Comparative analysis of complications of different reconstructive techniques following anterior decompression for multilevel cervical spondylotic myelopathy

A Meta-Analysis of Surgical Outcomes in 25727 Patients Undergoing Anterior Cervical Discectomy and Fusion or Anterior Cervical Corpectomy and Fusion for Cervical Deformity

STUDY DESIGN

Systematic Review.

OBJECTIVES

To evaluate which cervical deformity correction technique between anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) produces better clinical, radiographic, and operative outcomes.

METHODS

We conducted a meta-analysis comparing studies involving ACDF and ACCF. Adult patients with either original or previously treated cervical spine deformities were included. Two independent reviewers categorized extracted data into clinical, radiographic, and operative outcomes, including complications. Clinical assessments included patient-reported outcomes; radiographic evaluations examined C2-C7 Cobb angle, T1 slope, T1-CL, C2-7 SVA, and graft stability. Surgical measures included surgery duration, blood loss, hospital stay, and complications.

RESULTS

26 studies (25727 patients) met inclusion criteria and were extracted. Of these, 14 studies (19077 patients) with low risk of bias were included in meta-analysis. ACDF and ACCF similarly improve clinical outcomes in terms of JOA and NDI, but ACDF is significantly better at achieving lower VAS neck scores. ACDF is also more advantageous for improving cervical lordosis and minimizing the incidence of graft complications. While there is no significant difference between approaches for most surgical complications, ACDF is favorable for reducing operative time, intraoperative blood loss, and length of hospital stay.

CONCLUSIONS

While both techniques benefit cervical deformity patients, when both techniques are feasible, ACDF may be superior with respect to VAS neck scores, cervical lordosis, graft complications and certain perioperative outcomes. Further studies are recommended to address outcome variability and refine surgical approach selection.

Could the different surgical goals of fusion and non-fusion also be achieved in combination within the same patient? Clinical and radiological outcome of hybrid cervical spine surgery

PURPOSE

Hybrid cervical spine surgery (HS) is a novel surgical strategy wherein an artificial disc replacement is done with a cervical fusion nearby with a stand-alone titanium cage to combine the advantages in both procedures. The aim of this study was to evaluate interactions of these devices within the same patient, and to analyze, if the different goal of each implant is accomplished.

METHODS

Thirty-six patients were treated surgically within a non-randomized retrospective study framework with HS. Patients were examined preoperatively followed by clinical and radiological examination at least one year postoperative. Clinical outcome was detected with NDI, VAS arm/neck, pain self-assessment questionnaires and subjective patient satisfaction. Radiological assessments included RoM, segmental lordosis, cervical lordosis of C2-C7, subsidence, ap-migration and heterotopic ossifications (HO) at the cTDR levels.

RESULTS

Statistically significant improvement of all clinical scores was observed (NDI 37.5 to 5.76; VASarm 6.41 to 0.69; VASneck 6.78 to 1.48). Adequate RoM was achieved at cTDR levels. RoM in the ACDF levels was reduced statistically significant (p < 0.001), and solid fusion (> 2°) was achieved in all evaluated fusion level. Global lordosis (C2-C7) increased statistically significant (2.4° to 8.1°). Subsidence and HO at the cTDR levels did not occur.

CONCLUSIONS

HS results in preservation of the segmental motion in the cTDR and fast and solid fusion in the cage cohort simultaneously. Patient safety was proven. In carefully selected cases, HS is a safe and viable treatment option by choosing the right "philosophy" level per level.

Correlation of imaging characteristics of degenerative cervical myelopathy and the surgical approach with improvement for postoperative neck pain and neural function: a retrospective cohort study

Background

Complex degenerative cervical spondylotic myelopathy (DCM) is characterized by a variety of complex imaging features. The surgical method for DCM remains controversial. This study aimed to examine the correlation between the imaging characteristics of DCM with varying degrees of complexity and the surgical approach and clinical outcome.

Methods

A retrospective cohort study involving retrospective data collection was performed. A total of 139 patients with DCM who underwent surgery between January 2015 and January 2018 in the Orthopedics Department of Shanxi Bethune Hospital were divided into 3 groups according to the complexity of imaging features: 18 patients in the mild group, 66 patients in the moderate group, and 55 patients in the severe group. The Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) scores were used to compare the effects of neck pain and neural function prior to surgery according to the rate of improvement as of the last follow-up. Routine X-ray films were obtained at the follow-up of 3-6 months. The necessity of computed tomography (CT) and magnetic resonance imaging (MRI) examinations was determined based on clinical findings and X-ray images. Analysis of variance (ANOVA) was used to compare groups, the least significant difference (LSD) test was used for multiple comparisons, and the Chi-square test was used to compare classification indicators (imaging manifestations, gender), with P<0.05 being statistically significant. Binary logistic regression analysis was performed to determine the primary influencing factors of the JOA recovery rate.

Results

In all three groups, JOA and VAS scores at the final follow-up were significantly higher than those before surgery (P<0.001). There were significant differences in the preoperative VAS and JOA scores between any two groups, as well as in the VAS and JOA scores and improvement rates at the last follow-up between the mild group and the moderate group and between the mild group and the severe group (P<0.001). Age, preoperative JOA scores, MRI intramedullary hyperintensity signal, and the degree of spinal cord compression were primarily related to the nervous system recovery rate (P<0.001).

Conclusions

Age, MRI intramedullary hyperintensity signal, degree of spinal cord compression, and other variables were associated with the improvement of neural function in patients with DCM. Therefore, in addition to the JOA improvement rate or VAS score, additional factors, such as the patient's condition, the improvement in quality of life, and the patient's financial capacity, should be considered in evaluating the improvement of postoperative neck pain and neural function.

Comparison of Postoperative Complications and Outcomes in Anterior Cervical Spine Surgery: Ossification of the Posterior Longitudinal Ligament Versus Cervical Spondylotic Myelopathy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To compare the frequency of complications and outcomes between patients with ossification of the posterior longitudinal ligament (OPLL) of the cervical spine and those with cervical spondylotic myelopathy (CSM) who underwent anterior surgery.

SUMMARY OF BACKGROUND DATA

Anterior cervical spine surgery for OPLL is an effective surgical procedure; however, it is complex and technically demanding compared with the procedure for CSM. Few reports have compared postoperative complications and clinical outcomes after anterior surgeries between the 2 pathologies.

METHODS

Among 1434 patients who underwent anterior cervical spine surgery at 3 spine centers within the same spine research group from January 2011 to March 2021, 333 patients with OPLL and 488 patients with CSM were retrospectively evaluated. Demographics, postoperative complications, and outcomes were reviewed by analyzing medical records. In-hospital and postdischarge postoperative complications were investigated. Postoperative outcomes were evaluated 1 year after the surgery using the Japanese Orthopaedic Association score.

RESULTS

Patients with OPLL had more comorbid diabetes mellitus preoperatively than patients with CSM ( P <0.001). Anterior cervical corpectomies were more often performed in patients with OPLL than in those with CSM (73.3% and 14.5%). In-hospital complications, such as reoperation, cerebrospinal fluid leak, C5 palsy, graft complications, hoarseness, and upper airway complications, occurred significantly more often in patients with OPLL. Complications after discharge, such as complications of the graft bone/cage and hoarseness, were significantly more common in patients with OPLL. The recovery rate of the Japanese Orthopaedic Association score 1 year postoperatively was similar between patients with OPLL and those with CSM.

CONCLUSION

The present study demonstrated that complications, both in-hospital and after discharge following anterior spine surgery, occurred more frequently in patients with OPLL than in those with CSM.

No Difference in Two-Year Revisions Between Hybrid Fusion and Two-Level Anterior Discectomy and Fusion: A National Database Study

STUDY DESIGN

Retrospective Cohort.

OBJECTIVE

This study utilized a large national database to compare two-year revision rates, in addition to complications and costs, of hybrid surgery (HS) compared to two-level anterior cervical discectomy and fusion (ACDF).

METHODS

This study used the PearlDiver Mariner dataset selecting for patients aged 18 and older who had at least 90-day active longitudinal follow-up who underwent two-level ACDF or two-level Hybrid surgery (single level ACDF and single level CDA). Patients with prior spinal trauma, infection, cancer, or posterior fusion were excluded. Primary outcomes measures were 90-day major and minor medical complications, ED visits, readmissions, as well as two-year revisions. Patients were also assessed for postoperative dysphagia, incidental durotomy, vascular injury, 90-day surgical site, and implant complications. Additionally, hospitalization and postoperative costs were evaluated.

RESULTS

There were 4570 two-level ACDF surgeries and 888 hybrid surgeries. After matching the cohorts, no statistical differences in demographics were found. There were no differences in reoperation rates at all measured time points nor 2-year complications. HS had a lower incidence of major (1.6% vs 3.1%, P = .003) and minor complications (3.0% vs 4.6%, P = .009) than ACDF. 90-day readmission was lower in the HS cohort (2.8% vs 4.2%), P = .024. HS was associated with reduced hospitalization costs -$2614 (-$3916 to -$904, P < .001). 3516 patients had ACDF, and 699 had HS with at least 2 years of follow-up.

CONCLUSION

Hybrid surgery is a safe and effective surgical treatment for cervical disease in appropriately selected patients.

Surgical tactics of two-segmental cervical degenerative diseases: risk factors retrospective assessment and preoperative planning

Background

Currently, in the specialized literature there are no substantiated clinical and radiological indications for differentiated use of anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) in the treatment of patients with two-segmental cervical degenerative diseases. The objectives of this study were to (I) identify risk factors that were associated with unsatisfactory results of two-level ACDF and one-level ACCF in the treatment of patients with cervical degenerative diseases despite current perioperative management, and (II) develop a clinical and radiological algorithm for personalized surgical tactics.

Methods

We retrospectively identified risk factors for the development of unsatisfactory clinical postoperative results after two-level ACDF (n=81) and one-level ACCF (n=78), operated in the period of 2009-2019 for two-segmental cervical degenerative disease.

