Complications After 3- and 4-Level Anterior Cervical Diskectomy and Fusion

Anterior cervical discectomy and fusion versus cervical disc arthroplasty: an epidemiological review of 433,660 surgical patients from 2011 to 2021

BACKGROUND CONTEXT

Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are commonly performed operations to address cervical radiculopathy and myelopathy. Trends in utilization and revision surgery rates warrant investigation.

PURPOSE

To explore the epidemiology, postoperative complications, and reoperation rates of ACDF and CDA.

DESIGN

Retrospective cohort study.

PATIENT SAMPLE

A total of 433,660 patients who underwent ACDF or CDA between 2011 and 2021 were included in this study.

OUTCOME MEASURES

The following data were observed for all cases: patient demographics, complications, and revisions.

METHODS

The PearlDiver database was queried to identify patients who underwent ACDF and CDA between 2011 and 2021. Epidemiological analyses were performed to examine trends in cervical procedure utilization by age group and year. After matching by age, sex, Charlson Comorbidity Index (CCI), levels of operation, and reason for surgery, the early postoperative (2-week), short-term (2-year), and long-term (5-year) complications of both cervical procedures were examined.

RESULTS

In total, 404,195 ACDF and 29,465 CDA patients were included. ACDF utilization rose by 25.25% between 2011 and 2014 while CDA utilization rose by 654.24% between 2011-2019 followed by relative plateauing in both procedures. Mann-Kendall trend test confirmed a significant but small rise in ACDF and large rise in CDA procedures from 2011 to 2021 (p<.001). After matching, ACDF and CDA had an overall complication rate of 12.20% and 8.77%, respectively, with the most common complications being subsequent anterior revision (4.96% and 3.35%) and dysphagia (3.70% and 2.98%). The ACDF cohort, especially multilevel ACDF patients, generally had more complications and higher revision rates than the CDA cohort (p<.05).

CONCLUSIONS

While ACDF utilization has plateaued since 2014, CDA rates have risen by a staggering 654.24% over the past decade. ACDF and CDA complication and revision rates were relatively low in comparison to previously published values, with significantly lower rates in CDA. Although a lack of radiographic data in this study limits its power to recommend either procedure for individual patients with cervical radiculopathy or myelopathy, CDA may be associated with minor improvement in the complication and revision profile.

Four-level ACDF surgical series 2000-2022: a systematic review of clinical and radiological outcomes and complications

OBJECTIVE

The primary objective of this investigation is to systematically scrutinize extant surgical studies delineating Four-Level Anterior Cervical Discectomy and Fusion (4L ACDF), with a specific emphasis on elucidating reported surgical indications, clinical and radiological outcomes, fusion rates, lordosis correction, and the spectrum of complication rates.

METHODS

The literature review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, employing the MEDLINE (PubMed), Embase, and Scopus databases. This analysis encompasses studies implementing the 4L ACDF procedure, with detailed extraction of pertinent data pertaining to surgical methodologies, types of employed interbody cages, clinical and radiological endpoints, rates of fusion, and the incidence of complications.

RESULTS

Among the 15 studies satisfying inclusion criteria, a marginal increment in the year 2022 (21.4%) was discerned, with a preponderance of study representation emanating from China (35.7%) and the United States (28.6%). 50% of the studies were single-surgeon studies. Concerning follow-up, studies exhibited variability, with 42.9% concentrating on periods of five years or less, and an equivalent proportion extending beyond this timeframe. Across the amalgamated cohort of 2457 patients, males constituted 51.6%, manifesting a mean age range of 52.2-61.3 years. Indications for surgery included radiculopathy (26.9%) and myelopathy (46.9%), with a predilection for involvement at C3-7 (24.9%). Meta-analysis yielded an overall complication rate of 16.258% (CI 95%: 14.823%-17.772%). Dysphagia (4.563%), haematoma (1.525%), hoarseness (0.205%), C5 palsy (0.176%) were the most prevalent complications of 4L ACDF. Fusion rates ranging from 41.3% to 94% were documented.

