Comparison of 3 reconstructive techniques in the surgical management of multilevel cervical spondylotic myelopathy

Would the one-stage combined approach lead to better long-term neurological outcomes than the posterior approach alone in multilevel degenerative cervical myelopathy patients with T2-Weighted increased signal intensity? An 8-year follow-up results and propensity score matching analysis

BACKGROUND

T2-weighted increased signal intensity (ISI) is commonly recognized as a sign of more severe spinal cord lesions, usually accompanied by worse neurological deficits and possibly worse postoperative neurological recovery. The combined approach could achieve better decompression and better neurological recovery for multilevel degenerative cervical myelopathy (MDCM). The choice of surgical approach for MDCM with intramedullary T2-weighted ISI remains disputed. This study aimed to compare the neurological outcomes of posterior and one-stage combined posteroanterior approaches for MDCM with T2-weighted ISI.

METHODS

A total of 83 consecutive MDCM patients with confirmed ISI with at least three intervertebral segments operated between 2012 and 2014 were retrospectively enrolled. Preoperative demographic, radiological and clinical condition variables were collected, and neurological conditions were evaluated by the Japanese Orthopedic Assessment score (JOA) and Neck Disability Index (NDI). Propensity score matching analysis was conducted to produce pairs of patients with comparable preoperative conditions from the posterior-alone and combined groups. Both short-term and mid-term surgical outcomes were evaluated, including the JOA recovery rate (JOARR), NDI improvements, complications, and reoperations.

RESULTS

A total of 83 patients were enrolled, of which 38 and 45 patients underwent posterior surgery alone and one-stage posteroanterior surgery, respectively. After propensity score matching, 38 pairs of comparable patients from the posterior and combined groups were matched. The matched groups presented similar preoperative clinical and radiological features and the mean follow-up duration were 111.6 ± 8.9 months. The preoperative JOA scores of the posterior and combined groups were 11.5 ± 2.2 and 11.1 ± 2.3, respectively (p = 0.613). The combined group presented with prolonged surgery duration(108.8 ± 28.0 and 186.1 ± 47.3 min, p = 0.028) and greater blood loss(276.3 ± 139.1 and 382.1 ± 283.1 ml, p<0.001). At short-term follow-up, the combined group presented a higher JOARR than the posterior group (posterior group: 50.7%±46.6%, combined group: 70.4%±20.3%, p = 0.024), while no significant difference in JOARR was observed between the groups at long-term follow-up (posterior group: 49.2%±48.5%, combined group: 59.6%±47.6%, p = 0.136). No significant difference was found in the overall complication and reoperation rates.

CONCLUSIONS

For MDCM patients with ISI, both posterior and one-stage posteroanterior approaches could achieve considerable neurological alleviations in short-term and long-term follow-up. With greater surgical trauma, the combined group presented better short-term JOARR but did not show higher efficacy in long-term neurological function preservation in patients with comparable preoperative conditions.

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

STUDY DESIGN

Retrospective Cohort.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III.

Two-Level Corpectomy and Fusion vs. Three-Level Anterior Cervical Discectomy and Fusion without Plating: Long-Term Clinical and Radiological Outcomes in a Multicentric Retrospective Analysis

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) represent effective alternatives in the management of multilevel cervical spondylotic myelopathy (CSM). A consensus on which of these techniques should be used is still missing.

METHODS

The databases of three centers were reviewed (January 2011-December 2018) for patients with three-level CSM, who underwent three-level ACDF without plating or two-level ACCF with expandable cage (VBRC) or mesh (VBRM). Demographic data, surgical strategy, complications, and implant failure were analyzed. The Neck Disability Index (NDI), the Visual Analog Scale (VAS), and the cervical lordosis were compared between the two techniques at 3 and 12 months. Logistic regression analyses investigated independent factors influencing clinical and radiological outcomes.

RESULTS

Twenty-one and twenty-two patients were included in the ACDF and ACCF groups, respectively. The median follow-up was 18 months. ACDFs were associated with better clinical outcomes at 12 months (NDI: 8.3% vs. 19.3%, p < 0.001; VAS: 1.3 vs. 2.6, p = 0.004), but with an increased risk of loss of lordosis correction ≥ 1° (OR = 4.5; p = 0.05). A higher complication rate in the ACDF group (33.3% vs. 9.1%; p = 0.05) was recorded, but it negatively influenced only short-term clinical outcomes. ACCFs with VBRC were associated with a higher risk of major complications but ensured better 12-month lordosis correction (p = 0.002). No significant differences in intraoperative blood loss were noted.

