A retrospective review of cervical corpectomy: indications, complications and outcome

Management Considerations for Cervical Corpectomy: Updated Indications and Future Directions

Together, lower back and neck pain are among the leading causes of acquired disability worldwide and have experienced a marked increase over the past 25 years. Paralleled with the increasing aging population and the rise in chronic disease, this trend is only predicted to contribute to the growing global burden. In the context of cervical neck pain, this symptom is most often a manifestation of cervical degenerative disc disease (DDD). Traditionally, multilevel neck pain related to DDD that is recalcitrant to both physical and medical therapy can be treated with a procedure known as cervical corpectomy. Presently, there are many flavors of cervical corpectomy; however, the overarching goal is the removal of the pain-generating disc via the employment of the modern anterior approach. In this review, we will briefly detail the pathophysiological mechanism behind DDD, overview the development of the anterior approach, and discuss the current state of treatment options for said pathology. Furthermore, this review will also add to the current body of literature surrounding updated indications, surgical techniques, and patient outcomes related to cervical corpectomy. Finally, our discussion ends with highlighting the future direction of cervical corpectomy through the introduction of the "skip corpectomy" and distractable mesh cages.

Anterior Cervical Corpectomy and Fusion for Degenerative Cervical Spondylotic Myelopathy: Case Presentation With Surgical Technique Demonstration and Review of Literature

Anterior cervical corpectomy and fusion (ACCF) provides an extensive decompression and provides a large surface area for fusion in patients presenting with cervical spondylotic myelopathy. Unfortunately, this procedure is a more difficult spinal surgery to perform (compared with a traditional anterior cervical discectomy and fusion) and has a higher incidence of overall complications. In literature, ACCF has functional outcomes that seem clinically equivalent to those for multilevel anterior cervical discectomy and fusion, especially when contained to 1 vertebral body level, and in cases, for which both posterior and anterior procedures would be appropriate surgical options, may provide greater long-term clinical benefit than posterior fusion or laminoplasty. In this manuscript, we summarize the indications and outcomes following ACCF for degenerative cervical spondylotic myelopathy. We then describe a case presentation and associated surgical technique with a discussion of complication avoidance with this procedure.

The Effect of Rod Pattern, Outrigger, and Multiple Screw-Rod Constructs for Surgical Stabilization of the 3-Column Destabilized Cervical Spine - A Biomechanical Analysis and Introduction of a Novel Technique

Objective

Anterior-only reconstructions for cervical multilevel corpectomies are prone to fail under continuous mechanical loading. This study sought to define the mechanical characteristics of different constructs in reducing a range of motion (ROM) of the 3-column destabilized cervical spine, including posterior cobalt-chromium (CoCr)-rods, outrigger-rods (OGR), and a novel triple rod construct using lamina screws (6S3R). The clinical implications of biomechanical findings are discussed in depth from the perspective of the challenges surgeons face cervical deformity correction.

Methods

Three-column deficient cervical spinal models were produced based on reconstructed computed tomography scans. The corpectomy defect between C3 and C7 end-level vertebrae was restored with anterior titanium (Ti) mesh-cage. The ROM was evaluated in a customized 6-degree of freedom spine tester. Tests were performed with different rod materials (Ti vs. CoCr), varying diameter rods (3.5 mm vs. 4.0 mm), with and without anterior plating, and using different construct patterns: bilateral rod fixation (standard-group), OGR-group, and 6S3R-Group. Construct stability was expressed in changes and differences of ROM (°).

Results

The largest reduction of ROM was noticed in the 6S3R-group compared to the standard- and the OGR-group. All differences observed were emphasized with an increasing number of corpectomy levels and if anterior plating was not added. For all simulated 1-, 2-, and 3-level corpectomy constructs, the OGR-group revealed decreased ROM for all motion directions compared to the standard-group. An increase of construct stiffness was also recorded for increased rod diameter (4.0 mm) and stiffer rod material (CoCr), though these effects lacked behind the more advanced construct pattern.

Conclusion

A novel reconstructive technique, the 6S3R-construct, was shown to outperform all other constructs and might resemble a new standard of reference for advanced posterior fixation.

