Clinical outcomes of multilevel anterior corpectomy and fusion as a revision surgery of the cervical spine: report of seven cases

Clinicoradiological Outcome of 3 or More Levels of Anterior Cervical Corpectomy and Reconstruction

BACKGROUND

Studies reporting multilevel anterior cervical corpectomy (>2 levels) and reconstruction in patients with long-segment anterior cervical compression are few and surgical outcomes are variable with increased surgical morbidity and a high incidence of graft-related complications. The aim of this study is to evaluate the effectiveness and safety of cervical corpectomy and anterior reconstruction of 3 or more levels in patients with long-segment anterior cervical compression.

METHODS

We retrospectively reviewed patients who had undergone 3 or more levels of anterior cervical corpectomy and reconstruction from 2014 to 2018. Clinical and radiological parameters such as Nurick grading, modified Japanese Orthopedic Association (mJOA) score, cervical segmental angle, cervical sagittal angle, graft subsidence, and fusion rate were evaluated preoperatively and at a 2-year follow-up. Patients were divided into 2 groups according to their anterior reconstruction, either with fibular strut autogenous graft or titanium mesh cage and rigid anterior cervical plating for subgroup analysis. Patients whose bone stock was found to be poor had undergone posterior instrumentation as a staged procedure.

RESULTS

There were 48 patients (mean age: 58.17 years) in the cohort: 42 had undergone 3-level and 6 had undergone 4-level cervical corpectomy with an ossified posterior longitudinal ligament and multilevel cervical spondylotic myelopathy being the main surgical indications. C5 to C7 corpectomy was most common. Of the cohort, 83.4% had standalone anterior reconstruction and only 8 patients (16.6%) had supplementation with posterior instrumentation. Our subgroup analysis showed statistically significant change in Nurick grading, mJOA score, cervical segmental angle, and sagittal angle in both groups at a 2-year follow-up (P < .05). Overall fusion rate was 89.5%. Decreased incidence of graft subsidence, statistically significant less graft subsidence (P = .002) and a higher fusion rate (P = .001) were noted in titanium mesh cage group at 2-year follow-up.

CONCLUSIONS

Multilevel anterior cervical corpectomy and reconstruction is a safe and efficacious procedure. A titanium mesh cage filled with autogenous bone graft and a rigid anterior cervical plate gives best results. Posterior instrumentation should be considered along with a multilevel cervical corpectomy construct in patients with poor bone stock.

LEVEL OF EVIDENCE

4.

Anterior cervical multilevel decompression and fusion using fibular strut as revision surgery for failed cervical laminoplasty

STUDY DESIGN

Retrospective analyses of six cases.

OBJECTIVE

To describe six patients with previous failed laminoplasty who were subsequently managed by anterior cervical decompression and fusion (ACDF) using fibular strut as revision surgeries.

SUMMARY OF BACKGROUND DATA

While several complications and unsatisfactory results of cervical laminoplasty have been reported, there is no general consensus on how to best surgically treat these pathological conditions.

METHODS

Six patients, who had been treated by laminoplasty for cervical spondylotic myelopathy (n = 2) or ossification of posterior longitudinal ligament (OPLL, n = 4) and had unfavorable outcomes, underwent ACDF using autogenous fibular strut grafts. The pathological factors associated with the poor outcomes were intraforaminal spur, slip, spondylotic change, disc herniation, and increase of OPLL in size. Clinical outcomes were assessed by evaluating the modified Japanese Orthopedic Association score (JOA score) of cervical myelopathy, severity of radicular pains, axial pains, and perioperative complications. In addition, C2-7 angle and the presence of bony union were analyzed.

RESULTS

The revision ACDF significantly increased the mean ± SD. JOA score, from 10.3 ± 3.9 to 13.5 ± 2.7 points (p = 0.028), with a recovery rate of 47.1 ± 26.7%. Radicular pain and axial pain also improved. C2-7 angle was not changed significantly. Solid fusion was achieved in all patients at 12.2 ± 4.2 months after revision surgery.

CONCLUSION

ACDF with fibular strut graft was effective as a revision procedure for failed laminoplasty.

