Anterior discectomy and fusion for the management of neck pain

The Positive Side Effect of Anterior Cervical Decompression and Fusion on Axial Neck Pain

STUDY DESIGN

Observational Cohort Study.

OBJECTIVES

This study aims to comprehensively assess the outcomes of anterior cervical spine surgery in patients who have undergone surgical intervention for radiculopathy or myelopathy, with a specific focus on the surgery's impact on axial neck pain.

METHODS

Data from an institutional spine surgery registry were analyzed for patients who underwent anterior cervical spine surgery between January 2016 and March 2022. Patient demographics, clinical variables, and outcome measures, including the Neck Disability Index (NDI), numeric rating scales for neck and arm pain (NRS-Neck and NRS-Arm), and 36-Item Short Form Health Survey (SF-36) scores, were collected. Statistical analysis included paired t-tests, chi-squared tests, and multivariate linear regression.

RESULTS

Of 257 patients, 156 met the inclusion criteria. Patients showed significant improvement in NDI, NRS-Neck, NRS-Arm, SF-36 (Physical and Mental components), and all changes exceeded the minimum clinically important difference. Multivariate regression revealed that lower preoperative physical and mental component scores and higher preoperative NRS-Neck predicted worse NDI scores at follow-up.

CONCLUSIONS

This study underscores that anterior cervical fusion not only effectively alleviates arm pain and disability but also has a positive impact on axial neck pain, which may not be the primary target of surgery. Our findings emphasize the potential benefits of surgical intervention when neck pain coexists with neurologic compression. This contribution adds to the growing body of evidence emphasizing the importance of precise diagnosis and patient selection. Future research, ideally focusing on patients with isolated neck pain, should further explore alternative surgical approaches to enhance treatment options.

Is neck pain treatable with surgery?

INTRODUCTION

Neck pain is one of the most common complaints in clinical practice and can be caused by a wide variety of conditions. While cervical spine surgery is a well-accepted option for radicular pain and myelopathy, surgery for isolated neck pain is controversial. The identification of the source of pain is challenging and subtle, and misdiagnosis can lead to inappropriate treatment. MATERIALS AND METHODS AND RESULTS: We conducted a thorough literature review to discuss and compare different causes of neck pain. We then supplemented the literature with our senior author's expert analysis of treating cervical spine pathology.

CONCLUSIONS

This study provides an in-depth discussion of neck pain and its various presentations, as well as providing insight into treatment strategies and diagnostic pearls that may prevent mistreatment of cervical spine pathology.

Cervical Disc Arthroplasty Usage Has Leveled Out From 2010 to 2021

STUDY DESIGN

Descriptive epidemiologic study.

OBJECTIVE

To compare trends in utilization and predictive factors for single-level cervical disc arthroplasty (CDA) relative to anterior cervical discectomy and fusion (ACDF) over the years.

BACKGROUND

CDA is an alternative to ACDF for the treatment of cervical spine pathologies. With both procedures performed for similar indications, controversy on best practices exists.

MATERIALS AND METHODS

Patients who underwent single-level CDA or ACDF were identified in the 2010 through 2021 PearlDiver M151Ortho data set. The yearly number of CDAs performed and proportionality was assessed. Predictive patient factors for undergoing CDA as opposed to ACDF were determined. Kaplan Meyer survival analysis with an endpoint of cervical spine reoperation compared 5-year outcomes between CDA and ACDF.

RESULTS

From 2010 to 2021, 19,301 single-level CDAs and 181,476 single-level ACDFs were identified. The proportional utilization of CDA relative to ACDF increased from 4.00% in 2010 to 14.15% in 2018 ( P < 0.0001), after which there was a plateau between 2018 and 2021 where proportional utilization was 14.47% ( P = 0.4654). Multivariate analysis identified several predictors of undergoing CDA rather than ACDF, including: younger age [odds ratio (OR) per decade decrease: 1.72], having surgery performed in the Midwest, Northeast, or West (relative to South, OR: 1.16, 1.13, 2.26, respectively), having Commercial insurance (relative to Medicare, OR: 1.75), and having surgery performed by an orthopedic surgeon (relative to a neurological surgeon, OR: 1.54) ( P < 0.0001 for each). There was no statistically significant difference in 5-year survival to further cervical spine surgery between CDA and ACDF at 5 years (97.6% vs. 97.7%, P = 0.4249).

CONCLUSIONS

Although the use of CDA relative to ACDF rose from 2010 to 2018, its use has subsequently plateaued between 2018 and 2021 and remained a relatively low percentage of the single-level anterior cervical surgeries performed (14.47% in 2021). The causes for such changes in the trend are unclear.

Influence of Predominant Neck versus Arm Pain on Clinical Outcomes in Cervical Disc Replacement

OBJECTIVE

We aim to compare the postoperative clinical outcomes, through patient-reported outcome measures (PROMs) and minimum clinically important difference (MCID), in patients undergoing cervical disc replacement (CDR) with preoperative predominant neck pain (pNP) or arm pain (pAP).

METHODS

Patients undergoing primary CDR were separated into pNP or pAP cohorts. Demographic, perioperative characteristics, PROMs at preoperative and postoperative time points, and MCID were compared using inferential statistics. Assessed PROMs included Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF), 12-Item Short Form Physical/Mental Component Score (SF-12 PCS/MCS), visual analog scale (VAS) neck, VAS arm, and Neck Disability Index.

RESULTS

There were a total of 84 patients, with 54 patients in the pNP cohort. The pNP cohort showed significant postoperative improvement in all PROMs, except for 6-week and 1-year SF-12 PCS, 1-year SF-12 MCS, and 6-month VAS arm score (P ≤ 0.023, all). The pAP cohort showed significant postoperative improvement in all PROMs, apart from 6-month to 1-year SF-12 PCS, and all SF-12 MCS (P ≤ 0.041, all). Greater MCID achievement rates were found in the pNP cohort for SF-12 MCS (P = 0.030). The pAP cohort had higher MCID achievement rates in VAS arm score and Neck Disability Index (P ≤ 0.046, all).

CONCLUSIONS

Independent of predominant pain location, patients reported improved physical function, pain, and disability outcomes. Patients with pNP had higher MCID achievement rates in mental function. Patients with pAP had higher rates of MCID achievement in arm pain and disability outcomes. Considering the predominant location of preoperative pain may be helpful in managing expectations for patients undergoing CDR.

Multimodal analgesic protocol for cervical disc replacement in the ambulatory setting: Clinical case series

Background

Effective pain management is paramount for outpatient surgical success. This study aims to report a case series of patients undergoing cervical disc replacement (CDR) in an ambulatory surgery center (ASC) with the use of an enhanced multimodal analgesic (MMA) protocol.

Methods

Primary, single-/2-level CDR procedures at an ASC with an enhanced MMA protocol were included. ASC patients were discharged day of surgery. Patient-reported outcome measures (PROMs) were administered at preoperative/6-week/12-week/6-month/1-year/2-year timepoints and included Visual Analogue Scale (VAS) neck, VAS arm, Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), and 12-Item Short-Form Physical and Mental Composite Score (SF-12 PCS/SF-12 MCS). A t-test assessed postoperative PROM improvement from baseline. MCID achievement was determined by comparing ΔPROM scores to previously established thresholds.

Results

106 patients were included, 76 single-level and 30 2-level. Most single-levels occurred at C5-C6, most 2-levels at C5-C7. One 2-level patient developed a hematoma 5 days postoperatively and underwent revision for evacuation. Five patients reported postoperative dysphagia; all were quickly resolved. One patient had an episode of seizure secondary to serotonin syndrome from concealed drug use. Patient was reintubated, transferred, and treated for serotonin syndrome. Two patients experienced postoperative nausea/vomiting. Cohort significantly improved from baseline for all PROMS at all timepoints except SF-12 MCS at 1-year/2-years and SF-12 PCS at 2 years (p < 0.047, all). Overall MCID achievement rates were: VAS arm (48.7%), VAS neck (69.1%), NDI (98.9%), SF-12 MCS (50.0%), SF-12 PCS (54.6%), and PROMIS-PF (73.4%).