Reduction and Open Fixation of a Cervical Teardrop Fracture: A Technical Note

BACKGROUND

Cervical teardrop fractures are hyperflexion and axial loading injuries associated with significant ligamentous disruption. Patients sustaining these types of injury are classically treated with a cervical corpectomy and anterior fusion. However, there are notable disadvantages of this approach, namely, disruption of the patient's true anatomic alignment and a reduction in the number of fixation points available for cervical fusion. Here we present a novel method of open reduction and internal fixation in a neurologically intact patient with cervical teardrop fracture.

CASE DESCRIPTION

A 34-year-old man presented to Ryder Trauma Center after a helmeted motorcycle accident. The patient was found to be neurologically intact on arrival, and imaging demonstrated a C5 teardrop fracture without bony retropulsion. The patient was taken to the operating room for an open reduction and internal fixation of the fracture using a novel technique. This technique used traditional diskectomies at the C4-5 and C5-6 levels, along with a temporary, unicortical screw into the C5 body to capture the anteriorly displaced fragment. A bicortical screw was then placed into the contralateral side, and now, having fully reduced the fracture, the first (temporary) screw was replaced with a bicortical screw. The patient was neurologically intact postoperatively, with 2-month follow-up computed tomography scan demonstrating stable reduction of the fracture.

CONCLUSIONS

Here we present a novel technique for open reduction and internal fixation of a cervical teardrop fracture that does not require cervical corpectomy. This technique is particularly useful in patients with an anteriorly displaced fragment and without neurologic deficit or compromise.

Anterior cervical corpectomy and fusion in a 7-year-old boy: a case report

Bicycle mishap, a common and ordinary event occurring in children, can have devastating consequences associated with cervical spine injury. Furthermore, either diagnosis or surgical management of cervical spine injury in children is a challenging issue. This research report a challenging case of an anterior cervical corpectomy and fusion with plating in a 7-year-old boy due to cervical spine instability with spinal cord compression after a bicycle mishap. After 20 months of the primary surgery, the titanium-based cervical plate was removed by a second surgery to allow the growth of the cervical spine.

Biomechanics of Cervical "Skip" Corpectomy Versus Standard Multilevel Corpectomy

STUDY DESIGN

In vitro biomechanical study of flexibility with finite-element simulation to estimate screw stresses.

OBJECTIVE

To compare cervical spinal stability after a standard plated 3-level corpectomy with stability after a plated 3-level "skip" corpectomy where the middle vertebra is left intact (ie, two 1-level corpectomies), and to quantify pullout forces acting on the screws during various loading modes.

SUMMARY OF BACKGROUND DATA

Clinically, 3-level cervical plated corpectomy has a high rate of failure, partially because only 4 contact points affix the plate to the upper and lower intact vertebrae. Leaving the intermediate vertebral body intact for additional fixation points may overcome this problem while still allowing dural sac decompression.

METHODS

Quasistatic nonconstraining torque (maximum 1 N m) induced flexion, extension, lateral bending, and axial rotation while angular motion was recorded stereophotogrammetrically. Specimens were tested intact and after corpectomy with standard plated and strut-grafted 3-level corpectomy (7 specimens) or "skip" corpectomy (7 specimens). Screw stresses were quantified using a validated finite-element model of C3-C7 mimicking experimentally tested groups. Skip corpectomy with C5 screws omitted was also simulated.

RESULTS

Plated skip corpectomy tended to be more stable than plated standard corpectomy, but the difference was not significant. Compared with standard plated corpectomy, plated skip corpectomy reduced peak screw pullout force during axial rotation (mode of loading of highest peak force) by 15% (4-screw attachment) and 19% (6-screw attachment).

CONCLUSIONS

Skip corpectomy is a good alternative to standard 3-level corpectomy to improve stability, especially during lateral bending. Under pure moment loading, the screws of a cervical multilevel plate experience the highest pullout forces during axial rotation. Thus, limiting this movement in patients undergoing plated multilevel corpectomy may be reasonable, especially until solid fusion is achieved.

