 papers were extracted, which included 1019 articles and 148 reviews. The specific flow chart of the screening is shown in Figure 1. It could be seen from Figure 2A that the number of annual publications on TDR research showed a relatively stable growth trend. Global research on TDR has grown over the past few decades, from 6 articles from 1993 to 1995 to 251 articles from 2017 to 2019. In terms of citations, there is a clear upward trend, especially in 2017 to 2019 reached 6731 times. Among them, the highly cited papers often reflected the academic influence and importance. From this, it can be inferred that the field of TDR has attracted extensive research interest and will continue to growth in the future.

Figure 2.

Figure 2.

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Overview of publications. (A) Trends in the number of publications and citations on total disc replacement (TDR) research from 1993 to 2022. (B) Distribution of publications.

3.2. Analysis of countries

These articles were from 53 different countries and regions. The global contribution of TDR was visually analyzed and displayed by value in the world map (Fig. 2B). The number of publications and citations were intuitively displayed (only the top 10 countries/regions) (Fig. 3A and B). The highest number of articles was from the United States (n = 523), followed by China (n = 264), and Germany (n = 101). In terms of citations, the United States was far more active than any other countries/regions, followed by China, Germany, and South Korea. It can be inferred that those countries are of high quality and influence in the field of TDR research. Next, we use VOSviewer to analyze and visualize the cooperation between countries (Fig. 3C). The size of the node represents the number of publications by the country, and the degree of cooperation (named as total link strength [TLS]) is indicated by the thickness of the line. This visual cooperation network diagram shows that the United States is still the main contributor, and cooperates closely with China, Germany, South Korea, France, and England. However, the cooperative relationship among other countries/regions was weaker.

Figure 3.

Figure 3.

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Highest impact countries on total disc replacement (TDR). (A) The top 10 countries in publications. (B) The top10 countries in citations. (C) Visualization map of each country generated by using VOSviewer. The thickness of the lines reflected the citation strength.

3.3. Analysis of institutions and journals

The 1167 articles were from 1228 research institutions. Table 1 summarizes the top 10 most productive institutions, of which the first there were Sichuan University (n = 73), Texas Back Institute (n = 49), and Hospital for Special Surgery (n = 32). However, the institution with the highest total citations and average citations was Texas Back Institute. In addition, the other 7 of the top 10 most prolific institutions were from the United States, except Sichuan University, National Yang-Ming University, and Peking University. At the same time, there were 120 institutions with more than 4 published articles (Fig. 4A), among which the major contributor on TDR research were Texas Back Institute (TLS = 2836), Spine Institute of Louisiana (TLS = 1878), Sichuan University (TLS = 1686), Hospital for Special Surgery (TLS = 1357), Rush University (TLS = 1301). In additional, the strongest cooperative relationship between the Spine Institute of Louisiana and the Texas Back Institute indicated that their research directions may be more similar.

Table 1.

Top 10 institutions publishing most on total disc replacement.

Rank Organization Country Counts Total citations Mean citations Total link strength
1 SiChuan University China 73 618 8.47 3230
2 Texas Back Institute United States 49 2444 49.88 5470
3 Hospital for Special Surgery United States 32 931 29.09 2317
4 Rush University United States 28 1058 37.79 2473
5 Spine Institute of Louisiana United States 27 1247 46. 19 3541
6 Texas Back Institute Research Foundation United States 21 740 35.24 1836
7 National Yang-Ming University China 21 456 21.71 1559
8 Orthopedic Center of St. Louis United States 20 528 26.40 1846
9 Columbia University United States 18 250 13.89 1234
10 Peking University China 18 250 13.89 858
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Figure 4.

Figure 4.

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(A) The distribution of organizations involved in total disc replacement (TDR) research. Each node in this map represents an institution that occurred at least 5 times. (B) The dual-map overlay of journals generated by using CiteSpace (left: citing journals; right: cited journals).