Results

Satisfactory clinical results after two-level ACDF were noted in cases with total kyphotic deformity of less than 15°; local kyphotic deformity less than 10˚; the absence of circumferential spondylotic cervical stenosis; the absence of a myelopathic lesion at the level of the vertebral body; absence of migrating intervertebral disk (IVD) hernia more than 1/3 of the vertebral body; T1 slope vertebra less than 15°; IVD degeneration according to Suzuki A. 0-II; facet joint (FJ) degeneration according to Okamoto A. I-III; interbody height (IH) more than 2 mm. Satisfactory clinical results after single-level ACCF were registered in cases with IVD degeneration according to Suzuki A. III; FJ degeneration according to Okamoto A. IV-V; IH 3 mm or less; regardless of the cervical lordosis, the angle of local kyphotic deformity and T1 slope, the presence of circumferential spondylotic cervical stenosis, the localization of the myelopathic lesion and the distance of migration IVD herniation.

Conclusions

Individual planning and differentiated implementation of ACDF and ACCF in patients with two-segmental cervical degenerative disease, taking into account a comprehensive preoperative clinical and radiological assessment, contributes to the effective elimination of existing neurological symptoms, reducing the intensity of neck pain and upper limbs pain, restoring the functional state and quality of patients' lives in the minimum 24 months postoperative period, as well as reducing the number of postoperative complications and reoperations.

Translation, Adaptation, and Validation of a Spanish Version of the Japanese Orthopaedic Association Cervical Myelopathy Questionnaire

STUDY DESIGN

Translation and psychometric testing of a questionnaire.

OBJECTIVE

Translation, adaptation, and validation of the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) to the Spanish language.

SUMMARY OF BACKGROUND DATA

Degenerative cervical myelopathy (DCM) has a clear impact on quality of life (QoL). The JOACMEQ is a self-administered questionnaire used to assess DCM-related disability and its impact on QoL. It is compound of five domains: Cervical Function, Upper Extremity Function, Lower Extremity Function, Blader Function, and QoL. Despite its increasing use, the JOACMEQ has not yet been translated and validated for Spanish-speaking patients.

METHODS

A total of 180 patients completed the Spanish version. Of these, 145 (80%) had DCM (mean age: 62.53; SD: 9.92), while 35 had neck pain without DCM (age: 52.71; SD: 10.29). The psychometric properties measured were construct validity, internal consistency, reproducibility, concurrent validity, and discriminatory ability.

RESULTS

We recruited 145 patients with DCM (mean age: 62.5) and 35 with cervical pain (mean age: 52.7). After factor analysis, our data showed very strong construct validity, with questions strongly loaded and clustered for five factors. Internal consistency proved high (Cronbach's α coefficient of 0.912). The intraclass correlation coefficient showed very good reproducibility for all domain (intraclass correlation coefficient range between 0.85 and 0.95). A high correlation between the JOACMEQ QoL domain and neck disability index was also found (Spearman's ρ=-0.847, P <0.01) confirming concurrent validity. The receiver operating characteristic curves proved to be significant in the upper (area under the curve=0.65, P =0.006) and lower (area under the curve=0.661, P =0.003) extremities, confirming discriminatory ability.

CONCLUSIONS

Our proposed Spanish version of the JOACMEQ retains the psychometric characteristics of the original JOACMEQ and could prove useful for the evaluation of patients with DCM in Spanish-speaking countries.

[Clinical outcomes of 3D-printing stand-alone artificial vertebral body in anterior cervical surgeries]

OBJECTIVE

To explore the short-term outcomes of 3D-printing stand-alone artificial vertebral body (AVB) in the surgical procedure of anterior cervical corpectomy and fusion (ACCF).

METHODS

Following the proposal of IDEAL (idea, development, exploration, assessment, and long-term follow-up) framework, we designed and conducted this single-armed, retrospective cohort study. The patients with cervical spondylotic myelopathy were recruited, and these patients exclusively received the surgical procedure of single-level ACCF in our single center. After the process of corpectomy, the size was tailored using different trials and the most suitable stand-alone AVB was then implanted. This AVB was manufactured by the fashion of 3D-printing. Two pairs of screws were inserted in an inclined way into the adjacent vertebral bodies, to stabilize the AVB. The participants were regularly followed-up after the operation. Their clinical data were thoroughly reviewed. We assessed the neurological status according to Japanese Orthopedic Association (JOA) scale. We determined the fusion based on imaging examination six months after the operation. The recorded clinical data were analyzed using specific software and they presented in suitable styles. Paired t test was employed in comparison analysis.

RESULTS

In total, there were eleven patients being recruited eventually. The patients were all followed up over six months after the operation. The mean age of the cohort was (57.2±10.2) years. The mean operation time was (76.1±23.1) min and the median bleeding volume was 150 (100, 200) mL. The postoperative course was uneventful for all the cases. Dysphagia, emergent hematoma, and deterioration of neurological function did not occur. Mean JOA scores were 13.2±2.2 before the operation and 16.3±0.8 at the final follow-up, which were significantly different (P < 0.001). The mean recovery rate of neurological function was 85.9%. By comparing the imaging examinations postoperatively and six months after the operation, we found that the average subsidence length was (1.2±1.1) mm, and that there was only one cases (9.1%) of the severe subsidence (>3 mm). We observed significant improvement of cervical lordosis after the operation (P=0.013). All the cases obtained solid fusion.

CONCLUSION

3D-printing stand-alone AVB presented favorable short-term outcome in one-level ACCF in this study. The fusion rate of this zero-profile prosthesis was satisfactory and the complication rate was relatively low.

Network Meta-Analysis of C5 Palsy After Anterior Cervical Decompression of Three to Six Levels: Comparing Three Different Procedures

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Using a network meta-analysis (NMA), this study aimed to compare the risks of C5 palsy after three different procedures of anterior cervical decompression.

SUMMARY OF BACKGROUND DATA

C5 palsy is a well-known complication affecting the quality of life after anterior procedures. Due to the limited evidence on the various procedures available, we evaluate the basis for selection to prevent palsy and achieve maximal decompression in cases spanning 3-6 levels.

MATERIALS AND METHODS

We conducted a comprehensive search for C5 palsy and complications after 3representative procedures, including anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and their combination (hybrid), involving 3 to 6 intervertebral levels. The incidence of C5 palsy was compared using a NMA.

RESULTS

We identified 1655 patients in 11 studies who met inclusion criteria. Sixty-nine patients (4.2%) developed delayed C5 palsies. The incidences among ACDF, ACCF, and hybrid cases were 2.3% (16/684, 95% CI: 1.4% to 3.8%), 6.4% (39/613, 95% CI: 4.7% to 8.6%), and 3.9% (14/358, 95% CI: 2.3% to 6.5%), respectively ( P < 0.01). A NMA was performed for 15 pairwise comparisons across the 3 procedure arms: ACDF versus hybrid, 7/232 (3.0%) versus 11/234 (4.7%); hybrid versus ACCF, 14/301 (4.3%) versus 18/224 (8.0%); ACCF versus ACDF, 38/523 (7.8%) versus 16/619 (2.6%). Compared with ACDF, the risk of C5 palsy was significantly higher in ACCF (odds ratio: 2.72, 95% CI: 1.47 to 5.01), whereas ACDF versus hybrid did not significantly differ in risk (odds ratio: 1.56, 95% CI: 0.68 to 3.60).

CONCLUSION

We determined that ACCF was associated with a higher risk of postoperative C5 palsy than ACDF in cases spanning 3 to 6 intervertebral levels. If practicable, ACDF surgery may be an appropriate choice for cases requiring anterior decompression of 3 to 6 levels.

LEVEL OF EVIDENCE

Level III.

Clinical and surgical results related to anterior-only multilevel cervical decompression and instrumented fusion for degenerative disease

Introduction

Anterior-only multilevel cervical decompression and fusion surgery (AMCS) on 3-5-levels is challenging due to potential complications. Also, outcome predictors after AMCS are poorly understood.

Research Question

We hypothesize that in patients with at most mild/moderate cervical kyphosis (CK) of the cervical spine, restoration of cervical lordosis (CL) positively influences clinical outcomes.

Methods

Analysis of consecutive patients presenting with symptomatic degenerative cervical disease or non-union undergoing AMCS. We measured CL from C2 to C7, Cobb angle of fused levels (fusion angle, FA), C7-Slope, and sagittal vertical axis C2-7 (cSVA, stratified into ≤4cm∖>4cm). Patients with excellent outcome were grouped in BEST-outcomes and with moderate/poor outcomes in WORST-outcomes.

Results

We included 244 patients. Fifty-four percent had 3-, 39% 4-level and 7% had 5-level fusion. At mean follow-up of 26 months, 41% of patients achieved BEST-outcome and 23% WORST-outcome. Complications and reoperation rates did not significantly differ. Non-union significantly influenced outcomes. The number of patients with non-union was significantly higher in patients with a preoperative cSVA>4cm (OR 13.1 (95%CI:1.8-96.8). Our model, based on the multivariable analysis with WORST-outcome as outcome variable showed a high accuracy (NPV=73%, PPV=77%, specificity=79%, sensitivity=71%).

Discussion and Conclusion

In 3-5-level AMCS, improvement of FA and cSVA were independent predictors of clinical outcome. Improvement of CL positively influenced clinical outcomes and rates of non-union.

Comparison of Two Anterior Reconstructive Techniques in the Treatment of 3-Level and 4 Level Cervical Spondylotic Myelopathy: A Meta-analysis of Last Decade

Study Design

A meta-analysis.

Objective

Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) are widely used in the treatment of cervical spondylotic myelopathy (CSM). However, the clinical outcomes and complications between ACDF and ACCF treating multi-level CSM remain poorly understood. Thus, we performed a meta-analysis to compare the clinical outcomes and complications of the two procedures in the treatment of 3-level and 4-level CSM.