CONCLUSIONS

Three-level ACDF without plating was associated with better clinical outcomes than two-level ACCF despite worse losses in lordosis correction, which is ideal for fragile patients without retrovertebral compressions. In multilevel CSM, the relationship between the degree of lordosis correction and clinical outcome advantages still needs to be investigated.

The use of a new high-speed shielded curved drill is associated with improved intraoperative and clinical outcomes after cervical corpectomy and fusion procedures: a retrospective case series

BACKGROUND

Anterior cervical corpectomy and fusion (ACCF) is an effective technique to address multi-level degenerative cervical myelopathy. However, as the number of surgical levels increases, the outcomes worsen with respect to complication rates, range of motion and length of surgery. This study aimed to determine the clinical outcome of ACCF procedures performed using a new distally curved and shielded drilling device.

METHODS

A retrospective study was conducted on 43 ACCF procedures in which the device was used for osteophyte removal. Patient files were reviewed to assess the early clinical results and complications following ACCF. Clinical outcomes were evaluated using patient neck and arm pain scores and SF-36 questionnaires. Hospitalization characteristics were compared with historical controls.

RESULTS

All procedures were uneventful and without major complications or neurological deterioration. Single-level ACCF procedures required an average of 71 min and followed by an average hospitalization of 3.3 days. Osteophyte removal, verified by intraoperative imaging, was satisfactory. Average neck pain score was improved by 0.9 points (p = 0.24). Average arm pain score was improved by 1.8 points (p = 0.06). SF-36 scores were improved in all domains.

CONCLUSIONS

The new curved device enabled safe and efficient removal of osteophytes sparing adjacent vertebral removal in ACCF procedures, thus improving the clinical outcome.

Correction and Maintenance of Cervical Alignment: 3-Level ACDF Versus Corpectomy-ACDF "Hybrid" Procedures

STUDY DESIGN

Longitudinal observational comparative cohorts.

OBJECTIVE

The objective of this study is to compare 3 and 12-month radiographic sagittal parameters and patient-reported outcomes (PROs) in patients who underwent 3-level ACDF or a hybrid procedure.

SUMMARY OF BACKGROUND DATA

Anterior Cervical Discectomy and Fusion (ACDF), Anterior Cervical Corpectomy and Fusion (ACCF), and hybrids (combination ACCF-ACDF) are common procedures used to treat symptomatic cervical spondylosis. Although there is a relative abundance of literature comparing 1-level ACCF versus 2-level ACDF and 2-level ACCF versus 3-level ACDF, detailed comparisons of 3-level ACDF versus hybrid procedures have not been extensively addressed.

METHODS

Patients who underwent a 3-Level ACDF (3L-ACDF, N=47) or 1-Level Corpectomy/1-Level ACDF (Hybrid, N=52) with at least a 12-month post-op data available were identified. Standard demographic, surgical and PROs were collected in addition to preoperative and postoperative radiographic data, including C2 plumb line (C2PL), C2-C7 lordosis (CL), segmental lordosis (SL), and T1 slope (T1S).

RESULTS

The 2 cohorts were similar in terms of demographics. At 3 months post-op, CL (9.04° vs. -2.12°, P =0.00) and SL (6.06° vs. -2.26°, P =0.003) were significantly greater in the 3L-ACDF group versus the HYBRID group. This significant difference was maintained at 12 months postoperative for CL [(6.62° vs. -0.60°, P =0.015) but not for SL (2.36° vs. -1.09°, P =0.199)]. There were no differences in PROs between the 2 groups before surgery, at 3 months postoperative or 12 months postoperative. Seven patients required revision surgery in the 1-year study period (1 in the 3L-ACDF, and 6 in the Hybrid P <0.001).

CONCLUSIONS

Three level ACDF resulted in greater C2-C7 lordosis and segmental lordosis postoperatively, which was maintained at 1 year for cervical lordosis. While PROs were similar between the groups, patients with hybrid instrumentation required significantly more revision surgeries than those treated with 3-level ACDF.

Cervical sagittal alignment changes following anterior cervical discectomy and fusion, laminectomy with fusion, and laminoplasty for multisegmental cervical spondylotic myelopathy

OBJECTIVE

Cervical sagittal alignment changes (CSACs) influence outcomes and health-related quality-of-life. Anterior cervical discectomy and fusion (ACDF), laminectomy with fusion (LCF), and laminoplasty (LP) are common treatments for multisegmental cervical spondylotic myelopathy; however, these approaches need to be compared.