All papers were published in 174 different journals. According to the results of Table 2, the top 10 journals with the most active publications in the TDR research field were all from the United States. Among all the journals, Spine, European Spine Journal, Journal of Neurosurgery-Spine ranked in the top 3, with 205, 118, and 68 articles, respectively. At the same time, they are also the top 3 journals with the most citations, with 8192, 3430, and 3099 times. In terms of the 2022 journal citation report, 4 journals of the top 10 were located in Q1 or Q2. Among them, the journals with the highest Impact Factor (IF) was the Spine journal (IF = 4.297). The relationship between citing journals (left) and cited journals (right) was shown in the dual-map overlap of journals (Fig. 4B). It could be seen that there were mainly 3 paths, which represents the citation links. The citation links indicated that papers published in neurology/sports/ophthalmology journals were often cited in papers published in health/nursing/medicine journals, sports/rehabilitation/sport journals, and psychology/education/social journals.

Table 2.

Top 10 journals in the field of total disc replacement.

Rank Journal Articles Total citations Mean citations Country JCR (2022) IF (2022)
1 Spine 205 8192 39.96 United States Q2 3.241
2 European Spine Journal 118 3430 29.07 United States Q2 2.721
3 Journal of Neurosurgery-Spine 68 3099 45.57 United States Q2 3.467
4 Spine Journal 66 2195 33.26 United States Q1 4.297
5 International Journal of Spine Surgery 54 494 9. 15 United States NA NA
6 World Neurosurgery 45 258 5.73 United States Q3 2.21
7 Journal of Spinal Disorders & Techniques 44 1729 39.30 United States NA NA
8 Global Spine Journal 26 153 5.88 United States Q3 2.23
9 Clinical Spine Surgery 24 122 5.08 United States Q3 1.723
10 Medicine 20 143 7. 15 United States Q3 1.817
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JCR = journal citation report.

3.4. Authors and co-cited authors

A total of 3753 authors participated in the TDR study. As shows in Table 3, the most prolific authors were Liu H (n = 70), followed by Wang BY (n = 51), Hong Y (n = 42), and Meng Y (n = 36). However, total citation frequency analysis indicated that McAfee, PC and Guyer, RD were the major contributors in the field of TDR. In CiteSpace software, the between centrality (BC) above 0.1 was also known as a key node and was often used to measure the importance of publications. Among them, only Kim, KD (n = 0.12) was more significant than 0.10, which was usually identified as hubs nodes shown by the purple rings (Fig. 5A). From the figure, we can see the level of cooperation between different authors. The size of circles represents the number of published articles; the thickness of the line among the circles indicates the degree of cooperation between authors, and the different colors represents different years.

Table 3.

The 10 most productive authors and the top 10 co-cited authors with the highest citations.

Rank Author Count Total citations Average citations Centrality Co-cited author Total citations Centrality
1 Liu H 70 426 6.09 0.04 McAfee PC 347 0. 13
2 Wang BY 51 262 5.14 0 Hilibrand AS 285 0.07
3 Hong Y 42 183 4.36 0.02 Zigler JE 261 0. 14
4 Meng Y 36 178 4.94 0.02 Sasso RC 250 0.03
5 Ding C 28 165 5.89 0.03 Goffin J 241 0.05
6 Wu TK 25 136 5.44 0.01 Mummaneni PV 207 0.01
7 Kim KD 25 888 35.52 0. 12 Bertagnoli R 198 0.02
8 Guyer RD 24 1318 54.92 0.07 Delamarter RB 180 0. 12
9 McAfee PC 23 1988 86.43 0.05 Anderson PA 172 0.02
10 Yang Y 23 149 6.48 0.05 Murrey D 164 0.04
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Figure 5.

Figure 5.

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The visual map of authorship carried on CiteSpace. (A) The visualization map of the cited authors’ network. (B) Co-operation network of the co-cited authors.