Methods

An extensive search of the literature was performed in the English databases of PubMed, Embase, and Cochrane Library and the Chinese databases of CNKI and WANFANG. We collected factors, including demographic data, surgical factors, and complications. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

Results

Finally, 14 articles (5429 patients) were included in our study. No significant difference was found in preoperative and 3-month follow-up Japanese Orthopedic Association (JOA) scores, neck disability index, preoperative C2-C7, segmental angle, operation time, as well as the number of dysphagia, hoarseness, cerebral fluid leakage, infection, epidural hematoma, axial pain, hardware breakage, and pseudarthrosis between ACDF and ACCF. However, our findings showed that blood loss (P < 0.00001), the number of total complications (P < 0 .00001), C5 palsy (P = 0.0004), graft dislodgement (P = 0.02), graft subsidence (P = 0.0003), and revision surgery (P = 0.0008) in ACDF were significantly less than in ACCF. Additionally, postoperative and change of C2-C7 (P < 0.00001), segment angle (P < 0.00001), and fusion rate (P = 0.001) in ACDF were significantly higher than in ACCF. Post-operative JOA in ACDF was significantly higher than in ACCF (P = 0.02).

Conclusions

Although the clinical efficacy of both surgeries was similar, ACDF was superior to ACCF in the reconstruction of cervical lordosis and the number of complications in the treatment of 3-level and 4-level CSM.

Comparison of Complications between Anterior Cervical Diskectomy and Fusion versus Anterior Cervical Corpectomy and Fusion in Two- and Three-Level Cervical Spondylotic Myelopathy: A Meta-analysis

BACKGROUND

 In this study, we systematically analyze the differences in complications between anterior cervical diskectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) in two- and three-level cervical spondylotic myelopathy (CSM).

METHODS

 We performed a systematic search in MEDLINE, EMBASE, PubMed, Web of Science, Cochrane databases, Chinese Biomedical Literature Database, CNKI, and Wan Fang Data for all relevant studies. All statistical analyses were performed using Review Manager version 5.3.

RESULTS

 A total of 11 articles with 849 study subjects were included, with 474 patients in the ACDF group and 375 patients in the ACCF group. The results of the meta-analysis showed that in C5 palsy (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.16-1.06), pseudarthrosis (OR: 1.07; 95% CI: 0.23-5.07), dysphagia (OR: 1.06; 95% CI: 0.60-1.86), infection (OR: 0.41; 95% CI: 0.16-1.09), cerebrospinal fluid leakage (OR: 1.21; 95% CI: 0.39-3.73), graft dislodgment (OR: 0.28; 95% CI: 0.06-1.37), and hematoma (OR: 0.32; 95% CI: 0.06-1.83), there are no significant differences between the ACDF and ACCF groups, whereas total complication (OR: 0.50; 95% CI: 0.31-0.80) showed that the ACDF group had a significantly lower morbidity than the ACCF group. Furthermore, the three-level subgroup of ACDF had significantly better results in C5 palsy (OR: 0.31; 95% CI: 0.11-0.88), infection (OR: 0.22; 95% CI: 0.05-0.94), graft dislodgment (OR: 0.07; 95% CI: 0.01-0.40), and total complication (OR: 0.37; 95% CI: 0.23-0.60) compared with the ACCF subgroup.

CONCLUSION

 In general, postoperative pseudarthrosis, dysphagia, cerebrospinal fluid leakage, hematoma, C5 palsy, infection, and graft dislodgment did not differ significantly between the two groups. Total complication was significantly less in the ACDF group compared to the ACCF group. In the three-level subgroup, the morbidity of C5 palsy, infection, and graft dislodgment was significantly lower in ACDF than in ACCF.

Anterior Canal Reconstruction and Fusion for Myelopathy Caused by Degenerative Cervical Kyphosis and Stenosis With or Without Ossification of the Posterior Longitudinal Ligament

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

To introduce an anterior surgical technique for myelopathy caused by degenerative cervical kyphosis and stenosis (DCKS) with or without ossification of the posterior longitudinal ligament (OPLL).

SUMMARY OF BACKGROUND DATA

The optimal approach in the treatment of DCKS remains a controversy because each anterior or posterior route surgery has advantages and disadvantages.

MATERIALS AND METHODS

In the period from June 2017 through June 2019, a consecutive cohort of adults diagnosed with DCKS underwent anterior canal reconstruction and fusion (ACRF). All patients underwent x-ray, computed tomography, and magnetic resonance imaging of the cervical spine. Radiologic assessment included kyphosis, canal area, canal reconstruction, OPLL, and spinal cord curvature and morphology. The Japanese Orthopaedic Association (JOA) scoring system was used to evaluate the neurological status. Surgery-related and implant-related complications were all recorded. Follow-up was carried out at 3, 6, 12, 24, and 36 months postoperation.

RESULTS

Fourty-one patients were included in the study, of which 19 presented with OPLL. Postoperatively, the canal area were significantly greater at last follow-up compared with preoperation (208.4 vs. 123.2 mm2; P=0.001). There was significant kyphosis correction (-17.6 vs. 8.5 degrees, P=0.001) at last follow-up. Ninety-six segmental canal reconstruction were performed, 89 (92.7%) reached bone fusion at both grooves with a mean time of 7.9 months. On sagittal magnetic resonance imaging, 33 (80.5%) patients presented with lordosis in the spinal cord curvature, 8 (19.5%) with straight. The mean JOA score at last follow-up was significantly better than preoperation (15.0 vs. 9.3 points; P<0.01). One patient presented with cerebrospinal fluid leakage, 1 with screw displacement and 2 with dysphagia.

CONCLUSION

ACRF, receiving good correction of kyphosis, amplified canal area, solid instrumented fusion and circumferential decompression, is an effective and safe surgical technique for cervical myelopathy caused by DCKS with or without OPLL.

LEVEL OF EVIDENCE

Level III-a retrospective analysis.

Risk Factors and Prevention of C5 Palsy After Anterior Cervical Decompression and Fusion: Similarity of the Pathomechanism With That After a Posterior Approach

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

The objective of this study was to review clinical and imaging findings after anterior cervical decompression and fusion, as a basis for prevention of C5 palsy.

SUMMARY OF BACKGROUND DATA

C5 palsy is a common postoperative complication in spine surgery, but the mechanistic basis for this condition is unknown.

MATERIALS AND METHODS

The subjects were 239 patients with cervical myelopathy who underwent anterior cervical decompression and fusion including at C4-C5 disk level at our hospital from 2001 to 2018. Twelve of these patients (5.0%) had C5 palsy postoperatively. Clinical features and imaging findings were compared in patients with and without C5 palsy.

RESULTS

In patients with C5 palsy, the sagittal alignment of the cervical spine was kyphotic, the width of the C5 intervertebral foramen was narrower, and the lateral decompressed line was wider beyond the medial part of the Luschka joint. Age, sex, disease, the number of fused segments, decompression width, and anterior shift of the spinal cord did not differ significantly between patients with and without C5 palsy.

CONCLUSIONS

These results indicate that the pathomechanism of C5 palsy may be dependent on the location of the lateral decompression line, especially in patients with cervical kyphosis and a narrow C5 intervertebral foramen. Excessive lateral decompression beyond the Luchka joint might lead to C5 root kinking between the intervertebral foramen and posterior edge of vertebra. This pathomechanism may be similar in anterior and posterior approaches. To prevent C5 palsy, the medial line of the Luschka joint should be confirmed intraoperatively and decompression should be performed within the Luschka joints. Alternatively, medial foraminotomy should be used in cases needing wide decompression, such as those with massive ossification of the posterior longitudinal ligament, lateral osteophytes, and symptomatic foraminal stenosis.

LEVEL OF EVIDENCE

Level III.

Long Segment Anterior Cervical Discectomy and Fusion, Including C2: Surgical Pearls and Review of Our Experience

STUDY DESIGN

A retrospective study of thirteen patients undergoing 5-level anterior spinal surgery for cervical myelopathy.

OBJECTIVE

While limited literature exists in reviewing the treatment of high cervical pathology extending caudally, we believe long segment surgery beginning at C2-3 can be accomplished with good success and is an option more patients may benefit from. We aim to describe the technique in accessing the C2-C3 disk space and efficacy of treating multilevel disease beginning at the C2 vertebral body. This includes an extensive technical report and surgical pearls.

SUMMARY OF BACKGROUND DATA

Compression at the level of C2 can be daunting to access because of steep approach required. Few studies have described the technique in reaching the C2 level, with less information describing the efficacy of a 5-level anterior fusion starting at C2.

METHODS

Patients who underwent surgery between 2000 and 2016 were identified utilizing the department billing database and ICD codes. Patients age, operative indications, levels treated, length of hospital stay, fusion outcome, and operative complications were explored. Independent analysis of fusion was performed.

RESULTS

The average length of hospital stay was 3.9 days. Eight patients reported significant improvement of hand weakness, numbness, and/or gait at 6 months follow-up. The most frequent complication was dysphagia (23%). One patient experienced recurrent symptoms secondary to nonunion, and another patient suffered a postoperative neurological worsening because of anterior spinal artery syndrome.

CONCLUSION

This retrospective review discusses the technique to visualize and fully decompress C2-C3 spinal segments. In addition, we explored the efficacy and perioperative risk in long segment anterior cervical discectomy and fusion.

Anterior Cervical Corpectomy with Fusion versus Anterior Hybrid Fusion Surgery for Patients with Severe Ossification of the Posterior Longitudinal Ligament Involving Three or More Levels: A Retrospective Comparative Study

Various studies have found a high incidence of early graft dislodgement after multilevel corpectomy. Although a hybrid fusion technique was developed to resolve implant failure, the hybrid and conventional techniques have not been clearly compared in terms of perioperative complications in patients with severe ossification of the posterior longitudinal ligament (OPLL) involving three or more levels. The purpose of this study was to compare clinical and radiologic outcomes between anterior cervical corpectomy with fusion (ACCF) and anterior hybrid fusion for the treatment of multilevel cervical OPLL. We therefore retrospectively reviewed the clinical and radiologic data of 53 consecutive patients who underwent anterior fusion to treat cervical OPLL: 30 underwent ACCF and 23 underwent anterior hybrid fusion. All patients completed 2 years of follow-ups. Implant migration was defined as subsidence > 3 mm. There were no significant differences in demographics or clinical characteristics between the ACCF and hybrid groups. Early implant failure occurred significantly more frequently in the ACCF group (5 cases, 16.7%) compared with the hybrid group (0 cases, 0%). The fusion rate was 80% in the ACCF group and 100% in the hybrid group. Although both procedures can achieve satisfactory neurologic outcomes for multilevel OPLL patients, hybrid fusion likely provides better biomechanical stability than the conventional ACCF technique.

