Single-blinded prospective randomized study comparing open versus needle technique for obtaining autologous cancellous bone from the iliac crest

Mesh cage reconstruction with autologous cancellous graft in anterior cervical discectomy and fusion

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To present the technique and results of anterior cervical discectomy and fusion (ACDF) by using mesh cage reconstruction with autologous cancellous bone graft.

BACKGROUND

Since the initial ACDF description by Bailey and Badgley, a variety of grafting techniques have been proposed. The primary disadvantage of autologous bone grafting is donor site pain when compared with allograft. However, autologous bone graft still remains the standard and cancellous bone retrieval through a cortical window minimizes subperiosteal stripping. This may improve donor site morbidity while providing the advantages of autologous bone graft.

METHODS

Thirty-seven patients who had undergone ACDF with cancellous bone graft by using mesh cages and anterior plating with at least 6 months follow-up were reviewed. All patients had autologous cancellous bone graft harvested through a cortical window with limited subperiosteal striping. Bone graft was then packed into and around a titanium mesh cage that furnishes structural support.

RESULTS

The principal diagnosis was radiculopathy in 30 patients, myeloradiculopathy in 2 patients, instability in 3 patients, and kyphosis in 2 patients. Sixty-four levels were fused: one 4-level fusion, eight 3-level fusions, eight 2-level fusions, and twenty 1-level fusions. All patients demonstrated improved neurologic function and resolution of preoperative pain postoperatively. The donor site for cancellous bone was the iliac crest in 33 patients and the manubrium in 4 patients. Perioperative donor site pain was absent in 35 of 38 patients by 6 weeks with resolution of donor site pain by 3 months in all patients. At most recent follow-up, no patients had donor site pain, no instrumentation failure, and no wound complications. Sixty-three of 64 (98.4%) of cervical segments fused. One pseudoarthrosis occurred in an attempted 4-level fusion, which fused after a second operation.

CONCLUSIONS

Autologous bone grafting with mesh cage reconstruction is an acceptable alternative to autologous tricortical structural graft or allograft with reduced donor site pain and excellent biologic arthrodesis.

Long-term outcome after anterior cervical discectomy without fusion

To retrospectively study the long-term outcome of patients after anterior cervical discectomy without fusion (ACD) compared to results published on the long-term outcome after ACD with fusion (ACDF). We reviewed the charts of all patients receiving ACD surgery between 1985 and 2000 to analyze the direct post-operative results as well as complications of the surgery. Moreover, 102 patients, randomly selected, were interviewed with the neck disability index to study possible persisting complaints up to 18 years after ACD surgery. A total of 551 Patients were identified. Two months post-operative follow up at the outpatient clinic revealed that 90.1% of patients were satisfied with the result of ACD surgery. At the time of the survey, this percentage had dropped to 67.6%. In addition, 20.6% and 11.8% had obtained moderate to severe complaints, respectively, in daily-life activities. Complaints were mainly localized in the neck region and occasionally provoked radiating pain in the arm. On the short term, ACD leads to a satisfied outcome. Over the longer term, patients report increasing complaints. The increase in complaints at the time of the survey may be the result of ongoing degenerative effects. Compared to published data on ACDF, there is no superiority of any fusion technique compared to ACD alone.

Design of the PROCON trial: a prospective, randomized multi-center study comparing cervical anterior discectomy without fusion, with fusion or with arthroplasty

BACKGROUND

PROCON was designed to assess the clinical outcome, development of adjacent disc disease and costs of cervical anterior discectomy without fusion, with fusion using a stand alone cage and implantation of a Bryan's disc prosthesis. Description of rationale and design of PROCON trial and discussion of its strengths and limitations.

METHODS/DESIGN

Since proof justifying the use of implants or arthroplasty after cervical anterior discectomy is lacking, PROCON was designed. PROCON is a multicenter, randomized controlled trial comparing cervical anterior discectomy without fusion, with fusion with a stand alone cage or with implantation of a disc. The study population will be enrolled from patients with a single level cervical disc disease without myelopathic signs. Each treatment arm will need 90 patients. The patients will be followed for a minimum of five years, with visits scheduled at 6 weeks, 3 months, 12 months, and then yearly. At one year postoperatively, clinical outcome and self reported outcomes will be evaluated. At five years, the development of adjacent disc disease will be investigated.

DISCUSSION

The results of this study will contribute to the discussion whether additional fusion or arthroplasty is needed and cost effective.

Subsidence of Stand-alone Cervical Carbon Fiber Cages

OBJECTIVE:

To investigate the number of subsidences of inserted cervical carbon fiber cages and to define predictive factors for subsidence.

METHODS:

All patients treated for a cervical herniated disc and fusion with a cervical carbon fiber cage between January 2002 and December 2003 were retrospectively identified. The radiological examinations were reviewed, and, especially, the presence of subsidence was noted. Possible predictive factors for subsidence were determined before the investigation.

RESULTS:

In 69 patients, there were 96 cages inserted, of which 29.2% subsided. Of all factors investigated, only smoking seemed to be predictive for subsidence, whereas insertion at C6 to C7 clearly had a higher risk at subsidence. Subsidence was not related to outcome or fusion.

CONCLUSION:

Although the high number of subsidence of cages has never been described before, clinical outcome and fusion rate is comparable with the literature.