CONCLUSION

The 4L ACDF is commonly performed to address mylopathy and radiculopathy. While the surgery carries a complication rate of around 16%, its effectiveness in achieving bone fusion can vary considerably.

Analysis of Complications in Multilevel Anterior Cervical Discectomy and Fusion Using Osteobiologics Other than Bone Morphogenetic Protein: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The aim of this study is to analyze the complications related to multilevel anterior cervical discectomy and fusion (ACDF) using osteobiologics other than bone morphogenetic protein (BMP).

METHODS

A systematic review of the literature was conducted using PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases. The search to identify studies reporting complications in multilevel ACDF surgery using osteobiologics other than bone morphogenetic protein was performed in August 2020. The study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA).

RESULTS

A total of 584 articles were found after searching the databases and removing duplicates. Next, screening was performed in a double reviewer process, and 153 eligible articles-with 4 retrospective studies-in full-text were selected; these met all inclusion criteria. A total of 197 patients received 3-level ACDF, while 72 patients received 4-level ACDF. Osteobiologics were used in all selected articles, allograft was used in 4 studies, autologous bone graft was utilized in 3 articles, and hydroxyapatite was used in 1 article. The main complications reported were dysphagia, adjacent segment disease, and pseudarthrosis.

CONCLUSIONS

Given the limited evidence, no conclusions on complications in multilevel ACDF using osteobiologics other than BMP could be made. However, descriptively, the most common complications found were dysphagia, adjacent segment disease, and pseudoarthrosis. Further prospective studies separately analyzing complications in multilevel ACDF by osteobiologics and a number of treated levels are needed.

AO Spine Guideline for the Use of Osteobiologics (AOGO) in Anterior Cervical Discectomy and Fusion for Spinal Degenerative Cases

STUDY DESIGN

Guideline.

OBJECTIVES

To develop an international guideline (AOGO) about the use of osteobiologics in anterior cervical discectomy and fusion (ACDF) for treating degenerative spine conditions.

METHODS

The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence was collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus.

RESULTS

Five conditional recommendations were created. A conditional recommendation is about the use of allograft, autograft or a cage with an osteobiologic in primary ACDF surgery. Other conditional recommendations are about the use of osteobiologic for single- or multi-level ACDF, and for hybrid construct surgery. It is suggested that surgeons use other osteobiologics rather than human bone morphogenetic protein-2 (BMP-2) in common clinical situations. Surgeons are recommended to choose 1 graft over another or 1 osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials.

CONCLUSION

This AOGO guideline is the first to provide recommendations for the use of osteobiologics in ACDF. Despite the comprehensive searches for evidence, there were few studies completed with small sample sizes and primarily as case series with inherent risks of bias. Therefore, high-quality clinical evidence is demanded to improve the guideline.

Multilevel Cervical Disk Arthroplasty: Moving Beyond Two Levels

Cervical disk arthroplasty (CDA) is well-studied for 1-level and 2-level cervical pathology. There is an increasing trend towards its utilization for greater than 2-level disease as an alternative to the gold standard, anterior cervical discectomy and fusion (ACDF). The number of high-level, prospective studies or randomized trials regarding multilevel CDA is limited but continues to grow as the procedure gains popularity. In appropriately indicated patients with multilevel disease caused by disk herniations or spondylosis without extensive facet arthropathy, CDA shows promising results. Multilevel CDA should be avoided in patients with prior spinal trauma, significant degenerative spondylolisthesis with translation, arthrodesis without mobility, severely incompetent facet joints, ossification of the posterior longitudinal ligament, or kyphotic deformity. With overall similar risk profiles to ACDF but lower theoretical rates of pseudarthrosis and adjacent segment disease, multilevel CDA has been shown to preserve, or perhaps even increase, preoperative cervical range of motion. There are negligible differences in postoperative neck and arm pain, VAS scores, modified Japanese Orthopaedic Association scores, and Neck Disability Index scores when comparing multilevel CDA and ACDF. Despite current indications for multilevel CDA largely being based on single and 2-level data, careful patient selection is critical. Expansion of indications can be expected as literature continues to emerge regarding outcomes and complications in multilevel CDA, as well as with improvements in prosthesis design.

