Comparison of anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy

Factors Affecting Length of Stay Following Elective Anterior and Posterior Cervical Spine Surgery

Background

Disease of the cervical spine is widely prevalent, most commonly secondary to degenerative disc changes and spondylosis.

Objective

The goal of the paper was to identify a possible discrepancy regarding the length of stay (LOS) between the anterior and posterior approaches to elective cervical spine surgery and identify contributing factors.

Methods

A retrospective study was performed on 587 patients (341 anterior, 246 posterior) that underwent elective cervical spinal surgery between October 2001 and March 2014. Pre- and intraoperative data were analyzed. Statistical analysis was performed using GraphPad Prism 5 (GraphPad Software, Inc., La Jolla, CA) and the Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY).

Results

Average LOS was 3.21 ± 0.32 days for patients that benefited from the anterior approach cervical spinal surgery and 5.28 ± 0.37 days for patients that benefited from the posterior approach surgery, P-value < 0.0001. Anterior patients had lower American Society of Anesthesiologists scores (2.43 ± 0.036 vs. 2.70 ± 0.044). Anterior patients also had fewer intervertebral levels operated upon (2.18 ± 0.056 vs. 4.11 ± 0.13), shorter incisions (5.49 ± 0.093 cm vs. 9.25 ± 0.16 cm), lower estimated blood loss (EBL) (183.8 ± 9.0 cc vs. 340.0 ± 8.7 cc), and shorter procedure times (4.12 ± 0.09 hours vs. 4.47 ± 0.10 hours). Chi-squared tests for hypertension, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and asthma showed no significant difference between groups.

Conclusions:

Patients with anterior surgery performed experienced a length of stay that was 2.07 days shorter on average. Higher EBL, longer incisions, more intervertebral levels, and longer operating time were significantly associated with the posterior approach. Future studies should include multiple surgeons. The goal would be to create a model that could accurately predict the postoperative length of stay based on patient and operative factors.

Comparison of Anterior and Posterior Surgery for Degenerative Cervical Myelopathy: An MRI-Based Propensity-Score-Matched Analysis Using Data from the Prospective Multicenter AOSpine CSM North America and International Studies

BACKGROUND

Surgeons often choose between 2 different approaches (anterior and posterior) for surgical treatment of degenerative cervical myelopathy on the basis of imaging features of spinal cord compression, the number of levels affected, and the spinal alignment. However, there is a lack of consensus on which approach is preferable. The objective of the present study was to use magnetic resonance imaging (MRI)-based propensity-score-matched analysis to compare postoperative outcomes between the anterior and posterior surgical approaches for degenerative cervical myelopathy.

METHODS

A total of 757 patients were enrolled in 2 prospective multicenter AOSpine studies, which involved 26 international sites. Preoperative MRIs were reviewed to characterize the causes of the cord compression, including single-level disc disease, multilevel disc disease, ossification of the posterior longitudinal ligament, enlargement of the ligamentum flavum, vertebral subluxation/spondylolisthesis, congenital fusion, number of compressed levels, or kyphosis. The propensity to choose anterior decompression was calculated using demographic data, preoperative MRI findings, and the modified Japanese Orthopaedic Association (mJOA) scores in a logistic regression model. We then performed 1-to-1 matching of patients who had received anterior decompression with those who had the same propensity score but had received posterior decompression to compare 2-year postoperative outcomes and 30-day perioperative complication rates between the 2 groups after adjustment for background characteristics.

RESULTS

A total of 435 cases were included in the propensity score calculation, and 1-to-1 matching resulted in 80 pairs of anterior and posterior surgical cases; 99% of these matched patients had multilevel compression. The anterior and posterior groups did not differ significantly in terms of the postoperative mJOA score (15.1 versus 15.3, p = 0.53), Neck Disability Index (20.5 versus 24.1, p = 0.44), or Short Form-36 (SF-36) Physical Component Summary (PCS) score (41.9 versus 40.9, p = 0.30). The overall rates of perioperative complications were similar between the 2 groups (16% versus 11%, p = 0.48); however, dysphagia/dysphonia was reported only in the anterior group whereas surgical site infection and C5 radiculopathy were reported only in the posterior group.

CONCLUSIONS

Anterior and posterior decompression for degenerative cervical myelopathy resulted in similar postoperative outcomes and rates of complications.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Spinal Cord Line Can Predict Postoperative Recovery for Multilevel Cervical Spondylotic Myelopathy

OBJECTIVE

To report a new index, the spinal cord (SC) line, and a new classification to predict postoperative recovery effect in patients with multilevel cervical spondylotic myelopathy (CSM).