Acute cervical epidural hematoma, screw pullout, and esophageal perforation after anterior cervical corpectomy surgery: report of a case

To report a series of complications related to anterior cervical surgery in the same patient. There have been many reports of complications related to anterior cervical surgeries. These include cervical hematoma, instrumentation extrusion, or esophageal injury after anterior cervical decompression. However, there have been no reports of all these complications occurring in 1 patient. This is our report of a patient who experienced all 3 of these complications. The patient was a 73-year-old man suffering from cervical spondylotic myelopathy who was treated with C5 anterior cervical corpectomy and fusion with titanium mesh and bone graft. The patient successively experienced cervical hematoma, screw pullout, and esophageal perforation, and was treated accordingly. Although the patient suffered a series of complications after anterior cervical corpectomy, all the complications were treated successfully. It serves as a caution that a first complication such as hematoma in anterior cervical corpectomy with fusion should be given enough attention to prevent further complications.

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.

Anterior Cervical Reconstruction Using Free Vascularized Fibular Graft after Cervical Corpectomy

Study Design Prospective study. Objective The aim of this study was to evaluate the clinical and radiologic results of using free vascularized fibular graft (FVFG) for anterior reconstruction of the cervical spine following with varying levels of corpectomy. Methods Ten patients underwent anterior cervical reconstruction using an FVFG after cervical corpectomy augmented with internal instrumentation. All patients were evaluated neurologically according to the Japanese Orthopaedic Association (JOA) and modified JOA scoring systems and the Nurick grading system. The neurologic recovery rate was determined, and the clinical outcome was assessed based on three factors: neck pain, dependence on pain medication, and ability to return to work. The fusion status and maintenance of lordotic correction by the strut graft were determined by measuring the lordosis angle and fused segment height (FSH). Results All patients achieved successful fusion. The mean follow-up period was 35.2 months (range, 28 to 44 months). Graft union occurred at a mean of 3.5 months. The mean loss of lordotic correction was 0.95 degrees, and the mean change in FSH was <1 mm. The neurologic recovery rate was excellent in four patients, good in five, and fair in one. All patients achieved satisfactory clinical outcome. No neurologic injuries occurred during the operations. Conclusion The use of FVFG is a valuable and effective technique in anterior cervical reconstruction for complex disorders.

In vitro evaluation of translating and rotating plates using a robot testing system under follower load

BACKGROUND CONTEXT

Various modifications to standard "rigid" anterior cervical plate designs (constrained plate) have been developed that allow for some degree of axial translation and/or rotation of the plate (semi-constrained plate)-theoretically promoting proper load sharing with the graft and improved fusion rates. However, previous studies about rigid and dynamic plates have not examined the influence of simulated muscle loading.

PURPOSE

The objective of this study was to compare rigid, translating, and rotating plates for single-level corpectomy procedures using a robot testing system with follower load.

STUDY DESIGN

In-vitro biomechanical test.

METHODS

N = 15 fresh-frozen human (C3-7) cervical specimens were biomechanically tested. The follower load was applied to the specimens at the neutral position from 0 to 100 N. Specimens were randomized into a rigid plate group, a translating plate group and a rotating plate group and then tested in flexion, extension, lateral bending and axial rotation to a pure moment target of 2.0 Nm under 100N of follower load. Range of motion, load sharing, and adjacent level effects were analyzed using a repeated measures analysis of variance (ANOVA).

RESULTS

No significant differences were observed between the translating plate and the rigid plate on load sharing at neutral position and C4-6 ROM, but the translating plate was able to maintain load through the graft at a desired level during flexion. The rotating plate shared less load than rigid and translating plates in the neutral position, but cannot maintain the graft load during flexion.

CONCLUSIONS

This study demonstrated that, in the presence of simulated muscle loading (follower load), the translating plate demonstrated superior performance for load sharing compared to the rigid and rotating plates.

Biomechanical testing of circumferential instrumentation after cervical multilevel corpectomy

STUDY DESIGN

Biomechanical investigation.

PURPOSE

This study describes ex vivo evaluation of the range of motion (ROM) to characterize the stability and need for additional dorsal fixation after cervical single-level, two-level or multilevel corpectomy (CE) to elucidate biomechanical differences between anterior-only and supplemental dorsal instrumentation.

METHODS

Twelve human cervical cadaveric spines were loaded in a spine tester with pure moments of 1.5 Nm in lateral bending (LB), flexion/extension (FE), and axial rotation (AR), followed by two cyclic loading periods for three-level corpectomies. After each cyclic loading session, flexibility tests were performed for anterior-only instrumentation (group_1, six specimens) and circumferential instrumentation (group_2, six specimens).