METHODS

Our study included 167 patients who underwent ACDF, LCF, or LP. Patients were divided into four groups according to C2-C7 Cobb angle (CL): kyphosis (CL < 0°), straight (0° ≤ CL < 10°), lordosis (10° ≤ CL < 20°), and extreme lordosis (20° ≤ CL) groups. CSACs consist of two parts. CSAC from the preoperative period to the postoperative period is surgical correction change (SCC). CSAC from the postoperative period to the final follow-up period is postoperative lordosis preserving (PLP). Outcomes were evaluated using the Japanese Orthopaedic Association score and the neck disability index.

RESULTS

ACDF, LCF, and LP had equivalent outcomes. ACDF had greater SCC than LCF and LP. During follow-up, lordosis decreased in the ACDF and LCF groups but increased in the LP group. For straight alignment, ACDF had greater CSAC and greater SCC than the LCF and LP groups but similar PLP. For lordosis alignment, ACDF and LP had positive PLP, and LCF had negative PLP. For extreme lordosis, ACDF, LP, and LCF had negative PLP; however, cervical lordosis in the LP group was relatively stable during follow-up.

CONCLUSIONS

ACDF, LCF, and LP have different CSAC, SCC, and PLP according to a four-type cervical sagittal alignment classification. Preoperative cervical alignment is an important consideration in deciding the type of surgical treatment in CSM.

Comparison Between Sagittal Balance Outcomes After Corpectomy, Laminectomy, and Fusion for Cervical Spondylotic Myelopathy: A Matched Cohort Study

Cervical spondylotic myelopathy (CSM) can be successfully decompressed via either anterior cervical corpectomy and fusion (ACCF) or posterior laminectomy with fusion (LMF). However, few studies have compared the isolated effect of both techniques on cervical sagittal balance, a surrogate end point for clinical outcomes.We aimed to compare the sagittal balance radiological outcomes of ACCF against LMF. A case-matched controlled study of radiological cervical alignment parameters (C0-2, C2-3, index angles, T1 slope, and sagittal vertical axis (SVA)) in two groups of patients was performed by using pre- and postoperative neutral cervical X-rays.In total, 34 patients were enrolled (ACCF n = 17; LMF n = 17). The mean preoperative C2-7 angle was similar (11.58 ± 16.00° for ACCF; 13.36 ± 12.21° for LMF) in both cohorts. Both led to a loss of lordosis (-2.68 ± 13.8°, p = 0.43; -2.94 ± 11.5°, p = 0.31, respectively). At the C0-2, the two operations induced opposite variations (-0.9 ± 8.0°, p = 0.709 for ACCF; 3.5 ± 15.4°, p = 0.357 for LMF). ACCF led to a significant increase in SVA (7.1 ± 11.9 mm, p = 0.002). The C2-3 disk angle more pronouncedly increased with LMF.Both techniques show an equivalent kyphotic effect, with a greater disadvantage for ACCF. The negative impact on SVA changes is greater with ACCF. Both affect the C0-2 unit, with a tendency for kyphosis with ACCF and one for lordosis with LMF. When choosing the appropriate decompression and fusion technique, preoperative sagittal balance parameters should be included in the decision-making process.

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

Study Design

A meta-analysis.

Objective

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III-a retrospective analysis.

Comparison of Laminoplasty vs. Laminectomy for Cervical Spondylotic Myelopathy: A Systematic Review and Meta-Analysis

OBJECTIVES

Laminoplasty (LP) and laminectomy (LC) with or without fusion are recommended as treatment procedures for cervical spondylotic myelopathy (CSM). The purpose of this study is to conduct a meta-analysis to analyze the results of CSM patients undergoing LP or LC surgery.

METHODS

We systematically and comprehensively searched Web of Science, Cochrane Library, PubMed, EMBASE, OVID, VIP database, Google Scholar, Chinese Bio-medicine Literature database, and China Scientific Journal Full-text database to July 2021 for randomized controlled trials (RCTs) and observational case series that compared LP and LC in patients with CSM. The main endpoints were the surgical process, radiographic outcomes, clinical outcomes, and surgical complications.

RESULTS

A total of 19 were included the inclusion criteria in this meta-analysis (n = 4,348 patients). There was no significant difference in range of motion (ROM), sagittal vertical axis (SVA), Japanese Orthopedic Association (JOA), Cobb angle, visual analog scale (VAS), cervical curvature index (CCI), Nurick score, Neck Dysfunction Index (NDI), and complications. LP was found to be superior than LC in terms of complications of C5 radiculopathy and surperficial infection.