Three-Staged Surgical Strategy as a Combined Approach for Multilevel Cervical Pyogenic Spondylodiscitis

Cervical pyogenic spondylodiscitis is rare but can lead to severe clinical problems that often require aggressive surgical treatment for neurological deterioration and life-threatening conditions. Although combined surgical procedures are often utilized to treat multilevel cervical regions, there is a clinical debate regarding the appropriate order and timing of surgeries using the anterior and posterior approaches. Here, we report a case of severe multilevel cervical pyogenic spondylodiscitis treated using a three-staged surgical strategy consisting of cervical laminectomy, posterior fixation, and anterior corpectomy and fusion with an autologous long bone graft; the outcome was quite favorable. Our report demonstrates the safety and usefulness of three-staged surgery in the multilevel cervical region, especially under urgent situations.

Hybrid Anterior Cervical Discectomy and Fusion and Cervical Disc Arthroplasty: An Analysis of Short-Term Complications, Reoperations, and Readmissions

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Although cervical disc arthroplasty (CDA) has become a well-established and effective treatment for symptomatic cervical degeneration, many patients with multilevel disease are not good candidates for CDA at all levels. For such patients, hybrid surgery (HS)-a combination of adjacent anterior cervical discectomy and fusion (ACDF) and CDA-may be more appropriate. Given the novelty of HS and the relative dearth of studies adequately assessing short-term perioperative complications, this current study sought to assess the short-term morbidity profile of HS, differences in operative duration, length of stay (LOS), and readmission and reoperation rates and reasons relative to a 2-level ACDF cohort.

METHODS

All patients who underwent HS and 2-level ACDF were identified between 2011 and 2018 using a large, prospectively collected registry. Baseline patient characteristics and postoperative complications were compared using bivariate and/or multivariate analysis.

RESULTS

A total of 390 patients undergoing HS were identified. Two-level procedures were the most common (74.9%). Patients undergoing HS were more likely to be younger, male, and have fewer comorbidities. There were no differences between HS and 2-level ACDF in rates of any postoperative complication, transfusion, readmissions, and operative duration. However, HS had a decreased LOS (0.5 days), relative to a 2-level ACDF. HS patients had low rates of reoperation (1.28%) with 1 case for hematoma evacuation and another for revision CDA.

CONCLUSIONS

This study represents one of the largest cohorts of patients undergoing HS reported to date. Patients undergoing HS are not at increased risk of perioperative complications relative to a 2-level ACDF and may benefit from shorter LOS.

Nerve Transfers After Cervical Spine Surgery: Multi-Institutional Case Series and Review of the Literature

BACKGROUND

Up to 10% of cervical spine surgeries are complicated by postoperative weakness. Although many patients recover with nonoperative management, some require surgery for restoration of function.

OBJECTIVE

To present the indications and outcomes of patients undergoing nerve transfers after developing weakness secondary to cervical spine decompression.

METHODS

A retrospective review of patients from 2 academic medical centers who underwent nerve transfer for C5-6 root injury after cervical spine surgery was performed.

RESULTS

Of the 10 treated patients, 9 experienced recovery at last follow-up, demonstrating improvements in strength and motion in the affected muscles. Successful nerve transfers occurred between 3 and 8 months after the index spinal surgery and included spinal accessory nerve to suprascapular nerve, triceps branch to anterior division of the axillary nerve, and/or ulnar or median fascicles to motor branches of the musculocutaneous nerve. The unsuccessful patient underwent nerve transfer surgery approximately 11 months after the index operation and failed to obtain functional recovery.

CONCLUSIONS

Patients who experience C5-6 weakness after cervical spine surgery should be evaluated and considered for nerve transfer surgery if they have continued severe functional deficits at 6 months postoperatively. Earlier referral for nerve transfer is associated with improved functional outcomes in this cohort.

Fusion and subsidence rates of vertebral body sliding osteotomy: Comparison of 3 reconstructive techniques for multilevel cervical myelopathy

BACKGROUND CONTEXT

Vertebral body sliding osteotomy (VBSO) was previously reported as a technique to decompress spinal canal by translating the vertebral body anteriorly and is indicated for cervical myelopathy caused by spondylosis or ossification of the posterior longitudinal ligament. However, little is known about its fusion and subsidence rates.

PURPOSE

To compare the fusion and subsidence rates of VBSO, anterior cervical discectomy and fusion (ACDF), and anterior cervical corpectomy and fusion (ACCF).

STUDY DESIGN/SETTING

Retrospective cohort study PATIENT SAMPLE: One hundred sixty-eight patients who underwent VBSO, ACDF, or ACCF for the treatment of cervical myelopathy and were followed-up for more than 2 years were retrospectively reviewed.

OUTCOME MEASURES

Fusion and subsidence rates, visual analog scale (VAS) scores for neck pain, neck disability index (NDI), and Japanese Orthopaedic Association (JOA) scores were assessed.

METHODS

Results of the VBSO, ACDF, and ACCF groups were compared using Student's t-test and chi-square test.

RESULTS

The fusion rate at 1-year postoperatively and the final follow-up for VBSO was 92.9% (37/42). VBSO demonstrated a higher 1-year fusion rate than ACDF (77.9% [74/95], p=0.04) and ACCF (74.2% [23/31], p=0.04). However, the fusion rate at the final follow-up did not demonstrate significant difference. The mean amount of subsidence (ACDF group, 1.5±1.2 mm; VBSO group, 1.5±1.5 mm; p=1.00) and rate of significant subsidence of > 3 mm (ACDF group, 13.7% [13/95]; VBSO group, 14.3% [6/42]; p=1.00) were similar for ACDF and VBSO. Furthermore, the mean amount of subsidence in VBSO was significantly less than that in ACCF (1.5±1.5 mm vs 2.4±2.0 mm; p=0.04). Neck pain VAS, NDI, and JOA scores were not significantly different among the groups.

CONCLUSIONS

VBSO demonstrated faster solid union than ACDF and ACCF, although the fusion rates at the final follow-up were similar. VBSO resulted in less subsidence than ACCF at the 1-year follow-up. VBSO could be applied safely when the shape and/or location of the pathologic foci and sagittal alignment favor its application without much concern for pseudarthrosis or subsidence.

A biomechanical analysis of four anterior cervical techniques to treating multilevel cervical spondylotic myelopathy: a finite element study

BACKGROUND

The decision to treat multilevel cervical spondylotic myelopathy (MCSM) remains controversial. The purpose of this study is to compare the biomechanical characteristics of the intervertebral discs at the adjacent segments and internal fixation, and to provide scientific experimental evidence for surgical treatment of MCSM.

METHODS

An intact C2-C7 cervical spine model was developed and validated. Four additional models were developed from the fusion model, including multilevel anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), hybrid decompression and fusion (HDF), and mACDF with cage alone (mACDF-CA). Biomechanical characteristics on the plate and the disc of adjacent levels (C2/3, C6/7) were comparatively analyzed.

RESULTS

Of the four models, stress on the upper (C2/3) adjacent intervertebral disc was the lowest in the mACDF-CA group and highest in the ACCF group. Stress on the intervertebral discs at adjacent segments was higher for the upper C2/3 than the lower C6/7 intervertebral disc. In all models, the mACDF-CA group had the lowest stress on the intervertebral disc, while the ACCF group had the highest stress. In the three surgical models with titanium plate fixation (mACDF, ACCF, and HDF), the ACCF group had the highest stress at the titanium plate-screw interface, while the mACDF group had the lowest stress.

CONCLUSION

Among the four anterior cervical reconstructive techniques for MCSM, mACDF-CA makes little effect on the adjacent disc stress, which might reduce the incidence of adjacent segment degeneration (ASD) after fusion. However, the accompanying risk of the increased incidence of cage subsidence should never be neglected.

Comparison of Clinical Outcomes and Sagittal Alignment After Different Levels of Anterior Cervical Discectomy and Fusion in Patients With Cervical Spondylotic Myelopathy: From One-level to Three-level

STUDY DESIGN

A nonrandomized and prospective study.

OBJECTIVE

The aim of this study was to compare clinical outcomes and sagittal alignment after one-level, two-level, and three-level anterior cervical discectomy and fusion (ACDF) in patients with cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

ACDF is a widely used surgical approach for CSM. It remains controversial regarding to whether corrected lordosis can be maintained over time after different levels ACDF.

METHODS

A total of 175 patients with cervical spondylotic myelopathy who underwent ACDF were enrolled in this retrospective study. The neurofunctional assessment was performed with the Japanese Orthopedic Association (JOA) score and the recovery rate of JOA score. Radiographic parameters included C2-C7 lordosis, fused segments lordosis, T1 slope, the cervical sagittal vertical axis (cSVA).

RESULTS

Patients with more fusion levels had more operative time and blood loss and higher rate of complications. All patients showed a larger cervical lordosis than that preoperatively and the restored lordosis increased with more segments involved. The restored lordosis had little change during the whole follow-up in one-level and two-level group. CL decreased from 25.65 ± 9.31° on the third postoperative day to 20.25 ± 10.03° at the final follow-up in three-level group (P = 0.001). Only T1 slope in three-level increased significantly from preoperative 26.55 ± 9.36° to 29.06 ± 7.54° on the third postoperative day (P = 0.011) and decreased to 26.89 ± 7.22° (P = 0.043) at final follow-up. The JOA score all increased significantly at the last follow-up in each group, but the recovery rate of the JOA score in each group was similar (P = 0.096).

CONCLUSION

ACDF with different levels had similar postoperative clinical outcomes. Three-level ACDF has an apparent advantage in restoring lordosis, a poor ability to maintain lordosis, and a higher incidence of complications compared to one-level or two-level ACDF.Level of Evidence: 3.

Does Obesity Affect Outcomes of Multilevel ACDF as a Treatment for Multilevel Cervical Spondylosis?: A Retrospective Study

STUDY DESIGN

This was a retrospective study of the clinical and radiologic outcomes of multilevel anterior cervical discectomy and fusion (ACDF) surgery for multilevel cervical spondylosis patients.

OBJECTIVE

In this retrospective study, we intended to determine the relationship of neck circumference, neck length, and body mass index (BMI) with the outcomes of multilevel ACDF surgeries for patients with multilevel cervical spondylosis.