Conclusion

Outpatient CDR, incorporating an enhanced MMA protocol, can be safely and effectively performed with proper patient selection and surgical technique. Patients saw timely discharge, well-controlled postoperative pain, and favorable long-term outcomes.

Influence of Predominant Neck vs Arm Pain on ACDF Outcomes: A Follow-Up Study

OBJECTIVE

To assess differences in postoperative PROMs and MCID attainment following single-level ACDF based on predominant preoperative pain symptom.

METHODS

Primary, single-level ACDFs were identified. PROMs included VAS arm and neck/SF-12 PCS/PROMIS-PF/NDI, collected preoperatively and at 6-week/12-week/6-month/1-year/2-year postoperative timepoints. Patients were grouped: pAP (preoperative VAS arm > preoperative VAS neck) vs pNP (preoperative VAS neck > preoperative VAS arm). Chi-square and Student's t-test compared demographic and perioperative characteristics. Student's t-test evaluated change from preoperative to postoperative PROM values, and compared PROMs between groups. MCID achievement was determined using established threshold values. MCID attainment rates were compared using chi-squared.

RESULTS

110 patients were assessed-52 pNP/58 pAP. Demographics did not differ between cohorts. Total 1-year arthrodesis rate was 95.7% and did not differ by grouping. pNP patients improved significantly from preoperative to postoperative at 12-weeks-1-year for PROMIS-PF, 6-months/1-year for SF-12 PCS, 6-weeks-1-year for VAS neck, 6-weeks-6-months for VAS arm, and 6-weeks through 2-years for NDI(p≤0.035, all). pAP patients improved significantly from preoperative to all postoperative timepoints for PROMIS-PF, 6-months-2-years for SF-12 PCS, 6-weeks-1-year for VAS neck, 6-weeks-1-year for VAS arm, and 6-weeks-6-months for NDI(p≤0.040, all). Mean PROMIS-PF was higher for pAP at 6-weeks, preoperative VAS neck lower for pAP, and preoperative VAS arm higher for pAP(p≤0.013, all). MCID attainment was significantly higher among pAP only for PROMIS-PF from 6-weeks-6-months, SF-12 PCS 6-weeks, and VAS arm 12-weeks.

CONCLUSION

Predominant pain symptom demonstrated little effect on perioperative characteristics and postoperative PROMs. ACDF candidates will likely experience similar clinically meaningful postoperative improvements in physical function/disability/pain.

Cervical Disc Arthroplasty for Axial Neck Pain: Comparison of Outcomes to 2 Other Common Cervical Conditions

BACKGROUND

Cervical disc arthroplasty (CDA) is an established treatment for degenerative disc disease with radiculopathy and/or myelopathy. There is, however, little published evidence of its effectiveness to relieve pain and improve function in patients with a primary diagnosis of axial neck pain. Such patients were excluded from all previous Food and Drug Administration clinical trials for CDA. We compare the outcomes of patients who underwent CDA for 3 common cervical conditions from 2003 to 2018.

METHODS

Seven hundred and eighty-two CDA patients at a single site were grouped by primary diagnosis: predominant axial neck pain (ANP) (n = 257), predominant radiculopathy (RAD) (n = 331), or a combination of both (ANP + RAD) (n = 195). Mixed models for repeated measures predicted and analyzed scores at all time points, adjusting for diagnosis group, time point, and, if statistically significant, number of operative levels and demographic characteristics. Outcome measures included the Neck Disability Index, numerical pain scales (intensity plus frequency), the Veterans RAND 12 Item Health Survey (VR-12) Physical Component Score, the Mental Component Score, and reoperations. Patients were assessed preoperatively and postoperatively at 6 weeks, 3 months, 6 months, 1 year, and annually thereafter.

RESULTS

At baseline, arm pain scores in the ANP group were statistically lower (P = .0002) than in the RAD and ANP + RAD groups, consistent with preoperative diagnoses. Surgeries included 40.8% 1-level, 41.6% 2-level, 14.7% 3-level, and 2.9% 4-level. For all outcome measures, improvements were statistically significant from baseline to each postoperative time point without statistical difference between the 3 diagnosis groups. In total, 45/782 patients (5.8%) underwent a secondary surgery: 3.5% ANP, 5.8% RAD, and 8.7% ANP + RAD. Days to reoperation did not statistically differ between groups (P = .489).

CONCLUSIONS

Appropriately selected patients with predominant axial neck pain treated with CDA may achieve clinical and functional outcomes comparable to patients with a primary diagnosis of radiculopathy or of axial neck pain with concomitant radiculopathy.

CLINICAL RELEVANCE

This study provides information that should help clinicians decide whether to offer CDA for patients with a primary diagnosis of axial neck pain and to appropriately counsel such patients about expected outcomes.

LEVEL OF EVIDENCE

4.

Impact of predominant symptom location among patients undergoing cervical spine surgery on 12-month outcomes: an analysis from the Quality Outcomes Database

OBJECTIVE

The impact of the type of pain presentation on outcomes of spine surgery remains elusive. The aim of this study was to assess the impact of predominant symptom location (predominant arm pain vs predominant neck pain vs equal neck and arm pain) on postoperative improvement in patient-reported outcomes.

METHODS

The Quality Outcomes Database cervical spine module was queried for patients undergoing 1- or 2-level anterior cervical discectomy and fusion (ACDF) for degenerative spine disease.

RESULTS

A total of 9277 patients were included in the final analysis. Of these patients, 18.4% presented with predominant arm pain, 32.3% presented with predominant neck pain, and 49.3% presented with equal neck and arm pain. Patients with predominant neck pain were found to have higher (worse) 12-month Neck Disability Index (NDI) scores (coefficient 0.24, 95% CI 0.15-0.33; p < 0.0001). The three groups did not differ significantly in odds of return to work and achieving minimal clinically important difference in NDI score at the 12-month follow-up.

CONCLUSIONS

Analysis from a national spine registry showed significantly lower odds of patient satisfaction and worse NDI score at 1 year after surgery for patients with predominant neck pain when compared with patients with predominant arm pain and those with equal neck and arm pain after 1- or 2-level ACDF. With regard to return to work, all three groups (arm pain, neck pain, and equal arm and neck pain) were found to be similar after multivariable analysis. The authors' results suggest that predominant pain location, especially predominant neck pain, might be a significant determinant of improvement in functional outcomes and patient satisfaction after ACDF for degenerative spine disease. In addition to confirmation of the common experience that patients with predominant neck pain have worse outcomes, the authors' findings provide potential targets for improvement in patient management for these specific populations.

Does the Predominant Pain Location Influence Functional Outcomes, Satisfaction and Return to Work After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

STUDY DESIGN

Retrospective review of prospectively-collected registry data.

OBJECTIVES

The aim of this study was to determine how different combinations of preoperative neck pain (NP) and arm pain (AP) influence functional outcomes, patient satisfaction, and return-to-work in patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical radiculopathy (DCR).

SUMMARY OF BACKGROUND DATA

Surgeons often base decisions on the traditional belief that the predominance of radicular upper extremity symptoms is a stronger indication for cervical spine surgery than axial pain. However, there is a paucity of literature supporting this notion.

METHODS

A prospectively maintained registry was reviewed for all patients who underwent primary ACDF for DCR. Patients were categorized into three groups depending on predominant pain location: AP predominant ([APP]; AP > NP), NP predominant ([NPP]; NP > AP), and equal pain predominance ([EPP]; NP = AP). Patients were prospectively followed for at least 2 years.

RESULTS

In total, 303 patients were included: 27.4% APP, 38.9% NPP, and 33.7% EPP cases. The APP group was significantly older (P = 0.030), although there were no other preoperative differences among the three groups. After adjusting for baseline differences, the SF-36 Physical Component Summary was significantly better in the APP group at 6 months (P = 0.048) and 2 years (P = 0.039). In addition, they showed a trend towards better 6-month Neck Disability Index (P = 0.077) and 2-year SF-36 Mental Component Summary (P = 0.059). However, an equal proportion of patients in each group achieved the Minimal Clinically Important Difference for each outcome, were satisfied, and returned to work 2 years after surgery.