In co-cited author network analysis (Table 3), the most frequently co-cited were McAfee PC (n = 347), followed by Hilibrand AS (n = 285), Zigler JE (n = 261), Sasso RC (n = 250), and Goffin J (n = 241). In terms of the centrality, there were 3 authors whose centrality exceeded 0.10, of which Zigler JE (0.14) was the highest, followed by McAfee PC (0.13), and Delamarter RB (0.12). The centrality was displayed by the purple rings in Figure 5B, indicating that these 3 authors had the important influence in this field. At the same time, compared with the cooperation network between authors, the co-cited authors have a closer cooperation relationship.

3.5. Analysis of references and citations

A total of 62,497 references and 1167 papers were included in this study, of which 187 papers had been cited no <40 times. Table 4 listed the top 10 articles with the highest citation, of which Mummaneni PV et al (n = 411), followed by Murrey D et al (n = 370), Blumenthal S et al (n = 358), and Heller JG et al (n = 348). The journal of Spine was the main contributor in this field, contributing 6 of the top 10 most cited articles. In addition, the top 10 most co-cited references of TDR studies were shown in Table 5. The result showed that Hilibrand AS, Mummaneni PV, and Murrey D had the highest total citation frequency, each with more than 200 times. Figure 6A visually displayed the co-citation network analysis of the references. The network consisted of 570 unique nodes and 1455 links. The size of nodes on the lines indicated the number of cited references and the color indicated the time evolution.

Table 4.

Top 10 cited articles in the field of total disc replacement.

Rank Author Title Citations Citations/Y Journal Y IF (2022)
1 Mummane ni PV Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: a randomized controlled clinical trial 411 25.69 Journal of Neurosurgery-Spine 2007 3.467
2 Murrey D Results of the prospective, randomized, controlled multicenter Food and Drug Administration investigational, device exemption study of the ProDisc-C total disc replacement vs anterior discectomy and fusion for the treatment of 1-level symptomatic cervical disc disease 370 26.43 Spine Journal 2009 4.297
3 Blumenthal S A prospective, randomized, multicenter food and drug administration Investigational device exemptions study of lumbar total disc replacement with the CHARITE (TM) artificial disc vs lumbar fusion
Part I: Evaluation of clinical outcomes		 358 19.89 Spine 2005 3.241
4 Heller JG Comparison of BRYAN Cervical Disc Arthroplasty With Anterior Cervical Decompression and Fusion Clinical and Radiographic Results of a Randomized, Controlled, Clinical Trial 348 24.86 Spine 2009 3.241
5 Fairbank J Results of the prospective, randomized, multicenter food and drug administration investigational device exemption study of the ProDisc (R)-L total disc replacement vs circumferential fusion for the treatment of 1-level degenerative disc disease 290 18.13 Spine 2007 3.241
6 Coric D Prospective, randomized, multicenter study of cervical arthroplasty: 269 patients from the KineflexIC artificial disc investigational device exemption study with a minimum 2-y follow-up Clinical article 245 20.42 Journal of Neurosurgery-Spine 2011 3.467
7 Goffin J Intermediate follow-up after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis: Single-level and bi-level 235 1 1.75 Spine 2003 3.241
8 Dmitriev AE Adjacent level intradiscal pressure and segmental kinematics following a cervical total disc arthroplasty - An in vitro human cadaveric model 227 12.61 Spine 2005 3.241
9 McAfee PC Classification of heterotopic ossification (HO) in artificial disk replacement 226 1 1.3 Journal of Spinal Disorders & Techniques 2003 NA
10 Harrop JS Lumbar adjacent segment degeneration and disease after arthrodesis and total disc arthroplasty 215 14.33 Spine 2008 3.241
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Table 5.

Top 10 co-cited references concerning the research of total disc replacement.