Comparison between 3-level and 4level anterior cervical discectomy and fusion in the treatment of cervical spondylotic myelopathy: A meta-analysis

Objective

Our objective is to estimate the clinical effectiveness of 3-level and 4-level anterior cervical discectomy and fusion (ACDF) in the management of cervical spondylotic myelopathy (CSM).

Methods

We conducted a thorough search in English databases. We gathered the data on surgical variables and complications to contrast the clinical effectiveness between 3-level and 4-level. We utilized RevMan 5.3 and STATA 12.0 to analyze the data.

Results

Finally, eight studies met inclusion criteria of this study. Our findings indicated that operation time [p for heterogeneity = 0.23, I2 = 32 %, p＜0.00001, OR = -24.93, 95%CI (-32.39,-17.49)], blood loss [p for heterogeneity = 0.33, I2 = 10 %, p＜0.00001, OR = -60.87, 95%CI (-85.43,-36.32)] and the total number of complications [p for heterogeneity = 0.36, I2 = 0 %, p = 0.004, OR = 0.37, 95%CI (0.18,0.72)] in 3-level ACDF were significantly less than in 4-level ACDF. No marked difference was found in hospital stay, revision rate, fusion rate, the number of readmissions, infection, hematoma, or pseudarthrosis between 3-level and 4-level ACDF.

Conclusions

It is easy to understand that performing 4-level needs more operation time and blood loss. No obvious discrepancy was found with regard to the subgroups of complications between the two procedures, yet 4-level procedures had a more number of complications.

Multilevel cervical disc arthroplasty: a review of optimal surgical management and future directions

OBJECTIVE

Cervical disc arthroplasty (CDA) has been recognized as a popular option for cervical radiculopathy or myelopathy caused by disc problems that require surgery. There have been prospective randomized controlled trials comparing CDA to anterior cervical discectomy and fusion (ACDF) for 1- and 2-level disc herniations. However, the indications for CDA have been extended beyond the strict criteria of these clinical trials after widespread real-world experiences in the past decade. This article provides a bibliometric analysis with a review of the literature to understand the current trends of clinical practice and research on CDA.

METHODS

The PubMed database was searched using the keywords pertaining to CDA in human studies that were published before August 2022. Analyses of the bibliometrics, including the types of papers, levels of evidence, countries, and the number of disc levels involved were conducted. Moreover, a systematic review of the contents with the emphasis on the current practice of multilevel CDA and complex cervical disc problems was performed.

RESULTS

A total of 957 articles published during the span of 22 years were analyzed. Nearly one-quarter of the articles (232, 24.2%) were categorized as level I evidence, and 33.0% were categorized as levels I or II. These studies clearly demonstrated the viability and effectiveness of CDA regarding clinical and radiological outcomes, including neurological improvement, maintenance, and preservation of segmental mobility with relatively low risks for several years postoperation. Also, there have been more papers published during the last decade focusing on multilevel CDA and fewer involving the comparison of ACDF. Overall, there was a clustering of CDA papers published from the US and East Asian countries. Based on substantial clinical data of CDA for 1- and 2-level disc diseases, the practice and research of CDA show a trend toward multilevel and complex disease conditions.

CONCLUSIONS

CDA is an established surgical management procedure for 1- and 2-level cervical disc herniation and spondylosis. The success of motion preservation by CDA-with low rates of complications-has outscored ACDF in patients without deformity. For more than 2-level disc diseases, the surgery shows a trend toward multiple CDA or hybrid ACDF-CDA according to individual evaluation for each level of degeneration.

Is 3D-printed Titanium cage a reliable option for 3-level anterior cervical discectomy and fusion in treating degenerative cervical spondylosis?

Background

To assess the clinical and radiographical outcomes of 3-level anterior cervical discectomy and fusion (ACDF) with a 3D-printed titanium cage in treating degenerative cervical spondylosis.