METHODS

On T2-weighted magnetic resonance imaging (MRI) of the cervical spine, point A is the posteroinferior point of the spinal cord at C2, and point B is the posterosuperior point of the spinal cord at C7. The SC line is defined as a line connecting A and B. The posterior surface of the compressor at the compression level does not exceed the line in SC line type I, touches the line in type II, and exceeds the line in type III. Between January 2010 and January 2015, 121 patients with multilevel CSM who underwent surgery through an anterior approach (anterior cervical corpectomy with fusion or anterior cervical discectomy and fusion) or a posterior approach (laminoplasty or laminectomy) in our hospital were studied retrospectively. The patients were classified into 3 groups according to SC line type (I, II, or III).

RESULTS

In the anterior surgical approach group, the Japanese Orthopaedic Association (JOA) recovery rate at the last follow-up was 84.88 ± 3.06% for SC line type I, 78.05 ± 2.89% for type II, and 68.69 ± 3.21% for type III. In the posterior surgical approach group, the JOA recovery rate at last follow-up was 69.35 ± 8.73% for type I, 58.05 ± 5.88% for type II, and 47.98 ± 4.31% for type III. The anterior surgery approach was associated with a higher postoperative recovery rate than the posterior surgery approach in type II and type III groups (type II anterior vs. type II posterior: 78.05 ± 2.89% vs. 58.05 ± 5.88%, P = 0.003; type III anterior vs. type III posterior: 68.69 ± 3.21% vs. 47.98 ± 4.31%, P = 0.001). In contrast, the anterior and posterior surgery were associated with similar postoperative recovery rates in the type I group (84.88 ± 3.06% vs. 69.35 ± 8.73%; P = 0.820).

CONCLUSIONS

The SC line and its classifications can predict postoperative recovery in patients with multilevel CSM.

Safe placement of lateral mass screw in the subaxial cervical spine: a case series

PURPOSE

Laminectomy with lateral mass screw fixation has been proven to be an effective method to treat the multilevel cervical degenerative myelopathy and severe cervical spondylosis. However, accurate and safe insertion of the lateral mass screw is technically demanding due to the individual variations of the anatomy of the lateral mass of the subaxial cervical spine. Misplaced lateral mass screw is not uncommon, and operation-related complications still beset the surgeons, which may impair the clinical outcomes. This study aimed to introduce a novel strategy for safe and accurate insertion of lateral mass screw in the subaxial cervical spine.

METHODS

From July 2014 to March 2015, 24 patients with multilevel cervical degenerative myelopathy at C3-C6 levels received laminectomy. Before the operation, the screw insertion technique depended on the pre-operative imaging and operative exploration. Following this strategy, the lateral mass screws were inserted into the subaxial cervical spines. Post-operative radiograph was performed to observe the locations of the lateral mass screws and the cervical curvature. Patients were followed up, and the functional neurological recovery was evaluated by the modified Japanese Orthopedic Association (JOA) disability scale, the Neck Disability Index (NDI) and NDI ranking system.

RESULTS

All screws were inserted into the lateral mass of C3-C6 cervical vertebrae following the current technique. Post-operative CT scans confirmed all screws inserted into the safe zone and relative safe zone of the lateral mass without any screw placed into the transverse foramen. The angle between the lateral mass screw and the vertical line was 40.49 ± 5.44 degrees on the axial CT images. Twenty-four patients were followed up for an average of 25.79 months (range, 20-30 months), and 22 cases evaluated as no or mild disability. According to the JOA score, NDI score and NDI ranking system, the postoperative function of the patients was significantly better when compared with their preoperative corresponding data (all p < 0.001) CONCLUSION: Inserting lateral mass screw following this new strategy is safe and easy to perform without any screw-related neurovascular complications, which contribute to the rigid fixation of the subaxial cervical spine and the satisfactory functional recovery.

Smith-Robinson procedure with and without Caspar plating as a treatment for cervical spondylotic myelopathy: A 26-year follow-up of 23 patients

PURPOSE

The purpose of this study was to assess long-term follow-up data after anterior cervical decompression and fusion (ACDF) with and without Caspar plating (ACDF + PS) for the treatment of cervical spondylotic myelopathy (CSM) with special focus on functional outcome, pain, and repeat surgery for adjacent segment disease (ASD).

METHOD

Hospital records of 45 patients who were affected by CSM and underwent ACDF or ACDF + PS at least 17 years ago were reviewed. Information about diagnosis, surgical report, pre- and postoperative clinical process, and complications was analyzed. Clinical outcome was assessed using a standardized questionnaire including the Neck Disability Index (NDI), modified JOA-score, Odom's criteria, limitations in quality of life, and questions about the current neurological status and pain.