CONCLUSION

Although patients with NPP had slightly poorer function and quality of life, all patients experienced a clinically meaningful improvement in patient-reported outcomes, regardless of the predominant pain location. High rates of satisfaction and return-to-work were also achieved. In the context of proper indications, these findings suggest that ACDF can be equally effective for DCR patients with varying combinations of NP or AP.Level of Evidence: 3.

Prevalence and Discordance of the "Startle Response" with True Discogenic Pain According to Spine Intervention Society Guidelines for Provocation Discography: A Cohort Study

SUMMARY OF BACKGROUND DATA

The literature on cervical provocation discography (C-PD) is sparse. A "Startle Response" during C-PD is a known phenomenon that might be mistaken as an indicator of discogenic pain at the provoked disc level, but this has not been quantitatively described.

OBJECTIVES

To determine the incidence of the Startle Response and its concordance/discordance with true-positive C-PD in patients referred for surgical planning or evaluation after ruling out other axial pain generators.

METHODS

Retrospective cohort study of consecutive patients who received C-PD at an outpatient spine center. The primary outcome was the rate of discordance of the Startle Response with true-positive C-PD according to the operational criteria of the Spine Intervention Society (SIS) guidelines.

RESULTS

One hundred five discs were provoked in 36 individuals (19 female, mean age [SD] = 45.7 [10.9] years). C-PD was performed at a median of three levels (range = 1-5) with C4/5 (N = 30), C5/6 (N = 30), and C6/7 (N = 31) the most commonly evaluated. Twenty-six of 36 patients reported responses consistent with true-positive C-PD. A Startle Response was observed in 14 patients (39%, 95% confidence interval [CI] = 23-57%), and 22 of 105 (21%, 95% CI = 14-30%) provoked discs. Of the 14 patients who exhibited a Startle Response, four had negative C-PD results (29%, 95% CI = 8-58%). As assessed per disc, C-PD results were positive in 12 of the 22 (55%, 95% CI = 32-76%) provoked discs that generated a Startle Response.

CONCLUSIONS

The present data demonstrate high discordance, 45% (95% CI = 24-68%), between the Startle Response and true-positive C-PD. Clinicians should be aware of this phenomenon and take care to distinguish it from a true-positive response during C-PD, as defined by the SIS guidelines. Misinterpretation of the Startle Response as a positive C-PD result may lead to inappropriate future care decisions in a substantial proportion of patients.

The Role of Anterior Cervical Discectomy and Fusion on Relieving Axial Neck Pain in Patients With Single-Level Disease: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

This study aims to evaluate the effects of anterior cervical decompression and fusion (ACDF) on axial neck pain in adult patients receiving surgery for myelopathy, radiculopathy, or a combination of both.

METHODS

Two independent reviewers completed a librarian-assisted search of 4 databases. Visual Analogue Scale (VAS) and Neck Disability Index (NDI) scores were extracted preoperatively and at 3, 6, 12, 24, 36, 48, and 48+ months postoperatively for ACDF groups and pooled using a random-effects model.

RESULTS

Of 17 850 eligible studies, 37 were included for analysis, totaling 2138 patients analyzed with VAS and 2477 with NDI score. Individual VAS mean differences were reduced at 6 weeks (-2.5 [95% confidence interval (CI): -3.5 to -1.6]), 3 months (-2.9 [-3.7 to -2.2]), 6 months (-3.2 [-3.9 to -2.6]), 12 months (-3.7 [-4.3 to -3.1]), 24 months (-4.0 [-4.4 to -3.5]), 48 months (-4.6 [-5.5 to -3.8]), and >48 months (-4.7 [-5.8 to -3.6]) follow-up (P < .0001 for all endpoints). Individual NDI mean differences were reduced at 6 weeks (-26.7 [-30.9 to -22.6]), 3 months (-29.8 [-32.7 to -26.8]), 6 months (-31.2 [-35.5 to -26.8)], 12 months (-29.3 [-33.2 to -25.4]), 24 months (-28.9 [-32.6 to -25.2]), 48 months (-33.1 [-37.4 to -28.7]), and >48 months (-37.6 [-45.9 to -29.3]) follow-up (P < .0001 for all endpoints).

CONCLUSIONS

ACDF is associated with a significant reduction in axial neck pain compared with preoperative values in patients being treated specifically for myelopathy or radiculopathy. This influences the preoperative discussions surgeons may have with patients regarding their expectations for surgery. The effects seen are stable over time and represent a clinically significant reduction in axial neck pain.

Retrospective Analysis of Arthrodesis from Various Options after Anterior Cervical Discectomy

Introduction:

Anterior cervical discectomy is a surgical procedure performed to treat a herniated/degenerated disc in the cervical region. There have been various studies comparing arthrodesis rates among various procedures. Our patients belonged to varied socioeconomic background and underwent anterior cervical microdiscectomy without/with instrumentation.

Aim:

The present study was performed to study and compare the arthrodesis rates in the patients operated for anterior cervical microdiscectomy with and without fusion/instrumentation procedures at our institution.

Materials and Methods:

This is a retrospective study performed at Vydehi Institute of Medical Sciences and Research Centre, Bengaluru. Pre- and post-operative X-rays were assessed in 96 patients who had undergone anterior cervical discectomy with/without fusion from June 2012 to June 2015. Radiographic arthrodesis was assessed in all patients. An arbitrary grading was designed by us and categorized into Grade I to IV. The criteria considered for adequate arthrodesis in this study were: (a) <2° movement on dynamic X-rays, (b) restored disc space height (±2 mm accepted), and (c) evidence of solid bone mass around disc space. Arthrodesis was categorized as Grade I if all the above 3 criteria on X-rays was fulfilled, Grade II if any 2 of the criteria was fulfilled, Grade III if any 1 of the criteria was fulfilled, and Grade IV when pseudoarthrosis/none of the criteria was fulfilled. Grade I arthrodesis was noted in about 79 patients (82.2%), Grade II in 14 patients, and only 3 patients had Grade III arthrodesis. There were no patients with absent arthrodesis/pseudoarthrosis.

Results:

Satisfactory arthrodesis was noted in 82% of the total patients, with patients undergoing fusion ± instrumentation procedure having better results.

Conclusions:

Arthrodesis by an interbody graft/implant with/without plating increases chances of success as compared to anterior cervical discectomy alone. Patients should be motivated for any of the available options for fusion/instrumentation

Cervical Discs as a Source of Neck Pain. An Analysis of the Evidence

OBJECTIVESBACKGROUND

Objectives To determine the extent and strength of evidence that supports the belief that cervical intervertebral discs are a source of neck pain.

DESIGN

Design The evidence from anatomical, laboratory, experimental, diagnostic, and treatment studies was summarized and analyzed for concept validity, face validity, content validity, and construct validity.

RESULTS

Results Evidence from basic sciences shows that cervical discs have a nociceptive innervation, and experimental studies show that they are capable of producing neck pain. Disc stimulation has been developed as a diagnostic test but has rarely been used in a disciplined fashion. The prevalence of cervical disc pain has not been properly established but appears to be low. No treatment has been established that reliably achieves complete relief of neck pain in substantial proportions of patients.

CONCLUSIONS

Conclusions Basic science evidence supports the concept of cervical disc pain, but epidemiologic and clinical evidence to vindicate the clinical application of the concept is poor or lacking.

Integral Fixation Titanium/Polyetheretherketone Cages for Cervical Arthrodesis: Evolution of Cage Design and Early Radiological Outcomes and Fusion Rates

Objective

To evaluate the initial outcomes of a composite cage with integral fixation using the Redmond titanium (Ti)/polyetheretherketone (PEEK) anterior cervical discectomy and fusion (ACDF) device.