CONCLUSION

Our results indicate that LP can achieve better results in C5 radiculopathy and superficial infection in surgical treatment of CSM compared with LC. Further high-quality research is warranted to further verify our findings.

SYSTEMATIC REVIEW REGISTRATION

PRISMA: CRD42018107070.

Anterior Cervical Discectomy and Fusion Using Zero-P System for Treatment of Cervical Spondylosis: A Meta-Analysis

Objective

The current study aimed to explore the efficacy of Zero profile intervertebral fusion system (Zero-P) and traditional anterior plate cage system (PC) in the treatment of cervical spondylotic myelopathy (CSM). Further, the present study evaluated effects of the treatments on medical security, height of intervertebral disc, adjacent-level ossification development (ALOD), and adjacent segmentation disease (ASD) through a systematic retrospective analysis.

Methods

Studies on Zero-P system and traditional anterior plate cage system for ACDF in the treatment of CSM were searched in PubMed, Web of Science, Ovid, Embase, and Cochrane Library databases. Two independent researchers screened articles, extracted data, and evaluated the quality of the articles based on the inclusion and exclusion criteria of the current study. RevMan5.3 software was used for meta-analysis following the guidelines of Cochrane collaboration network. Cervical curvature, interbody fusion rate, preoperative and postoperative disc height index (DHI), fusion cage sinking rate, postoperative dysphagia, ASD, ALOD, and loosening of screw were compared between the two groups.

Results

A total of 17 literatures were included in the present study, including 6 randomized controlled trials and 11 observational studies. The studies comprised a total of 1204 patients with CSM, including 605 patients in the Zero-P system group (Zero-P group) and 599 patients in the traditional animal plate cage group (PC group). Results of this meta-analysis showed that postoperative dysphagia [OR = 0.40, CI (0.28, 95% 0.58), P < 0.00001], ALOD [OR = 0.09, CI (0.02, 95% 0.39), P = 0.001], ASD [OR = 0.42, CI (0.20, 95% 0.86), P = 0.02], and screw loosening [OR = 0.20, CI (0.08, 95% 0.52), P = 0.0009] of the Zero-P group were significantly lower compared with the PC group. On the other hand, preoperative cervical curvature [WMD = −0.23, CI (−1.38, 95% 0.92), P = 0.69], postoperative cervical curvature [WMD = −0.38, CI (−1.77, 95% 1.01), P = 0.59], cage sinking rate [OR = 1.41, CI [0.52, 95% 3.82], P = 0.50], intervertebral fusion rate [OR = 0.76, CI (0.27, 95% 2.48), P = 0.38], preoperative DHI [WMD = −0.04, CI (−0.14, 95% 0.22), P = 0.65], and postoperative DHI [WMD = 0.06, CI (−0.22, 95% 0.34), P = 0.675] were not significantly different between the two groups.

Conclusion

It was evident that the Zero-P system used in ACDF is superior compared with the traditional anterior plate cage system in postoperative dysphagia, avoiding ALOD, ASD, and screw loosening.

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

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Effectiveness of three-dimensional printing artificial vertebral body and interbody fusion Cage in anterior cervical surgery]

Objective

To evaluate the effectiveness of three-dimensional (3D) printing artificial vertebral body and interbody fusion Cage in anterior cervical disectomy and fusion (ACCF) combined with anterior cervical corpectomy and fusion (ACDF).

Methods

The clinical data of 29 patients with multilevel cervical spondylotic myelopathy who underwent ACCF combined with ACDF between May 2018 and December 2019 were retrospectively analyzed. Among them, 13 patients were treated with 3D printing artificial vertebral body and 3D printing Cage as 3D printing group and 16 patients with ordinary titanium mesh Cage (TMC) and Cage as TMC group. There was no significant difference in gender, age, surgical segment, Nurick grade, disease duration, and preoperative Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) score, and Cobb angle of fusion segment between the two groups ( P>0.05). The operation time, intraoperative blood loss, hospitalization stay, complications, and implant fusion at last follow-up were recorded and compared between the two groups; JOA score was used to evaluate neurological function before operation, immediately after operation, at 6 months after operation, and at last follow-up; VAS score was used to evaluate upper limb and neck pain. Cobb angle of fusion segment was measured and the difference between the last follow-up and the immediate after operation was calculated. The height of the anterior border (HAB) and the height of the posterior border (HPB) were measured immediately after operation, at 6 months after operation, and at last follow-up, and the subsidence of implant was calculated.