Methods

In this study, 25 patients with degenerative cervical spondylosis who underwent 3-level ACDF using a 3D-printed titanium cage from March 2019 to June 2021 were retrospectively enrolled. The patient-reported outcome measures (PROMs) were evaluated by visual analog scale (VAS) for the neck (VAS-neck) and arm pain (VAS-arm), Neck Disability Index (NDI) score, Japanese Orthopedic Association (JOA) score, SF-12 concise health survey, and the Odom criteria. The radiographical parameters, including C2-C7 lordosis, segmental angle, segmental height, and subsidence, were assessed. The mean duration of follow-up was 25.6 months.

Results

Bony fusion was achieved in all patients (100%). In three patients (12%) mild dysphagia was observed during the follow-up. The VAS-neck, VAS-arm, NDI score, JOA score, SF-12 score, C2-C7 lordosis, and segmental angle improved noticeably at the latest follow-up. Based on the Odom criteria, 22 patients (88%) reported satisfactory (excellent or good). The mean loss of C2-C7 lordosis and segmental angle between the immediate postoperative and the latest follow-up values were 1.6° ± 0.5° and 1.1° ± 0.5°, respectively. The mean subsidence was 0.9 ± 0.6 mm.

Conclusion

In patients with multi-level degenerative cervical spondylosis, 3-level ACDF using the 3D-printed titanium cage can effectively relieve the symptoms, stabilize the spine, and restore segmental height and cervical curvature. It is proven to be a reliable option for patients with 3-level degenerative cervical spondylosis. However, a future comparative study involving a larger population and longer follow-up time may be required to further evaluate the safety, efficacy and outcomes of our preliminary results.

Minimally Invasive Full‐endoscopic Posterior Cervical Foraminotomy and Discectomy: Introducing a Simple and Useful Localization Technique of the “V” Point

Objective

Conventional localization technique of V point for full‐endoscopic posterior cervical foraminotomy and discectomy (FPCD) required repeated fluoroscopies, especially in patients with short and thick necks. To address this issue, the present study aimed to introduce a new localization technique of V point, and further evaluate its efficacy.

Methods

A K‐wire was inserted and fixed at the pedicle eye under A/P fluoroscopy, then a working channel was established quickly along with it. Thirty‐four patients who underwent minimally invasive FPCD assisted by the new technique were included in this study. The clinical and radiological data were collected and analyzed, including radiation dose, operative time, positioning time, visual analog scale (VAS) for neck and arm pain, neck disability index (NDI) scores, Cobb angle of operative level and range of motion of the cervical spine.

Results

All operations were performed successfully, and no iatrogenic nerve or vascular injury occurred. None of the patients needed to be transferred to open surgery or revision surgery. The mean radiation dose was found to be1.68 ± 0.36 mSv. The mean positioning time observed was 10.68 ± 5.42 min and the average operation time was 81.18 ± 10.87 min. The operation time significantly declined as the number of patients increased. A significant difference in operation time between the first (96.22 ± 10.36 min) and last quartile (75.00 ± 3.84 min) of cases was observed (t = 4.82, P < 0.001). The VAS scores for neck and arm pain, and NDI scores were significantly improved after surgery (P_VAS−Neck<0.0001, P_VAS−Arm<0.0001, P_NDI<0.0001). Based on MacNab criteria, the excellent plus good rate was 91.17%. The Cobb angle of operative level and range of motion of the cervical spine were significantly improved postoperatively (t = 2.846, P_OA = 0.015; t = 2.232, P_ROM−CA = 0.026).

Conclusion

The new image‐assisted V point localization technique is simple and useful with little radiation exposure and short positioning time. FPCD assisted by the new technique could be a safe and effective alternative on properly selected patients.

Clinical outcomes following one-, two-, three-, and four-level anterior cervical discectomy and fusion: a national database study

BACKGROUND CONTEXT

Anterior cervical discectomy and fusion (ACDF) is a common surgical procedure. There is markedly less data on outcomes after three- and four-level cases than one- and two-level cases.