RESULTS

Twenty-three patients with a mean follow-up of 26 years were evaluated. ACDF was performed in nine and ACDF + PS in 14 patients, respectively. At follow-up 78.3% of patients were free of pain, 91.3% had no motor deficit, 73.9% had no sensory deficit, and 60.7% had no gait disturbance. The current mean NDI is 14% (range 2-44%), the mean modified JOA-score was 17.2 (range 15-18). According to Odom's criteria 78.3% of patients had clinical success. In four patients repeat surgery was indicated due to pseudarthrosis or symptomatic ASD (17.4%).

CONCLUSIONS

ACDF and ACDF + PS yield significant decrease in neck pain, a significant increase in sensorimotor function and a high rate of clinical success. Patients with preoperative gait disturbance completely recovered in about 60% of cases. Overall prevalence for ASD was 17.4% after 25 years.

Complication and Reoperation Rates Following Surgical Management of Cervical Spondylotic Myelopathy in Medicare Beneficiaries

STUDY DESIGN

Retrospective database review.

OBJECTIVE

To compare complication and reoperation rates after anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCFs), and anterior cervical corpectomy and fusion (ACCF) for cervical spondylotic myelopathy (CSM) using a large national database of Medicare beneficiaries.

SUMMARY OF BACKGROUND DATA

CSM is the most common cause of myelopathy in patients over 55 years and is considered the most common cause of spinal cord dysfunction in the world. Surgical treatment includes ACDF, PCF, or ACCF procedures.

METHODS

The PearlDiver database (2005-2012) was utilized to determine revision rates after surgical treatment of CSM by one of the aforementioned surgical treatments. Specifically, 1 to 2 level ACDF, ACCF, and PCF and 3+ level PCF cohorts were included. Each cohort was stratified by the age of 65 years. Survivorship curves were graphed and compared.

RESULTS

Of the patients younger than 65 years of age, there were 10,557 patients treated with 1 to 2 level ACDF procedures, 1319 patients with 1 to 2 level PCF procedures, 1203 patients with 1 to 2 level ACCF procedures, and 2312 patients treated with 3+ level PCF procedures. Of the elderly patients, 24,310 patients were treated with 1 to 2 level ACDFs, 4776 with 1 to 2 level PCF procedures, 3109 with 1 to 2 level ACCFs, and 7760 with 3+ level PCFs. Patients younger than 65 years of age were significantly more likely to have a reoperation procedure, than those 65 years or older when analyzing ACCF, ACDF, and 3+ level PCF procedures. ACCFs were significantly more likely than ACDFs to require reoperation. Patients treated with PCF were consistently more likely to have nondysphagia-related complications than those treated with ACDF. Rates of transfusion, dysphagia, and hematoma/seroma formation were significantly increased with ACCF compared with ACDF within the elderly population.

CONCLUSION

The elderly are significantly less likely to have a revision surgery after surgical treatment for CSM. Patients treated with ACCF are more likely to need a revision than those treated with ACDF.

LEVEL OF EVIDENCE

3.

Is there a relationship between psychological stress or anxiety and chronic nonspecific neck-arm pain in adults? A systematic review and meta-analysis

PURPOSE

To systematically review and analyze the research evidence linking stress or anxiety to chronic nonspecific neck-arm pain (NSNAP) in adults.

SUBJECTS AND METHODS

Data were obtained from Pubmed, Scopus, PsycInfo, Web of Science, Physiotherapy Evidence Database (PEDro) and The Cochrane library database from their inception to July 2015. Two authors independently conducted the searches, extracted data, and completed methodological quality assessments. The methodological quality of the cohort and case-control studies was evaluated using the Newcastle-Ottawa scale, whilst the quality of the Randomized Controlled Trial (RCT) was evaluated using the PEDro scale.

RESULTS

Twenty-eight studies involving 39,166 participants met the inclusion criteria. Four studies, including 5 pair-wise comparisons, were included in the meta-analysis: Three were cohort studies and 1 was a cross-sectional study. The meta-analysis outcome demonstrated a relationship between chronic NSNAP and psychological stress. The estimate odds ratio for all studies combined was 2.33 (95% CI, 1.04-5.18; p=0.039). A high heterogeneity of the findings appeared (Q=28.94, I²=86% p=0.00).

CONCLUSION

This study shows that there is a strong relationship between stress and chronic NSNAP. Despite this finding, we cannot support that stress is a risk factor for chronic NSNAP due to the low quality of the results according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). It was not possible to make a quantitative analysis comparing the relationship between anxiety and chronic NSNAP. However, according to the qualitative analysis there is a strong relationship between anxiety and chronic NSNAP.