SUMMARY OF BACKGROUND DATA

Obesity has become a worldwide epidemic problem since the beginning of the 21st century. However, no study has focused on how local or whole-body obesity indexes (neck circumference, length of neck, and BMI) are related to the outcome of anterior cervical surgery.

METHODS

A total of 156 consecutive patients with multilevel cervical spondylosis who underwent anterior cervical surgery in our department from 2010 to 2016 were enrolled in our study. Preoperative parameters of patients such as the neck circumference, length of neck, height and weight were measured, and the BMI was also calculated. Neck circumference and length of neck in neutral position ratio was determined as an index for evaluated the neck situation. Preoperative and postoperative neurological functions were evaluated using the neck disability index (NDI) and Japan Orthopedic Association (JOA) scores. Postoperative complications during the follow-up period were also recorded. Correlations between the obesity indexes and the various factors were analyzed.

RESULTS

The mean follow-up duration was 3.9±1.4 years (2.0-7.3 y). Compared with the preoperative score, the NDI and JOA score had significantly improved. There were 46 patients (29.49%) developed complications after surgery. Patients in the obese group had the highest rate of complications. Neck circumference and length of neck in neutral position ratio, BMI, and number of operation levels were significant risk factors for the occurrence of dysphagia after multilevel ACDF.

CONCLUSIONS

Patients with a higher BMI, larger neck circumference, and shorter neck length may have a longer operation duration, more blood loss, and more postoperative complications. The authors recommended that the presence of obesity and neck circumference and length should be carefully considered in the perioperative risk assessment for a multilevel ACDF surgery.

Anterior Cervical Decompression and C5 Palsy: A Systematic Review and Meta-analysis of Three Reconstructive Surgeries

STUDY DESIGN

A systematic review and meta-analysis were performed with the literature including the case of C5 palsy following anterior cervical decompression surgery.

OBJECTIVE

The aim of this study was to compare three reconstructive procedures of anterior cervical decompression, the incidences of delayed C5 palsy and other complications were assessed.

SUMMARY OF BACKGROUND DATA

Delayed C5 palsy is now a well-known complication after cervical decompression surgery. The etiology of C5 palsy has been studied, especially after posterior surgery. However, in anterior surgery there has been a lack of investigation due to procedure variation. Additionally, limited evidence exists regarding the risk of C5 palsy in surgical procedures.

METHODS

We performed an extensive literature search for C5 palsy and other complications with ACDF, ACCF, and their combination (Hybrid). Gross incidences of C5 palsy after these three procedures were compared, and specific superiorities (or inferiorities) were investigated via comparison of binary outcomes between two of three groups using odds ratios (OR).

RESULTS

Twenty-six studies met the inclusion criteria. A total of 3098 patients were included and 5.8% of those developed C5 palsy. Meta-analyses demonstrated that ACDF had a lower risk of palsy than ACCF (OR 0.36, 95% confidence interval [CI] 0.16-0.78), whereas ACDF versus Hybrid (OR 0.60, 95% CI 0.24-1.51) and Hybrid versus ACCF (OR 1.11, 95% CI 0.29-4.32) were not significantly different. Although these differences were not observed in shorter lesion subgroups, there were significant differences between the three procedures in longer lesion subgroups (P = 0.0005). Meta-analyses revealed that in longer lesions, ACDF had a significantly lower incidence than ACCF (OR 0.42, 95% CI 0.22-0.82). Additionally, Hybrid surgery was noninferior for palsy occurrence compared to ACCF, and suggested a trend for reduced rates of other complications compared to ACCF.

CONCLUSION

ACDF may yield better outcomes than Hybrid and ACCF. Furthermore, Hybrid may have advantages over ACCF in terms of surgical complications.

LEVEL OF EVIDENCE

3.

Anterior bone loss after cervical disc replacement: A systematic review

BACKGROUND

Anterior bone loss (ABL) is a relatively easily neglected condition after cervical disc replacement (CDR). Whether this phenomenon is a radiological anomaly or a complication remains controversial. Several studies have reported the clinical characteristics of ABL and speculated on the pathogenic mechanism based on a certain type of artificial disc, while the overall understanding of ABL is lacking.

AIM

To describe the prevalence, impacts, and risk factors of ABL after CDR.

METHODS

We searched the PubMed, Cochrane Library, and Excerpta Medica databases using the terms “bone loss” or “bone remodeling” or “bone absorption” or “osteolysis” or “implant loosening” or “implant migration” or “hypersensitivity” or “hyperreactivity”, “cervical disc replacement” or “cervical disc arthroplasty” or “total disc replacement”. Eligible manuscripts on the prevalence and impacts of ABL were reviewed by the authors. Data extraction was performed using an established extraction form. The results of the included studies were described narratively.

RESULTS

Six studies met the inclusion and exclusion criteria. One was a prospective study and the others were retrospective studies. A total of 440 patients with 536 segments were included. The artificial cervical discs included Bryan, Baguera-C, Discocerv, and Mobi-C. The prevalence of ABL ranged from 3.13% to 91.89%, with a combined overall prevalence of 41.84%. ABL occurred within 6 mo and stopped 12 mo after surgery. Several cases were noted to have a self-healing process. Severe ABL resulted in segmental kyphosis, implant subsidence, and persistent neck pain. ABL may be related to heterotopic ossification. Multilevel surgery may be one of the risk factors for ABL.

CONCLUSION

ABL is a common condition after CDR. The underlying mechanisms of ABL may include stress concentration and injury to nutrient vessels. ABL should be considered a complication after CDR as it was associated with neck pain, implant subsidence, and heterotopic ossification.

A prospective randomized cohort study on 3D-printed artificial vertebral body in single-level anterior cervical corpectomy for cervical spondylotic myelopathy

Background

This was a prospective randomized cohort study aiming at examining the safety and efficacy of artificial vertebral body (AVB) fabricated by electron beam melting (EBM) in comparison to conventional titanium mesh cage (TMC) used in single-level anterior cervical corpectomy and fusion (SL-ACCF).

Methods

Forty patients with cervical spondylotic myelopathy (CSM) underwent SL-ACCF using either the EBM-AVB or the TMC. Patients were evaluated for their demographics, radiological characteristics, neurologic function [using the Japanese Orthopaedic Association (JOA) scale], and health-related quality-of-life (HRQoL) aspects [using the Short Form 36 (SF-36)] before and after the surgery and comparison was made between the two groups both at baseline and the last follow-up. The Student t-text, paired-sample t-text, and Fisher's exact test were used when appropriate to detect any statistical significance at the level of α=0.05.

Results

Post-operative recovery was uneventful for all patients and no revision surgery was required. There were no significant differences between the EBM-AVB group and the TMC group at baseline. Patients in both groups demonstrated significant improvement in cervical alignment, JOA score, and SF-36 score after the surgery. Six months post-operatively, patients in the EBM-AVB group were found to have significantly less loss of fusion height and lower incidence for severe implant subsidence compared with the TMC group. Patients in the two groups were comparable at the last follow-up regarding their rate of fusion, cervical alignment, JOA recovery rate, SF-36 score, and by Odom's criteria.

Conclusions

For CSM patients undergoing SL-ACCF, the EBM-AVB group demonstrated comparable outcomes regarding patient cervical alignment, neurologic function, and HRQoL in comparison with the TMC group. Furthermore, the use of EBM-AVB was associated with decreased loss of the height of the fusion mass and a lower rate for severe implant subsidence.

Biomechanical evaluation comparing zero-profile devices versus fixed profile systems in a cervical hybrid decompression model: a biomechanical in vitro study

BACKGROUND CONTEXT

The use of zero-profile devices and the need for posterior fixation in conjunction with a cervical hybrid decompression model have yet to be investigated.

PURPOSE

To compare the biomechanics of zero-profile and fixed profile cervical hybrid constructs composed of anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF). Fixed profile devices included anterior plating, whereas zero-profile devices included integrated screws.

STUDY DESIGN

In vitro cadaveric biomechanical study.

METHODS

Twelve fresh-frozen cadaveric spines (C2-C7) were divided into two groups of equal bone mineral density, fixed profile versus zero profile (n=6). Groups were instrumented from C3-C6 with either (1) an expandable ACCF device and a static ACDF spacer with an anterior plate (Hybrid-AP) or (2) a zero-profile ACCF spacer with adjacent zero-profile ACDF spacer (Hybrid-Z). Motion was captured for the (1) intact condition, (2) a hybrid model with lateral mass screws (LMS), (3) a hybrid model without LMS, and (4) a hybrid model without LMS following simulated repetitive loading (fatigue).

RESULTS

Hybrid-AP with LMS reduced motion in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) by 77%, 88%, and 82%, respectively, compared with intact. Likewise, Hybrid-Z with LMS exhibited the greatest reduction in motion relative to intact in FE, LB, and AR by 90%, 95%, and 66%, respectively. Following simulated in vivo fatiguing, an increase in motion was observed for both groups in all planes, particularly during Hybrid-Z postfatigue condition where motion increased relative to intact by 29%. Overall, biomechanical equivalency was observed between Hybrid-AP and Hybrid-Z groups (p>.05). Three (50%) of the Hybrid-Z group specimens exhibited signs of implant migration from the inferior endplate during testing.

CONCLUSIONS

Fixed profile systems using an anterior plate for supplemental fixation is biomechanically more favorable to maintain stability and prevent dislodgement. Dislodgement of 50% of the Hybrid-Z group without LMS emphasizes the necessity for posterior fixation in a zero-profile cervical hybrid decompression model.