Rank Author Title Cited frequency Journal Y IF (2022)
1 Hilibrand AS Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis 297 Journal of Bone And Joint Surgery-American Volume 1999 6.558
2 Mummane ni PV Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: a randomized controlled clinical trial 218 Journal of Neurosurgery-Spine 2007 3.467
3 Murrey D Results of the prospective, randomized, controlled multicenter Food and Drug Administration investigational device exemption study of the ProDisc-C total disc replacement vs anterior discectomy and fusion for the treatment of 1-level symptomatic cervical disc disease 208 Spine Journal 2009 4.297
4 Heller JG Comparison of BRYAN cervical disc arthroplasty with anterior cervical decompression and fusion: clinical and radiographic results of a randomized, controlled, clinical trial 195 Spine 2009 3.421
5 Eck JC Biomechanical study on the effect of cervical spine fusion on adjacent-level intradiscal pressure and segmental motion 175 Spine 2002 3.421
6 McAfee PC Classification of heterotopic ossification (HO) in artificial disk replacement 159 Journal of Spinal Disorders & Techniques 2003 NA
7 Blumenthal S A prospective, randomized, multicenter food and drug administration Investigational device exemptions study of lumbar total disc replacement with the CHARITE (TM) artificial disc vs lumbar fusion
Part I: Evaluation of clinical outcomes		 142 Spine 2005 3.421
8 Goffin J Intermediate follow-up after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis: Single-level and bi-level 133 Spine 2003 3.421
9 Coric D Prospective, randomized, multicenter study of cervical arthroplasty: 269 patients from the KineflexIC artificial disc investigational device exemption study with a minimum 2-y follow-up Clinical article 131 Journal of Neurosurgery-Spine 2011 3.467
10 Robertson JT Assessment of adjacent-segment disease in patients treated with cervical fusion or arthroplasty: a prospective 2-y study 124 Journal of Neurosurgery-Spine 2005 3.467
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Figure 6.

Figure 6.

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(A) Knowledge map of the references co-citation. (B) Timeline view of co-cited references on total disc replacement (TDR) research.

We also built a timeline viewer for these co-citation references by using CiteSpace. The timeline view can cluster the similar literatures and take time into account. The modularity Q value and the mean silhouette S value were the important indicator that can measure the clustering effect, and the higher the values were, the better the clustering result. From the timeline view (Fig. 6B), the modularity Q-value was 0.7383, and the mean silhouette S-value was also as high as 0.9078, indicating that the result was satisfactory. In addition, it visually showed that the largest cluster was “cervical arthroplasty” (#3), while the “disc replacement” (#5) was the earliest research in this field. Meanwhile, “bone loss” (#1), “cervical radiculopathy” (#3), and “hybrid surgery,” were the most frequently cited areas of TDR research, indicating that more and more researchers were focusing on the application of them in this TDR field.

3.6. Analysis of keywords and research hotspots

Keyword analysis can effectively identify research hotspots and frontiers of TDR field and provide assistance to researchers. Keywords co-occurrence map was extracted by using CiteSpace software. Our study map included 397 nodes and 2200 links (Fig. 7A). In the keywords co-occurrence map, “arthroplasty,” “replacement,” “fusion,” and “TDR” were the major nodes in this field, and their size represented the co-occurring frequencies of keywords. Clustering analysis of the keywords was performed by using log-likelihood ratio. A total of 21 clusters were obtained, with a Q value of 0.561 and a mean S value of 0.8124 (Fig. 7B). Further analysis of clusters can provide additional insights into the research progress in this field. The top 10 clusters identified are as follows: “cerbical disc arthroplasty,” “lumbar spine,” “artificial disc,” “cervical disc prosthesis,” “cervical spine,” “range of motion,” “disc replacement,” “rotation,” “retrieval analysis,” and “extended hospitalization.”

Figure 7.

Figure 7.

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(A) Citespace visualization map of keywords co-occurrence. (B) Clustered network of keywords. (C) Timeline view of keywords on total disc replacement (TDR) research. The time evolution is indicated with different colored lines, and the nodes on the lines indicate the references cited.