Results

The operation time of 3D printing group was significantly less than that of TMC group ( t=3.336, P=0.002); there was no significant difference in hospitalization stay and intraoperative blood loss between the two groups ( P>0.05). All patients were followed up 12-19 months (mean, 16 months). There was no obvious complication in both groups. There were significant differences in JOA score, VAS score, and Cobb angle at each time point between the two groups ( P<0.05). There was an interaction between time and group in the JOA score ( F=3.705, P=0.025). With time, the increase in JOA score was different between the 3D printing group and the TMC group, and the increase in the 3D printing group was greater. There was no interaction between time and group in the VAS score ( F=3.038, P=0.065), and there was no significant difference in the score at each time point between the two groups ( F=0.173, P=0.681). The time of the Cobb angle interacted with the group ( F=15.581, P=0.000). With time, the Cobb angle of the 3D printing group and the TMC group changed differently. Among them, the 3D printing group increased more and the TMC group decreased more. At last follow-up, there was no significant difference in the improvement rate of JOA score between the two groups ( t=0.681, P=0.502), but the Cobb angle difference of the 3D printing group was significantly smaller than that of the TMC group ( t=5.754, P=0.000). At last follow-up, the implant fusion rate of the 3D printing group and TMC group were 92.3% (12/13) and 87.5% (14/16), respectively, and the difference was not significant ( P=1.000). The incidence of implant settlement in the 3D printing group and TMC group at 6 months after operation was 15.4% (2/13) and 18.8% (3/16), respectively, and at last follow-up were 30.8% (4/13) and 56.3% (9/16), respectively, the differences were not significant ( P=1.000; P=0.264). The difference of HAB and the difference of HPB in the 3D printing group at 6 months after operation and last follow-up were significantly lower than those in the TMC group ( P<0.05).

Conclusion

For patients with multilevel cervical spondylotic myelopathy undergoing ACCF combined with ACDF, compared with TMC and Cage, 3D printing artificial vertebrae body and 3D printing Cage have the advantages of shorter operation time, better reduction of height loss of fusion vertebral body, and maintenance of cervical physiological curvature, the early effectiveness is better.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN/SETTING

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Correlation between different instrumentation variants and the degree of destabilization in treating cervical spondylotic spinal canal stenosis by unilateral hemilaminectomy with bilateral decompression: a biomechanical investigation

PURPOSE

Unilateral hemilaminectomy with bilateral decompression (BDZ) was proposed as an alternative decompressive procedure in cervical spondylotic myelopathy (CSM). Despite promising clinical results, the destabilizing effect is yet unknown. We therefore performed a biomechanical study to investigate whether lateral mass screw fixation should follow BDZ.

METHODS

Six human C2-C7 cervical specimens were tested under various conditions: native, unilateral hemilaminectomy with bilateral decompression without/with fixation (BDZ/BDF), unilateral hemilaminectomy with bilateral decompression and unilateral foraminotomy without/with fixation (UFZ/UFF), unilateral hemilaminectomy with bilateral decompression and bilateral foraminotomy without/with fixation (BFZ/BFF), and laminectomy without/with fixation (LAZ/LAF). Instrumention was applied from C3-C6. For each condition, the three-dimensional kinematics of the cervical specimen were measured in three main loading directions with an ultrasonic motion analysis system. ANOVA was used to determine differences between the specific segment conditions to assess the parameter's range of motion (ROM) and neutral zone (NZ).

RESULTS

For flexion-extension, lateral bending and axial rotation, ROM of BDZ, UFZ, BFZ and LAZ remained at the level of the native condition (p > 0.74), whereas fixation reduced ROM significantly (p < 0.01). Between BDF, UFF, BFF and LAF, no significant differences in reduction in ROM were seen (p > 0.49). Results for NZ were equivalent to ROM in flexion-extension and lateral bending. For axial rotation, NZ remained almost constant on the native level for all tested conditions.

CONCLUSION

Bilateral decompression via a hemilaminectomy, even if combined with foraminotomy, could be a less invasive treatment option for multilevel CSM in patients with lordotic cervical alignment and absence of segmental instability.

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

STUDY DESIGN

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

3.

A comparison of the perioperative outcomes of anterior surgical techniques for the treatment of multilevel degenerative cervical myelopathy

OBJECTIVE

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults. Multilevel ventral compressive pathology is routinely managed through anterior decompression and reconstruction, but there remains uncertainty regarding the relative safety and efficacy of multiple discectomies, multiple corpectomies, or hybrid corpectomy-discectomy. To that end, using a large national administrative healthcare data set, the authors sought to compare the perioperative outcomes of anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and hybrid corpectomy-discectomy for multilevel DCM.

