A systematic review and meta-analysis of Anterior Cervical Decompression and Fusion: Comparing the ROI-CTM Self-Locking System with Traditional Cage-Plate Internal Fixation in the Treatment of Degenerative Cervical Spondylosis

A systematic review and meta-analysis of Anterior Cervical Decompression and Fusion: Comparing the ROI-CTM Self-Locking System with Traditional Cage-Plate Internal Fixation in the Treatment of Degenerative Cervical Spondylosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review A systematic review and meta-analysis of Anterior Cervical Decompression and Fusion: Comparing the ROI-CTM Self-Locking System with Traditional Cage-Plate Internal Fixation in the Treatment of Degenerative Cervical Spondylosis Xin Wang, Jun Liu, Yanjie Zhou, Hailong Shi, Bo Li, Xiangshan Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6110433/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: Anterior Cervical Decompression and Fusion (ACDF) is a well-established surgical intervention for degenerative cervical spondylosis. While the use of plates is known to improve fusion rates and stability, it may also be associated with an increased risk of adjacent vertebral degeneration and postoperative dysphagia. This meta-analysis aims to compare the clinical outcomes and complications between the ROI-C TM self-locking system and traditional cage-plate internal fixation in the context of ACDF for degenerative cervical spondylosis to guide the selection of appropriate internal fixation methods. Methods: A comprehensive literature search was conducted in PubMed, Cochrane Library, Web of Science, and Embase to identify relevant English-language studies on the use of the ROI-C TM self-locking system and cage-plate internal fixation in ACDF for degenerative cervical spondylosis and the search period spanned from the inception of each database to September 2024. Two researchers independently screened and selected studies based on predefined inclusion and exclusion criteria. The quality of the included randomized controlled trials was strictly assessed according to the Cochrane Collaboration's guidelines, and the Newcastle-Ottawa Scale (NOS) was applied to evaluate the quality of cohort studies. The meta-analysis was performed using RevMan 5.4 software, with outcome indicators including operation time, intraoperative blood loss, Japanese Orthopedic Association (JOA) score, Neck Disability Index (NDI), C2-C7 Cobb angle, fusion rate, incidence of adjacent segment degeneration, cage subsidence rate, and incidence of dysphagia. Results: The analysis included ten articles, consisting of nine retrospective cohort studies and one randomized controlled trial, encompassing 947 patients (468 in the ROI-C group and 479 in the fusion cage-plate group). The meta-analysis revealed that the ROI-C group had significantly shorter operation times [MD = -14.03, 95% CI (-17.12, -10.95), P < 0.00001] and less intraoperative blood loss [MD = -16.34, 95% CI (-19.84, -12.84), P < 0.00001] compared to the cage-plate group. Furthermore, the ROI-C group exhibited a significantly lower rate of postoperative adjacent segment degeneration [RR = 0.40, 95% CI (0.27, 0.60), P < 0.00001] and total dysphagia rate [RR = 0.20, 95% CI (0.14, 0.29), P < 0.00001]. However, no significant differences were observed between the two groups in terms of JOA score, NDI index, C2-C7 Cobb angle, fusion rate, and cage subsidence rate (P≥0.05). Conclusion: In the context of ACDF procedures, both the ROI-C TM self-locking system and traditional cage-plate internal fixation provide satisfactory clinical results. The ROI-C TM self-locking system streamlines the ACDF process, significantly reducing operation times and intraoperative blood loss. It also presents a clear advantage in lowering the risk of postoperative dysphagia and adjacent segment degeneration. However, due to the potential for higher cage subsidence rates, its use should be approached with caution in patients with risk factors for cage subsidence, such as osteoporosis and vertebral endplate damage. anterior cervical approach ACDF cervical spondylosis ROI-C self-locking system meta-analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Background Degenerative cervical spondylosis is the most prevalent non-traumatic, progressive spinal disorder, primarily characterized by a suite of clinical symptoms and signs attributable to nerve compression as a result of cervical structural degeneration. The condition commonly presents with neck and radicular arm pain, fine motor dysfunction, gait instability, and urinary bladder dysfunction. Amidst societal progression and lifestyle shifts, the incidence of this disease is on the rise, with a significant proportion of patients who fail conservative treatment requiring surgical intervention [1] . Anterior cervical decompression and fusion (ACDF) is a frequently employed surgical technique. To augment immediate postoperative stability of the fusion segment, enhance fusion rates, and mitigate the risk of bone graft displacement, traditional ACDF often incorporates the use of an anterior fusion cage in conjunction with plate internal fixation. This approach has been documented to facilitate the reconstruction of cervical lordosis and to preserve the height of the intervertebral space [2] . However, as follow-up periods extend, complications associated with anterior plates, such as plate loosening and migration, oesophagal compression leading to dysphagia, and adjacent segment degeneration, have become increasingly apparent, posing challenges to clinical management [3] . With the aim of minimizing the incidence of complications associated with plate - screw constructs, the ROI - C TM self - locking system, which is meticulously designed in accordance with the "zero - profile" concept, received approval from the National Medical Products Administration for clinical application in 2011. The ROI-C TM system eschews the traditional anterior plate in favour of a dual-embedded fusion device that integrates support, fixation, and fusion capabilities. During surgery, once the fusion device is positioned, the embedded piece is inserted vertically to achieve immediate stability, eliminating the need for anterior plate fixation. Biomechanical studies have indicated that the ROI-C TM self-locking cage provides stability comparable to traditional cage-plate internal fixation [4] . Moreover, numerous studies have demonstrated that the use of the ROI-C TM self-locking system can significantly diminish the risk of postoperative dysphagia and adjacent segment degeneration [5] . However, some studies have suggested that the ROI-C TM self-locking system may have a higher rate of cage subsidence compared to traditional cage-plate internal fixation [6, 7] . There remains considerable debate surrounding the relative merits and drawbacks of these two internal fixation techniques in the treatment of degenerative cervical spondylosis. To date, there is no meta-analysis on the efficacy of the ROI-C TM self-locking system and traditional cage-plate internal fixation in treating degenerative cervical spondylosis. This study aims to address this gap by conducting a meta-analysis of the clinical outcomes and complications associated with both treatment modalities. The objective is to provide evidence-based guidance for the selection of internal fixation methods in ACDF procedures. Information and methods 1.1 Source of data Prospective Register of Systematic Reviews (CRD42024547137), and the screening process adheres strictly to the PRISMA guidelines for conducting systematic reviews. Use endnote document management software, Investigators Wang Xin and Zhou Yanjie systematically searched PubMed, Cochrane Library, Web of Science, and Embase for English-language literature on the application of the ROI-C TM self-locking system and cage-plate internal fixation in ACDF for treating degenerative cervical spondylosis. The search terms included "anterior cervical discectomy and fusion," "ACDF," "self-locking," "stand-alone," "zero-profile," and "ROI-C," and the retrieval period extended from the inception of each database to September 2024. The literature search strategy, as depicted in Figure 1. Studies originating from the same institutions were carefully evaluated to prevent any duplication in data collection. 1.2 Literature Inclusion and Exclusion Criteria Inclusion criteria: (1) patients diagnosed with degenerative cervical spondylosis based on clinical and imaging evidence; (2) study types limited to randomized controlled trials (RCTs) or cohort studies (CS) in English; (3) the intervention group underwent anterior cervical decompression with ROI-C TM self-locking system internal fixation, while the control group received anterior cervical decompression fusion with cage-plate internal fixation; (4) studies containing one or more outcome indicators; (5) a minimum postoperative follow-up period of 1 year. Exclusion criteria: (1) animal experiments, cadaver experiments, or biomechanical studies; (2) literature on patients with a history of cervical spine surgery, preoperative diagnosis of spinal tumours, scoliosis, infection, fracture, severe osteoporosis, or severe ossification of the posterior longitudinal ligament; (3) studies on combined surgical treatments; (4) potential for duplicate data from the same research centre; (5) systematic reviews, meta-analyses, literature reviews, and case reports; (6) articles that could not be downloaded or for which data was difficult to obtain. 1.3 Literature Extraction and Quality Evaluation Two researchers independently screened the literature, extracted data, and assessed the quality of the studies. Information extracted included study type, year, first author, gender, age, number of patients, interventions, outcome indicators, and follow-up time. The Cochrane bias risk tool was utilized to evaluate the quality of RCTs, while the Newcastle-Ottawa Scale (NOS) was applied to assess the quality of cohort studies. Studies were scored out of 10, with 8-9 points indicating high-quality literature, 6-7 points for medium-quality literature, and 5 points or below for low-quality literature. 1.4 Outcome Measures Outcome measures included operation time, intraoperative blood loss, Japanese Orthopedic Association (JOA) score, Neck Disability Index (NDI), C2-C7 Cobb angle, fusion rate, incidence of adjacent segment degeneration, cage subsidence rate, and incidence of dysphagia. 1.5 Statistical Analysis Data from the included studies were pooled for meta-analysis using RevMan 5.4.1 software. Mean difference (MD) was selected as the effect size index for continuous variables, including operation time, intraoperative blood loss, JOA score, NDI index, and C2-C7 Cobb angle. Risk ratio (RR) was used for binary data, such as fusion rate, incidence of adjacent segment degeneration, cage subsidence rate, and incidence of postoperative dysphagia, with a 95% confidence interval (CI). Heterogeneity was assessed using the I 2 statistic. The fixed-effect model was employed for homogeneous data (P > 0.1, I 2 ≤ 50%), and the random-effects model was used for heterogeneous data (P 50%). Subgroup analyses were conducted for outcomes highly related to the surgical segment, such as operation time and intraoperative blood loss. Sensitivity analyses were performed on outcomes with high heterogeneity to explore potential sources. Results 2.1 Retrieval Results The literature search yielded a total of 1297 articles. After excluding duplicates, reviews, and meta-analyses, 721 articles remained. Titles and abstracts were screened, leading to the exclusion of 69 articles. A full-text review eliminated non-compliant literature, resulting in 10 articles that met the inclusion and exclusion criteria, comprising 9 retrospective cohort studies [8-16] and 1 randomized controlled trial [17] . A total of 947 patients were included, with 468 in the ROI-C group and 479 in the fusion cage-plate group, as depicted in Figure 2. 