Hybrid decompression and reconstruction technique for cervical spondylotic myelopathy: case series and review of the literature

The primary treatment of choice for patients with cervical spondylotic myelopathy (CSM) is surgical decompression. The benefit of operative intervention has been well established but, the surgeons' decision of operative approach remains nuanced based on patient-specific variables and surgeon preference. Decompression can involve a cervical corpectomy or a discectomy. A hybrid construct is when both a cervical corpectomy and a discectomy are done in the same patient. The purpose of this study was to review the evidence on the clinical and biomechanical outcomes of hybrid decompression and reconstruction techniques in patients with multilevel CSM. A retrospective study was performed on consecutive patients who received hybrid anterior decompression and reconstruction at Rush University between 2013-2018. Preoperative clinical and radiographic variables were analyzed to characterize specific factors leading to the decision of the surgical approach. In addition, we performed a systematic review and meta-analysis to assess superiority in terms of operative time, blood loss, cervical lordosis, patient-reported outcomes (PRO), fusion rates, and complications. Hybrid surgery (HS) was utilized in cases where multilevel CSM was present in conjunction with stenosis posterior to the vertebral body or acute kyphotic deformity. Our meta-analysis highlighted comparable PRO, complications, and rate of success fusion between 3-level anterior cervical discectomy and fusion (ACDF) and hybrid technique. Furthermore, hybrid fusion led to increased postoperative cervical lordosis, higher fusion rate, lower total complication rate, lower implant failure/mesh subsidence rate, and lower blood loss than 2-level corpectomy. The cervical hybrid technique that combines cervical corpectomy and discectomy represents a balanced option with the benefits of two commonly utilized cervical spine procedures in patients with multilevel CSM. The literature on hybrid technique suggests in cases where multilevel ACDF is not feasible, combining discectomy and corpectomy is superior to two-level corpectomy with lower complication rates, improved clinical outcome, spinal alignment correction, and stronger biomechanical properties.

Complications of anterior cervical spine surgery: a systematic review of the literature

The anterior approach to the cervical spine is commonly utilized for a variety of degenerative, traumatic, neoplastic, and infectious indications. While many potential complications overlap with those of the posterior approach, the distinct anatomy of the anterior neck also presents a unique set of hazards. We performed a systematic review of the literature to assess the etiology, presentation, natural history, and management of these complications. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a PubMed search was conducted to evaluate clinical studies and case reports of patients who suffered a complication of anterior cervical spine surgery. The search specifically included articles concerning adult human subjects, written in the English language, and published from 1989 to 2019. The PubMed search yielded 240 articles meeting our criteria. The overall rates of complications were as follows: dysphagia 5.3%, esophageal perforation 0.2%, recurrent laryngeal nerve palsy 1.3%, infection 1.2%, adjacent segment disease 8.1%, pseudarthrosis 2.0%, graft or hardware failure 2.1%, cerebrospinal fluid leak 0.5%, hematoma 1.0%, Horner syndrome 0.4%, C5 palsy 3.0%, vertebral artery injury 0.4%, and new or worsening neurological deficit 0.5%. Morbidity rates in anterior cervical spine surgery are low. Nevertheless, the unique anatomy of the anterior neck presents a wide variety of potential complications involving vascular, aerodigestive, neural, and osseous structures.

The change of cervical sagittal parameters plays an important role in clinical outcomes of cervical spondylotic myelopathy after multi-level anterior cervical discectomy and fusion

BACKGROUND

Cervical sagittal parameters were closely related with clinical outcomes after multi-level ACDF. Our purpose was to evaluate the clinical outcomes and cervical sagittal parameters in patients with MCSM after ACDF and to identify the risk factors of poor clinical outcomes.

MATERIAL AND METHODS

ACDF was performed in 89 patients with MCSM. Based on average JOA recovery rate, patients were divided good-outcome group (group GO) and poor-outcome group (group PO). The cervical sagittal parameters including Cobb angle, SVA, T1S, cranial tilt and cervical tilt were measured. Multivariate logistic regression was used to identify risk factors.

RESULTS

Fifty-four patients (60.67%) were divided into group GO, while 35 patients (39.33%) were divided into group PO. Cobb angle, SVA and T1S was corrected from preoperative average 11.80° ± 9.63°, 23.69 mm ± 11.69 mm and 24.43° ± 11.78° to postoperative average 15.08° ± 9.05°, 18.79 mm ± 10.78 mm and 26.92° ± 11.94° respectively (p < 0.001). △Cobb angle (p = 0.008) and △SVA (p = 0.009) showed significantly statistical differences between two groups. Longer symptom duration, lower preoperative JOA score, smaller △Cobb angle and larger △SVA were identified as risk factors of poor clinical outcomes.

CONCLUSION

Multi-level ACDF is an effective surgical method to treat patients with MCSM. However, long duration of preoperative symptoms, lower preoperative JOA score, smaller △Cobb angle and larger △SVA are risk factors for poor outcomes in patients with MCSM after ACDF. Sagittal parameters should be paid attention to in surgery.

Anterior Surgical Techniques for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations

Objective

This study was performed to review the literature and to present the most up-to-date information and recommendations on the indications, complications, and success rate of anterior surgical techniques for cervical spondylotic myelopathy (CSM). The commonly performed anterior surgical procedures are multiple-level anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion and its variants (skip corpectomy and hybrid surgery), and oblique corpectomy without fusion.

Methods

A comprehensive literature search and analysis were performed using MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and the Web of Science for peer-reviewed articles published in English during the last 10 years.

Results

Corpectomy is mandated for ventral compression of fewer than 3 vertebral segments where single-level disc and osteophyte excision is inadequate to decompress the cord. Endoscopic or oblique partial corpectomy improves the sagittal canal diameter by 67% and obviates the need for an additional bone graft procedure.

Conclusion

The indications of anterior surgery in patients with CSM include a straightened or kyphotic spine with a compression level lower than 3. With an appropriate choice of implants and meticulous surgical technique, surgical complications can be seen only rarely. Improvements after anterior surgery for CSM have been reported in 70% to 80% of patients.

Preoperative and Intraoperative Skull Traction Combined with Anterior-Only Cervical Operation in the Treatment of Severe Cervical Kyphosis (>50 Degrees)

OBJECTIVE

To evaluate the clinical and radiographic outcomes of an anterior-only approach for the correction of severe cervical kyphotic deformities.

METHODS

We performed a retrospective study of 33 consecutive patients with severe cervical kyphosis treated with an anterior cervical operation and preoperative and intraoperative skull traction. Cobb angle, kyphosis index (KI), kyphosis level, C2-7 sagittal vertical axis (SVA), and T1 slope were measured. The preoperative and postoperative Japanese Orthopedic Association (JOA) scores, visual analog scale (VAS) score for neck pain, Neck Disability Index (NDI) scores, and cervical alignment were compared.

RESULTS

The mean angle of the kyphosis was 83.2 ± 20.4°. The mean Cobb angle of the operative region was 71.7 ± 18.5° preoperation, which was reduced to 10.6 ± 5.7° postoperation (mean correction, 85.2%). The mean KI was 75.1 ± 18.2 preoperation, which was reduced to 14.4 ± 9.1 postoperation (mean correction, 80.8%). The preoperative and postoperative mean C2-7 Cobb angle was 53.8 ± 16.5° and 14.7 ± 7.6°, respectively. The preoperative and postoperative mean C2-7 SVA was 3.9 ± 14.5 mm and 12.8 ± 7.3 mm, respectively. The preoperative and postoperative mean T1 slope was -9.4 ± 15.7° and 7.3 ± 13.1°, respectively. The average postoperative C2-7 Cobb angle, Cobb angle of the operative region, KI, C2-7 SVA, and T1 slope changed significantly compared with preoperative values (P < 0.05). The average postoperative JOA, VAS, and NDI scores improved significantly compared with preoperative scores (P < 0.05).

CONCLUSIONS

Preoperative and intraoperative skull traction combined with anterior-only cervical operation may be a safe and effective technique for treating severe cervical kyphosis. If the postoperative correction is >80%, sufficient decompression could be achieved.

Radiological Fusion Criteria of Postoperative Anterior Cervical Discectomy and Fusion: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Diagnosis of pseudarthrosis after anterior cervical fusion is difficult, and often depends on the surgeon's subjective assessment because recommended radiographic criteria are lacking. This review evaluated the available evidence for confirming fusion after anterior cervical surgery.

METHODS

Articles describing assessment of anterior cervical fusion were retrieved from MEDLINE and SCOPUS. The assessment methods and fusion rates at 1 and 2 years were evaluated to identify reliable radiographical criteria.

RESULTS

Ten fusion criteria were described. The 4 most common were presence of bridging trabecular bone between the endplates, absence of a radiolucent gap between the graft and endplate, absence of or minimal motion between adjacent vertebral bodies on flexion-extension radiographs, and absence of or minimal motion between the spinous processes on flexion-extension radiographs. The mean fusion rates were 90.2% at 1 year and 94.7% at 2 years. The fusion rate at 2 years had significant independence (P = .048).

CONCLUSIONS

The most common fusion criteria, bridging trabecular bone between the endplates and absence of a radiolucent gap between the graft and endplate, are subjective. We recommend using <1 mm of motion between spinous processes on extension and flexion to confirm fusion.

Anterior cervical discectomy and fusion versus hybrid surgery in multilevel cervical spondylotic myelopathy: A meta-analysis

OBJECTIVE

A meta-analysis was performed to compare the radiographic and surgical outcomes between anterior cervical discectomy and fusion (ACDF) and hybrid surgery (HS, corpectomy combined with discectomy) in the treatment for multilevel cervical spondylotic myelopathy (mCSM).

SUMMARY OF BACKGROUND DATA

Both ACDF and HS are used to treat mCSM, however, which one is better treatment for mCSM remains considerable controversy.

METHODS

An extensive search of literature was searched in PubMed/Medline, Embase, the Cochrane library, CNKI, and WANFANG databases on ACDF versus HS treating mCSM from January 2011 to December 2017. The following variables were extracted: blood loss, operation time, fusion rate, Cobb angles of C2-C7, total complications, dysphagia, hoarseness, C5 palsy, infection, cerebral fluid leakage, epidural hematoma, and graft subsidence. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

RESULTS

A total of 4 studies including 669 patients were included in our study. The pooled analysis showed that there were no significant difference in the operation time, fusion rate, Cobb angles of C2-C7, dysphagia, hoarseness, C5 palsy, infection, cerebral fluid leakage, epidural hematoma, and graft subsidence. However, there were significant difference between 2 groups in blood loss [P < .00001, SMD = -30.29 (-45.06, -15.52); heterogeneity: P = .38, I = 0%= and total complications [P = .04, OR = 0.66 95%CI (0.44, 0.98); heterogeneity: P = .37, I = 4%].