Timeline view of the keywords network was made with CiteSpace (Fig. 7C). The timeline view places time at the top, and nodes in the same cluster are arranged horizontally in chronological order. From the timeline view (Fig. 7C), “disc design,” “juxtafusion degeneration” and “artificial disc replacement” were first introduced in 1993 and have been extensively researched. Among them, the largest cluster was “cervical disc arthroplasty” (#0), while “cervical discprosthesis” (#3) was the earliest research in this field. At the same time, “cervical disc arthroplasty” (#0) and “cervical discprosthesis” (#3) were also recent research hotspots. The keywords burst refer to the words that were applied frequently in the short term, which can reflect the emerging trends, new topics, and potential hotspots in this field.[21] The strength value was an index to measure the strength of citation burst. And the higher the value, the stronger the burst. Figure 8 showed the top 20 keywords with the strongest citation bursts, with the blue line representing the base timeline and the red line representing the burst duration of a topic. The explosion of keywords in this field began in 1999, and “prosthesis” (14.66) had the strongest bursts, followed by “minimum follow up” (14.34) and “cervical disc arthroplasty” (12.16). Notably, “metaanalysis,” “cervical disc arthroplasty,” “7 year follow up,” “diskectomy,” “heterotopic ossification” and “cervical disc replacement” represented some of the current hostspots.

Figure 8.

Figure 8.

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Top 20 keywords with the strongest citation bursts in the research on total disc replacement (TDR) between 1993 and 2022.

4. Discussion

In the era of big data, researchers need to fully understand the development situation of their research fields. Different from systematic review and meta-analysis, bibliometric analysis is a mature method for quantifying quality and academic impact, and has been widely used to evaluate the development characteristics of a specific topic.[22] By comprehensively analyzing the existing literature, it intuitively shows the development trend of research and predicts the future research hotspots by using visual software such as VOSviewer and CiteSpace.[23,24] This study provided a bibliometric analysis of TDR from 1993 to 2022. The analysis revealed a consistent increase in the number of published papers and citations in this field, with a notable surge between 2017 and 2019 (Fig. 2A). While fusion remains the preferred surgical treatment for spinal degeneration diseases, researchers both domestically and internationally have shown a growing interest in the adverse effects of fusion, such as loss of motor function and the occurrence of long-term adjacent segment degeneration.[25] At the same time, TDR, which can combat these complications, is gradually receiving attention.

In 1956, Van Steenburgghe MH[26] first puts forward the conception of disc arthroplasty. After that, Reitz[27] reported the research results on the implantation of a spherical prosthesis after removal of a diseased cervical disc in 1964, and 2 years later Fernstrom[28] carried out the clinical practice on the replacement of cervical and lumbar discs with stainless steel balls. However, they failed due to the postoperative prosthesis subsidence. Despite this, the research on TDR has not stopped. With the advancement of technology and disc prosthesis design, lumbar disc replacement achieved good clinical results and gradually became popular in the 1980s. And it was approved by the United State food and drug administration in 2004. In addition, clinical trials of artificial cervical discs based on the development of lumbar prostheses were successful in 1998.[29] The results indicate that cervical artificial disc can effectively reduce the occurrence of adjacent segment disease. Recently, a 10-year follow-up clinical study[30] showed that artificial cervical discs maintained good motor performance and significantly improved neck disability index scores compared with anterior cervical discectomy and fusion (ACDF).

According to the analysis of the visualized results (Fig. 3A), the United States, China, and Germany are the top 3 producers in the TDR research field. It is worth noting that the United States has more research institutions than any other country, accounting for 7 out of the top 10 productive institutions, indicating its strong scientific research capabilities (Table 1). Among them, the Texas Back Institute had the highest total number of citations and the average citations, 2444 and 49.88 times, respectively. In addition, although Sichuan University from China ranked first in the number of publications, its citation level was relatively low. The results suggest that Chinese institutions need to improve their research quality and reference value to increase their international influence. Meanwhile, the United States has close cooperation with many countries and is a major contributor to the national cooperation network (Fig. 3C). Thus, the United States made a great contribution to TDR research, occupies the dominant position, and has played a key role in the global cooperation. And China is a potential force to be reckoned with in TDR research.