2.2 Clinical Characteristics of Included Studies The baseline characteristics of the included studies are summarized in Table 1. Table 1 Basic characteristics of the studies Study type Total cases (male/female) Age（Years） (x ± s) Follow-up period（month） (x ± s) Fusion segments Outcome index ROI-C CCP ROI-C CCP ROI-C CCP He2021 [9] RCS 19/23 20/25 62.59±8.21 61.15±7.52 26.6±3.3 27.1±3.5 1 ①②③④⑤⑥⑧⑨ He2022 [10] RCS 11/22 12/22 61.59±8.21 60.15 ± 7.52 26.6±3.4 27.1±3.8 2 ①②③④⑤⑥⑨ Hofstetter2015 [11] RCS 16/19 18/17 56.8±1.6 51.5±2.0 13.0±1.6 14.8±2.1 1-3 ①②⑥⑦⑨ li2022 [12] RCS 43/58 55/51 57.1±8.4 58.6±9.2 60.2 60.9 1-2 ①②③④⑤⑥⑦⑧⑨ Liu2016 [13] RCS 10/18 12/20 56.6±9.7 57.5±9.5 23.3±6.9 24.2±6.4 3-4 ①②③⑤⑥⑦⑨ Wang2014 [14] RCS 12/18 14/19 56.8±11.0 54.0±10.0 24.1±7.8 23.8±8.2 1-2 ①②③④⑤⑥⑦⑧⑨ Gao2023 [8] RCS 26/31 23/25 58.40±6.72 58.63±7.39 12+ 12+ 1-4 ①②③④⑤⑥⑦⑨ Xiong2023 [15] RCS 16/15 15/24 52.26±8.45 51.08±10.95 24.52±5.32 25.18±12.78 2 ①②③⑤⑥⑦⑧⑨ zho‘ [16] RCS 23/28 22/25 62.3±6.7 64.4±3.2 39.7±3.2 42.2±4.1 1-3 ①②③④⑥⑦⑧⑨ Zhou2020 [17] RCT 26/34 29/31 62.3±6.4 64.5±6.4 36 36 1-3 ⑥⑦⑧ Note: Retrospective cohort study (RCS); randomized controlled trial (RCT); ROI-C TM self-locking group ( ROI-C ); cage-plate group ( CCP ); outcome indicators: 1 operation time, 2 intraoperative blood loss, 3 JOA score, 4 NDI index, 5 C2-C7 cobb angle, 6 fusion rate, 7 adjacent vertebral lesion rate, 8 cage subsidence rate, 9 incidences of dysphagia. 2.3 Literature Quality Evaluation Results The quality of the randomized controlled trials was assessed using the Cochrane bias risk tool [17] , and no trials were identified with a high risk of bias, as depicted in Figure 3. The Newcastle-Ottawa Scale was employed to evaluate the included retrospective cohort studies. Nine studies [8-16] were evaluated, with seven [9, 10, 12-16] scoring 8 points each and two [8, 11] scoring 7 points. The detailed scoring results are presented in Table 2. Table 2 Newcastle-Ottawa Scale score results Selection Comparability Outcome 得分 Score A B C D E F G H He2021 [9] 1 1 1 0 2 1 1 1 8 He2022 [10] 1 1 1 0 2 1 1 1 8 Hofstetter2015 [11] 1 1 1 0 1 1 1 1 7 li2023 [12] 1 1 1 0 2 1 1 1 8 Liu2016 [13] 1 1 1 0 2 1 1 1 8 Wang2015 [14] 1 1 1 0 2 1 1 1 8 Gao2023 [8] 1 1 1 0 1 1 1 1 7 Xiong2023 [15] 1 1 1 0 2 1 1 1 8 zho‘ [16] 1 1 1 0 2 1 1 1 8 Note: A, the representativeness of the exposed group; B, the representation of the non-exposed group; C,the determination of exposure factors ; D,affirming that there is no outcome index to be observed at the beginning of the study; E,the comparability between the exposed group and the non-exposed group was considered in the design and statistical analysis; F,evaluation of outcome indicators; G,the follow-up time is long enough; H,integrity of exposed and non-exposed groups; 2.2 Meta-analysis results 2.2.1 Operation Time A total of nine studies [8-16] reported on operation time, with five [8, 12-14, 16] providing a segmented analysis. Within these, four studies [8, 12-14] compared two surgical time groups, and one study [16] examined three distinct groups. The subgroup data were pooled using the mean and standard deviation for each group, as calculated on the online statistical tool http://statstodo.com/CombineMeansSDs.php. These combined values were subsequently utilized for meta-analysis. Data from Hofstetter [11] , originally presented as Mean ± SEM, were converted to Mean ± SD within the RevMan software for consistency. A fixed-effect model was applied for analysis (P = 0.54, I 2 = 0%). The meta-analysis revealed a statistically significant reduction in operation time in the group utilizing the ROI-C TM self-locking system compared to the cage-plate fixation group [MD = -14.03, 95% CI (-17.12, -10.95), P < 0.00001], as illustrated in Figure 4. 2.2.2 Intraoperative Blood Loss Nine studies [8-16] reported on intraoperative blood loss, with segmental subgroup analyses provided in five [8, 12-14, 16] . Among these, four studies [8, 12-14] compared two groups regarding blood loss, while one study [16] evaluated three groups. The mean and standard deviation for each subgroup were pooled using the online calculator at http://statstodo.com/CombineMeansSDs.php. Data from Hofstetter [11] , initially presented as Mean ± SEM, were converted to Mean ± SD format within the RevMan software to ensure consistency for meta-analysis. Despite moderate heterogeneity among the studies (P = 0.07, I 2 = 45%), a fixed-effect model was employed for the analysis. The meta-analysis indicated a statistically significant reduction in intraoperative blood loss in the ROI-C TM self-locking system group compared to the cage-plate group [MD = -16.34, 95% CI (-19.84, -12.84), P < 0.00001], as depicted in Figure 5. 2.2.3 Preoperative and Postoperative JOA Scores Eight studies [8-10, 12-16] compared the preoperative Japanese Orthopaedic Association (JOA) scores between the two groups, demonstrating no significant heterogeneity (P = 0.87, I 2 = 0%). A fixed-effect model was applied, and the pooled results indicated no statistically significant difference in preoperative JOA scores [MD = -0.03, 95% CI (-0.27, 0.20), P = 0.80]. Meanwhile, four studies [9, 10, 12, 14] evaluated JOA scores at one month postoperatively, while eight studies [8-10, 12-16] assessed scores at the final follow-up. There was significant heterogeneity between the studies (P = 0.01, I 2 = 55%), and a random-effects model was used. The results showed that there was no significant difference in JOA scores at one month postoperatively [MD = -0.21, 95% CI (-0.69, 0.27), P = 0.39] or at the final follow-up [MD = 0.18, 95% CI (-0.14, 0.49), P = 0.27], as depicted in Figure 6. 2.2.4 Preoperative and Postoperative NDI Scores Seven studies [8-10, 12-14, 16] compared the preoperative Neck Disability Index (NDI) scores between the two groups, demonstrating no significant heterogeneity (P = 0.40, I 2 = 3%). A fixed-effect model was applied, and the pooled results indicated no statistically significant difference in preoperative NDI scores [MD = -0.04, 95% CI (-0.47, 0.40), P = 0.87]. Concurrently, four studies [9, 10, 13, 14] evaluated NDI scores at one month postoperatively, while seven studies [8-10, 12-14, 16] assessed scores at the final follow-up. The fixed-effect model, used despite moderate heterogeneity (P = 0.06, I 2 = 44%), revealed no significant difference in NDI scores at one month postoperatively [MD = 0.39, 95% CI (-0.68, 1.45), P = 0.47] or at the final follow-up [MD = 0.15, 95% CI (-0.15, 0.45), P = 0.32], as depicted in Figure 7. 2.2.5 Preoperative and Postoperative C2-C7 Cobb Angles Seven studies [8-10, 12-14, 16] compared the preoperative C2-C7 Cobb angle between the two groups, demonstrating no significant heterogeneity (P = 1.00, I 2 = 0%). A fixed-effect model was applied, and the pooled results indicated no statistically significant difference in preoperative C2-C7 Cobb angle [MD = 0.53, 95% CI (-0.16, 1.21), P = 0.13]. In tandem, five studies [9, 10, 12-14] evaluated C2-C7 Cobb angle at one month postoperatively, while seven studies [8-10, 12-14, 16] assessed angles at the final follow-up. A fixed-effect model was used (P = 0.99, I 2 = 0%). The results showed that there was no significant difference in C2-C7 Cobb angle at one month postoperatively [MD = -0.00, 95% CI (-0.76, 0.76), P = 1.00] or at the final follow-up [MD = -0.28, 95% CI (-0.82, 0.26), P = 0.32], as depicted in Figure 8. 2.2.6 Fusion rate A total of ten studies [8-17] assessed the fusion rate at the final follow-up, demonstrating no significant heterogeneity (P = 0.99, I 2 = 0%). A fixed-effect model was applied, and the pooled analysis revealed no significant difference in the fusion rates between the ROI-C TM self-locking system group and the cage-plate group at the last follow-up [RR = 1.01, 95% CI (0.99, 1.03), P = 0.44], as illustrated in Figure 9. 2.2.7 Adjacent Segment Degeneration Eight studies [8, 11-17] evaluated the incidence of adjacent segment degeneration, demonstrating no significant heterogeneity (P = 0.49, I 2 = 0%). A fixed-effect model was applied, and The meta-analysis revealed a statistically significant difference in the rate of adjacent segment degeneration between the two groups, with the ROI-CTM self-locking system demonstrating a substantial reduction in the incidence of postoperative adjacent segment degeneration [RR = 0.40, 95% CI (0.27, 0.60), P < 0.00001], as depicted in Figure 10. 2.2.8 Postoperative Cage Subsidence Five studies [9, 12, 15-17] compared the postoperative cage subsidence between the two groups, and the heterogeneity was high (P = 0.05, I 2 = 59%), which was analyzed by a random-effects model. The results showed that there was no significant difference in the subsidence rate of the fusion cage between the two groups [RR = 1.46, 95% CI (0.68, 3.11), P = 0.33], as illustrated in Figure 11. 2.2.9 Postoperative Dysphagia Incidence In a series of analyses, four studies [8, 12, 14, 15] compared the incidence of dysphagia two weeks postoperatively, three studies [9, 10, 12] at one month, five studies [8, 9, 11-13] at three months, and eight studies [8-10, 12-16] at the final follow-up between two groups. Employing a fixed-effect model due to the lack of heterogeneity (P = 0.97, I 2 = 0%), the results consistently demonstrated a significantly lower incidence of dysphagia in the ROI-C TM self-locking group compared to the cage-plate group at all time points: two weeks [RR = 0.20, 95% CI (0.11, 0.35), P < 0.00001], one month [RR = 0.32, 95% CI (0.16, 0.64), P = 0.001], three months [RR = 0.14, 95% CI (0.05, 0.38), P < 0.0001], and at the final follow-up [RR = 0.14, 95% CI (0.05, 0.38), P = 0.0001]. The overall incidence of dysphagia was also significantly lower in the ROI-C TM self-locking group [RR = 0.20, 95% CI (0.14, 0.29), P < 0.00001], as depicted in Figure 12. 2.3 Subgroup analysis 2.3.1 Operation Time According to the surgical segment, the operation time was categorized into three subgroups: single-segment, double-segment, and multi-segment. A total of four studies [9, 12, 14, 16] documented the operation time for single-segment procedures, the same number of studies [9, 12, 14, 16] reported on double-segment operations, and two studies [8, 13] provided data on multi-segment operations. Liu specifically recorded the operation times for both three-segment and four-segment procedures, which were grouped under multi-segment operations. Due to high heterogeneity (P < 0.00001, I 2 = 93%), a random-effects model was employed for analysis. The results indicated that the ROI-C TM self-locking group had a significantly shorter operation time compared to the fusion cage-plate group in single-segment [MD = -13.11, 95% CI (-17.62, -8.60), P < 0.00001], double-segment [MD = -14.00, 95% CI (-14.96, -13.03), P < 0.00001], and multi-segment [MD = -24.68, 95% CI (-28.13, -21.22), P < 0.00001] operations, as illustrated in Figure 13. 2.3.2 Intraoperative Blood Loss For the subgroup analysis based on surgical segment, the single segment, double segment, and multi-segment intraoperative blood loss were examined. A total of four studies [9, 12, 14, 16] reported on blood loss for single-segment surgeries, four studies [9, 12, 14, 16] reported on double-segment surgeries, and two studies [8, 13] reported on multi-segment surgeries. The data of Liu et al.were also included in the multi-segment group. A fixed-effect model was applied for analysis due to the moderate heterogeneity (P = 0.3, I 2 = 15%). The results indicated that the ROI-C TM self-locking group experienced less intraoperative blood loss compared to the cage-plate group in single-segment [MD = -15.89, 95% CI (-18.81, -12.98), P < 0.00001], double-segment [MD = -17.70, 95% CI (-23.03, -12.37), P < 0.00001], and multi-segment [MD = -17.53, 95% CI (-23.27, -11.79), P < 0.00001] surgeries, as depicted in Figure 14. 