CONCLUSIONS

Based on our meta-analysis, except for blood loss and total complications, both ACDF and hybrid surgery are effective options for the treatment of multilevel cervical spondylotic myelopathy.

Two-level cervical corpectomy-long-term follow-up reveals the high rate of material failure in patients, who received an anterior approach only

In contrast to a one-level cervical corpectomy, a multilevel corpectomy without posterior fusion is accompanied by a high material failure rate. So far, the adequate surgical technique for patients, who receive a two-level corpectomy, remains to be elucidated. The aim of this study was to determine the long-term clinical outcome of patients with cervical myelopathy, who underwent a two-level corpectomy. Outcome parameters of 21 patients, who received a two-level cervical corpectomy, were retrospectively analyzed concerning reoperations and outcome scores (VAS, Neck Disability Index (NDI), Nurick scale, modified Japanese Orthopaedic Association score (mJOAS), Short Form 36-item Health Survey Questionnaire (SF-36)). The failure rate was determined using postoperative radiographs. The choice over the surgical procedures was exercised by every surgeon individually. Therefore, a distinction between two groups was possible: (1) anterior group (ANT group) with a two-level corpectomy and a cervical plate, (2) anterior/posterior group (A/P group) with two-level corpectomy, cervical plate, and additional posterior fusion. Both groups benefitted from surgery concerning pain, disability, and myelopathy. While all patients of the A/P group showed no postoperative instability, one third of the patients of the ANT group exhibited instability and clinical deterioration. Thus, a revision surgery with secondary posterior fusion was needed. Furthermore, the ANT group had worse myelopathy scores (mJOAS_{ANT group} = 13.5 ± 2.5, mJOAS_{A/P group} = 15.7 ± 2.2). Patients with myelopathy, who receive a two-level cervical corpectomy, benefitted from surgical decompression. However, patients with a sole anterior approach demonstrated a very high rate of instability (33%) and clinical deterioration in a long-term follow-up. Therefore, we recommend to routinely perform an additional posterior fusion after two-level cervical corpectomy.

Incidence of C5 nerve root palsy after cervical surgery: A meta-analysis for last decade

PURPOSE

We aim to perform a meta-analysis on incidence of C5 nerve root palsy (C5 palsy) for patients after cervical surgery.

METHODS

An extensive search of the literature was performed in PubMed/MEDLINE, Embase, the Cochrane library, CNKI, and WANFANG databases on incidence of C5 palsy from January 2007 to January 2017. Prevalence of C5 palsy related to different surgery methods was calculated and data analysis was conducted with STATA 12.0.

RESULTS

A total of 61 studies containing 721 patients with C5 palsy in total 11,481 patients (6.3%) were included in our study. The incidences after anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), anterior corpectomy combined with discectomy (ACCDF), laminoplasty (LP) and laminectomy and fusion (LF) were 5.5%, 7.5%, 6%, 4.4%, and 12.2%, respectively. Compared with anterior approaches (5%), female patients (4%) and patients with cervical spondylotic myelopathy (CSM) (4.8%), posterior approaches (6.2%), male patients (5.7%) and patients with ossification of posterior longitudinal ligament (OPLL) (8.1%) have a higher prevalence. In ACDF and LP, patients with OPLL (5.5%, 8.1%, respectively) have a higher incidence than those in patients with CSM (4.7%, 3.1%, respectively); however, in LF, patients with CSM and OPLL have similar incidence of C5 palsy (13% vs 13.1%). In most cases, C5 palsy was unilateral (74.5%).

CONCLUSIONS

Based on our meta-analysis, posterior approaches, male patients and patients with OPLL have a higher incidence of C5 palsy. In ACDF and LP, patients with OPLL have a higher incidence of C5 palsy, but in LF, patients with CSM and OPLL have similar result.

A Comparison of Multilevel Anterior Cervical Discectomy and Corpectomy in Patients With 4-level Cervical Spondylotic Myelopathy: a Minimum 2-year Follow-up Study: Multilevel Anterior Cervical Discectomy

STUDY DESIGN

Retrospective clinical series.

OBJECTIVES

To compare perioperative parameters, clinical outcomes, radiographic parameters, and complication rates of segmental anterior cervical corpectomy and fusion (sACCF) plus preservation of middle vertebrae with those of multilevel anterior cervical discectomy and fusion (mACDF) in 70 patients with 4-level cervical spondylotic myelopathy (CSM).

METHODS

Between July 2006 and May 2011, 70 consecutive patients [49 males and 21 females; mean age 56.8 y (range, 38-72 years)] with 4-level CSM were enrolled in this study and divided into sACCF (n=39) group and mACDF (n=31) group. The study compared perioperative parameters, complication rates, clinical parameters, and radiologic parameters.

RESULTS

No significant differences between the groups were found in demographic, baseline disease characteristics, operation time, hospital stay, and follow-up time. Significant improvements of clinical outcome were seen from preoperative to postoperative in both groups. Satisfaction was rated as excellent or good by 79.5% of the sACCF group and 80.6% of the mACDF group, which was not a significant difference. Mean postoperative cervical lordosis was significantly greater in the mACDF group than in the sACCF group. Blood loss was significantly greater in the sACCF group than in the mACDF group and instrumentation-related and/or graft-related complication rate significantly lower for the mACDF group. Both sACCF and mACDF groups achieved solid fusion rates (87.1% and 90.3%, respectively).

CONCLUSIONS

Both mACDF and sACCF provide satisfactory clinical outcomes and fusion rates for 4-level CSM. However, mACDF is associated with better radiologic parameter, less blood loss, and lower instrumentation-related and/or graft-related complication rate.

The influence of sagittal profile alteration and final lordosis on the clinical outcome of cervical spondylotic myelopathy. A Delta-Omega-analysis

Purpose

Decompression and maintaining or restoring a cervical lordosis are major goals in the surgical treatment of cervical spondylotic myelopathy (CSM). Numerous studies support the assumption that cervical lordosis is a key factor for neurological recovery and pain reduction. However, even kyphotic patients can be asymptomatic. The balance of the spine is subject of an increasing number of publications. The main purpose of the study was to evaluate the validity of lordotic alignment on the course of CSM and to set this parameter in context with well-validated tools, namely the modified Japanese Orthopaedic Association scoring system (mJOAS) and the visual analogue scale (VAS), to predict and measure the clinical outcome after surgery.

Methods

This is a retrospective study with prospectively collected data of a heterogeneous cohort. The authors analyzed the records of 102 patients suffering from CSM that underwent decompressive surgery and instrumentation. Clinical outcome was assessed by using the mJOAS, VAS and Odom’s criteria. The radiological analysis involved comparison of pre- and postoperative radiographs. The patients were divided into subgroups to be able to compare the influence of various amounts of correction (3 Delta-groups: <0°, 1–7° and ≥8°) and final lordosis (4 Omega-groups: 0–7°, 8–14°, 15–21°, ≥22°).

Results

219 levels were fused in 102 patients. Surgery improved the clinical outcome of all groups significantly. A lordotic profile was achieved in all analyzed groups. Patients that showed small lordosis after surgery (<8°) did not have an inferior clinical outcome compared to patients with larger cervical lordosis (>14°). The comparison of Odom’s criteria showed that preoperatively kyphotic patients benefitted more from surgery than lordotic patients (p = 0.029), but no differences could be seen comparing neck pain and neurological improvement. The improvement of pain and neurological impairment measured by VAS and mJOAS supports the statistical impact and validity of the data despite comparatively small numbers of patients. The lack of postoperative kyphosis is a major limitation of the study to encompass the impact of sagittal alignment on clinical outcome.

Conclusions

Decompression and stabilization appear to be key elements of surgical treatment of CSM. While the achievement of cervical lordosis remains a major goal of surgery, clinical improvement is not hindered in patients who show small lordosis. However, kyphosis should be eliminated in symptomatic patients. The terms “balance” and “physiologic lordosis” remain complex entities without clear definition. To check the results of our study controlled randomized trials to validate and determine the exact role of cervical balance on the course of CSM would be helpful.

Prevalence of complications after surgery in treatment for cervical compressive myelopathy: A meta-analysis for last decade

PURPOSE

We aim to perform a meta-analysis on prevalence of all kinds of operation-related complications following surgery treating cervical compressive myelopathy (CCM) and to provide reference for surgeons making surgical plan.

METHODS

An extensive search of literature was performed in PubMed/MEDLINE, Embase, the Cochrane library, CNKI, and WANFANG databases on incidence of operation-related complications from January 2007 to November 2016. Data was calculated and data analysis was conducted with STATA 12.0 and Revman 5.3.

RESULTS

A total of 107 studies included 1705 of 8612 patients (20.1%, 95% CI 17.3%-22.8%) on overall complications. The incidence of C5 plasy, cerebrospinal fluid (CSF), infection, axial pain, dysphagia, hoarseness, fusion failure, graft subsidence, graft dislodgment, and epidural hematoma is 5.3% (95% CI 4.3%-6.2%), 1.9% (95% CI 1.3%-2.4%), 2.8% (95% CI 1.7%-4.0%), 15.6% (95% CI 11.7%-19.5%), 16.8% (95% CI 13.6%-19.9%), 4.0% (95% CI 2.3%-5.7%), 2.6% (95% CI 0.2%-4.9%), 3.7% (95% CI 2.0%-5.5%), 3.4% (95% CI 2.0%-4.8%), 1.1% (95% CI 0.7%-1.5%), respectively. Patients with ossification of posterior longitudinal ligament (OPLL) (6.3%) had a higher prevalence of C5 plasy than those with cervical spondylotic myelopathy (CSM) (4.1%), and a similar trend in CSF (12.2% vs 0.9%). Individuals after laminectomy and fusion (LF) had highest rate of C5 plasy (15.2%), while those who underwent anterior cervical discectomy and fusion (ACDF) had the lowest prevalence (2.0%). Compared with patients after other surgical options, individuals after anterior cervical corpectomy and fusion (ACCF) have the highest rate of CSF (4.2%), infection (14.2%), and epidural hematoma (3.1%). Patients after ACDF (4.8%) had a higher prevalence of hoarseness than those with ACCF (3.0%), and a similar trend for dysphagia between anterior corpectomy combined with discectomy (ACCDF) and ACCF (16.8% vs 9.9%).