Methods

Data from 50 consecutive patients were prospectively collected from a single senior surgeon cohort. All cages were between 5 and 8 mm in height, and were packed with supercritical CO₂ sterilized allograft. Patients were followed up for a minimum of 6 months, and implant complications were assessed.

Results

From the original cohort, three were unavailable for follow‐up. Forty‐seven patients with a total of 58 operative levels were observed for a mean of 7.9 months. A fusion rate of 96% was achieved. Good to excellent outcomes were seen in 92% of patients. There were no cases of implant Ti/PEEK delamination or implant failure, with excellent early fusion rates using supercritical CO₂ allograft.

Conclusions

The present study demonstrates the development of a composite ACDF cage design that is a safe and effective treatment option with the potential for early osseointegration and interbody fusion. Supercritical CO₂ sterilized allograft was an effective graft material supporting fusion.

Cervical disc degeneration and neck pain

Cervical intervertebral disc has long been considered a common source of neck pain. However, the pain caused by the disc itself has not been clearly defined so far, and its diagnosis and treatment has always been controversial. Degenerative cervical disc has a rich supply of nerve fibers, is prone to inflammatory reactions, and is susceptible to pain that can be provoked by disc stimulation or distention, and can be eliminated by block. Overwhelming clinical evidence demonstrates that neck pain in patients with degenerative cervical radiculopathy or myelopathy can be subsided rapidly by anterior cervical surgery, further indicating that this neck pain stems from the pathology of cervical disc itself. Cervical discography is advocated as the only test that connects disease to symptoms, but the procedure remains controversial. If strict criteria and technique are maintained, discography can discriminate painful, symptomatic discs from nonpainful, asymptomatic discs. Discogenic neck pain alone without cervical disc herniation or cervical spondylosis accounts for a large proportion of chronic neck pain. For these patients who continue to have refractory neck pain and fail to respond to conservative treatment, anterior cervical fusion surgery or artificial cervical disc replacement may be a better choice, and preoperative cervical discography can guarantee the excellent surgical results. Existing basic and clinical studies have scientifically shown that cervical intervertebral disc degeneration can lead to neck pain.

Arm Pain Versus Neck Pain: A Novel Ratio as a Predictor of Post-Operative Clinical Outcomes in Cervical Radiculopathy Patients

Background

Informed patient selection and counseling is key in improving surgical outcomes. Understanding the impact that certain baseline variables can have on postoperative outcomes is essential in optimizing treatment for certain symptoms, such as radiculopathy from cervical spine pathologies. The aim was to identify baseline characteristics that were related to improved or worsened postoperative outcomes for patients undergoing surgery for cervical spine radiculopathic pain.

Methods

Retrospective review of prospectively collected data. Patient Sample: Surgical cervical spine patients with a diagnosis classification of "degenerative." Diagnoses included in the "degenerative" category were those that caused radiculopathy: cervical disc herniation, cervical stenosis, and cervical spondylosis without myelopathy. Baseline variables considered as predictors were: (1) age, (2) body mass index (BMI), (3) gender, (4) history of cervical spine surgery, (5) baseline Neck Disability Index (NDI) score, (6) baseline SF-36 Physical Component Summary (PCS) scores, (7) baseline SF-36 Mental Component Summary (MCS) scores, (8) Visual Analog Scale (VAS) Arm score, and (9) VAS Neck. Outcome Measures: Improvement in NDI (≥50%), VAS Arm/Neck (≥50%), SF-36 PCS/MCS (≥10%) scores at 2-years postoperative. An arm-to-neck ratio (ANR) was also generated from baseline VAS scores. Univariate and multivariate analyses evaluated predictors for 2-year postoperative outcome improvements, controlling for surgical complications and technique.

Results

Three hundred ninety-eight patients were included. Patients with ANR ≤ 1 (n = 214) were less likely to reach improvements in 2-year NDI (30.0% vs 39.2%, P = .050) and SF-36 PCS (42.4% vs 53.5%, P = .025). Multivariate analysis for neck disability revealed higher baseline SF-36 PCS (odds ratio [OR] 1.053) and MCS (OR 1.028) were associated with over 50% improvements. Higher baseline NDI were reduced odds of postoperative neck pain improvement (OR 0.958). Arm pain greater than neck pain at baseline was associated with both increased odds of postoperative arm pain improvement (OR 1.707) and SF36 PCS improvement (OR 1.495).

Conclusions

This study identified specific symptom locations and health-related quality of life (HRQL) scores, which were associated with postoperative pain and disability improvement. In particular, baseline arm pain greater than neck pain was determined to have the greatest impact on whether patients met at least 50% improvement in their upper body pain score. These findings are important for clinicians to optimize patient outcomes through effective preoperative counseling.

Eleven-Year Follow-Up of Two Cohorts of Patients Comparing Stand-Alone Porous Tantalum Cage Versus Autologous Bone Graft and Plating in Anterior Cervical Fusions

BACKGROUND

Anterior cervical discectomy and fusion with a porous tantalum cage is an accepted method to treat degenerated cervical discs, with good results, similar to those with autologous bone graft and plating at short- and mid-term follow-up. However, to date, long-term follow-up studies have been performed.

METHODS

We performed a retrospective, single-center study to evaluate the outcomes of 2 cohorts from a previous prospective randomized controlled trial comparing stand-alone tantalum cage (group 1, 27 patients) with autologous bone graft and plating (group 2, 30 patients) for single-level anterior cervical discectomy and fusion at 11 years of follow-up. The usual clinical and radiological outcomes and "overall success," proposed by the Food and Drug Administration, were evaluated.

RESULTS

The improvement in clinical outcomes achieved postoperatively was maintained similarly in the 2 cohorts at 11 years of follow-up. In group 1, the cage had subsided 2-3 mm in 12 patients (44%), segmental lordosis was maintained in 16 patients (59%), adjacent segment degeneration had developed or progressed in 27 of the adjacent segments (50%) in 15 patients (56%), and postoperative nonprogressive deformation of the anterior aspect of the cage was observed in 7 (26%) and minor fragmentation in 3 (11%) patients. In group 2, segmental lordosis was maintained in 90% of the patients and adjacent segment degeneration had developed or progressed in 15 patients (50%).

CONCLUSIONS

These results show that the clinical and radiological outcomes achieved at mid-term follow-up using a tantalum cage for single-level anterior cervical discectomy and fusion will be maintained for 11 years postoperatively, similar to the results with autologous bone graft and plating.

UPPER CERVICAL RADICULOPATHY: THE HIDDEN PATHOLOGY OF THE SPINE

Axial neck pain can frequently be a vexing clinical problem for practitioners. Cervical spine surgery is generally regarded as less successful for axial neck pain than arm complaints. Although only few case series exist in the literature, there is evidence to suggest that upper cervical radiculopathy could be an important, treatable source of axial neck pain. Unlike patients with axial neck pain, patients with radiculopathy usually present with unilateral pain, particularly in the trapezial, parascapular, mid clavicular, or even in the form of suboccipital headaches. Similar to other regions of the cervical spine, initial imaging often consists of plain radiographs of the cervical spine, with the use of magnetic resonance imaging (MRI) or computed tomography (CT) if further evaluation of the pathology is warranted. Selective injections and electromyography can be used in conjunction with the imaging studies to aid with proper diagnosis. The surgical management of upper cervical radiculopathy is reserved for patients who fail to improve with non-operative modalities. Anterior cervical discectomy and fusion (ACDF) remain the most commonly performed and most reliable procedure for the treatment of cervical radiculopathy. Wide decompression of disc material from uncinate to uncinate is performed with or without a foraminotomy on the symptomatic side to address anterior compressive pathology. Artificial disc replacement (ADR) has been recently introduced in hopes of maintaining motion at the pathologic levels. Young patients (<40 years old) with minimal facet joint arthrosis are best indicated for this surgery. Posterior cervical foraminotomy avoids many approach related complications associated with anterior surgery and is the preferred approach when anterior surgery is contraindicated. Very few studies with small sample sizes (likely due to underdiagnosis) make it difficult to perform a comparative analysis of the different types of procedures. Ultimately, an accurate diagnosis is likely the most important predictor of a positive surgical outcome.