2.4 Sensitivity analysis In the meta-analysis, the randomized controlled study by Zhou [17] was initially excluded and then re-integrated for analysis. This exclusion and re-inclusion did not significantly alter the outcomes regarding operation time, intraoperative blood loss, fusion rate, or the heterogeneity of postoperative degeneration in adjacent vertebrae. The consistency of results before and after this exclusion suggests that the meta-analysis findings are robust. Sensitivity analysis of the postoperative JOA score indicated that the study by Li [12] might be a source of heterogeneity. Upon its removal, heterogeneity was markedly reduced (I 2 = 0%). The fixed-effect model analysis confirmed no significant difference in postoperative JOA scores between the two groups (P > 0.05), further supporting the reliability of the meta-analysis results (Figure 15). Upon sequentially eliminating each subgroup's operation time data and re-analyzing, no significant change in heterogeneity was observed compared to the initial analysis, and no clear source of heterogeneity was identified. The larger heterogeneity across studies may stem from the strong correlation between operation time and factors such as the surgeon's experience, habits, and proficiency, as well as the number of surgical segments. In the analysis of postoperative cage subsidence, the exclusion of Xiong [15] significantly reduced heterogeneity (P = 0.62, I 2 = 0%), and the fixed-effect model showed no significant difference in cage subsidence rates between the groups at the final follow-up [RR = 1.01, 95% CI (0.99, 1.03), P = 0.44] (Figure 16). However, the exclusion of He [9] led to a reduction in heterogeneity (P = 0.21, I 2 = 33%). The fixed-effect model revealed a significant difference in postoperative fusion cage sedimentation rates between the groups [RR = 2.34, 95% CI (1.48, 3.69), P = 0.0003] (Figure 17). These changes in meta-analysis results imply a potential instability in the findings. Given that postoperative cage subsidence is influenced by various factors, including the surgeon's technique and bone mineral density, these factors may contribute to the instability of the results. Due to the limited literature on postoperative cage subsidence rates, further research is warranted. Discussion Zero-profile self-locking systems, categorized based on their locking mechanisms, are primarily divided into two types [18] . The first type secures fixation with angled self-locking screws, exemplified by the Zero-P system and its enhancements. The second type involves the insertion of a sharp double titanium inlay into the adjacent vertebral body, as seen in the ROI-C TM system. At present, the screw-type self-locking system is widely used in clinical practice. At present, many literatures have pointed out that screw-type self-locking systems can significantly reduce the incidence of postoperative dysphagia and adjacent segment degeneration compared with traditional cage-plate internal fixation and can achieve satisfactory clinical efficacy in single-segment and multi-segment ACDF [19-21] . However, challenges arise in certain anatomies, such as obese patients with short necks, where the use of angled screws is hindered by the mandible and sternum's stress shielding, complicating screw placement in specific cervical segments like C2-3, C3-4, and C6-7. The ROI-C TM system addresses these issues with its vertical curved inlay locking mechanism, broadening the applicability of internal fixation techniques [18] . Clinical studies on the use of the ROI-C TM self-locking system and traditional cage-plate internal fixation for the treatment of degenerative cervical spondylosis are gradually increasing. One study has pointed out that both methods can achieve satisfactory clinical outcomes. However, there is some debate regarding their fusion rates and postoperative stability [6] . To further explore the advantages and disadvantages of these two internal fixation methods, a meta-analysis of their clinical outcomes and complications in the treatment of degenerative cervical spondylosis was conducted. The aim is to provide evidence-based support for the choice of internal fixation methods in anterior cervical decompression and fusion surgery. The meta-analysis revealed that the ROI - CTM self - locking system, consisting of a radiolucent polyether - ether - ketone (PEEK) cage and two integrated self - locking wings, shows comparable clinical efficacy to traditional cage - plate internal fixation. Yet, the ROI-C TM system stands out with advantages such as reduced operation time, decreased intraoperative blood loss, and lower rates of postoperative adjacent segment degeneration and dysphagia. Neurological function improvement is typically assessed using JOA and NDI scores. Our study found no significant difference in these scores between the ROI-C TM system and the traditional cage-plate method, both one month postoperatively and at the final follow-up. Although some heterogeneity in JOA scores was noted, it was resolved through sensitivity analysis after excluding a study by Li [12] . This indicates that both methods are equally effective in decompressing and enhancing neurological function, and the larger sample size and the observation bias of the researchers may be the main reasons for the heterogeneity. The Cobb angle method, a widely utilized technique in clinical practice, was employed to assess cervical curvature. Drawing on the logistic regression analysis by Wu [22] , which suggests that adjacent segment degeneration (ASD) is more likely with postoperative Cobb angle losses exceeding 5.5°, our study found no significant difference in C2-C7 Cobb angles between the ROI-C TM system and the cage-plate method at one-month post-surgery and the last follow-up. This suggests similar effectiveness in maintaining cervical curvature over both the short and long term. Fusion rates also showed no significant difference between the two groups, indicating equivalent postoperative stability for the ROI-C TM system compared to the cage-plate fixation. Additionally, studies by Li [12] and Zhou [16] observed that the ROI-C TM system had a shorter fusion time than the traditional cage-plate approach. The ROI-C TM self-locking system offers a straightforward surgical approach with minimal exposure. Our study indicates that this system significantly reduces both operation time and intraoperative blood loss. A subgroup analysis revealed that across various surgical segments, the ROI-C TM system consistently outperformed the cage-plate combination in terms of reduced operation time and blood loss, with operation time increasing incrementally per segment. However, the difference in intraoperative blood loss among subgroups did not reach statistical significance, potentially due to the muscle gap approach used in anterior cervical ACDF procedures, which inherently involves less blood loss. The shorter operation times with the ROI-C TM system contribute to decreased perioperative and surgical risks, while reduced trauma is associated with a lower incidence of postoperative complications. Notably, the heterogeneity observed across studies was substantial, largely attributed to variations in surgeon experience, habits, proficiency, and the complexity of the surgical segments. Nonetheless, sensitivity analysis and the use of a transformation effect model confirmed the stability of our findings, lending credibility to our conclusions. Postoperative complications, particularly dysphagia and adjacent segment degeneration have been strongly linked to the use of anterior plates [23, 24] . Our study aligns with findings that the ROI-C TM self-locking system markedly reduces the occurrence of these issues. Notably, dysphagia in most patients improved within the first postoperative month, with significant resolution by the third month [25] . Upon analyzing dysphagia rates post-surgery at 1, 3 months, and at the final follow-up, a clear trend emerged: the incidence of dysphagia diminished over time, with the ROI-C TM group consistently showing lower rates compared to the cage-plate group. The ROI-C TM system's zero-profile design, which eliminates the need for anterior titanium plates and resides within the intervertebral space, minimizes prevertebral soft tissue, oesophagal, and adjacent vertebral body irritation, consequently decreasing the risk of postoperative degeneration and persistent dysphagia. Furthermore, this system's minimally invasive approach reduces paravertebral soft tissue damage, shorter operation times, and intraoperative blood loss, which collectively contribute to a lower risk of early postoperative dysphagia [26-28] . In our analysis, the ROI-C TM self-locking system appeared to have a higher incidence of postoperative cage subsidence when compared to the cage-plate internal fixation method. However, this difference did not reach statistical significance (P = 0.33). Given the significant heterogeneity observed (P = 0.05, I 2 = 59%), sensitivity analysis was used to delete the literature one by one, and the conclusion changed, suggesting that the stability of the results was questionable. Despite this, the collective literature included in this review leans towards the notion that the ROI-C TM self-locking system may be predisposed to higher subsidence rates than traditional cage-plate internal fixation. Li [12] posits that the potentially suboptimal fixation strength of the cervical anchoring inserts within the ROI-C TM interbody fusion cage could be culpable for an increased risk of cage subsidence. Echoing this concern, He [9] stresses the importance of preserving the cortical bone endplate as much as possible to lower the risk of subsidence. Furthermore, Xiong [15] observed a noteworthy pattern in two-segment ACDF cases, where the ROI-C TM cage exhibited more severe subsidence in the lower intervertebral space compared to the upper. This observation may be attributed to the fact that the lower intervertebral space is subject to greater mechanical stress than its upper counterpart. The relationship between cage subsidence and clinical efficacy remains a subject of debate. Ryu's long-term follow-up study [29] demonstrated that cage subsidence did not significantly impact clinical outcomes when adequate foraminal decompression was achieved. Interestingly, subsidence has been correlated with higher fusion rates in the short term, a finding that aligns with our observations. Despite a higher incidence of postoperative cage subsidence among patients who received the ROI-C TM self-locking system, our study found no significant difference in cervical curvature and fusion rates compared to the traditional cage-plate fixation. Importantly, none of the patients with cage subsidence exhibited neurological symptoms, and there were no instances of reoperation. However, acknowledging the limited duration of follow-up in our study, it is imperative to conduct extended follow-up studies to confirm these preliminary results. The limitations of this study: ①The study predominantly comprised retrospective research with a dearth of randomized controlled trials, contributing to a lower quality of evidence and potentially flawed statistical findings. ②Differences in researchers' experience and measurement methods resulted in high heterogeneity across some indicators, increasing the risk of systematic and random errors.③High heterogeneity was observed in the postoperative subsidence index of the fusion cage, but the reasons could not be further explored due to the limited number of studies. ④The lack of data on hospitalization time, operation costs, and long-term follow-up cases prevented a comprehensive comparison of the two internal fixation materials. In the context of ACDF procedures, both the ROI-C TM self-locking system and traditional cage-plate internal fixation provide satisfactory clinical results. The ROI-C TM self-locking system streamlines the ACDF process, significantly reducing operation times and intraoperative blood loss. It also presents a clear advantage in lowering the risk of postoperative dysphagia and adjacent segment degeneration. However, due to the potential for higher cage subsidence rates, its use should be approached with caution in patients with risk factors for cage subsidence, such as osteoporosis and vertebral endplate damage. Considering the limitations and potential biases of this study, more large-scale prospective and randomized controlled studies, as well as long-term follow-ups, are needed to provide further evidence to validate our findings. Abbreviations ROI-C Cage-plate ACDF NOS CI JOA NDI RR RCT RCS ROI-C TM Self-Locking System Cage combined with plate implant (CCP) Anterior cervical decompression and fusion Newcastle-Ottawa Scale Confdence intervals Japanese Orthopaedic Association Neck Disability Index Risk ratio Randomized controlled trial Retrospective cohort study Declarations Availability of data and materials The patient data adopted are from the internet. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing interests Confirmed by all authors, this meta - analysis did not receive any funding from manufacturers. None of the authors in the team hold stocks or equity in relevant manufacturers, nor have they received consulting fees, speaking fees, research grants, or any other form of financial support from manufacturers. 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Medicine (Baltimore). 2022 Sep 23;101(38):e30673. doi: 10.1097/MD.0000000000030673. PMID: 36197165; PMCID: PMC9509047. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6110433","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":422320112,"identity":"8ef47915-f7cd-4bc0-93a1-9780550af1d9","order_by":0,"name":"Xin 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10","display":"","copyAsset":false,"role":"figure","size":37979,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the incidence of postoperative adjacent segment degeneration between ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking group（ROI-C）and cage-plate group\u003c/p\u003e","description":"","filename":"image10.png","url":"https://assets-eu.researchsquare.com/files/rs-6110433/v1/8156d18ded6de6d61b8c81b5.png"},{"id":83648380,"identity":"419df31c-acda-4f66-8fad-70adc077c87d","added_by":"auto","created_at":"2025-05-30 06:21:39","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":31865,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the incidence of cage subsidence between ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking group（ROI-C）and cage-plate group（CCP）\u003c/p\u003e","description":"","filename":"image11.png","url":"https://assets-eu.researchsquare.com/files/rs-6110433/v1/1f56f7b199293762ae58ca4e.png"},{"id":83648387,"identity":"e7a83c32-cd79-4cb1-ba32-cb8a18591cda","added_by":"auto","created_at":"2025-05-30 06:21:39","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":111659,"visible":true,"origin":"","legend":"\u003cp\u003eThe incidence of dysphagia between ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking group（ROI-C）and cage-plate group（CCP）compared after operation, 1 month after operation and 3 months after operation;\u003c/p\u003e","description":"","filename":"image12.png","url":"https://assets-eu.researchsquare.com/files/rs-6110433/v1/357203c8655b645e4c5b6e6b.png"},{"id":83648397,"identity":"a029c9cb-22f1-473e-ac18-d35f28124881","added_by":"auto","created_at":"2025-05-30 06:21:40","extension":"png","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":78051,"visible":true,"origin":"","legend":"\u003cp\u003eSubgroup analysis of operation time of different segments between ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking group（ROI-C）and cage-plate group（CCP）\u003c/p\u003e","description":"","filename":"image13.png","url":"https://assets-eu.researchsquare.com/files/rs-6110433/v1/6697bf2a2846f3e8102894e5.png"},{"id":83648386,"identity":"0dd4c1fb-fa79-4135-aec8-cb25b7f2555c","added_by":"auto","created_at":"2025-05-30 06:21:39","extension":"png","order_by":14,"title":"Figure 14","display":"","copyAsset":false,"role":"figure","size":76374,"visible":true,"origin":"","legend":"\u003cp\u003eSubgroup analysis of intraoperative blood loss of different segments between ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking group（ROI-C）and cage-plate group（CCP）\u003c/p\u003e","description":"","filename":"image14.png","url":"https://assets-eu.researchsquare.com/files/rs-6110433/v1/c27b9024eb4314b39626ae72.png"},{"id":83648378,"identity":"806f491f-d97c-4be5-9e62-593a216e50a5","added_by":"auto","created_at":"2025-05-30 06:21:39","extension":"png","order_by":15,"title":"Figure 15","display":"","copyAsset":false,"role":"figure","size":65680,"visible":true,"origin":"","legend":"\u003cp\u003eThe forest map of JOA score after removing Li\u003c/p\u003e","description":"","filename":"image15.png","url":"https://assets-eu.researchsquare.com/files/rs-6110433/v1/c696e81acc15b0035d5fa110.png"},{"id":83648381,"identity":"26f840d5-0612-40cf-b68c-d20070f65715","added_by":"auto","created_at":"2025-05-30 06:21:39","extension":"png","order_by":16,"title":"Figure 16","display":"","copyAsset":false,"role":"figure","size":32162,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of postoperative cage subsidence after removal of Xiong\u003c/p\u003e","description":"","filename":"image16.png","url":"https://assets-eu.researchsquare.com/files/rs-6110433/v1/3d2da339a41ec57f6c2c0626.png"},{"id":83648382,"identity":"e59d10d1-0eeb-4315-b605-2c0614d23cd3","added_by":"auto","created_at":"2025-05-30 06:21:39","extension":"png","order_by":17,"title":"Figure 17","display":"","copyAsset":false,"role":"figure","size":32341,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of postoperative cage subsidence after removal of He\u003c/p\u003e","description":"","filename":"image17.png","url":"https://assets-eu.researchsquare.com/files/rs-6110433/v1/224a0d5d8a74703b407a31b1.png"},{"id":88109357,"identity":"b51c6fdc-cf59-4c58-bed1-aba6437a903c","added_by":"auto","created_at":"2025-08-01 13:09:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1776798,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6110433/v1/f0f504ae-2144-4e17-bd6a-1eed426056b0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A systematic review and meta-analysis of Anterior Cervical Decompression and Fusion: Comparing the ROI-CTM Self-Locking System with Traditional Cage-Plate Internal Fixation in the Treatment of Degenerative Cervical Spondylosis","fulltext":[{"header":"Background","content":"\u003cp\u003eDegenerative cervical spondylosis is the most prevalent non-traumatic, progressive spinal disorder, primarily characterized by a suite of clinical symptoms and signs attributable to nerve compression as a result of cervical structural degeneration. The condition commonly presents with neck and radicular arm pain, fine motor dysfunction, gait instability, and urinary bladder dysfunction. Amidst societal progression and lifestyle shifts, the incidence of this disease is on the rise, with a significant proportion of patients who fail conservative treatment requiring surgical intervention\u003csup\u003e[1]\u003c/sup\u003e. Anterior cervical decompression and fusion (ACDF) is a frequently employed surgical technique. To augment immediate postoperative stability of the fusion segment, enhance fusion rates, and mitigate the risk of bone graft displacement, traditional ACDF often incorporates the use of an anterior fusion cage in conjunction with plate internal fixation. This approach has been documented to facilitate the reconstruction of cervical lordosis and to preserve the height of the intervertebral space\u003csup\u003e[2]\u003c/sup\u003e. However, as follow-up periods extend, complications associated with anterior plates, such as plate loosening and migration, oesophagal compression leading to dysphagia, and adjacent segment degeneration, have become increasingly apparent, posing challenges to clinical management\u003csup\u003e[3]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eWith the aim of minimizing the incidence of complications associated with plate - screw constructs, the ROI - C\u003csup\u003eTM\u003c/sup\u003e self - locking system, which is meticulously designed in accordance with the \"zero - profile\" concept, received approval from the National Medical Products Administration for clinical application in 2011. The ROI-C\u003csup\u003eTM\u003c/sup\u003e system eschews the traditional anterior plate in favour of a dual-embedded fusion device that integrates support, fixation, and fusion capabilities. During surgery, once the fusion device is positioned, the embedded piece is inserted vertically to achieve immediate stability, eliminating the need for anterior plate fixation. Biomechanical studies have indicated that the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking cage provides stability comparable to traditional cage-plate internal fixation\u003csup\u003e[4]\u003c/sup\u003e. Moreover, numerous studies have demonstrated that the use of the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system can significantly diminish the risk of postoperative dysphagia and adjacent segment degeneration\u003csup\u003e[5]\u003c/sup\u003e. However, some studies have suggested that the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system may have a higher rate of cage subsidence compared to traditional cage-plate internal fixation\u003csup\u003e[6, 7]\u003c/sup\u003e. There remains considerable debate surrounding the relative merits and drawbacks of these two internal fixation techniques in the treatment of degenerative cervical spondylosis.\u003c/p\u003e\n\u003cp\u003eTo date, there is no meta-analysis on the efficacy of the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system and traditional cage-plate internal fixation in treating degenerative cervical spondylosis. This study aims to address this gap by conducting a meta-analysis of the clinical outcomes and complications associated with both treatment modalities. The objective is to provide evidence-based guidance for the selection of internal fixation methods in ACDF procedures.\u003c/p\u003e"},{"header":"Information and methods ","content":"\u003cp\u003e\u003cstrong\u003e1.1 Source of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProspective Register of Systematic Reviews (CRD42024547137), and the screening process adheres strictly to the PRISMA guidelines for conducting systematic reviews. Use endnote document management software, Investigators Wang Xin and Zhou Yanjie systematically searched PubMed, Cochrane Library, Web of Science, and Embase for English-language literature on the application of the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system and cage-plate internal fixation in ACDF for treating degenerative cervical spondylosis. The search terms included \u0026quot;anterior cervical discectomy and fusion,\u0026quot; \u0026quot;ACDF,\u0026quot; \u0026quot;self-locking,\u0026quot; \u0026quot;stand-alone,\u0026quot; \u0026quot;zero-profile,\u0026quot; and \u0026quot;ROI-C,\u0026quot; and the retrieval period extended from the inception of each database to September 2024. The literature search strategy, as depicted in Figure 1. Studies originating from the same institutions were carefully evaluated to prevent any duplication in data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2 Literature Inclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria: (1) patients diagnosed with degenerative cervical spondylosis based on clinical and imaging evidence; (2) study types limited to randomized controlled trials (RCTs) or cohort studies (CS) in English; (3) the intervention group underwent anterior cervical decompression with ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system internal fixation, while the control group received anterior cervical decompression fusion with cage-plate internal fixation; (4) studies containing one or more outcome indicators; (5) a minimum postoperative follow-up period of 1 year.