CONCLUSIONS

Based on our meta-analysis, patients with OPLL have a higher incidence of C5 palsy and CSF. Patients after LF have a higher incidence of C5 palsy, ACCDF have a higher incidence of dysphagia, ACCF have a higher incidence of CSF and infection and ACDF have a higher incidence of hoarseness. These figures may be useful in the estimation of the probability of complications following cervical surgery.

Anterior cervical discectomy and fusion versus anterior cervical corpectomy and fusion in multilevel cervical spondylotic myelopathy: A meta-analysis

BACKGROUND

Both anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) are used to treat multilevel cervical spondylotic myelopathy (mCSM); however, which one is better treatment for mCSM remains considerable controversy. A meta-analysis was performed to compare clinical outcomes, radiographic outcomes, and surgical outcomes between ACDF and ACCF in treatment for mCSM.

METHODS

An extensive search of literature was performed in Pubmed/MEDLINE, Embase, the Cochrane library, CNKI, and WANFANG databases on ACDF versus ACCF treatment for mCSM from January 2011 to August 2016. The following variables were extracted: length of hospital stay, blood loss, operation time, Japanese Orthopedic Association (JOA) scores, Neck Disability Index (NDI) score, fusion rate, Cobb angles of C2 to C7, dysphagia, hoarseness, C5 palsy, infection, cerebral fluid leakage, donor site pain, epidural hematoma, graft subsidence, graft dislodgment, pseudoarthrosis, and total complications. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

RESULTS

A total of 8 studies containing 878 patients were included in our study. The results showed that ACDF is better than ACCF in the angle of C2 to C7 at the final follow-up (P < 0.00001, standardized mean difference = 4.76 [3.48, 6.03]; heterogeneity: P = 0.17, I = 43%), C5 plasy (P = 0.02, odds ratio [OR] 0.42, 95% confidence interval [CI] 0.21, 0.86; heterogeneity: P = 0.52, I = 0%), blood loss (P < 0.00001, standardized mean difference = -53.12, 95% CI -64.61, -41.64; heterogeneity: P = 0.29, I = 20%), fusion rate (P = 0.04, OR 2.54, 95% CI 1.05, 6.11; heterogeneity: P = 0.29, I = 20%), graft subsidence (P = 0.004, OR 0.11, 95% CI 0.02, 0.48; heterogeneity: P = 0.94, I = 0%), and total complications (P = 0.0009, OR 0.56, 95% CI 0.40, 0.79; heterogeneity: P = 0.29, I = 18%).However, there are no significant differences in length of hospital stay, operation time, JOA scores, NDI scores, preoperative angle of C2 to C7, dysphagia, hoarseness, infection, cerebral fluid leakage, donor site pain, epidural hematoma, graft dislodgment, and pseudoarthrosis (all P > 0.05).

CONCLUSIONS

Based on our meta-analysis, our results suggest that both ACDF and ACCF are good plans in clinical outcomes; however, ACDF is a better choice in radiographic outcomes and total complications for the treatment of multilevel CSM.

Four-level anterior cervical discectomy and fusion for cervical spondylotic myelopathy

PURPOSE

To review the outcome of 32 consecutive patients who underwent 4-level anterior cervical discectomy and fusion (ACDF) with cages and plates and were followed up for at least 5 years.

METHODS

Records of 19 men and 13 women aged 48 to 69 years who underwent 4-level ACDF with cages and plates for myelopathy (n=11) or myeloradiculopathy (n=21) at C3 to C7 by a single surgeon and were followed up for a minimum of 5 years were reviewed. Clinical outcome was assessed using the visual analogue scale (VAS), Neck Disability Index (NDI), and modified Japanese Orthopaedic Association (JOA) score for pain or myelopathic symptoms. Radiographic evaluation included fusion rate, range of motion, cervical lordosis (C2-to-C7 Cobb angle), and disc height.

RESULTS

The mean follow-up was 66 months. All patients had good recovery of muscle strength and resolution of limb sensory disturbance, except for 4 who still had some numbness. The mean VAS for neck and arm pain improved from 14.2 to 6.84 (p=0.012); the mean NDI improved from 31.62 to 12.17 (p<0.01); and the mean JOA score improved from 10.1 to 13.9 (p=0.027). The mean percentage of recovery was 62.9. The mean Cobb angle improved from 10.24º to 1.28º (p=0.019); the mean disc height improved from 4.12 to 6.58 mm (p<0.01). 30 (94%) patients achieved solid fusion.

CONCLUSION

Multilevel ACDF using PEEK cages and plates is safe and effective for multilevel cervical spondylotic myelopathy and achieves satisfactory mid-term outcome.

The application of a new type of titanium mesh cage in hybrid anterior decompression and fusion technique for the treatment of continuously three-level cervical spondylotic myelopathy

PURPOSE

To evaluate the efficacy and safety of a new type of titanium mesh cage (NTMC) in hybrid anterior decompression and fusion method (HDF) in treating continuously three-level cervical spondylotic myelopathy (TCSM).

METHODS

Ninety-four cases who had TCSM and accepted the HDF from Jan 2007 to Jan 2010 were included. Clinical and radiological outcomes were compared between cases who had the NTMC (Group A, n = 45) and traditional titanium mesh cage (TTMC, Group B, n = 49) after corpectomies. Each case accepted one polyetheretherketone cage (PEEK) after discectomy.

RESULTS

Mean follow-up were 74.4 and 77.3 months in Group A and B, respectively (p > 0.05). Differences in cervical lordosis (CL), segmental lordosis (SL), anterior segmental height (ASH) and posterior segmental height (PSH) between two groups were not significant preoperatively, 3-days postoperatively or at final visit. However, losses of the CL, SL, ASH and PSH were all significantly larger in Group B at the final visit, so did incidences of segmental subsidence and severe subsidence. Difference in preoperative Japanese Orthopedic Association (JOA), visual analog scale (VAS), neck disability index (NDI) or SF-36 between two groups was not significant. At the final visit, fusion rate, JOA, and SF-36 were all comparable between two groups, but the VAS and NDI were both significantly greater in Group B.

CONCLUSIONS

For cases with TCSM, HDF with the NTMC and TTMC can provide comparable radiological and clinical improvements. But application of the NTMC in HDF is of advantages in decreasing the subsidence incidence, losses of lordosis correction, VAS and NDI.

Outcomes of Spinal Fusion for Cervical Kyphosis in Children with Neurofibromatosis

BACKGROUND

Cervical kyphosis may occur with neurofibromatosis type I (NF1) and is often associated with vertebral dysplasia. Outcomes of cervical spinal fusion in patients with NF1 are not well described because of the rarity of the condition. We aimed to (1) characterize the clinical presentation of cervical kyphosis and (2) report the outcomes of posterior and anteroposterior cervical fusion for the condition in these children.

METHODS

The medical records and imaging studies of 22 children with NF1 who had undergone spinal fusion for cervical kyphosis (mean, 67°) at a mean age of 11 years and who had been followed for a minimum of 2 years were reviewed.

RESULTS

Thirteen children presented with neck pain; 10, with head tilt; 9, with a previous cervical laminectomy or fusion; and 5, with a neurologic deficit. Two patients had spontaneous dislocation of the mid-cervical spine without a neurologic deficit. Eleven had scoliosis, with the major curve measuring a mean of 61°. Nine patients underwent posterior and 13 underwent anteroposterior surgery. Twenty-one received spinal instrumentation, and 1 was not treated with instrumentation. Preoperative halo traction was used for 9 patients, and it reduced the mean preoperative kyphosis by 34% (p = 0.0059). At the time of final follow-up, all spinal fusion sites had healed and the cervical kyphosis averaged 21° (mean correction, 69%; p < 0.001). The cervical kyphosis correction was significantly better after the anteroposterior procedures (83%) than after the posterior-only procedures (58%) (p = 0.031). Vertebral dysplasia and erosion continued in all 17 patients who had presented with dysplasia preoperatively. Thirteen patients had complications, including 5 new neurologic deficits and 8 cases of junctional kyphosis. Nine patients required revision surgery. Junctional kyphosis was more common in children in whom ≤5 levels had been fused (p = 0.054).

CONCLUSIONS

Anteroposterior surgery provided better correction of cervical kyphosis than posterior spinal fusion in children with NF1. Erosion of vertebral bodies continued during the postoperative follow-up period in all patients who had presented with dysplastic changes preoperatively. The cervical spine should be screened in all children with NF1. Fusion should include at least 6 levels to prevent junctional kyphosis.

LEVEL OF EVIDENCE

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

Cervical corpectomies: results of a survey and review of the literature on diagnosis, indications, and surgical technique

OBJECTIVES

Cervical corpectomy is an uncommon procedure and there are only limited data on the procedure's indications, surgical approaches, and complications. The diagnosis, indications, surgical planning, and complications of cervical corpectomy were therefore surveyed to clarify the treatment strategies used by spinal surgeons in central Europe, with special attention to preoperative planning and decision-making for additional dorsal approaches in multilevel cases.

MATERIALS AND METHODS

An online survey with 18 questions on the preoperative, intraoperative, and postoperative management of cervical corpectomies was conducted. The relevant specialist societies in Germany and Austria provided 1137 contacts for surgeons, and the responses were compared with recent literature reports.

RESULTS

In all, 302 surgeons (27 %) completed the survey, with wide variability in the treatment options offered. Most (51 %) perform fewer than five anterior cervical corpectomy and fusion (ACCF) procedures per year; 35 % do 5-20 per year. Anterior cervical discectomy and fusion (ACDF) was preferred by 41 % of the participants to laminoplasty/laminectomy (19 %/16 %) and ACCF (12 %). Most indications for ACCF involved degenerative (27 %), traumatic (17 %), and neoplastic (20 %) conditions. Intraoperative and postoperative complications were mainly associated with hardware failure. One-third of the surgeons tend to use an additional dorsal approach to increase the corpectomy construct's stability for either two-level or three-level corpectomies.

CONCLUSIONS

There is no current consensus in central Europe on the treatment of complex cervical disease and cervical corpectomy. The procedure is still rare, and the need for additional dorsal fixation is unclear. Further studies are needed in order to establish evidence-based standards for patient care.