Anterior versus posterior surgery for multilevel cervical myelopathy, which one is better? A systematic review

The objective of the study is to perform a systematic review to compare the clinical outcomes and complications of anterior surgery with posterior surgery for multilevel cervical myelopathy (MCM). MEDLINE, EMBASE databases and other databases were searched for all the relevant original articles published from January 1991 to November 2009 comparing anterior with posterior surgery for MCM. Subgroup analysis was performed according to the follow-up years. The following end points were mainly evaluated: final follow-up JOA (Japanese Orthopaedic Association) scale, recovery rate and complication outcomes. Ten articles fulfilled all inclusion criteria. For multilevel CSM patients, the final follow-up JOA score for the anterior group was significantly higher than the posterior group (p < 0.05, WMD 0.83 [0.24, 1.43]) in the 'follow-up time ≤ 5 years' subgroup, but had no significant differences in the 'follow-up time > 5 years' subgroup (p > 0.05). The recovery rate for the anterior group was significantly higher than the posterior group (p < 0.05, WMD 10.08 [1.39, 18.78]) in the 'follow-up time ≤ 5 years' subgroup. No study reported the recovery rate for the follow-up time > 5 years. For multilevel OPLL patients, the final follow-up JOA score and recovery rate for the anterior group were both significantly higher than the posterior group in the 'follow-up time ≤ 5 years' subgroup (p < 0.05, WMD 2.50 [0.16, 4.85]; p < 0.05, WMD 29.48 [29.09, 29.87], respectively). One study [31] which mean follow-up time was 6 years was enrolled in the 'follow-up time > 5 years' subgroup. The results showed there was no significant difference in final follow-up JOA score and recovery rate between anterior and posterior group for patients with occupying ratio of OPLL <60% (p > 0.05), while in patients with occupying ratio ≥ 60%, the final follow-up JOA score and recovery rate of anterior surgery were both superior to that of posterior surgery (p < 0.05). For both multilevel CSM and OPLL patients, the complications for the anterior group were significantly more than the posterior group in the 'follow-up time ≤ 5 years' subgroup (p < 0.05, OR 7.33 [2.96, 18.20] for CSM patients; p < 0.05, OR 4.44 [1.80, 10.98] for OPLL patients), but were similar to the posterior group in the 'follow-up time >5 years' subgroup (p > 0.05). In conclusion, anterior surgery had better clinical outcomes and more complications at the early stage after operation for both multilevel CSM and OPLL patients. At the late stage, posterior surgery had similar clinical outcomes and complications to anterior surgery for CSM patients, and OPLL patients with occupying ratio of OPLL <60%. While for OPLL patients with occupying ratio ≥ 60%, anterior surgery had superior clinical outcome to posterior surgery.

Anterior corpectomy with iliac bone fusion or discectomy with interbody titanium cage fusion for multilevel cervical degenerated disc disease

STUDY DESIGN

Clinical and radiologic study evaluating the outcome after anterior corpectomy with iliac bone fusion compared with discectomy with interbody titanium cage fusion for multilevel cervical degenerated disc disease.

OBJECTIVES

To investigate the safety and effectiveness of interbody titanium cage with plate fixation in multilevel postdiscectomy fusion.

SUMMARY OF BACKGROUND DATA

The operation for segmental multilevel cervical degenerated disc disease remains controversial. Data on safety and efficacy of titanium cages in multilevel postdiscectomy fusion are rarely available. We investigated the safety and effectiveness of interbody fusion cages with plate fixation and compared the clinical and radiographical results between anterior corpectomy and iliac bone fusion with plate fixation and multilevel discectomy and cage fusion with plate fixation.

METHODS

Sixty-two patients were treated with either a multilevel discectomy and cage fusion with plate fixation (27 patients, group A) or an anterior corpectomy and iliac graft fusion with plate fixation (35 patients, group B). We evaluated the patients for cervical lordosis, fusion status, and stability 24 months postoperatively on the basis of spine radiographs. The patients' neurologic outcomes were assessed by the Japanese Orthopedic Association (JOA) scores. Neck pain was graded using a 10-point visual analog scale.

RESULTS

Both groups A and B demonstrated a significant increase in the JOA scores (preoperatively 11.1+/-2.1 and 10.4+/-3.5, postoperatively 14.3+/-2.4 and 13.9+/-2.1, respectively) and a significant decrease in the visual analog pain scores (preoperatively 8.5+/-1.1 and 8.7+/-1.5, postoperatively 2.9+/-1.8 and 3.0+/-2.0, respectively). However, there was no significant difference between groups A and B. Both groups A and B showed a significant increase in the cervical lordosis after operation and reached satisfactory fusion rates (96.3% and 91.4%, respectively). Three patients (two 2-level corpectomies and one 3-level corpectomy) had construct failures that required a second operation. Eight of 35 patients who underwent iliac bone fusion had donor site pain. The hospital stay in group A was significantly shorter than that in group B (P=0.022).

CONCLUSIONS

Either a multilevel discectomy and cage fusion with plating or a corpectomy and iliac bone fusion with plating provides good clinical results and similar fusion rates for cervical degenerative disc disease. However, absence of donor site complications and construct failures and shorter hospital stay make the multilevel discectomy and cage fusion with plate fixation better than corpectomy and strut graft fusion with plate fixation.