METHODS

Patients with a primary diagnosis of DCM who underwent an elective anterior cervical decompression and reconstruction operation over 3 cervical spinal segments were identified from the 2012-2017 National Surgical Quality Improvement Program database. Patients were separated into those undergoing 3-level discectomy, 2-level corpectomy, or a hybrid procedure (single-level corpectomy plus additional single-level discectomy). Outcomes included 30-day mortality, major complication, reoperation, and readmission, as well as operative duration, length of stay (LOS), and routine discharge home. Outcomes were compared between treatment groups by multivariable regression, adjusting for age and comorbidities (modified Frailty Index). Effect sizes were reported by adjusted odds ratio (aOR) or mean difference (aMD) and associated 95% confidence interval.

RESULTS

The study cohort consisted of 1298 patients; of these, 713 underwent 3-level ACDF, 314 2-level ACCF, and 271 hybrid corpectomy-discectomy. There was no difference in 30-day mortality, reoperation, or readmission among the 3 procedures. However, on both univariate and adjusted analyses, compared to 3-level ACDF, 2-level ACCF was associated with significantly greater risk of major complication (aOR 2.82, p = 0.005), longer hospital LOS (aMD 0.8 days, p = 0.002), and less frequent discharge home (aOR 0.59, p = 0.046). In contrast, hybrid corpectomy-discectomy had comparable outcomes to 3-level ACDF but was associated with significantly shorter operative duration (aMD -16.9 minutes, p = 0.002).

CONCLUSIONS

The authors found multiple discectomies and hybrid corpectomy-discectomy to have a comparable safety profile in treating multilevel DCM. In contrast, multiple corpectomies were associated with a higher complication rate, longer hospital LOS, and lower likelihood of being discharged directly home from the hospital, and may therefore be a higher-risk operation.

Clinical study on improving postoperative symptoms of cervical spondylotic myelopathy by Qishe pill

BACKGROUND

Cervical spondylotic myelopathy (CSM) is the most serious type of cervical spondylosis, which is often treated surgically in patients with progressive neurological symptoms following ineffective conservative treatment. However, some patients have residual symptoms such as neck pain, stiffness, and C5 nerve palsy after surgery. The Qishe pill can effectively relieve the symptoms of neck pain and numbness, but there is no evidence showing the efficacy and safety of the Qishe pill in treating symptoms after spinal cord surgery.

METHODS/DESIGN

A multicenter, randomized controlled clinical trial will be conducted to evaluate the efficacy and safety of the Qishe Pill. A total of 330 patients with CSM who receive surgical treatment will be randomly divided into 2 groups, treated for 12 weeks and with a 1-year follow-up. The primary outcome will be Japanese Orthopaedic Association score from the baseline to 4 weeks, 12 weeks, 24 weeks, and 48 weeks after surgery. Secondary outcomes will include Visual Analogue Scale score, Neck Disability Index, and imaging indicators (including magnetic resonance imaging and X-ray). Additionally, adverse reactions will be observed and recorded as safety indicators.

DISCUSSION

Although the Qishe pill can effectively improve the discomfort of the neck and upper limbs in clinical applications, there is a lack of clinical research on postoperative patients. This study will investigate the efficacy and safety of the Qishe pill in treating postoperative symptoms of CSM.

TRIAL REGISTRATION

Clinical Trials.gov ID: ChiCTR1900028173. Registered on 17 December 2019.

Zero-profile versus cage-plate interbody fusion system in anterior cervical discectomy and fusion for the treatment of multilevel cervical spondylosis: A protocol of systematic review and meta-analysis

BACKGROUND

The objective of this meta-analysis was to summarize and identify the available evidence from these studies to estimate which device was better for multilevel cervical spondylotic myelopathy (MCSM). And provides clinicians with evidence on which to base their clinical decision making.

METHODS

This review will include all studies comparing the new Zero-profile versus cage-plate interbody fusion system in anterior cervical discectomy and fusion (ACDF) for the treatment of MCSM. The search strategy will be performed in 9 databases. We will not establish any limitations to language and publication status, published from inception to the July, 2020. Two reviewers will screen, select studies, extract data, and assess quality independently. Outcome is operative time, blood loss, clinical function outcome, radiologic outcomes, and complications. The methodological quality including the risk of bias of the included studies will be evaluated. We will carry out statistical analysis using RevMan 5.3 software.