RESULTS

The flexibility tests for all circumferential instrumentations showed a significant decrease in ROM in comparison with the intact state and anterior-only instrumentations. In comparison with the intact state, supplemental dorsal instrumentation after three-level CE reduced the ROM to 12% (±10%), 9% (±12%), and 22% (±18%) in LB, FE, and AR, respectively. The anterior-only construct outperformed the intact state only in FE, with a significant ROM reduction to 57% (±35 %), 60% (±27%), and 62% (±35%) for one-, two- and three-level CE, respectively.

CONCLUSIONS

The supplemental dorsal instrumentation provided significantly more stability than the anterior-only instrumentation regardless of the number of levels resected and the direction of motion. After cyclic loading, the absolute differences in stability between the two instrumentations remained significant while both instrumentations showed a comparable increase of ROM after cyclic loading. The large difference in the absolute ROM of anterior-only compared to circumferential instrumentations supports a dorsal support in case of three-level approaches.

Radiological outcomes of static vs expandable titanium cages after corpectomy: a retrospective cohort analysis of subsidence

BACKGROUND

Mesh cages have commonly been used for reconstruction after corpectomy. Recently, expandable cages have become a popular alternative. Regardless of cage type, subsidence is a concern following cage placement.

OBJECTIVE

To assess whether subsidence rates differ between static and expandable cages, and identify independent risk factors for subsidence and extent of subsidence when present.

METHODS

A consecutive population of patients who underwent corpectomy between 2006 and 2009 was identified. Subsidence was assessed via x-ray at 1-month and 1-year follow-ups. In addition to cage type, demographic, medical, and cage-related covariates were recorded. Multivariate models were used to assess independent associations with rate, odds, and extent of subsidence.

RESULTS

Of 91 patients, 44.0% had expandable cages and 56.0% had static cages. One-month subsidence rate was 36.3%, and the 1-year subsidence rate was 51.6%. Expandable cages were independently associated with higher rates and odds of subsidence in comparison with static cages. Infection, trauma, and footplate-to-vertebral body endplate ratio of less than 0.5 were independent risk factors for subsidence. The presence of prongs on cages and posterior fusion 2 or more levels above and below corpectomy level had lower rates and odds of subsidence. Infection and cage placement in the thoracic or lumbar region had greater extent of subsidence when subsidence was present.

CONCLUSION

Expandable cages had higher rates and risk of subsidence in comparison with static cages. When subsidence was present, expandable cages had greater magnitudes of subsidence. Other factors including footplate-to-vertebral body endplate ratio, prongs, extent of supplemental posterior fusion, spinal region, and diagnosis also impacted subsidence.

Corpectomia cervical anterior e fixação com placa: análise retrospectiva

OBJETIVO: Avaliar os resultados clínicos e radiográficos de pacientes submetidos à corpectomia e fixação com placa cervical, com seguimento de dois anos. MÉTODOS: Análise retrospectiva de 2003 a 2009. Avaliaram-se o tipo de fratura (classificação AO), o grau de déficit neurológico (inicial e após dois anos - escala de Frankel), a taxa de complicações e a taxa de incorporação do enxerto ósseo (de acordo com radiografias dois anos depois da cirurgia). RESULTADOS: Vinte e um pacientes foram avaliados. De acordo com a classificação AO, 14 eram grupo A, 3 B e 4 C. Ao todo, sete pacientes apresentaram déficit neurológico inicial completo (Frankel A) e permaneceram com o déficit neurológico completo após dois anos. Dos seis pacientes que apresentaram déficit neurológico inicial incompleto (Frankel B, C e D), 33% (2 de 6) apresentaram melhora de um nível na escala de Frankel e 50% (3 de 6) deles evoluíram para recuperação completa (Frankel E). Os oito pacientes que não apresentaram lesão neurológica inicial (Frankel E) permaneceram sem déficit neurológico após dois anos. Três complicações clínicas foram verificadas: uma fístula esofágica, uma soltura asséptica do implante e uma infecção no sítio doador de enxerto. Todos os pacientes obtiveram consolidação do enxerto ósseo. CONCLUSÃO: A corpectomia cervical no tratamento da fratura-explosão permite a recuperação neurológica nos pacientes com lesão neurológica incompleta e apresenta baixos índices de complicações.