In terms of periodicals, the journal analysis can provide important information about high-impact journals. Impact factor (IF), journal citation report categories and total citations are important indicators to measure journal quality.[31] The top 3 publishing journals (Table 2) were the Spine (IF = 3.241, Q2), European Spine Journal (IF = 2.721, Q2), and Journal of Neurosurgery-Spine (IF = 3.467, Q2). A dual-map overlay shows TDR research are mainly published in the disciplines of neurology, sports, ophthalmology (Fig. 4B). Of note was that the top 10 common journals were from the US. Among them, Spine topped the list with 205 published articles and 8192 total citations, highlighting its leadership and significant contribution to the field. Liu H. was the most productive author in this field, with 70 publications and an average of 6.09 citations (Table 3). However, his total and average citations were much lower than McAfee PC, which had 1988 and 86.43 citations, respectively. Another notable one was the Kim KD, whose BC was up to 0.12, which was an important node in the authors’ cooperative network map. The BC was a widely used measure that can reflect the importance of nodes within the networks. In addition, the majority of authors were scattered with a density of only 0.0066, indicating a lack of collaboration between authors (Fig. 5B). In co-cited author network analysis, McAfee PC, Hilibrand AS, and Zigler JE were the top 3 with the highest citations. The BC of Zigler JE, McAfee PC and Delamarter RB were as high as 0.14, 0.13 and 0.12, respectively, indicating that the achievements of these authors had important influence in this field. As a result, it is suggested that researchers should strengthen cooperation with high-yielding, high co-cited, and high centrality authors.

Of the ten most commonly co-cited references, Hilibrand AS[32], Mummaneni PV, and Murrey D had the highest total citation frequency, each with more than 200 times. Through the timeline view of the co-citation references (Fig. 6B), it could be found that the earliest research focus on “disc replacement” (#5), and the current research directions were “bone loss” (#0), “cervical radiculopathy” (#3), and “hybrid surgery” (#8), indicating that the research of early TDR mainly laid emphasis on the design of intervertebral disc, and then turned to surgical indications and procedures and influencing factors.

Keyword analysis not only reflects the research hotspots and core contents, but also indicates the research trends.[33] In Figure 7A, the most frequent keywords were “arthroplasty,” “replacement,” “fusion,” and “TDR.” Based on the clustering analysis of keywords, ten different clusters are formed (Fig. 7B). Then, according to the timeline view analysis of clustering, the research hotspots and development frontiers in the field of TDR are determined. As shown in Figure 7C, “cervical disc arthroplasty” (#0) is not only the most studied cluster, but also the current research hotspot of TDR field. Keyword bursts are those terms that are frequently cited over a period of time and can reflect emerging trends and hotspots.[21] Since 1993, the top 20 keywords with the strongest citation bursts have been detected (Fig. 8). “Prosthesis,” “minimum follow up,” and “cervical disc arthroplasty” are the top 3 keywords with the strongest citation in chronological order, suggesting that artificial discs continue to be a major focus for researchers, especially for cervical spine applications. Currently, “cervical disc arthroplasty,” “metaanalysis,” “7 year follow up,” “cervical disc replacement,” “diskectomy,” “heterotopic ossification” are the lastest research foci and potential hotspots. In this study, the keyword “cervical disc arthroplasty” is not only a clustering label (#0) for keywords, but it is also among the top 20 keywords with the strongest citation bursts and still on bursts. This indicates that “cervical disc replacement” is a focus of researchers’ attention and a current hot topic in TDR research. In addition, more and more researchers are concerned about the long-term prognosis and complications such as heterotopic ossification[34,35] after TDR.