RESULTS

This study will summarize current evidence to assess the efficacy and safety of Zero-profile versus cage-plate interbody fusion system in ACDF for the treatment of MCSM.

CONCLUSION

The findings of this study will provide helpful evidence for the clinician, and will promote further studies, as well as comparing the 2 devices in ACDF for MCSM REGISTRATION NUMBER:: INPLASY202070095 (DOI number: 10.37766/inplasy2020.7.0095).

Is it necessary to place screws in the intervening vertebrae in two-level anterior cervical discectomy with fusion and plating?

OBJECTIVE

The clinical outcomes, radiological parameters, complication rate and the cost of implants in two-level ACDF with and without screws in the intervening segment were compared.

METHODS

A retrospective study of 68 patients who underwent 2-level ACDF from January 2014 to June 2016 was performed. The patients were divided into two groups: ACDF with screws in the intervening vertebra and those without screws in the intervening vertebra. Perioperative factors, clinical outcomes, postoperative complications, radiological parameters, and cost of the implants were evaluated in both groups.

RESULTS

No statistical differences in clinical outcomes, operative blood loss, hospital stay, restoration of cervical lordosis or segment height, postoperative complications, and fusion rate were found between the ACDF (middle vertebra with screw) and ACDF (middle vertebra without screw) groups (P > 0.05). But the operative time of added screw placement and cost of implants in the ACDF (middle vertebra without screw) group were significantly less than the ACDF (middle vertebra with screw) group (P < 0.05).

CONCLUSION

Two kinds of screw placement with ACDF were found to be similar in terms of clinical outcomes. However, ACDF (middle vertebra without screw) was found to be superior to ACDF (middle vertebra with screw) in terms of the screw placement time and cost of implants.

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

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

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

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

Compensatory Mechanisms for Kyphotic Change in the Cervical Spine According to Alignment Analysis of the Cases after Anterior Cervical Corpectomy and Fusion

BACKGROUND

Compensatory mechanisms for cervical kyphosis are unclear. Few alignment analyses have targeted ongoing cervical kyphosis and detailed the effects of compensatory alignment changes.

METHODS

We analyzed the radiographic alignment parameters of 31 patients (21 men and 10 women) with postoperative kyphotic changes after anterior cervical corpectomy and fusion (ACCF) between 2006 and 2015. This analysis included lordotic angle of the fusion area, fusion area length, cervical lordosis angle (CL), O-C7 angle (O-C7a), and cervical sagittal vertical axis (cSVA) as basic parameters and occipito-C2 angle (O-C2a), adjacent cranial angle, adjacent caudal angle, and T1 slope as compensatory parameters at 2 time points after surgery.

RESULTS

Alignment analysis revealed that CL was significantly decreased by 5.0 ± 7.7° (P < 0.01) and O-C7a was changed by only -0.2 ± 6.8° (P = 0.75). An inverse correlation was found between ΔCL and ΔO-C2a (ρ = -0.40), with a nearly 1:1 relationship in the scatter diagram. ΔT1 slope had no direct compensatory correlation with ΔCL (P = 0.28) but was strongly correlated with ΔcSVA (ρ = 0.78). The scatter diagram of ΔcSVA and ΔT1 slope showed compensatory relevance and a shifted point to its collapse as the T1 slope lost control of cSVA; thereafter, both parameters incessantly increased, and ΔT1 and ΔcSVA became positive.

CONCLUSIONS

When CL decreased after ACCF, ΔO-C2 immediately compensated for the CL loss that could lead to failure to obtain horizontal gaze. If cSVA increased, Δcaudal adjacent angle and ΔT1 slope (extension below the kyphosis) compensated for the horizontal offset translation. The noncompensatory status (ΔcSVA and ΔT1 positive) may necessitate further correction surgery in which the caudal fused level is beyond T1.

Multivariate analysis of poor outcome after anterior surgery in multilevel cervical spondylotic myelopathy patients with heterotopic ossification and preoperative kyphotic alignment

Objective

The aim of this study was to evaluate the risk factors for poor outcome in patients who underwent multi-segmental anterior surgery, and analyze postoperative complications.

Methods

We retrospectively reviewed 158 patients after anterior surgery due to multilevel cervical spondylotic myelopathy (m-CSM) between June 2008 and June 2016. Adjusted ORs and 95% CIs were determined by multivariate logistic regression analysis. Cutoff values and the area under the curve for continuous risk factors were calculated through receiver operating characteristic curve analysis. The chi-squared test was performed for the comparison of complications among the three surgical groups.