\u003c/p\u003e\n\u003cp\u003eExclusion criteria: (1) animal experiments, cadaver experiments, or biomechanical studies; (2) literature on patients with a history of cervical spine surgery, preoperative diagnosis of spinal tumours, scoliosis, infection, fracture, severe osteoporosis, or severe ossification of the posterior longitudinal ligament; (3) studies on combined surgical treatments; (4) potential for duplicate data from the same research centre; (5) systematic reviews, meta-analyses, literature reviews, and case reports; (6) articles that could not be downloaded or for which data was difficult to obtain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3 Literature Extraction and Quality Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo researchers independently screened the literature, extracted data, and assessed the quality of the studies. Information extracted included study type, year, first author, gender, age, number of patients, interventions, outcome indicators, and follow-up time. The Cochrane bias risk tool was utilized to evaluate the quality of RCTs,\u0026nbsp;while the Newcastle-Ottawa Scale (NOS) was applied to assess the quality of cohort studies. Studies were scored out of 10, with 8-9 points indicating high-quality literature, 6-7 points for medium-quality literature, and 5 points or below for low-quality literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.4 Outcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOutcome measures included operation time, intraoperative blood loss, Japanese Orthopedic Association (JOA) score, Neck Disability Index (NDI), C2-C7 Cobb angle, fusion rate, incidence of adjacent segment degeneration, cage subsidence rate, and incidence of dysphagia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.5 Statistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from the included studies were pooled for meta-analysis using RevMan 5.4.1 software. Mean difference (MD) was selected as the effect size index for continuous variables, including operation time, intraoperative blood loss, JOA score, NDI index, and C2-C7 Cobb angle. Risk ratio (RR) was used for binary data, such as fusion rate, incidence of adjacent segment degeneration, cage subsidence rate, and incidence of postoperative dysphagia, with a 95% confidence interval (CI). Heterogeneity was assessed using the I\u003csup\u003e2\u003c/sup\u003e statistic. The fixed-effect model was employed for homogeneous data (P \u0026gt; 0.1, I\u003csup\u003e2\u003c/sup\u003e \u0026le; 50%), and the random-effects model was used for heterogeneous data (P \u0026lt; 0.1, I\u003csup\u003e2\u003c/sup\u003e \u0026gt; 50%). Subgroup analyses were conducted for outcomes highly related to the surgical segment, such as operation time and intraoperative blood loss. Sensitivity analyses were performed on outcomes with high heterogeneity to explore potential sources.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e2.1 Retrieval Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe literature search yielded a total of 1297 articles. After excluding duplicates, reviews, and meta-analyses, 721 articles remained. Titles and abstracts were screened, leading to the exclusion of 69 articles. A full-text review eliminated non-compliant literature, resulting in 10 articles that met the inclusion and exclusion criteria, comprising 9 retrospective cohort studies\u003csup\u003e[8-16]\u003c/sup\u003e and 1 randomized controlled trial\u003csup\u003e[17]\u003c/sup\u003e. A total of 947 patients were included, with 468 in the ROI-C group and 479 in the fusion cage-plate group, as depicted in Figure 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Clinical Characteristics of Included Studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe baseline characteristics of the included studies are summarized in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Basic characteristics of the studies\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStudy type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eTotal cases (male/female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eAge（Years）\u003c/p\u003e\n \u003cp\u003e(x \u0026plusmn; s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eFollow-up period（month）\u003c/p\u003e\n \u003cp\u003e(x \u0026plusmn; s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFusion segments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003cp\u003eindex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eROI-C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eROI-C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eROI-C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHe2021\u003csup\u003e[9]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19/23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20/25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.59\u0026plusmn;8.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.15\u0026plusmn;7.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26.6\u0026plusmn;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27.1\u0026plusmn;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e①②③④⑤⑥⑧⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHe2022\u003csup\u003e[10]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.59\u0026plusmn;8.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.15 \u0026plusmn; 7.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26.6\u0026plusmn;3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27.1\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e①②③④⑤⑥⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHofstetter2015\u003csup\u003e[11]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16/19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18/17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56.8\u0026plusmn;1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51.5\u0026plusmn;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.0\u0026plusmn;1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.8\u0026plusmn;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e①②⑥⑦⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eli2022\u003csup\u003e[12]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43/58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55/51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57.1\u0026plusmn;8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58.6\u0026plusmn;9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e①②③④⑤⑥⑦⑧⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLiu2016\u003csup\u003e[13]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10/18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56.6\u0026plusmn;9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57.5\u0026plusmn;9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.3\u0026plusmn;6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.2\u0026plusmn;6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e①②③⑤⑥⑦⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWang2014\u003csup\u003e[14]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12/18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14/19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56.8\u0026plusmn;11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54.0\u0026plusmn;10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.1\u0026plusmn;7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.8\u0026plusmn;8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e①②③④⑤⑥⑦⑧⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGao2023\u003csup\u003e[8]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26/31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23/25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58.40\u0026plusmn;6.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58.63\u0026plusmn;7.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e①②③④⑤⑥⑦⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eXiong2023\u003csup\u003e[15]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16/15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15/24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52.26\u0026plusmn;8.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51.08\u0026plusmn;10.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.52\u0026plusmn;5.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.18\u0026plusmn;12.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e①②③⑤⑥⑦⑧⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ezho‘\u003csup\u003e[16]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23/28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22/25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.3\u0026plusmn;6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64.4\u0026plusmn;3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39.7\u0026plusmn;3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.2\u0026plusmn;4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e①②③④⑥⑦⑧⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eZhou2020\u003csup\u003e[17]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26/34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29/31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.3\u0026plusmn;6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64.5\u0026plusmn;6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e⑥⑦⑧\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Retrospective cohort study (RCS); randomized controlled trial\u0026nbsp;(RCT); ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking group ( ROI-C ); cage-plate group ( CCP ); outcome indicators: 1 operation time, 2 intraoperative blood loss, 3 JOA score, 4 NDI index, 5 C2-C7 cobb angle, 6 fusion rate, 7 adjacent vertebral lesion rate, 8 cage subsidence rate, 9 incidences of dysphagia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Literature Quality Evaluation Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe quality of the randomized controlled trials was assessed using the Cochrane bias risk tool\u003csup\u003e[17]\u003c/sup\u003e, and no trials were identified with a high risk of bias, as depicted in Figure 3. The Newcastle-Ottawa Scale was employed to evaluate the included retrospective cohort studies. Nine studies\u003csup\u003e[8-16]\u003c/sup\u003e were evaluated, with seven\u003csup\u003e[9, 10, 12-16]\u003c/sup\u003e scoring 8 points each and two\u003csup\u003e[8, 11]\u003c/sup\u003e scoring 7 points. The detailed scoring results are presented in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eNewcastle-Ottawa Scale score results\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"520\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSelection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eComparability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 57px;\"\u003e\n \u003cp\u003e得分\u003c/p\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003eG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eH\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eHe2021\u003csup\u003e[9]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eHe2022\u003csup\u003e[10]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eHofstetter2015\u003csup\u003e[11]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eli2023\u003csup\u003e[12]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eLiu2016\u003csup\u003e[13]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eWang2015\u003csup\u003e[14]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eGao2023\u003csup\u003e[8]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eXiong2023\u003csup\u003e[15]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003ezho‘\u003csup\u003e[16]\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Note: A, the representativeness of the exposed group; B, the representation of the non-exposed group; C,the determination of exposure factors ; D,affirming that there is no outcome index to be observed at the beginning of the study; E,the comparability between the exposed group and the non-exposed group was considered in the design and statistical analysis; F,evaluation of outcome indicators; G,the follow-up time is long enough; H,integrity of exposed and non-exposed groups;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Meta-analysis results\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.1 Operation Time\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of