PURPOSE

To compare perioperative 90-day adverse events and 5-year reoperation rates between isolated one-, two-, three-, and four-level ACDF cases.

STUDY DESIGN/SETTING

Retrospective review of a large national database.

PATIENT SAMPLE

Overall, 97,081 patients undergoing ACDF were identified, of which one-level cases were 42,382 (43.7%), two-level cases were 24,055 (24.8%), three-level cases were 28,293 (29.1%), and four-level cases were 2,361 (2.4%).

OUTCOME MEASURES

Ninety-day adverse events and 5-year reoperation rates.

METHODS

The 2010 to Q1 2020 PearlDiver database was queried to identify patients who underwent elective ACDF for degenerative pathology without corpectomy or concomitant posterior procedures. Univariate and multivariate analyses were performed to compare outcomes of subcohorts with varying number of levels addressed by ACDF.

RESULTS

Of the 97,081 cases identified, patient characteristics and complication rates differed between the cohorts defined by levels treated. Univariate analyses revealed statistically different rates of 90-day any, serious, and minor adverse event rates between the groups, but the differences were all less than 2.5%. Readmission rates were statistically different by 2.9%, dysphagia by 3.2%, and prolonged length of stay by 6.3%.By multivariate analyses, three-level ACDF cases were not found to have greater 90-day adverse outcomes than two-level cases. Four-level ACDF cases were found to have significantly greater odds ratios of readmission, dysphagia, and prolonged length of stay (relative to one-level cases, OR 1.28, 1.63, and 1.97, respectively) but not other 90-day adverse events. Reoperation rates at five years for one-, two-, three-, and four-level cases were 13.0%, 13.5%, 15.0%, and 22.1%, respectively (log-rank p<.001).

CONCLUSIONS

The current study represents one of the largest comparative studies of patients undergoing one-, two-, three-, and four-level ACDF. While odds of 90-day adverse events were not greater for three- versus two-level cases, four-level cases had several that were higher odds than one-level cases. Reoperation and dysphagia rates were higher for four-level cases than lesser levels. While these outcomes were found to be acceptable, they should help guide hospital planning and patient counseling.

Clinical outcomes and revision rates following four-level anterior cervical discectomy and fusion

Studies on outcomes after four-level anterior cervical discectomy and fusion (ACDF) are limited in the literature. The purpose of this study was to report on clinical outcomes and revision rates following four-level ACDF. Patients operated with four-level ACDF were identified in a prospectively accrued single institution database. Outcome scores included the Neck Disability Index (NDI) and Visual Analogue Scale (VAS) for neck and arm pain. Reoperation rates were determined. Any complications were identified from a review of the medical records. Twenty-eight patients with a minimum of 12 months follow up were included in the analysis. The mean age at surgery was 58.5 years. The median radiographic follow up time was 23 (IQR = 16–31.25) months. Cervical lordosis was significantly improved postoperatively (− 1 to − 13, p < 0.001). At the median 24 (IQR = 17.75–39.50) months clinical follow up time, there was a significant improvement in the NDI (38 to 28, p = 0.046) and VAS for neck pain scores (5.1 to 3, p = 0.012). The most common perioperative complication was transient dysphagia (32%) followed by hoarseness (14%). Four (14%) patients required revision surgery at a median 11.5 (IQR = 2–51) months postoperatively. The results of this study indicate that patients who undergo four-level ACDF have a significant improvement in clinical outcomes at median 24 months follow up. Stand-alone four-level ACDF is a valid option for the management of complex cervical degenerative conditions.