Long-term follow-up of cervical radiographic sagittal spinal alignment after 1- and 2-level cervical corpectomy for the treatment of spondylosis of the subaxial cervical spine causing radiculomyelopathy or myelopathy: a retrospective study

Object

Few data exist regarding long-term outcomes after cervical corpectomy for spondylotic cervical myelopathy and radiculomyelopathy. In this retrospective review, long-term radiographic outcomes are reported for 130 patients after 1- or 2-level cervical corpectomy for spondylotic myelopathy or radiculomyelopathy.

Methods

Electronic medical records including clinical data and radiographic images during a 15-year period (1993–2008) were reviewed at the Cincinnati Department of Veterans Affairs Medical Center. All patients underwent radiographic follow-up for at least 12 months (range 12–156, mean 45 ± 39.3 months), as well as clinical follow-up performed by neurosurgery staff for a mean of 29.3 ± 39.6 months (range 4–156 months). Clinical parameters at surgery and last examination included the Chiles modified Japanese Orthopaedic Association (mJOA) Myelopathy Scale. Measurements included cervical spine sagittal alignment on lateral radiographs preoperatively and postoperatively, focal Cobb angles at operated levels, and C2–7 regional alignment. Statistical analysis included the Student t-test and chi-square test. Perioperative complications and additional surgery in the cervical spine were recorded.

Results

The mJOA scores improved from a mean of 11.91 ± 2.4 preoperatively to 14.9 ± 2.33 postoperatively. The mean sagittal lordosis of the C2–7 spine increased from −16.2° ± 9.2° preoperatively to −18.5° ± 11.9° at last follow-up. Focal Cobb angles averaged a slight kyphotic angulation of 4.1° ± 2.3° at latest radiographic follow-up; of note, 7 patients (5.4%), all who had cylindrical titanium mesh cages (CTMCs), showed severe kyphotic angulation (+8.4° ± 2.4°). Patients with preoperative myelopathy showed clinical improvement at follow-up. The fusion rate was 96.2%; 3 of the 5 patients with radiographic evidence of nonfusion were smokers. Patients with postoperative kyphosis had significantly more chronic neck pain (visual analog scale score >4 lasting more than 6 months) and visits related to pain (p <0.01). Those with CTMCs had higher rates of postoperative kyphosis, chronic neck pain, and visits related to pain, irrespective of the number of levels fused (p <001). At latest follow-up, although a kyphotic increase occurred in the focal cervical sagittal Cobb angles, lordosis increased in C2–7 sagittal Gore angles. Two patients (1.5%) underwent revision of the implanted graft and/or hardware, and 5 patients (3.8%) had another procedure for adjacent-level pathologies 1–9 years later (mean 4.4 ± 2.7 years).

Conclusions

Long-term follow-up data in our veteran population support cervical corpectomy as an effective, long-lasting treatment for spondylotic myelopathy of the cervical spine. Use of CTMCs without end caps was associated with statistically significant increased postoperative kyphotic angulation and chronic pain. Despite an increase in focal kyphosis over time, regional cervical sagittal lordotic alignment had increased at the latest follow-up. Further investigation will include the association of chronic neck pain and postoperative kyphosis, and high fusion rates among a veteran population of heavy smokers.

Single stage circumferential cervical surgery (selective anterior cervical corpectomy with fusion and laminoplasty) for multilevel ossification of the posterior longitudinal ligament with spinal cord ischemia on MRI

OBJECTIVE

Anterior cervical corpectomy with fusion (ACF) or laminoplasty may be associated with substantial number of complications for treating multilevel cervical ossification of the posterior longitudinal ligament (OPLL) with significant cord compression. For more safe decompression and stabilization in multilevel cervical OPLL with prominent cord compression, we propose circumferential cervical surgery (selective ACF and laminoplasty) based on our favorable experience.

METHODS

Twelve patients with cervical myelopathy underwent circumferential cervical surgery and all patients showed multilevel OPLL with signal change of the spinal cord on magnetic resonance imaging (MRI). A retrospective review of clinical, radiological, and surgical data was conducted.