nine studies\u003csup\u003e[8-16]\u003c/sup\u003e reported on operation time, with five\u003csup\u003e[8, 12-14, 16]\u003c/sup\u003e providing a segmented analysis. Within these, four studies\u003csup\u003e[8, 12-14]\u003c/sup\u003e compared two surgical time groups, and one study\u003csup\u003e[16]\u003c/sup\u003e examined three distinct groups. The subgroup data were pooled using the mean and standard deviation for each group, as calculated on the online statistical tool http://statstodo.com/CombineMeansSDs.php. These combined values were subsequently utilized for meta-analysis. Data from Hofstetter\u003csup\u003e[11]\u003c/sup\u003e, originally presented as Mean \u0026plusmn; SEM, were converted to Mean \u0026plusmn; SD within the RevMan software for consistency. A fixed-effect model was applied for analysis (P = 0.54, I\u003csup\u003e2\u003c/sup\u003e = 0%). The meta-analysis revealed a statistically significant reduction in operation time in the group utilizing the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system compared to the cage-plate fixation group [MD = -14.03, 95% CI (-17.12, -10.95), P \u0026lt; 0.00001], as illustrated in Figure 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.2 Intraoperative Blood Loss\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNine studies\u003csup\u003e[8-16]\u003c/sup\u003e reported on intraoperative blood loss, with segmental subgroup analyses provided in five\u003csup\u003e[8, 12-14, 16]\u003c/sup\u003e. Among these, four studies\u003csup\u003e[8, 12-14]\u003c/sup\u003e compared two groups regarding blood loss, while one study\u003csup\u003e[16]\u003c/sup\u003e evaluated three groups. The mean and standard deviation for each subgroup were pooled using the online calculator at http://statstodo.com/CombineMeansSDs.php. Data from Hofstetter\u003csup\u003e[11]\u003c/sup\u003e, initially presented as Mean \u0026plusmn; SEM, were converted to Mean \u0026plusmn; SD format within the RevMan software to ensure consistency for meta-analysis. Despite moderate heterogeneity among the studies (P = 0.07, I\u003csup\u003e2\u003c/sup\u003e = 45%), a fixed-effect model was employed for the analysis. The meta-analysis indicated a statistically significant reduction in intraoperative blood loss in the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system group compared to the cage-plate group [MD = -16.34, 95% CI (-19.84, -12.84), P \u0026lt; 0.00001], as depicted in Figure 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.3 Preoperative and Postoperative JOA Scores\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEight studies\u003csup\u003e[8-10, 12-16]\u003c/sup\u003e compared the preoperative Japanese Orthopaedic Association (JOA) scores between the two groups, demonstrating no significant heterogeneity (P = 0.87, I\u003csup\u003e2\u003c/sup\u003e = 0%). A fixed-effect model was applied, and the pooled results indicated no statistically significant difference in preoperative JOA scores [MD = -0.03, 95% CI (-0.27, 0.20), P = 0.80]. Meanwhile, four studies\u003csup\u003e[9, 10, 12, 14]\u003c/sup\u003e evaluated JOA scores at one month postoperatively, while eight studies\u003csup\u003e[8-10, 12-16]\u003c/sup\u003e assessed scores at the final follow-up. There was significant heterogeneity between the studies (P = 0.01, I\u003csup\u003e2\u003c/sup\u003e = 55%), and a random-effects model was used. The results showed that there was no significant difference in JOA scores at one month postoperatively [MD = -0.21, 95% CI (-0.69, 0.27), P = 0.39] or at the final follow-up [MD = 0.18, 95% CI (-0.14, 0.49), P = 0.27], as depicted in Figure 6.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.4 Preoperative and Postoperative NDI Scores\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeven studies\u003csup\u003e[8-10, 12-14, 16]\u003c/sup\u003e compared the preoperative Neck Disability Index (NDI) scores between the two groups, demonstrating no significant heterogeneity (P = 0.40, I\u003csup\u003e2\u003c/sup\u003e = 3%). A fixed-effect model was applied, and the pooled results indicated no statistically significant difference in preoperative NDI scores [MD = -0.04, 95% CI (-0.47, 0.40), P = 0.87]. Concurrently, four studies\u003csup\u003e[9, 10, 13, 14]\u003c/sup\u003e evaluated NDI scores at one month postoperatively, while seven studies\u003csup\u003e[8-10, 12-14, 16]\u003c/sup\u003e assessed scores at the final follow-up. The fixed-effect model, used despite moderate heterogeneity (P = 0.06, I\u003csup\u003e2\u003c/sup\u003e = 44%), revealed no significant difference in NDI scores at one month postoperatively [MD = 0.39, 95% CI (-0.68, 1.45), P = 0.47] or at the final follow-up [MD = 0.15, 95% CI (-0.15, 0.45), P = 0.32], as depicted in Figure 7.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.5 Preoperative and Postoperative C2-C7 Cobb Angles\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeven studies\u003csup\u003e[8-10, 12-14, 16]\u003c/sup\u003e compared the preoperative C2-C7 Cobb angle between the two groups, demonstrating no significant heterogeneity (P = 1.00, I\u003csup\u003e2\u003c/sup\u003e = 0%). A fixed-effect model was applied, and the pooled results indicated no statistically significant difference in preoperative C2-C7 Cobb angle [MD = 0.53, 95% CI (-0.16, 1.21), P = 0.13]. In tandem, five studies\u003csup\u003e[9, 10, 12-14]\u003c/sup\u003e evaluated C2-C7 Cobb angle at one month postoperatively, while seven studies\u003csup\u003e[8-10, 12-14, 16]\u003c/sup\u003e assessed angles at the final follow-up. A fixed-effect model was used (P = 0.99, I\u003csup\u003e2\u003c/sup\u003e = 0%). The results showed that there was no significant difference in C2-C7 Cobb angle at one month postoperatively [MD = -0.00, 95% CI (-0.76, 0.76), P = 1.00] or at the final follow-up [MD = -0.28, 95% CI (-0.82, 0.26), P = 0.32], as depicted in Figure 8.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.6 Fusion rate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of ten studies\u003csup\u003e[8-17]\u003c/sup\u003e assessed the fusion rate at the final follow-up, demonstrating no significant heterogeneity (P = 0.99, I\u003csup\u003e2\u003c/sup\u003e = 0%). A fixed-effect model was applied, and the pooled analysis revealed no significant difference in the fusion rates between the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system group and the cage-plate group at the last follow-up [RR = 1.01, 95% CI (0.99, 1.03), P = 0.44], as illustrated in Figure 9.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.7 Adjacent Segment Degeneration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEight studies\u003csup\u003e[8, 11-17]\u003c/sup\u003e evaluated the incidence of adjacent segment degeneration, demonstrating no significant heterogeneity (P = 0.49, I\u003csup\u003e2\u003c/sup\u003e = 0%). A fixed-effect model was applied, and The meta-analysis revealed a statistically significant difference in the rate of adjacent segment degeneration between the two groups, with the ROI-CTM self-locking system demonstrating a substantial reduction in the incidence of postoperative adjacent segment degeneration [RR = 0.40, 95% CI (0.27, 0.60), P \u0026lt; 0.00001], as depicted in Figure 10.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.8 Postoperative Cage Subsidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFive studies\u003csup\u003e[9, 12, 15-17]\u003c/sup\u003e compared the postoperative cage subsidence between the two groups, and the heterogeneity was high (P = 0.05, I\u003csup\u003e2\u003c/sup\u003e = 59%), which was analyzed by a random-effects model. The results showed that there was no significant difference in the subsidence rate of the fusion cage between the two groups [RR = 1.46, 95% CI (0.68, 3.11), P = 0.33], as illustrated in Figure 11.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.9 Postoperative Dysphagia Incidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn a series of analyses, four studies\u003csup\u003e[8, 12, 14, 15]\u003c/sup\u003e compared the incidence of dysphagia two weeks postoperatively, three studies\u003csup\u003e[9, 10, 12]\u003c/sup\u003e at one month, five studies\u003csup\u003e[8, 9, 11-13]\u003c/sup\u003e at three months, and eight studies\u003csup\u003e[8-10, 12-16]\u003c/sup\u003e at the final follow-up between two groups. Employing a fixed-effect model due to the lack of heterogeneity (P = 0.97, I\u003csup\u003e2\u003c/sup\u003e = 0%), the results consistently demonstrated a significantly lower incidence of dysphagia in the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking group compared to the cage-plate group at all time points: two weeks [RR = 0.20, 95% CI (0.11, 0.35), P \u0026lt; 0.00001], one month [RR = 0.32, 95% CI (0.16, 0.64), P = 0.001], three months [RR = 0.14, 95% CI (0.05, 0.38), P \u0026lt; 0.0001], and at the final follow-up [RR = 0.14, 95% CI (0.05, 0.38), P = 0.0001]. The overall incidence of dysphagia was also significantly lower in the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking group [RR = 0.20, 95% CI (0.14, 0.29), P \u0026lt; 0.00001], as depicted in Figure 12.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Subgroup analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.1 Operation Time\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the surgical segment, the operation time was categorized into three subgroups: single-segment, double-segment, and multi-segment. A total of four studies\u003csup\u003e[9, 12, 14, 16]\u003c/sup\u003e documented the operation time for single-segment procedures, the same number of studies\u003csup\u003e[9, 12, 14, 16]\u003c/sup\u003e reported on double-segment operations, and two studies\u003csup\u003e[8, 13]\u003c/sup\u003e provided data on multi-segment operations. Liu specifically recorded the operation times for both three-segment and four-segment procedures, which were grouped under multi-segment operations. Due to high heterogeneity (P \u0026lt; 0.00001, I\u003csup\u003e2\u003c/sup\u003e = 93%), a random-effects model was employed for analysis. The results indicated that the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking group had a significantly shorter operation time compared to the fusion cage-plate group in single-segment [MD = -13.11, 95% CI (-17.62, -8.60), P \u0026lt; 0.00001], double-segment [MD = -14.00, 95% CI (-14.96, -13.03), P \u0026lt; 0.00001], and multi-segment [MD = -24.68, 95% CI (-28.13, -21.22), P \u0026lt; 0.00001] operations, as illustrated in Figure 13.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.2 Intraoperative Blood Loss\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the subgroup analysis based on surgical segment, the single segment, double segment, and multi-segment intraoperative blood loss were examined. A total of four studies\u003csup\u003e[9, 12, 14, 16]\u003c/sup\u003e reported on blood loss for single-segment surgeries, four studies\u003csup\u003e[9, 12, 14, 16]\u003c/sup\u003e reported on double-segment surgeries, and two studies\u003csup\u003e[8, 13]\u003c/sup\u003e reported on multi-segment surgeries. The data of Liu et al.were also included in the multi-segment group. A fixed-effect model was applied for analysis due to the moderate heterogeneity (P = 0.3, I\u003csup\u003e2\u003c/sup\u003e = 15%). The results indicated that the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking group experienced less intraoperative blood loss compared to the cage-plate group in single-segment [MD = -15.89, 95% CI (-18.81, -12.98), P \u0026lt; 0.00001], double-segment [MD = -17.70, 95% CI (-23.03, -12.37), P \u0026lt; 0.00001], and multi-segment [MD = -17.53, 95% CI (-23.27, -11.79), P \u0026lt; 0.00001] surgeries, as depicted in Figure 14.