Anterior Cervical Discectomy and Fusion Outcomes over 10 Years: A Prospective Study

STUDY DESIGN

Prospective cohort study with >10-year follow-up.

OBJECTIVE

To assess the long-term, >10-year clinical outcomes of anterior cervical discectomy and fusion (ACDF) and to compare outcomes based on primary diagnosis of disc herniation, stenosis or advanced degenerative disc disease (DDD), number of levels treated, and preexisting adjacent level degeneration.

SUMMARY OF BACKGROUND DATA

ACDF is a proven treatment for patients with stenosis and disc herniation and results in significantly improved short- and intermediate-term outcomes. Motion preservation treatments may result in improved long-term outcomes but need to be compared to long-term ACDF outcomes reference.

METHODS

Patients who had disc herniation, stenosis, and DDD and underwent ACDF with or without decompression were prospectively enrolled and followed for a minimum of 10 years with outcome assessment at various intervals. All 159 consecutive patients had autogenous tricortical iliac crest bone graft and plate instrumentation used. Outcomes included visual analog scale for neck and arm pain. pain drawing, Oswestry Disability Index, and self-assessment of procedure success. Preoperative adjacent-level disc degeneration, pseudarthrosis, and secondary operations were analyzed.

RESULTS

For all diagnostic groups, significant outcomes improvement was seen at all follow-up periods for all scales relative to preoperative scores. Outcomes were not related to age, gender, number of levels treated, and minimally to preexisting degeneration at the adjacent level. The use of narcotic pain medication decreased substantially. Neurological deficits almost all resolved. Patient self-reported success ranged from 85% to 95%. Over the long term, additional surgery for pseudarthrosis (10%) occurred in the early follow-up period, and for adjacent segment degeneration (21%), which occurred linearly during the >10-year follow-up period.

CONCLUSION

ACDF leads to significantly improved outcomes for all primary diagnoses and was sustained for >10 years' follow-up. Secondary surgeries were performed for pseudarthrosis repair and for symptomatic adjacent-level degeneration.

LEVEL OF EVIDENCE

2.

Surgical and Functional Outcomes After Multilevel Cervical Fusion for Degenerative Disc Disease Compared With Fusion for Radiculopathy: A Study of Workers' Compensation Population

STUDY DESIGN

Retrospective cohort comparative study.

OBJECTIVE

To evaluate presurgical and surgical factors that affect return to work (RTW) status after multilevel cervical fusion, and to compare outcomes after multilevel cervical fusion for degenerative disc disease (DDD) versus radiculopathy.

SUMMARY OF BACKGROUND DATA

Cervical fusion provides more than 90% of symptomatic relief for radiculopathy and myelopathy. However, cervical fusion for DDD without radiculopathy is considered controversial. In addition, multilevel fusion is associated with poorer surgical outcomes with increased levels fused.

METHODS

Data of cervical comorbidities was collected from Ohio Bureau of Workers' Compensation for subjects with work-related injuries. The study population included subjects who underwent multilevel cervical fusion. Patients with radiculopathy or DDD were identified. Multivariate logistic regression was performed to identify factors that affect RTW status. Surgical and functional outcomes were compared between groups.

RESULTS

Stable RTW status within 3 years after multilevel cervical fusion was negatively affected by: fusion for DDD, age > 55 years, preoperative opioid use, initial psychological evaluation before surgery, injury-to-surgery > 2 years and instrumentation.DDD group had lower rate of achieving stable RTW status (P= 0.0001) and RTW within 1 year of surgery (P= 0.0003) compared with radiculopathy group. DDD patients were less likely to have a stable RTW status [odds ratio, OR = 0.63 (0.50-0.79)] or RTW within 1 year after surgery [OR = 0.65 (0.52-0.82)].DDD group had higher rate of opioid use (P= 0.001), and higher rate of disability after surgery (P= 0.002).

CONCLUSION

Multiple detriments affect stable RTW status after multilevel cervical fusion including DDD. DDD without radiculopathy was associated with lower RTW rates, less likelihood to return to work, higher disability, and higher opioid use after surgery. Multilevel cervical fusion for DDD may be counterproductive. Future studies should investigate further treatment options of DDD, and optimize patient selection criteria for surgical intervention.

LEVEL OF EVIDENCE

3.

Thirty-day readmission and reoperation rates after single-level anterior cervical discectomy and fusion versus those after cervical disc replacement

OBJECTIVE The goal of this study was to compare 30-day readmission and reoperation rates after single-level anterior cervical discectomy and fusion (ACDF) versus those after cervical disc replacement (CDR). METHODS The authors used the 2013-2014 American College of Surgeons National Surgical Quality Improvement Program database. Included were adult patients who underwent first-time single-level ACDF or CDR for cervical spondylosis or disc herniation. Primary outcome measures were readmission and/or reoperation within 30 days of the original surgery. Logistic regression analysis was used to assess the independent effect of the procedure (ACDF or CDR) on outcome, and results are presented as odds ratios with 95% confidence intervals. RESULTS A total of 6077 patients met the inclusion criteria; 5590 (92.0%) patients underwent single-level ACDF, and 487 (8.0%) patients underwent CDR. The readmission rates were 2.6% for ACDF and 0.4% for CDR (p = 0.003). When stratified according to age groups, only patients between the ages of 41 and 60 years who underwent ACDF had a significantly higher readmission rate than those who underwent CDR (2.5% vs 0.7%, respectively; p = 0.028). After controlling for patient age, sex, body mass index, smoking status, history of chronic obstructive pulmonary disease (COPD), diabetes, hypertension, steroid use, and American Society of Anesthesiologists (ASA) class, patients who underwent CDR were significantly less likely to undergo readmission within 30 days than patients who underwent ACDF (OR 0.23 [95% CI 0.06-0.95]; p = 0.041). Patients with a history of COPD (OR 1.97 [95% CI 1.08-3.57]; p = 0.026) or hypertension (OR 1.62 [95% CI 1.10-2.38]; p = 0.013) and those at ASA Class IV (OR 14.6 [95% CI 1.69-125.75]; p = 0.015) were significantly more likely to require readmission within 30 days. The reoperation rates were 1.2% for ACDF and 0.4% for CDR (p = 0.086), and multivariate analysis revealed that CDR was not associated with lower odds of reoperation (OR 0.60 [95% CI 0.14-2.55]; p = 0.492). However, increasing age was associated with a higher risk (OR 1.02 [95% CI 1.00-1.05]; p = 0.031) of reoperation; a 2% increase in risk per year of age was found. CONCLUSIONS Patients who underwent single-level ACDF had a higher readmission rate than those who underwent single-level CDR in this study. When stratified according to age, this effect was seen only in the 41- to 60-year age group. No significant difference in the 30-day single-level ACDF and single-level CDR reoperation rates was found. Although patients in the ACDF group were older and sicker, other unmeasured covariates might have accounted for the increased rate of readmission in this group, and further investigation is encouraged.

Titanium/Polyetheretherketone Cages for Cervical Arthrodesis with Degenerative and Traumatic Pathologies: Early Clinical Outcomes and Fusion Rates

OBJECTIVE

Anterior cervical discectomy and fusion is the most commonly employed surgical technique for treating cervical spondylosis. Although autologous bone grafts are considered the gold standard in achieving fusion, associated short- and long-term morbidities have led to a search for alternative materials. These have included carbon-fiber, titanium alloy (Ti) and ceramic and polyetheretherketone (PEEK) based implants. Recent attempts to optimize cage implants through using composite designs have combined Ti and PEEK. However, there are few published reports on the clinical and radiological outcomes of commercially available composite cages. Our study aimed to provide and evaluate initial outcomes of a composite Ti/PEEK cage.