RESULTS

There were 9 men and 3 women with mean age of 56.7 years and a mean follow up period of 15.6 months. The average corpectomy level was 1.16 and laminoplasty level was 4.58. The average Japanese Orthopedic Association score for recovery was 5.1 points and good clinical results were obtained in 11 patients (92%) (p < 0.05). The average space available for the cord improved from 58.2% to 87.9% and the average Cobb's angle changed from 7.63 to 12.27 at 6 months after operation without failure of fusion (p < 0.05). Average operation time was 8.36 hours, with an estimated blood loss of 760 mL and duration of bed rest of 2.0 days. There were no incidences of significant surgical complications, including wound infection.

CONCLUSION

Although the current study examined a small sample with relatively short-term follow-up periods, our study results demonstrate that circumferential cervical surgery is considered favorable for safety and effectiveness in multilevel OPLL with prominent cord compression.

Cervical Corpectomy: Complications and Outcomes

Objective:

Previously, information on cervical corpectomy complication rates has been obtained from retrospective analysis of single-institution data. The aim of this study was to report 30-day mortality and complication rates after cervical corpectomy using multicenter prospective data from the Veterans Affairs National Surgical Quality Improvement Program database.

Methods:

The National Surgical Quality Improvement Program database was used to identify 1560 patients who underwent cervical corpectomy in United States Veterans Affairs hospitals from 1997 to 2006. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on morbidity and mortality rates.

Results:

A total of 1560 patients underwent corpectomy, with an overall in-hospital mortality rate of 1.6%, a complication rate of 18.4%, and a mean length of stay of 6 days. Multivariate analysis identified age older than 80 years (odds ratio [OR], 21.24), history of Type 1 diabetes (OR, 2.36), American Society of Anesthesiologists class greater than 3 (OR, 6.93), and dependent functional status (OR, 3.17) as the most significant preoperative predictors of complications. Three or more corpectomy levels (OR, 2.46) and operative duration longer than 6 hours (OR, 3.45) were also found to be significant predictors of postoperative complications. Patients who underwent 3 or more levels of corpectomy had a return-to-operating room rate of 17.9% and a graft/instrumentation failure rate of 5.4% compared with those who underwent single-level corpectomy, who had rates of 6.2 and 1.87%, respectively. Patients who were returned to the operating room had significantly higher mortality rates (7.0 versus 1.2%) and accounted for 39.9% of the total number of complications. Multivariate analysis identified age, American Society of Anesthesiologists class, history of disseminated cancer, and diabetes as the most significant predictors of mortality. Patients with Type 1 diabetes had 4-fold higher mortality rates compared with patients with no history of diabetes or diet-controlled diabetes.

Conclusion:

We have analyzed the morbidity and mortality data on the largest series of corpectomy reported to date. We have demonstrated the impact of age, American Society of Anesthesiologists class, and number of operated levels on complication rates. Type 1 diabetes was established as a strong risk factor for 30-day mortality after cervical corpectomy.

Preliminary experience of titanium mesh cages for pathological fracture of middle and lower cervical vertebrae

The advantages and disadvantages of titanium mesh cages (TMCs) assisted by anterior cervical plates (ACPs) for interbody fusion following cervical corpectomy were investigated. Between January 2002 and September 2006, 17 patients with cervical radiculomyelopathy caused by metastasis-induced pathologic fractures were selected for anterior corpectomy. TMCs were inserted into the post-corpectomy defect and stabilized by placement of ACPs filled with Triosite. Post-operative plain X-ray films indicated maintenance of spinal stability. No ceramic, donor site or surgery-related complications were observed. True trabeculation was observed in axial and reconstructive CT scans in all surviving patients one year after surgery. Neurological recovery, pain control, and good quality of life were achieved. Short hospital stays, minimal blood loss, short operation times and brief periods of bed confinement were also observed. We conclude that a TMC assisted by an ACP is safe and effective for interbody fusion following cervical corpectomy for pathological fractures resulting from cervical vertebral metastases.

Comparison of multisegment anterior cervical fixation using bone strut graft versus a titanium rod and buttress prosthesis: analysis of outcome with long-term follow-up and interview by independent physician

STUDY DESIGN

A retrospective study of 73 consecutive patients who underwent cervical corpectomy and anterior strut fixation over 3 or more disc levels between July 1989 and May 1999.

OBJECTIVE

To compare the efficacy of cervical spine fixation by autologous strut graft from iliac crest or fibula versus a titanium prosthesis without bone graft.