The surgical outcome of multilevel anterior cervical discectomy and fusion in myelopathic elderly and younger patients

The elderly population has an increased risk of degenerative cervical myelopathy due to multilevel disease, causing motor and sensory dysfunctions and a poor quality of life. Multilevel anterior cervical discectomy and fusion (ACDF) is an alternative surgical treatment option, but has a perceived higher risk of complications. The goal of this study is to report the outcome. We retrospectively reviewed patients from 2006 to 2019 undergoing multilevel ACDF for degenerative cervical myelopathy and compared outcomes and complications between elder patients (aged 70 and above) and younger patients (below 70). The patients' comorbidities, and postoperative complications, radiographic parameters such as C2-C7 Cobb angle, C2-C7 sagittal vertical axis, inter-body height of surgical levels and fusion rate were recorded. Japanese Orthopaedic Association (JOA) score and modified Odom's score were collected. Included were 18 elderly (mean age 74, range 70-87) and 45 young patients (mean age 56, range 43-65) with a follow-up of 43.8 and 55.5 months respectively. Three-level ACDF was the most common. The ratios of ASA class III patients were 94.4% and 48.9% (p < 0.001). The Charlson comorbidity indexes were 4.3 ± 1.03 and 2.1 ± 1.11 (p < 0.001). The average lengths of hospital stays were 4.9 and 4.6 days. Eleven patients (61.1%) in the elderly group experienced at least one short-term complication, compared with 16 patients (35.6%) in the younger group (p < 0.05). The middle-term complications were comparable (22.2% and 20.0%). The JOA score, recovery rate and modified Odom score showed comparable result between groups. Despite its extensiveness, multilevel ACDF is feasible for the elder patients with good clinical outcome and fusion rate. When compared to younger cohort, there is a trend of lower preoperative JOA score and recovery rate. The short-term complication rate is higher in the elderly group.

Intervertebral-spreader-assisted anterior cervical discectomy and fusion prevents postoperative axial pain by alleviating facet joint pressure

Objective

To evaluate the relationship of postoperative cervical axial pain with different vertebral distraction methods used during ACDF procedures in cervical spondylosis patients.

Methods

Ninety-four single-level cervical spondylotic myelopathy patients with significantly loss of intervertebral disc height who underwent ACDF surgery in our institute between January 2018 and January 2020 were enrolled. Cervical spine lateral radiographs were taken preoperatively, 3 days, 1-month, 2-month and 6-month after the surgery. The intervertebral disc height (IDH), interfacet distance (IFD), JOA (Japanese Orthopaedic Association) score, NDI (Neck Disability Index) score, nVAS (Neck Visual Analogue Scale) score and aVAS (Arm Visual Analogue Scale) score were measured. The correlation of clinical parameters and intervertebral disc height was evaluated. Then the correlation of clinical outcomes and different distraction method was evaluated. The patients were randomly divided into two groups, one uses Casper pin distractor system alone for distraction (Caspar alone group) and the other uses spreader assisted distraction method (Casper + spreader group). In biomechanical study, four cervical spine cadavers were selected for facet pressure measurements under different vertebral distraction methods, and the facet joint pressure was measured using force sensors.

Results

Satisfactory cervical fusion and neurological recovery were achieved in all patients. No significant correlation of IDH, IFD, JOA, NDI or aVAS with nVAS score was found. No significant difference between the change in disc height and clinical outcomes was found. However, by comparing the clinical parameters of patients in different vertebral distraction groups, we found significant changes in the early nVAS and NDI scores (P = 0.11, P = 0.48) of the Casper + spreader group (3 days postoperation), and was associated with a better nVAS score at 2 months postoperation (P < 0.05). The biomechanical study in cervical cadavers also showed significantly and continuously decreased facet joint pressure in the spreader assisted vertebral distraction group (P < 0.01).

Conclusions

Spreader-assisted vertebral distraction method effectively alleviates postoperative neck pain in degenerative cervical spondylosis patients treated with ACDF. The mechanism may be related to the transient relief of facet joint pressure during the vertebral distraction procedure in ACDF.

Instrumented Four-Level Anterior Cervical Discectomy and Fusion: Long-Term Clinical and Radiographic Outcomes

Background

There is a paucity of data on outcomes following four-level anterior cervical discectomy and fusions (ACDFs), especially the sagittal balance (SB) parameters.