METHODS

In this prospective single senior surgeon cohort study, 31 consecutive patients underwent a modified Smith-Robinson technique under general anesthesia and relevant data were collected. The study patients were aged between 18 and 75 years and underwent surgery from November 2013 to May 2014. Indications for surgery included traumatic and degenerative cervical disease that was unsuitable for or unresponsive to conservative management. All cages were between 5 and 8 mm and packed with super critical fluid sterilized allograft and bone marrow aspirate before insertion. Patients were followed-up for a minimum of 12 months. Fusion was assessed using fine cut CT and anteroposterior and lateral radiographs. Clinical outcomes were measured using a Visual Analogue Scale, Neck Oswestry Disability Index and Patient's Satisfaction Index.

RESULTS

Six of the original cohort were unavailable for adequate follow-up. The remaining 25 patients (17 men, 8 women; 33 operative levels) were observed for a mean of 14.6 months (range, 12-16 months). All operation levels were between C4 and C7 . Single-level operations were performed in 19 patients and additional plating in 14 patients. A fusion rate of 96% was achieved. Patients in both plated and non-plated groups experienced statistically significant improvements; good to excellent outcomes being seen in 92% of patients. There was one complication, namely recurrent laryngeal nerve palsy, which had partially resolved at 6 months follow-up.

CONCLUSION

The present study shows that enhancement of PEEK cages with Ti endplates is a safe and effective treatment with the potential for early osseointegration and early radiological evidence of fusion.

Return to Work Rates After Single-level Cervical Fusion for Degenerative Disc Disease Compared With Fusion for Radiculopathy in a Workers' Compensation Setting

STUDY DESIGN

A retrospective comparative cohort study.

OBJECTIVE

To compare return to work (RTW) rates for patients who underwent single-level cervical fusion for radiculopathy compared with fusion for degenerative disc disease (DDD) as an indication for surgery.

SUMMARY OF BACKGROUND DATA

Studies have shown that workers' compensation subjects have less favorable surgical and functional outcomes compared with the general population. Cervical decompression and fusion have provided great results with relieving radicular symptoms. Fusion for DDD, however, remains controversial.

METHODS

We retrospectively collected data of 21 169 subjects with cervical comorbidities who filed their claims for work-related injuries with Ohio Bureau of Workers' Compensation (BWC) between 1993 and 2011. The primary outcome was whether subjects met RTW criteria within 3-year follow-up after fusion. The secondary outcome measures and data on presurgical characteristics and secondary outcomes of each cohort were also collected.

RESULTS

Successful RTW status was affected by a number of presurgical risk factors: DDD as an indication for surgery, age of more than 50 years, out of work for more than 6 months, psychological evaluation, opioid use, legal litigation, and permanent disability. The DDD group had lower rate of successful RTW status (50.9%) and was less likely to have a sustained RTW status (odds ratio = 0.61, 95% confidence interval: 0.48-0.79, P = 0.0001) compared with the radiculopathy group (successful RTW rate 62.9%). RTW rate within 1 year after surgery was lower in the DDD group (39.9%) compared with the radiculopathy group (53.1%; P = 0.0001). DDD patients were absent 112 days more on average after surgery compared with radiculopathy patients (P = 0.0003).

CONCLUSION

Cervical fusion for DDD is associated with lower rate of successful RTW status when compared with fusion for radiculopathy in a worker's compensation setting. The decision to include surgical intervention in the management plan of cervical DDD should be approached with caution as the surgical outcome might not necessarily lead to improved postsurgical functionality and achieve sustained early RTW.

LEVEL OF EVIDENCE

4.

New Classification for Clinically Symptomatic Adjacent Segment Pathology in Cervical Disc Disease

STUDY DESIGN

Clinical adjacent segment pathology (CASP) is common after cervical disc surgery. A critical examination of 320 patients operated for cervical disc prolapse revealed that CASP can also occur in patients with congenital and degenerative fusion of cervical spine. This has not been studied in depth and there is a need for a practically applicable classification of CASP.

PURPOSE

To develop a new classification scheme of CASP.

OVERVIEW OF LITERATURE

A review of the literature did not reveal a practically applicable classification incorporating the occurrence of CASP in congenital and degenerative fusion cases.

METHODS

This was a retrospective analysis of 320 patients operated (509 disc spaces) on for cervical disc prolapse. Cases (n=316) were followed-up for 3-11 years. Random sampling of 220 patients with postoperative magnetic resonance imaging (MRI) in 165 cases was analyzed.

RESULTS

Six symptomatic CASP cases required resurgery (1.9%), eight cases involved MRI proven CASP with axial neck pain only and 13 patients were asymptomatic with radiological adjacent segment pathology (RASP). The frequency rate was 8.5% (27/316). Four cases of congenital or degenerative fusion of vertebra developed CASP requiring surgery. CASP is classified as primary or secondary follows. Primary A1 was congenital fusion of vertebra and primary A2 was degenerative fusion of the vertebra. Secondary, which was after cervical disc surgery, comprised B1 (RASP in asymptomatic patients), B2 (CASP in patients with axial neck pain), and B3 (CASP with myeloradiculopathy). B3 was subdivided into single-level CASP (B3a) and multiple-level CASP (B3b).

CONCLUSIONS

Symptomatic CASP requiring resurgery is infrequent. CASP can occur in patients with congenital and degenerative fusion of the cervical spine. A new classification for CASP along with treatment strategy is proposed. Patients in Primary CASP and B3 CASP require resurgery while others require only observation.

Reoperations Following Cervical Disc Replacement

Cervical disc replacement (CDR) has emerged as an alternative surgical option to cervical arthrodesis. With increasing numbers of patients and longer follow-ups, complications related to the device and/or aging spine are growing, leaving us with a new challenge in the management and surgical revision of CDR. The purpose of this study is to review the current literature regarding reoperations following CDR and to discuss about the approaches and solutions for the current and future potential complications associated with CDR. The published rates of reoperation (mean, 1.0%; range, 0%-3.1%), revision (mean, 0.2%; range, 0%-0.5%), and removal (mean, 1.2%; range, 0%-1.9%) following CDR are low and comparable to the published rates of reoperation (mean, 1.7%; range; 0%-3.4%), revision (mean, 1.5%; range, 0%-4.7%), and removal (mean, 2.0%; range, 0%-3.4%) following cervical arthrodesis. The surgical interventions following CDR range from the repositioning to explantation followed by fusion or the reimplantation to posterior foraminotomy or fusion. Strict patient selection, careful preoperative radiographic review and surgical planning, as well as surgical technique may reduce adverse events and the need for future intervention. Minimal literature and no guidelines exist for the approaches and techniques in revision and for the removal of implants following CDR. Adherence to strict indications and precise surgical technique may reduce the number of reoperations, revisions, and removals following CDR. Long-term follow-up studies are needed, assessing the implant survivorship and its effect on the revision and removal rates.

Cervical total disc replacement is superior to anterior cervical decompression and fusion: a meta-analysis of prospective randomized controlled trials

BACKGROUND

Despite being considered the standard surgical procedure for symptomatic cervical disc disease, anterior cervical decompression and fusion invariably accelerates adjacent segment degeneration. Cervical total disc replacement is a motion-preserving procedure developed as a substitute to fusion. Whether cervical total disc replacement is superior to fusion remains unclear.

METHODS

We comprehensively searched PubMed, EMBASE, Medline, and the Cochrane Library in accordance with the inclusion criteria to identify possible studies. The retrieved results were last updated on December 12, 2014. We classified the studies as short-term and midterm follow-up.

RESULTS

Nineteen randomized controlled trials involving 4516 cases were identified. Compared with anterior cervical decompression and fusion, cervical total disc replacement had better functional outcomes (neck disability index [NDI], NDI success, neurological success, neck pain scores reported on a numerical rating scale [NRS], visual analog scales scores and overall success), greater segmental motion at the index level, fewer adverse events and fewer secondary surgical procedures at the index and adjacent levels in short-term follow-up (P < 0.05). With midterm follow-up, the cervical total disc replacement group indicated superiority in the NDI, neurological success, pain assessment (NRS), and secondary surgical procedures at the index level (P < 0.05). The Short Form 36 (SF-36) and segmental motion at the adjacent level in the short-term follow-up showed no significant difference between the two procedures, as did the secondary surgical procedure rates at the adjacent level with midterm follow-up (P > 0.05).