SUMMARY OF BACKGROUND DATA

Strut grafting after multilevel anterior cervical corpectomy remains a challenging procedure, with published dislocation rates from 0% to 71%, and nonunion from 0% to 54%. This paper describes a quicker and easier alternative to the use of a bone strut, imparting a very high degree of immediate spinal stability, and osseous integration equivalent to bone fusion.

METHODS

Thirty-eight bone-graft operations and 38 titanium prosthesis operations were performed on 73 patients between July 24, 1989 and May 20, 1999. Average follow-up was 53.2 months (range 19.8-134).

RESULTS

The group of patients who received the prosthesis was significantly older than the bone-grafted group and required significantly more segments excised, but operation times were significantly shorter than for the bone strut operation. The titanium prosthesis had a lower incidence of dislodgement in the early postoperative period (1/38 vs. 4/38 for bone struts) but a higher rate of late reoperation (4/38 vs. 1/38 for bone struts). The SF-36 scores in the domain of Physical Function (only) were significantly higher in the bone-grafted group (P = 0.016, Mann Whitney), consistent with the difference in mean ages of the 2 groups. The groups were indistinguishable by Odom criteria, patient verdict, pain scores, analgesic intake, length of hospital stay, radiologic fusion rate, and residual symptoms.

CONCLUSION

A titanium rod and buttress prosthesis may be a faster and easier alternative to conventional iliac crest/fibula autograft after multisegmental cervical vertebral corpectomy.

Implantation of a distractible titanium cage after cervical corpectomy: technical experience in 20 consecutive cases

BACKGROUND

This prospective observational study was undertaken to investigate the advantages, the safety, and the drawbacks of reconstructing a cervical corpectomy with a distractible corpectomy cage. According to the author's literature search, this is the second clinical report on a distractible cervical corpectomy cage.

METHOD

20 Consecutive patients underwent a single- or multi-level cervical corpectomy for spondylotic myelopathy, traumatic fracture, or tumor. The corpectomy defect was reconstructed by means of a distractible titanium cage, and local bone from the corpectomy was layed around the cage for fusion. An anterior cervical plate and/or a posterior lateral mass or pedicle screw fixation was added in all patients. The average follow-up was 14 months, and all patients had at least 12 months of follow-up.

FINDINGS

No hardware failure occurred in any of the patients. Construct stability was achieved in 19 out of 20 patients (95%) at 12 months postoperatively. The mean regional lordosis was 1 degrees preoperatively, 9 degrees postoperatively, and 7 degrees at the follow-up. Mean neck pain on a VAS was 3.9 preoperatively, and 2.6 at 12 months. There were three perioperative complications: transient neurological worsening in one patient, one transient vocal cord paralysis, and persistent dysphagia in one patient.

CONCLUSION

A single- or multi-level cervical corpectomy can be safely and effectively reconstructed by a distractible titanium cage and local bone graft in combination with anterior cervical plating and/or posterior lateral mass/pedicle screw fixation. Potential advantages of this technique are an unforced cage insertion in its non-distracted position, press-fitting the cage into the corpectomy defect through cage distraction, correction of kyphosis or preservation of local lordosis through cage distraction, and the absence of donor site morbidity. However, the stability rate in the current series did not exceed the fusion rates of auto- or allografts.

Surgical management of cervical myelopathy: indications and techniques for laminectomy and fusion

BACKGROUND

Cervical spondylotic myelopathy (CSM) is a commonly encountered surgical disease that may be approached through a variety of operative techniques. Operative goals in the treatment of CSM include effective neural element decompression and maintaining spinal stability to avoid delayed deformity progression and neurologic compromise. Determining the most appropriate operative approach requires careful consideration of the patient's clinical presentation and radiographic imaging.

PURPOSE

To review the indications and techniques for multilevel laminectomy and fusion in the treatment of CSM.

CONCLUSIONS

When indications permit, a multilevel laminectomy is an effective and safe method of neural element decompression. Recognizing the potential for spinal instability is essential to prevent neurologic compromise and intractable axial neck pain caused by deformity progression. A variety of techniques have been described to supplement the posterior tension band after laminectomy; however, lateral mass fixation has evolved into the preferred stabilization technique. Although clinical success is well documented, a successful outcome is dependent on a comprehensive, individualized evaluation of each patient presenting with CSM.