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Sensitivity analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the meta-analysis, the randomized controlled study by Zhou\u003csup\u003e[17]\u003c/sup\u003e was initially excluded and then re-integrated for analysis. This exclusion and re-inclusion did not significantly alter the outcomes regarding operation time, intraoperative blood loss, fusion rate, or the heterogeneity of postoperative degeneration in adjacent vertebrae. The consistency of results before and after this exclusion suggests that the meta-analysis findings are robust.\u003c/p\u003e\n\u003cp\u003eSensitivity analysis of the postoperative JOA score indicated that the study by Li\u003csup\u003e[12]\u003c/sup\u003e might be a source of heterogeneity. Upon its removal, heterogeneity was markedly reduced (I\u003csup\u003e2\u003c/sup\u003e = 0%). The fixed-effect model analysis confirmed no significant difference in postoperative JOA scores between the two groups (P \u0026gt; 0.05), further supporting the reliability of the meta-analysis results (Figure 15).\u003c/p\u003e\n\u003cp\u003eUpon sequentially eliminating each subgroup\u0026apos;s operation time data and re-analyzing, no significant change in heterogeneity was observed compared to the initial analysis, and no clear source of heterogeneity was identified. The larger heterogeneity across studies may stem from the strong correlation between operation time and factors such as the surgeon\u0026apos;s experience, habits, and proficiency, as well as the number of surgical segments.\u003c/p\u003e\n\u003cp\u003eIn the analysis of postoperative cage subsidence, the exclusion of Xiong\u003csup\u003e[15]\u003c/sup\u003e significantly reduced heterogeneity (P = 0.62, I\u003csup\u003e2\u003c/sup\u003e = 0%), and the fixed-effect model showed no significant difference in cage subsidence rates between the groups at the final follow-up [RR = 1.01, 95% CI (0.99, 1.03), P = 0.44] (Figure 16). However, the exclusion of He\u003csup\u003e[9]\u003c/sup\u003e led to a reduction in heterogeneity (P = 0.21, I\u003csup\u003e2\u003c/sup\u003e = 33%). The fixed-effect model revealed a significant difference in postoperative fusion cage sedimentation rates between the groups [RR = 2.34, 95% CI (1.48, 3.69), P = 0.0003] (Figure 17). These changes in meta-analysis results imply a potential instability in the findings. Given that postoperative cage subsidence is influenced by various factors, including the surgeon\u0026apos;s technique and bone mineral density, these factors may contribute to the instability of the results. Due to the limited literature on postoperative cage subsidence rates, further research is warranted.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eZero-profile self-locking systems, categorized based on their locking mechanisms, are primarily divided into two types\u003csup\u003e[18]\u003c/sup\u003e. The first type secures fixation with angled self-locking screws, exemplified by the Zero-P system and its enhancements. The second type involves the insertion of a sharp double titanium inlay into the adjacent vertebral body, as seen in the ROI-C\u003csup\u003eTM\u003c/sup\u003e system. At present, the screw-type self-locking system is widely used in clinical practice. At present, many literatures have pointed out that screw-type self-locking systems can significantly reduce the incidence of postoperative dysphagia and adjacent segment degeneration compared with traditional cage-plate internal fixation and can achieve satisfactory clinical efficacy in single-segment and multi-segment ACDF\u003csup\u003e[19-21]\u003c/sup\u003e. However, challenges arise in certain anatomies, such as obese patients with short necks, where the use of angled screws is hindered by the mandible and sternum's stress shielding, complicating screw placement in specific cervical segments like C2-3, C3-4, and C6-7. The ROI-C\u003csup\u003eTM\u003c/sup\u003e system addresses these issues with its vertical curved inlay locking mechanism, broadening the applicability of internal fixation techniques\u003csup\u003e[18]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eClinical studies on the use of the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system and traditional cage-plate internal fixation for the treatment of degenerative cervical spondylosis are gradually increasing. One study has pointed out that both methods can achieve satisfactory clinical outcomes. However, there is some debate regarding their fusion rates and postoperative stability\u003csup\u003e[6]\u003c/sup\u003e. To further explore the advantages and disadvantages of these two internal fixation methods, a meta-analysis of their clinical outcomes and complications in the treatment of degenerative cervical spondylosis was conducted. The aim is to provide evidence-based support for the choice of internal fixation methods in anterior cervical decompression and fusion surgery.\u003c/p\u003e\n\u003cp\u003eThe meta-analysis revealed that the ROI - CTM self - locking system, consisting of a radiolucent polyether - ether - ketone (PEEK) cage and two integrated self - locking wings, shows comparable clinical efficacy to traditional cage - plate internal fixation. Yet, the ROI-C\u003csup\u003eTM\u003c/sup\u003e system stands out with advantages such as reduced operation time, decreased intraoperative blood loss, and lower rates of postoperative adjacent segment degeneration and dysphagia.\u003c/p\u003e\n\u003cp\u003eNeurological function improvement is typically assessed using JOA and NDI scores. Our study found no significant difference in these scores between the ROI-C\u003csup\u003eTM\u003c/sup\u003e system and the traditional cage-plate method, both one month postoperatively and at the final follow-up. Although some heterogeneity in JOA scores was noted, it was resolved through sensitivity analysis after excluding a study by Li\u003csup\u003e[12]\u003c/sup\u003e. This indicates that both methods are equally effective in decompressing and enhancing neurological function, and the larger sample size and the observation bias of the researchers may be the main reasons for the heterogeneity. The Cobb angle method, a widely utilized technique in clinical practice, was employed to assess cervical curvature. Drawing on the logistic regression analysis by Wu\u003csup\u003e[22]\u003c/sup\u003e, which suggests that adjacent segment degeneration (ASD) is more likely with postoperative Cobb angle losses exceeding 5.5°, our study found no significant difference in C2-C7 Cobb angles between the ROI-C\u003csup\u003eTM\u003c/sup\u003e system and the cage-plate method at one-month post-surgery and the last follow-up. This suggests similar effectiveness in maintaining cervical curvature over both the short and long term. Fusion rates also showed no significant difference between the two groups, indicating equivalent postoperative stability for the ROI-C\u003csup\u003eTM\u003c/sup\u003e system compared to the cage-plate fixation. Additionally, studies by Li\u003csup\u003e[12]\u003c/sup\u003e and Zhou\u003csup\u003e[16]\u003c/sup\u003e observed that the ROI-C\u003csup\u003eTM\u003c/sup\u003e system had a shorter fusion time than the traditional cage-plate approach.\u003c/p\u003e\n\u003cp\u003eThe ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system offers a straightforward surgical approach with minimal exposure. Our study indicates that this system significantly reduces both operation time and intraoperative blood loss. A subgroup analysis revealed that across various surgical segments, the ROI-C\u003csup\u003eTM\u003c/sup\u003e system consistently outperformed the cage-plate combination in terms of reduced operation time and blood loss, with operation time increasing incrementally per segment. However, the difference in intraoperative blood loss among subgroups did not reach statistical significance, potentially due to the muscle gap approach used in anterior cervical ACDF procedures, which inherently involves less blood loss. The shorter operation times with the ROI-C\u003csup\u003eTM\u003c/sup\u003e system contribute to decreased perioperative and surgical risks, while reduced trauma is associated with a lower incidence of postoperative complications. Notably, the heterogeneity observed across studies was substantial, largely attributed to variations in surgeon experience, habits, proficiency, and the complexity of the surgical segments. Nonetheless, sensitivity analysis and the use of a transformation effect model confirmed the stability of our findings, lending credibility to our conclusions.\u003c/p\u003e\n\u003cp\u003ePostoperative complications, particularly dysphagia and adjacent segment degeneration have been strongly linked to the use of anterior plates\u003csup\u003e[23, 24]\u003c/sup\u003e. Our study aligns with findings that the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system markedly reduces the occurrence of these issues. Notably, dysphagia in most patients improved within the first postoperative month, with significant resolution by the third month\u003csup\u003e[25]\u003c/sup\u003e. Upon analyzing dysphagia rates post-surgery at 1, 3 months, and at the final follow-up, a clear trend emerged: the incidence of dysphagia diminished over time, with the ROI-C\u003csup\u003eTM\u003c/sup\u003e group consistently showing lower rates compared to the cage-plate group. The ROI-C\u003csup\u003eTM\u003c/sup\u003e system's zero-profile design, which eliminates the need for anterior titanium plates and resides within the intervertebral space, minimizes prevertebral soft tissue, oesophagal, and adjacent vertebral body irritation, consequently decreasing the risk of postoperative degeneration and persistent dysphagia. Furthermore, this system's minimally invasive approach reduces paravertebral soft tissue damage, shorter operation times, and intraoperative blood loss, which collectively contribute to a lower risk of early postoperative dysphagia\u003csup\u003e[26-28]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn our analysis, the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system appeared to have a higher incidence of postoperative cage subsidence when compared to the cage-plate internal fixation method. However, this difference did not reach statistical significance (P = 0.33). Given the significant heterogeneity observed (P = 0.05, I\u003csup\u003e2\u003c/sup\u003e = 59%), sensitivity analysis was used to delete the literature one by one, and the conclusion changed, suggesting that the stability of the results was questionable. Despite this, the collective literature included in this review leans towards the notion that the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system may be predisposed to higher subsidence rates than traditional cage-plate internal fixation. Li\u003csup\u003e[12]\u003c/sup\u003e posits that the potentially suboptimal fixation strength of the cervical anchoring inserts within the ROI-C\u003csup\u003eTM\u003c/sup\u003e interbody fusion cage could be culpable for an increased risk of cage subsidence. Echoing this concern, He\u003csup\u003e[9]\u003c/sup\u003e stresses the importance of preserving the cortical bone endplate as much as possible to lower the risk of subsidence. Furthermore, Xiong\u003csup\u003e[15]\u003c/sup\u003e observed a noteworthy pattern in two-segment ACDF cases, where the ROI-C\u003csup\u003eTM\u003c/sup\u003e cage exhibited more severe subsidence in the lower intervertebral space compared to the upper. This observation may be attributed to the fact that the lower intervertebral space is subject to greater mechanical stress than its upper counterpart.\u003c/p\u003e\n\u003cp\u003eThe relationship between cage subsidence and clinical efficacy remains a subject of debate. Ryu's long-term follow-up study\u003csup\u003e[29]\u003c/sup\u003e demonstrated that cage subsidence did not significantly impact clinical outcomes when adequate foraminal decompression was achieved. Interestingly, subsidence has been correlated with higher fusion rates in the short term, a finding that aligns with our observations. Despite a higher incidence of postoperative cage subsidence among patients who received the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system, our study found no significant difference in cervical curvature and fusion rates compared to the traditional cage-plate fixation. Importantly, none of the patients with cage subsidence exhibited neurological symptoms, and there were no instances of reoperation. However, acknowledging the limited duration of follow-up in our study, it is imperative to conduct extended follow-up studies to confirm these preliminary results.