Degenerative cervical myelopathy

Cervical myelopathy is the most common cause of acquired spinal cord compromise. The concept of degenerative cervical myelopathy (DCM), defined as symptomatic myelopathy associated with degenerative arthropathic changes in the spine axis, is being introduced. Given its progressive nature, treatment options have to be chosen in a timely manner. Surgical options include anterior discectomy and fusion (ACDF), anterior corpectomy and fusion (ACCF), arthroplasty (in highly select cases), posterior laminectomy with/without fusion, and laminoplasty. Indications for each should be carefully considered in individual patients. Riluzole, a sodium-glutamate antagonist, is a promising option to optimize neurologic outcomes post-surgery and is being examined in the CSM-Protect Randomized Controlled Trial. Preoperative risk assessment is mandatory for prognostication. Sagittal alignment is known to play an important role to optimize surgical outcome. Guidelines for optimal management of DCM are in process. In principle, all but the mildest cases of DCM should be offered surgery for optimal outcome.

Comparison of anterior decompression and fusion versus laminoplasty in the treatment of multilevel cervical ossification of the posterior longitudinal ligament: a systematic review and meta-analysis

Purpose

A meta-analysis was conducted to evaluate the clinical outcomes, complications, reoperation rates, and late neurological deterioration between anterior decompression and fusion (ADF) and laminoplasty (LAMP) in the treatment of multilevel cervical ossification of the posterior longitudinal ligament (OPLL).

Methods

All related studies published up to August 2015 were acquired by searching PubMed and EMBASE. Exclusion criteria were case reports, revision surgeries, combined anterior and posterior surgeries, the other posterior approaches including laminectomy or laminectomy and instrumented fusion, non-English studies, and studies with quality assessment scores of <7. The main end points including Japanese Orthopedic Association (JOA) score, recovery rate of JOA, cervical lordosis, complication rate, reoperation rate, and late neurological deterioration were analyzed. All available data was analyzed using RevMan 5.2.0 and Stata 12.0.

Results

A total of seven studies were included in the meta-analysis. The mean surgical level of ADF was 3.1, and the mean preoperative occupation ratios of ADF and LAMP group were 55.9% and 51.9%, respectively. No statistical difference was observed with regard to preoperative occupation ratio and preoperative JOA score. Although LAMP group had a higher preoperative cervical lordosis than ADF group (P<0.05, weighted mean difference [WMD] =−5.73, 95% confidence interval [CI] =−9.67–−1.80), significantly decreased cervical lordosis was observed in LAMP group after operation. ADF group had higher postoperative JOA score (P<0.05, WMD =2.18, 95% CI =0.98–3.38) and neurological recovery rate (P<0.05, WMD =27.22, 95% CI =15.20–39.23). Furthermore, ADF group had a lower late neurological deterioration rate than the LAMP group (P<0.05, risk difference =0.16, 95% CI =0.04–0.73). The complication rates of both groups had no statistical difference. However, LAMP group had a significantly lower reoperation rate than ADF group. The reoperation rate of ADF group (20.5%) was almost six times that of LAMP group (3.5%).

Conclusion

Our meta-analysis suggested that ADF was associated with better postoperative neurological function, neurological recovery rate, and less late neurological deterioration than LAMP in the treatment of multilevel cervical OPLL with a high mean occupation ratio. LAMP was associated with a decreased postoperative cervical lordosis, which might be a cause of late neurological deterioration. The complication rates of both groups showed no statistical difference. However, the reoperation rate was significantly higher in ADF group compared with LAMP group. Benefits and risks should be balanced when ADF or LAMP is selected.

Long-Term Outcomes of Cervical Laminoplasty in the Elderly

Incidences of cervical laminoplasty in the elderly are increasing; the influence of other age-related complications and neurological status must be considered for justifying surgery. This study identified the aforementioned influence on long-term outcomes of cervical laminoplasty in patients aged ≥75 years. Thirty-seven of 38 consecutive patients aged ≥75 years who underwent cervical laminoplasty were retrospectively evaluated. Minimum 5-year follow-up was acceptable if patients were complication-free. Follow-up was terminated when neurological evaluation was not possible, owing to death or other serious complications affecting activities of daily living (ADL). Postoperative neurological changes and newly developed severe complications were investigated. Postoperatively, one patient died of acute pneumonia, one remained nonambulatory owing to cerebral infarction, and 35 were ambulatory and were discharged. At a mean follow-up of 78 months, three patients died and nine developed serious complications severely affecting ADL. Of the 25 remaining patients, 23 remained ambulatory at mean follow-up of 105 months. Cox proportional hazard analysis revealed that postoperative motor upper and lower extremities JOA scores of ≤2 and ≤1, respectively, were risk factors for mortality or other severe complications. Postoperative neurological status can be maintained in the elderly if they remain complication-free. Poorer neurological status significantly affected their ADL and mortality.