Objective

We aimed to review the long-term clinical and radiographic outcomes for 41 consecutive patients that underwent instrumented four-level ACDF.

Materials and Methods

Records of 27 men and 14 women, aged 40-68 years, who underwent instrumented four-level ACDF and plating at C3-C7 (n = 37) or C4-T1 (n = 4) were retrospectively analyzed. Clinical outcomes that were assessed were the visual analog scale (VAS) for pain, neck disability index (NDI), Odom's criteria, improvement of symptoms, intraoperative and postoperative complications, SB, and need for revision surgery.

Results

The mean follow-up was 65 ± 36.3 months. The mean VAS for arm and neck pain significantly improved from 7.7 ± 1.4 to 3.5 ± 1.7 (P < 0.001). The NDI score significantly improved from 31 ± 8.2 to 19.3 ± 8.1 (P < 0.001). Concerning Odom's criteria, the grades were excellent (14), good (17), fair (9), and poor (1). Concerning intraoperative and postoperative complications, 10 cases developed dysphagia, 3 cases developed temporary dysphonia, 2 cases developed a postoperative hematoma, 1 patient developed C5 palsy, 1 vertebral artery (VA) injury, and 1 case had superficial infection. The average length of stay (LOS) was 2.9 ± 3.7 days. Three patients needed another surgery (one adjacent segment and two posterior foraminotomies). Regarding the mean change in SB parameters, Cobb's angle (CA) (C2-C7) was 14° ± 8.3°, fusion angle (FA) was 10.9 ± 10.9°, cervical straight vertical alignment (cSVA) was 0.6 ± 0.5 cm, T1 slope was 2.3° ± 3.4°, and disc height (DH) was 1.3 ± 0.9 mm.

Conclusion

Instrumented four-level ACDF is safe with a satisfactory outcome and supplementary posterior fusion was not required in any case.

Perioperative and swallowing outcomes in patients undergoing 4- and 5-level anterior cervical discectomy and fusion

OBJECTIVE

Anterior cervical discectomy and fusion (ACDF) is a common and robust procedure performed on the cervical spine. Literature on ACDF for 4 or more segments is sparse. Increasing the number of operative levels increases surgical complexity, tissue retraction, and risks of complications, particularly dysphagia. The overall risks of these complications and rates of dysphagia are not well studied for surgery on 4 or more segments. In this study, the authors evaluated their institution's perioperative experience with 4- and 5-level ACDFs.

METHODS

The authors retrospectively reviewed patients who underwent 4- or 5-level ACDF at their institution over a 6-year period (May 2013-May 2019). Patient demographics, perioperative complications, readmission rates, and swallowing outcomes were recorded. Outcomes were analyzed with a multivariate linear regression.

RESULTS

A total of 174 patients were included (167 had 4-level and 7 had 5-level ACDFs). The average age was 60.6 years, and 54.0% of patients (n = 94) were men. A corpectomy was performed in 12.6% of patients (n = 22). After surgery, 56.9% of patients (n = 99) experienced dysphagia. The percentage of patients with dysphagia decreased to 22.8% (37/162) at 30 days, 12.9% (17/132) at 90 days, and 6.3% (5/79) and 2.8% (1/36) at 1 and 2 years, respectively. Dysphagia was more likely at 90 days postoperatively in patients with gastroesophageal reflux (OR 4.4 [95% CI 1.5-12.8], p = 0.008), and the mean (± SD) lordosis change was greater in patients with dysphagia than those without at 90 days (19.8° ± 13.3° vs 9.1° ± 10.2°, p = 0.003). Dysphagia occurrence did not differ with operative implants, including graft and interbody type. The mean length of time to solid food intake was 2.4 ± 2.1 days. Patients treated with dexamethasone were more likely to achieve solid food intake prior to discharge (OR 4.0 [95% CI 1.5-10.6], p = 0.004). Postsurgery, 5.2% of patients (n = 9) required a feeding tube due to severe approach-related dysphagia. Other perioperative complication rates were uniformly low. Overall, 8.6% of patients (n = 15) returned to the emergency department within 30 days and 2.9% (n = 5) required readmission, whereas 1.1% (n = 2) required unplanned return to surgery within 30 days.