In bibliometrics, the number of citations of a research article can be regarded as an important indicator of the research field. In addition, it can be used to assess the author academic influence.[36] As shown in Table 4, the most cited article article in this study was Mummaneni PV et al,[37] which mainly reported a multicentre comparative study of cervical disc replacement and ACDF. The results showed that at 2 years of follow-up, the PRESTIGE ST cervical disc system maintained physiological segmental motion and was associated with improved clinical outcomes, improved neurological success, and a reduced rate of secondary surgeries compared with ACDF. The second most-influential article was published by Murrey D et al,[38] which received 370 total citations and an average of 26.43 citations per year. Murrey D et al revealed that compared with anterior discectomy or fusion, the ProDisc-C TDR was a safe and effective method for patients with cervical radiculopathy, which could improve postoperative neck disability index and cervical pain scores. Third in the number of publications was Blumenthal S et al,[39] whose research showed that CHARITE artificial disc was an effective alternative to disc fusion for symptomatic disc degeneration and could reduce hospital stays, reduce the reoperation rate. Therefore, TDR-related research in the lumbar and cervical spine has attracted much attention and achieved good clinical results, with excellent future trends.

Inevitably, there are some limitations to our study. First, we analyzed nearly 30 years of TDR studies, which may have resulted in missing publications prior to 1993. Second, the analysis of this study was based on English articles in the WoSCC database, and articles published in non-SCI journals or other databases and in other languages were ignored. Third, with the constant updating of literature, variations in retrieval results and analysis may exist. Nevertheless, our comprehensive analysis undoubtedly laid a foundation for scholars to quickly understand the research topics, research hotspots and development trends in the field of TDR.

5. Conclusion

A thorough examination of TDR research was carried out in this study. The research results show that the study of TDR rises year by year, and the future will also continue to develop. Globally, the US is the most important contributor in this field. Sichuan University is the institution with the highest productivity, while Texas Back Institute is the institution with the best influence. Spine is not only the journal with the most published research results, but also the journal with the highest total citation frequency. Of all the authors, Liu H is the most productive author. But McAfee PC is the most outstanding author in terms of average citation and co-citation. The study of Hilibrand AS et al is the most cited reference in the field of TDR. “Bone loss” (#0), “cervial radiculopathy” (#3), and “hybrid surgery” (#8) are the most frequently cited areas of current TDR research. Cervical disc replacement, long-term prognosis, heterotopic ossification, and other complications are the current hot spot and research direction in the field of TDR. In conclusion, TDR research was a kind of clinical research with great potential and application prospect, which was still in a highly developed stage.

Author contributions

Conceptualization: Jiongnan Xu, Tingxiao Zhao, Jun Zhang.

Data curation: Meng Ge, Tingxiao Zhao.

Investigation: Yanlei Li, Jinlong Tian.

Supervision: Tingxiao Zhao, Haiyu Shao, Weibin Wang.

Validation: Jinlong Tian.

Visualization: Yanlei Li, Haiyu Shao.

Writing – original draft: Yanlei Li.

Writing – review & editing: Jun Zhang, Weibin Wang.

Abbreviation:

ACDF
anterior cervical discectomy and fusion
BC
between centrality
DDD
degenerative disc disease
TDR
total disc replacement
TLS
total link strength
WoSCC
web of science core collection

YL, JT, and JX contributed equally to this work.

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are publicly available.

This study was supported by grants from Department of Health of Zhejiang Province (2020KY408 to Dr. Jun Zhang, 2022KY548 to Dr. Haiyu Shao, and 2022KY608 to Dr.Tingxiao Zhao), and the Ningbo Natural Science Foundation (2016A610145 to Dr. Weibin Wang).

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

How to cite this article: Li Y, Tian J, Xu J, Ge M, Shao H, Zhang J, Zhao T, Wang W. Global trends and frontiers of research on total disc replacement: A bibliometric analysis. Medicine 2023;102:36(e34984).

Contributor Information

Yanlei Li, Email: 792996240@qq.com.

Jinlong Tian, Email: jl18870315721@163.com.

Jiongnan Xu, Email: 98087683@qq.com.

Meng Ge, Email: spinegemeng@163.com.

Haiyu Shao, Email: shaohaiyu@163.com.

Jun Zhang, Email: spinecarezhangjun@163.com.

Tingxiao Zhao, Email: spinezhaotingxiao@163.com.

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