Delayed reconstruction by titanium mesh-bone graft composite in pyogenic spinal infection: a long-term follow-up study

OBJECTIVE

Use of instrumentation in spinal osteomyelitis remains controversial because of the perceived risk of persistent infection related to a devitalized graft and spinal hardware. Particularly, limited information is available regarding the long-term follow-up of patients. We retrospectively reviewed the use of titanium mesh-bone graft composite after corpectomy in pyogenic spinal infection with a minimum 3-year follow-up outcome.

METHODS

Four patients, two men and two women, with cervical and thoracic myelopathy caused by cervical (two cases) and thoracic (two cases) osteomyelitis and epidural abscess, were treated. Their age ranged from 49 to 74 years (mean age 58 years). In one case, the coexisting medical condition was diabetes. Neurologic deficits caused by direct spinal cord compression due to epidural abscess, segmental deformity, and instability were observed in all cases. After infection was clinically controlled by intravenous antibiotics, anterior debridement and fusion using titanium mesh cage along with anterior plate were performed. Two-stage treatment was performed in two cases.

RESULTS

The postoperative course was uneventful; all patients experienced relief of symptoms. No evidence of recurrence or residual infection was observed in any patient during the average follow-up period of 42-56 months (average 49.0 months).

CONCLUSIONS

Once infection is clinically controlled, a titanium mesh-bone graft composite and plate in combination with aggressive debridement might provide an effective therapy for spinal osteomyelitis requiring surgery. Despite studying a small number of patients, we can conclude that titanium mesh reconstruction can be useful as a surgical method in selected low-risk patients with vertebral osteomyelitis.

Complications and Long-Term Follow-Up Results in Titanium Mesh Cage Reconstruction After Cervical Corpectomy

OBJECTIVE

The incidence of the complications and long-term outcome with a minimum 2-year follow-up of anterior cervical reconstruction using titanium mesh cage is evaluated. Relevant literature was also reviewed to discuss the potential risk factors of the complications of this procedure.

METHODS

From 1999 to 2003, 26 patients with cervical spine disorders, (12 patients with OPLL, 7 with cervical spondylosis, 3 with vertebral tumors, 2 with osteomyelitis, and 2 with traumatic lesions) were operated on by this procedure. The series included 14 males and 12 females with a mean age of 60.9 years. Corpectomy was performed on 1 (14 cases), 2 (12 cases). Autologous bone fragments were taken from the excised vertebra.

RESULTS

The average improvement rate as scored on the neurosurgical cervical spine scale was 67.4%. The average follow-up period was 54.3 months (range, 24 to 72 months) in 21 who were followed up, and bone union was observed in all cases (22/22 cases) that could be followed up for more than 6 months postoperatively. The average time required for fusion was 6.7 months. Postoperative complications included dyspnea (1 case) and cerebrospinal fluid leakage (2 cases), which was treated by lumbar drainage, without any additional repair operation. No hardware-related complications or adjacent segment degenerative changes were encountered during the follow-up periods.

CONCLUSIONS

This reconstruction technique yielded good clinical results and helped to avoid complications associated with harvesting bone from the iliac crest donor site. However, risk factors related to the method should be carefully considered.

Candida albicans osteomyelitis of the spine: progressive clinical and radiological features and surgical management in three cases

Candida albicans vertebral osteomyelitis is rare. Three cases are presented. Without antifungal treatment, they developed spinal collapse and neurological deterioration within 3-6 months from the onset of symptoms. There was a delay of 4.5 and 7.5 months between the onset of symptoms and surgery. All patients were managed with surgical debridement and reconstruction and 12-week fluconazole treatment. The neurological deficits resolved completely. The infection has not recurred clinically or radiologically at 5-6 years follow-up. Although rare, Candida should be suspected as a causative pathogen in cases of spinal osteomyelitis. Without treatment the disease is progressive. As soon as osteomyelitis is suspected, investigations with MRI and percutaneous biopsy should be performed followed by medical therapy. This may prevent the need for surgery. However, if vertebral collapse and spinal cord compression occurs, surgical debridement, fusion and stabilisation combined with antifungal medications can successfully eradicate the infection and resolve the neurological deficits.