CONCLUSIONS

Cervical total disc replacement presented favorable functional outcomes, fewer adverse events, and fewer secondary surgical procedures. The efficacy and safety of cervical total disc replacement are superior to those of fusion. Longer-term, multicenter studies are required for a better evaluation of the long-term efficacy and safety of the two procedures.

Biphasic calcium phosphate contained within a polyetheretherketone cage with and without plating for anterior cervical discectomy and fusion

OBJECTIVE

To evaluate the properties of a combination bone graft consisting of biphasic calcium phosphate ceramic, polyetheretherketone (PEEK) cage in one- and two-level surgery.

METHODS

Over a 12-month time period, a prospective single surgeon series of 75 patients were included in the study and 58 patients selected based on adequate data points. From these 58 patients, 32 were supplemented with anterior plate fixation and 26 patients without plating. Duration of clinical follow-up was a mean of 12.4 months (range, 6-26 months) in the Plated Group and 10.5 months (range, 6-21 months) in the Non-Plated Group.

RESULTS

A 100% fusion rate with nil graft related complications was achieved in the Plated group compared with 96.2% fusion and 11.5% subsidence rates reported in the Non-Plated group. Patients in both groups experienced statistically significant improvement in pain and functional outcomes compared to their pre-operative status; however, there was no significant difference in outcome between the Plated and Non-Plated Groups.

CONCLUSIONS

Biphasic calcium phosphate ceramic contained within a PEEK cage is an effective implant for use in anterior cervical surgery with high fusion rates and good clinical outcome.

Long-term results after cervical anterior fusion using an autologous bone graft (Williams-Isu method)

OBJECTIVE

Cervical anterior fusion with autologous bone grafts (Williams-Isu method) is a modified, accepted method to treat spinal degenerative disease. Here we report minimum 10-year outcomes.

METHODS

Of 101 patients we treated by cervical anterior fusion using the Williams-Isu method, 50 patients were followed up for a mean of 177 months. Among the 51 patients lost to long-term follow-up 12 were contacted by telephone; they reported their condition as good and none required reoperation. We evaluated their clinical outcomes on the Japan Orthopedic Association (JOA) score and assessed radiologic findings.

RESULTS

The average JOA score was 12.5 preoperatively, 15.9 at 2 years after surgery (recovery rate 74.9%), and 15.5 at final follow-up (recovery rate 67.0%). All 5 reoperated patients were treated on the level adjacent to the original lesion. Radiographically, cervical alignment changed from 12.5° to 9.0°, the fused segment angle changed from 5.4° to -0.6°. Although worsening of the fused segment angle did not affect the clinical results, it did affect postoperative cervical sagittal alignment. Cervical alignment and range of motion (ROM) were not different between reoperated (group I) and nonreoperated patients (group II). Fused segment angle worsening was milder than expected in group I.

CONCLUSIONS

The long-term results after the Williams-Isu method were good. The fused segment angle loss of approximately 6° did not affect long-term outcomes although it did affect sagittal cervical alignment. Postoperative worsening of the fused segment angle and hyper ROM changes in the adjacent level were not related to the need for reoperation in our study.

Single level cervical fusion by an anterior approach using autologous bone graft influences the adjacent levels degenerative changes: clinical and radiographic results at 10-year minimum follow-up

INTRODUCTION

Cervical degenerative pathology can produce pain and disability and, in case of failure of conservative treatment surgery is indicated.

MATERIALS AND METHODS

107 patients affected by single level cervical degenerative pathology were surgically treated by Cloward procedure. On radiographs, the sagittal segmental alignment (SSA) of the affected level and sagittal alignment of the cervical spine were measured.

RESULTS

Preoperatively, mean SSA was 0.6° and at the last follow-up 1.8°. In particular, adjacent-level degeneration occurred more frequently in Group A than in Group B.

CONCLUSION

Lordotic SSA angle can be considered a protective factor against adjacent-level degeneration.

Adjacent segment motion after anterior cervical discectomy and fusion versus Prodisc-c cervical total disk arthroplasty: analysis from a randomized, controlled trial

STUDY DESIGN

Post hoc analysis of data acquired in a prospective, randomized, controlled trial.

OBJECTIVE

To compare adjacent segment motion after anterior cervical discectomy and fusion (ACDF) versus cervical total disc arthroplasty (TDA).

SUMMARY OF BACKGROUND DATA

TDA has been designed to be a motion-preserving device, thus theoretically normalizing adjacent segment kinematics. Clinical studies with short-term follow-up have yet to demonstrate a consistent significant difference in the incidence of adjacent segment disease.

METHODS

Two hundred nine patients at 13 sites were treated in a prospective, randomized, controlled trial of ACDF versus TDA for single-level symptomatic cervical degenerative disc disease (SCDD). Flexion and extension radiographs were obtained at all follow-up visits. Changes in ROM were compared using the Wilcoxon signed-rank test and the Mann-Whitney U test. Predictors of postoperative ROM were determined by multivariate analysis using mixed effects linear regression.

RESULTS

Data for 199 patients were available with 24-month follow-up. The groups were similar with respect to baseline demographics. A significant increase in motion at the cranial and caudal adjacent segments after surgery was observed in the ACDF group only (cranial: ACDF: +1.4° (0.4, 2.4), P = 0.01; TDA: +0.8°, (-0.1, +1.7), P = 0.166; caudal: ACDF: +2.6° (1.3, 3.9), P < 0.0001; TDA: +1.3, (-0.2, +2.8), P = 0.359). No significant difference in adjacent segment ROM was observed between ACDF and TDA. Only time was a significant predictor of postoperative ROM at both the cranial and caudal adjacent segments.

CONCLUSION

Adjacent segment kinematics may be altered after ACDF and TDA. Multivariate analysis showed time to be a significant predictor of changes in adjacent segment ROM. No association between the treatment chosen (ACDF vs. TDA) and ROM was observed. Furthermore clinical follow-up is needed to determine whether possible differences in adjacent segment motion affect the prevalence of adjacent segment disease in the two groups.

Sagittal segmental alignment as predictor of adjacent-level degeneration after a cloward procedure

BACKGROUND

The Cloward anterior interbody fusion is commonly performed for cervical disc herniation or spondylosis. In followup studies, various authors have noted clinically relevant adjacent-level degeneration. However, factors associated with adjacent-level degeneration are not well known.

QUESTIONS/PURPOSES

We asked whether the postoperative sagittal segmental alignment of the fused vertebrae could be used as a predictor of adjacent-level degeneration.

METHODS

We retrospectively studied 107 patients, aged 35 to 55 years, with one-level cervical disc disease between C4 and C7 operated on from 1985 to 1995 by discectomy and one-level anterior cervical fusion according to the Cloward procedure. In standard radiographs of the cervical spine in lateral view, the alignment of the involved intervertebral space (sagittal segmental alignment) and the sagittal alignment of the cervical spine were measured and the adjacent-level degeneration was assessed using the Kellgren and Lawrence criteria. The minimum followup was 10 years (mean, 16 years; range, 10-23 years).

RESULTS

Preoperatively, mean sagittal segmental alignment was 0.6°±2.0° and sagittal alignment of the cervical spine was 17.0°±4.9°. At last followup, the mean sagittal segmental alignment was 1.8°±4.1° and mean sagittal alignment of the cervical spine was 19.7°±6.6°. Adjacent-level degeneration was present in 60% of cases with postoperative sagittal segmental alignment of 0° or less and in 27% of cases with postoperative sagittal segmental alignment of more than 0°.