CONCLUSIONS

This is the largest series of patients undergoing 4- and 5-level ACDFs reported to date. This procedure was performed safely with minimal intraoperative complications. More than half of the patients experienced in-hospital dysphagia, which increased their overall length of stay, but dysphagia decreased over time.

Is Cervical Disc Replacement Valuable in 3-Level Hybrid Surgery Compared with 3-Level Anterior Cervical Discectomy and Fusion?

BACKGROUND

Cervical degenerative disc disease is common in clinical practice. Surgery is among the most effective treatments for patients with cervical radiculopathy, myelopathy, or stenosis. Which treatment is the best option for multilevel cervical degenerative disc disease is controversial. Hybrid surgery, combined cervical disc replacement and anterior cervical discectomy and fusion, may be an alternative treatment for multilevel cervical degenerative disc disease.

METHODS

Sixty-four patients with 3-level hybrid surgery and 37 patients with 3-level anterior cervical discectomy and fusion were reviewed retrospectively. Clinical outcomes were based on visual analog scale, Neck Disability Index, 36-Item Short Form Survey, and Japanese Orthopaedic Association scores and Japanese Orthopaedic Association recovery rate. Radiologic assessments included range of motion (ROM) of C2-C7 and adjacent level and cervical lordosis of C2-C7. Perioperative parameters, fusion condition, and complications were assessed.

RESULTS

There were no statistical differences observed between the 2 groups for Japanese Orthopaedic Association, Neck Disability Index, or visual analog scale scores. The hybrid surgery group had better physical and mental 36-Item Short Form Survey scores than the fusion group at 1-year follow-up (physical component summary: 49.34 vs. 46.70, P = 0.012; mental component summary: 45.67 vs. 43.95, P = 0.004). ROM of C2-C7 and adjacent levels was less compromised in the hybrid group compared with baseline (64.60% vs. 51.34%, P < 0.001). Cervical lordosis was decreased with time in both groups but was acceptable at final follow-up, and both groups showed solid fusion.

CONCLUSIONS

Normal ROM and solid fusion were achieved at both arthroplasty and arthrodesis levels. ROM of replacement levels in different locations of the 3-level construct was acceptable.

The safety and efficacy of anterior versus posterior decompression surgery in degenerative cervical myelopathy: a prospective randomized trial

OBJECTIVE

The safety and efficacy of anterior and posterior decompression surgery in degenerative cervical myelopathy (DCM) have not been validated in any prospective randomized trial.

METHODS

In this first prospective randomized trial, the patients who had symptoms or signs of DCM were randomly assigned to undergo either anterior cervical discectomy and fusion or posterior laminectomy with or without fusion. The primary outcome measures were the change in the visual analog scale (VAS) score, Neck Disability Index (NDI), and Nurick myelopathy grade 1 year after surgery. The secondary outcome measures were intraoperative and postoperative complications, hospital stay, and Odom's criteria. The follow-up period was at least 1 year.

RESULTS

A total of 68 patients (mean age 53 ± 8.3 years, 72.3% men) underwent prospective randomization. There was a significantly better outcome in the NDI and VAS scores in the anterior group at 1 year (p < 0.05). Nurick myelopathy grading showed nonsignificant improvement using the posterior approach group (p = 0.79). The mean operative duration was significantly longer in the anterior group (p < 0.001). No significant difference in postoperative complications was found, except postoperative dysphagia was significantly higher in the anterior group (p < 0.05). There was no significant difference in postoperative patient satisfaction (Odom's criteria) (p = 0.52). The mean hospital stay was significantly longer in the posterior group (p < 0.001).

CONCLUSIONS

Among patients with multilevel DCM, the anterior approach was significantly better regarding postoperative pain, NDI, and hospital stay, while the posterior approach was significantly better in terms of postoperative dysphagia and operative duration.