\u003c/p\u003e\n\u003cp\u003eThe limitations of this study: ①The study predominantly comprised retrospective research with a dearth of randomized controlled trials, contributing to a lower quality of evidence and potentially flawed statistical findings. ②Differences in researchers' experience and measurement methods resulted in high heterogeneity across some indicators, increasing the risk of systematic and random errors.③High heterogeneity was observed in the postoperative subsidence index of the fusion cage, but the reasons could not be further explored due to the limited number of studies. ④The lack of data on hospitalization time, operation costs, and long-term follow-up cases prevented a comprehensive comparison of the two internal fixation materials.\u003c/p\u003e\n\u003cp\u003eIn the context of ACDF procedures, both the ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system and traditional cage-plate internal fixation provide satisfactory clinical results. The ROI-C\u003csup\u003eTM\u003c/sup\u003e self-locking system streamlines the ACDF process, significantly reducing operation times and intraoperative blood loss. It also presents a clear advantage in lowering the risk of postoperative dysphagia and adjacent segment degeneration. However, due to the potential for higher cage subsidence rates, its use should be approached with caution in patients with risk factors for cage subsidence, such as osteoporosis and vertebral endplate damage. Considering the limitations and potential biases of this study, more large-scale prospective and randomized controlled studies, as well as long-term follow-ups, are needed to provide further evidence to validate our findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eROI-C\u003c/p\u003e\n \u003cp\u003eCage-plate\u003c/p\u003e\n \u003cp\u003eACDF \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNOS \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003cp\u003eJOA\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNDI\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRR\u003c/p\u003e\n \u003cp\u003eRCT \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eROI-C\u003csup\u003eTM\u003c/sup\u003e Self-Locking System\u003c/p\u003e\n \u003cp\u003eCage combined with plate implant (CCP)\u003c/p\u003e\n \u003cp\u003eAnterior cervical decompression and fusion\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNewcastle-Ottawa Scale\u003c/p\u003e\n \u003cp\u003eConfdence intervals\u003c/p\u003e\n \u003cp\u003eJapanese Orthopaedic Association\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNeck Disability Index\u003c/p\u003e\n \u003cp\u003eRisk ratio\u003c/p\u003e\n \u003cp\u003eRandomized controlled trial\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRetrospective cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient data adopted are from the internet.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConfirmed by all authors, this meta - analysis did not receive any funding from manufacturers. None of the authors in the team hold stocks or equity in relevant manufacturers, nor have they received consulting fees, speaking fees, research grants, or any other form of financial support from manufacturers. Additionally, there are no associations such as participating in research projects or clinical trials initiated by manufacturers between the authors and manufacturers, which could potentially affect the independence and objectivity of the research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAl-Shawwa A, Craig M, Ost K, Anderson D, Jacobs WB, Evaniew N, Tripathy S, Bouchard J, Casha S, Cho R, du Plessis S, Lewkonia P, Nicholls F, Salo PT, Soroceanu A, Swamy G, Thomas KC, Yang MMH, Cadotte DW. Focal compression of the cervical spinal cord alone does not indicate high risk of neurological deterioration in patients with a diagnosis of mild degenerative cervical myelopathy. J Neurol Sci. 2024 Jun 15;461:123042. doi: 10.1016/j.jns.2024.123042. 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PMID: 38872722; PMCID: PMC11172672.\u003c/li\u003e\n\u003cli\u003e Guo Z, Wu X, Yang S, Liu C, Zhu Y, Shen N, Guo Z, Su W, Wang Y, Chen B, Xiang H. Anterior Cervical Discectomy and Fusion Using Zero-P System for Treatment of Cervical Spondylosis: A Meta-Analysis. Pain Res Manag. 2021 Dec 16;2021:3960553. doi: 10.1155/2021/3960553. PMID: 34956433; PMCID: PMC8702348.\u003c/li\u003e\n\u003cli\u003e Sun Z, Liu Z, Hu W, Yang Y, Xiao X, Wang X. Zero-Profile Versus Cage and Plate in Anterior Cervical Discectomy and Fusion with a Minimum 2 Years of Follow-Up: A Meta-Analysis. World Neurosurg. 2018 Dec;120:e551-e561. doi: 10.1016/j.wneu.2018.08.128. Epub 2018 Aug 29. PMID: 30172062.\u003c/li\u003e\n\u003cli\u003e Zhang P, Zheng H, Luo J, Xu J. Comparative efficacy of zero-profile implant and conventional cage-plate implant in the treatment of single-level degenerative cervical spondylosis: a systematic review and meta-analysis. J Orthop Surg Res. 2024 Jun 19;19(1):364. doi: 10.1186/s13018-024-04729-5. PMID: 38898517; PMCID: PMC11188160.\u003c/li\u003e\n\u003cli\u003e Wu Z, Wang W, Zhou F, Xiang P, Li Y, Yang H, Chu G. Comparative analysis of risk factors associated with degeneration of adjacent segments: zero-profile anchored spacer vs. anterior cervical plate and cage construct. Front Med (Lausanne). 2024 Jun 3;11:1375554. doi: 10.3389/fmed.2024.1375554. PMID: 38887670; PMCID: PMC11182449.\u003c/li\u003e\n\u003cli\u003e Aldahamsheh O, Alhammoud A, Halayqeh S, Jacobs WB, Thomas KC, Nicholls F, Evaniew N. Stand-Alone Anchored Spacer vs Anterior Plate Construct in the Management of Adjacent Segment Disease after Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis of Comparative Studies. Global Spine J. 2024 Apr;14(3):1038-1051. doi: 10.1177/21925682231201787. Epub 2023 Sep 13. PMID: 37705344; PMCID: PMC11192131.\u003c/li\u003e\n\u003cli\u003e Tsalimas G, Evangelopoulos DS, Benetos IS, Pneumaticos S. Dysphagia as a Postoperative Complication of Anterior Cervical Discectomy and Fusion. Cureus. 2022 Jul 15;14(7):e26888. doi: 10.7759/cureus.26888. PMID: 35978748; PMCID: PMC9375980.\u003c/li\u003e\n\u003cli\u003e Mazmudar A, Paziuk T, Tran KS, Henry T, Oh S, Purtill C, Habbal D, Yalla G, Harrill Q, Sherrod B, Bisson E, Brodke D, Kepler C, Schroeder G, Vaccaro A, Hilibrand A, Rihn JA. Evaluating Dysphagia Duration and Severity After ACDF in Patients With Underlying Dysphagia - A Prospective, Multicenter Study. Global Spine J. 2023 Sep 6:21925682231201249. doi: 10.1177/21925682231201249. Epub ahead of print. PMID: 37671756.\u003c/li\u003e\n\u003cli\u003e Niu J, Song D, Liu Y, Wang H, Huang C, Yu H, Deng Z, Zou J, Yang H. 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PMID: 29665815; PMCID: PMC5905145.\u003c/li\u003e\n\u003cli\u003e Ryu HS, Han MS, Lee SS, Moon BJ, Lee JK. Influence of subsidence after stand-alone anterior cervical discectomy and fusion in patients with degenerative cervical disease: A long-term follow-up study. Medicine (Baltimore). 2022 Sep 23;101(38):e30673. doi: 10.1097/MD.0000000000030673. PMID: 36197165; PMCID: PMC9509047.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"anterior cervical approach, ACDF, cervical spondylosis, ROI-C, self-locking system, meta-analysis","lastPublishedDoi":"10.21203/rs.3.rs-6110433/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6110433/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e\u0026nbsp;Anterior Cervical Decompression and Fusion (ACDF) is a well-established surgical intervention for degenerative cervical spondylosis. While the use of plates is known to improve fusion rates and stability, it may also be associated with an increased risk of adjacent vertebral degeneration and postoperative dysphagia. This meta-analysis aims to compare the clinical outcomes and complications between the ROI-C\u003csup\u003eTM\u003c/sup\u003e\u0026nbsp;self-locking system and traditional cage-plate internal fixation in the context of ACDF for degenerative cervical spondylosis to guide the selection of appropriate internal fixation methods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u0026nbsp;A comprehensive literature search was conducted in PubMed, Cochrane Library, Web of Science, and Embase to identify relevant English-language studies on the use of the ROI-C\u003csup\u003eTM\u003c/sup\u003e\u0026nbsp;self-locking system and cage-plate internal fixation in ACDF for degenerative cervical spondylosis and the search period spanned from the inception of each database to September 2024. Two researchers independently screened and selected studies based on predefined inclusion and exclusion criteria. The quality of the included randomized controlled trials was strictly assessed according to the Cochrane Collaboration's guidelines, and the Newcastle-Ottawa Scale (NOS) was applied to evaluate the quality of cohort studies. The meta-analysis was performed using RevMan 5.4 software, with outcome indicators including operation time, intraoperative blood loss, Japanese Orthopedic Association (JOA) score, Neck Disability Index (NDI), C2-C7 Cobb angle, fusion rate, incidence of adjacent segment degeneration, cage subsidence rate, and incidence of dysphagia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The analysis included ten articles, consisting of nine retrospective cohort studies and one randomized controlled trial, encompassing 947 patients (468 in the ROI-C group and 479 in the fusion cage-plate group). The meta-analysis revealed that the ROI-C group had significantly shorter operation times [MD = -14.03, 95% CI (-17.12, -10.95), P \u0026lt; 0.00001] and less intraoperative blood loss [MD = -16.34, 95% CI (-19.84, -12.84), P \u0026lt; 0.00001] compared to the cage-plate group. Furthermore, the ROI-C group exhibited a significantly lower rate of postoperative adjacent segment degeneration [RR = 0.40, 95% CI (0.27, 0.60), P \u0026lt; 0.00001] and total dysphagia rate [RR = 0.20, 95% CI (0.14, 0.29), P \u0026lt; 0.00001]. However, no significant differences were observed between the two groups in terms of JOA score, NDI index, C2-C7 Cobb angle, fusion rate, and cage subsidence rate (P≥0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e In the context of ACDF procedures, both the ROI-C\u003csup\u003eTM\u003c/sup\u003e\u0026nbsp;self-locking system and traditional cage-plate internal fixation provide satisfactory clinical results. The ROI-C\u003csup\u003eTM\u003c/sup\u003e\u0026nbsp;self-locking system streamlines the ACDF process, significantly reducing operation times and intraoperative blood loss. It also presents a clear advantage in lowering the risk of postoperative dysphagia and adjacent segment degeneration. However, due to the potential for higher cage subsidence rates, its use should be approached with caution in patients with risk factors for cage subsidence, such as osteoporosis and vertebral endplate damage.\u003c/p\u003e","manuscriptTitle":"A systematic review and meta-analysis of Anterior Cervical Decompression and Fusion: Comparing the ROI-CTM Self-Locking System with Traditional Cage-Plate Internal Fixation in the Treatment of Degenerative Cervical Spondylosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-30 06:21:34","doi":"10.21203/rs.3.rs-6110433/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ccdaf0f7-863d-48ea-a7a3-6fc385d457f1","owner":[],"postedDate":"May 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-01T13:08:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-30 06:21:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6110433","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6110433","identity":"rs-6110433","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}