CONCLUSIONS

To prevent adjacent-level degeneration, we recommend proper lordotic sagittal segmental alignment when anterior interbody fusion of the cervical spine is indicated.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Avaliação do tratamento da discopatia degenerativa cervical pela artrodese via anterior utilizando placas associadas a cages ou cages em peek isoladamente

OBJETIVOS: Avaliar comparativamente o tratamento da discopatia degenerativa cervical por discectomia e artrodese cervical via anterior utilizando placas associadas a cages ou cages em PEEK isoladamente. MÉTODOS: Foi realizado um estudo retrospectivo comparativo entre dois grupos de pacientes operados pela técnica de discectomia e artrodese cervical via anterior. Foram selecionados aleatoriamente 70 pacientes, 35 operados com o método de fixação com placas associadas a cages - denominado Grupo I - e 35 com o cage em PEEK isoladamente - Grupo II. Realizou-se anamnese, exame físico, escores de dor (escala visual e analógica da dor) e função (critérios de Odom's, SF-36, Indice de incapacidade do pescoço) o pré e pós-operatório e exames de imagem. RESULTADOS: Houve predominância de pacientes do sexo feminino em ambos os grupos, com média de idade de 55 anos no Grupo I e 47 no Grupo II. Ambos os grupos apresentaram distribuição semelhante quanto ao número de níveis operados, assim como nas complicações encontradas e escores de dor, cervicalgia e SF36 no pré e pós-operatório. Houve 97.1% de fusão com 94.3% de bons resultados no Grupo I e 100% de fusão, com 97 % de bons resultados no Grupo II. CONCLUSÕES: O estudo comparativo da utilização de placas com cages e cages em PEEK isoladamente apresentou resultados semelhantes e satisfatórios para os grupos estudados, não se constatando superioridade ou inferioridade de um método com relação ao outro.

Anterior cervical discectomy and fusion for the management of axial neck pain in the absence of radiculopathy or myelopathy

STUDY DESIGN

 Systematic reviewStudy rationale: Anterior cervical discectomy and fusion (ACDF) is a proven, effective treatment for relieving neck pain due to degenerative conditions of the cervical spine. Since most patients also present with radiculopathy or myelopathy, little is known as to the effectiveness of ACDF to relieve pain and improve function in patients without radicular or myelopathic symptoms.

OBJECTIVE

 To examine the clinical outcome in patients undergoing (ACDF) for axial neck pain without radicular or myelopathic symptoms.

METHODS

 A systematic review was undertaken for articles published up to March 2010. Electronic databases and reference lists of key articles were searched to identify studies evaluating ACDF for the treatment of axial neck pain only. Radiculopathy and myelopathy, patients who suffered severe trauma, or with tumor/metastatic disease or infection were excluded. Two independent reviewers assessed the strength of evidence using the grading of recommendations assessment, development and evaluation (GRADE) system, and disagreements were resolved by consensus.

RESULTS

 No comparative studies were identified. Three case series met our inclusion criteria and were evaluated. All studies showed a mean improvement of pain of at least 50% approximately 4-years following surgery. Functional outcomes improved between 32% and 52% from baseline. Most patients reported satisfaction with surgery, 56% in one study and 79% in another. Complications varied among studies ranging from 1% to 10% and included pseudoarthrosis (9%), nonunion and revision (3%) and screw removal (1%).

CONCLUSION

 There is low evidence suggesting that patients with axial neck pain without radicular or myelopathic symptoms may receive some improvement in pain and function following ACDF. However, whether this benefit is greater than nontreatment or other treatments cannot be determined with the present literature.

Diagnosis and management of degenerative neck pain

Neck pain is a common presenting complaint, but the precise patho-aetiology is often unclear. Broadly speaking, the cause of neck pain can be considered as degenerative or non-degenerative (Table 1). While detailing the important non-degenerative causes the clinician should not miss, this article reviews the diagnosis and management of the common degenerative orthopaedic causes of neck pain.

Cervical disc herniation and cervical spondylosis surgically treated by Cloward procedure: a 10-year-minimum follow-up study

Background

Cervical degenerative pathology produces pain and disability, and if conservative treatment fails, surgery is indicated. The aim of this study was to determined whether anterior decompression and interbody fusion according to Cloward is effective for treating segmental cervical degenerative pathology and whether the results are durable after a 10-year-minimum follow-up.

Materials and methods

Fifty-one patients affected by single-level cervical degenerative pathology between C4 and C7 were surgically treated by the Cloward procedure. Clinical evaluation was rated using the Neck Disability Index (NDI) and the visual analog scale (VAS). At last follow-up, the outcomes were rated according to Odom’s criteria. On radiographs, the sagittal segmental alignment (SSA) of the affected level and the sagittal alignment of the cervical spine (SACS) were measured.

Results

Average NDI was 34 preoperatively and 11 at last follow-up. Average VAS was 7 preoperatively and 1 at last follow-up. According to Odom’s criteria, the outcome was considered excellent in 18 cases, good in 22, and fair in 11. Average SSA was 0.5 ± 2.1 preoperatively, 1.8 ± 3.8 at 6 months, and 1.8 ± 5.7 at last follow-up. Average SACS was 16.5 ± 4.0 preoperatively, 20.9 ± 5.8 at 6 months, and 19.9 ± 6.4 at last follow-up. Degenerative changes at the adjacent levels were observed in 18 patients (35.3%).

Conclusions

The Cloward procedure proved to be a suitable and effective technique for treating segmental cervical degenerative pathology, allowing good clinical and radiographic outcomes even at a long-term follow-up.

Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

STUDY DESIGN

Best evidence synthesis.

OBJECTIVE

To identify, critically appraise, and synthesize literature from 1980 through 2006 on surgical interventions for neck pain alone or with radicular pain in the absence of serious pathologic disease.

SUMMARY OF BACKGROUND DATA

There have been no comprehensive systematic literature or evidence-based reviews published on this topic.

METHODS

We systematically searched Medline for literature published from 1980 to 2006 on percutaneous and open surgical interventions for neck pain. Publications on the topic were also solicited from experts in the field. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our Best Evidence Synthesis.

RESULTS

Of the 31,878 articles screened, 1203 studies were relevant to the Neck Pain Task Force mandate and of these, 31 regarding treatment by surgery or injections were accepted as scientifically admissible. Radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence. We found there is support for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures. However, relatively rapid and substantial symptomatic relief after surgical treatment seems to be reliably achieved. It is not evident that one open surgical technique is clearly superior to others for radiculopathy. Cervical foramenal or epidural injections are associated with relatively frequent minor adverse events (5%-20%); however, serious adverse events are very uncommon (<1%). After open surgical procedures on the cervical spine, potentially serious acute complications are seen in approximately 4% of patients.

CONCLUSION

Surgical treatment and limited injection procedures for cervical radicular symptoms may be reasonably considered in patients with severe impairments. Percutaneous and open surgical treatment for neck pain alone, without radicular symptoms or clear serious pathology, seems to lack scientific support.

Cervical intradiscal radiofrequency lesioning: a feasiblity study

OBJECTIVE

The objective of this benchtop study was to establish if single site, long duration intradiscal radiofrequency (RF) at two different positions could generate adequate heating throughout the intervertebral disc to potentially ablate intradiscal nociceptors.

DESIGN

The disarticulated cervical spines from four fresh frozen cadavers were studied. Temperature recording was completed from two different positions of the RF needle. The needle was either placed in the middle of the disc in four discs, or it was inserted in the posterior quarter of the disc, in eight discs. Thermocouple measurements were made every 2 minutes from three positions: middle of the disc, posterolateral aspect of the disc, and in the anterior third of the disc.

SETTING

Fluoroscopy suite.

MATERIALS

Disarticulated cervical spine specimens.

INTERVENTIONS

Intradiscal RF lesioning in the middle and posterior portion of the cervical disc at 85 degrees C for 10 minutes.

OUTCOME MEASURES

Local temperature within the disc.

RESULTS

Lesioning in either the middle or posterior portion of the disc failed to provide sufficient temperature increases throughout the cervical disc to achieve adequate denervation.

CONCLUSIONS

As in the lumbar spine, intradiscal cervical RF provides too focal a thermal profile to effectively denervate the disc even in an ex vivo experiment. Thus, single site, long duration cervical intradiscal RF lesioning in vivo cannot be recommended.