Results

By analyzing 105 patients with good outcome and 53 patients with poor outcome, we established that the risk factors for poor outcome were advanced age (OR =1.12, P=0.003), longer duration of symptoms (OR =1.07, P=0.028), and bigger kyphotic angle at final follow-up (OR =1.29, P< 0.001). The optimal cutoff values for age, duration of symptoms, and kyphotic angle at final follow-up were 63.1 years, 15.5 months, and 5.3 angle. Postoperative complications occurred in 21 patients (13.3%). The incidence of dysphagia and cerebrospinal fluid leakage were higher in multilevel anterior cervical discectomy and fusion (m-ACDF) group than in other groups (P< 0.05).

Conclusion

Advanced age, longer duration of symptoms, and bigger kyphotic angle at final follow-up were the risk factors for poor postoperative outcome in patients with m-CSM. The complications after hybrid approach and m-ACDF approach were less than after anterior cervical corpectomy and fusion approach.

Anterior Cervical Corpectomy and Fusion Versus Anterior Cervical Discectomy and Fusion for Treatment of Multilevel Cervical Spondylotic Myelopathy: Insights from a National Registry

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) is the most common procedure for single-level cervical spondylotic myelopathy (CSM); however, for multilevel CSM, some patients may also undergo anterior cervical corpectomy and fusion (ACCF). We sought to assess differences in clinical outcomes between patients undergoing ACDF and those undergoing ACCF for multilevel CSM.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2007 to 2017 to identify patients diagnosed with CSM undergoing 1- or 2-level ACCF and 2- or 3-level ACDF. Three-to-one propensity scoring was used to match patients undergoing 1-level ACCF to those undergoing 2-level ACDF. Multivariable regression was performed to compare 30-day clinical outcomes between ACCF and ACDF recipients.

RESULTS

A total of 3708 patients undergoing 1-level ACCF (n = 729; 18.7%) or 2-level ACDF (n = 3179; 81.3%) were identified. On multivariable regression, 1-level ACCF was associated with significantly longer length of stay (coefficient, 0.79; 95% confidence interval [CI], 0.46-1.11; P < 0.001), longer operative time (coefficient, 19.01; 95% CI, 11.94-26.08; P < 0.001), decreased odds of readmissions (odds ratio [OR], 0.95; 95% CI, 0.91-0.99; P = 0.018), and increased odds of complications (OR, 1.02; 95% CI, 1.00-1.04; P = 0.028) compared with those undergoing 2-level ACDF. A total of 939 patients undergoing either 2-level ACCF (n = 348; 37.1%) or 3-level ACDF (n = 591; 62.9%) were identified. On multivariable regression, 2-level ACCF was associated with significantly longer length of stay (coefficient, 1.17; 95% CI, 0.55-1.79; P < 0.001) and increased risk of complications (OR, 1.05; 95% CI, 1.01-1.08; P = 0.004) compared with 3-level ACDF.

CONCLUSIONS

Our analyses indicate that ACCF may be associated with worse clinical outcomes than ACDF following multilevel treatment for CSM.

Incidence of dysphagia of zero-profile spacer versus cage-plate after anterior cervical discectomy and fusion: A meta-analysis

BACKGROUND

The purpose of this study is to evaluate the rate of dysphagia between zero-profile spacer versus cage-plate for the treatment of multilevel cervical spondylotic myelopathy (CSM).

METHODS

The authors searched electronic databases for relevant studies that compared the clinical effectiveness of zero-profile spacer versus cage-plate for the treatment of patients with multilevel CSM. The following outcome measures were extracted: the Japanese Orthopaedic Association (JOA) scores, Neck Disability Index (NDI) score and fusion rate, dysphagia rate, adjacent segment degeneration, and cervical lordosis. Newcastle-Ottawa Quality Assessment Scale was used to evaluate the quality of each study. Data extraction and quality assessment were conducted, and RevMan 5.2 was used for data analysis.

RESULTS

A total of 10 studies were included in our meta-analysis. Our pooled data revealed that zero-profile spacer was associated with decreased dysphagia rate at postoperatively 1, 3, and 6 months, and the final follow-up when compared with cage-plate group. No significant difference was observed in terms of postoperative JOA score, NDI score, and fusion rate. Compared with zero-profile spacer, the postoperative adjacent segment degeneration was significant higher in cage-plate. Pooled data from the relevant studies revealed that cervical lordosis was significantly lower in zero-profile spacer compared with cage-plate.

CONCLUSIONS

Our meta-analysis reveals zero-profile spacer is better than the cage-plate in terms of dysphagia. This suggests zero-profile spacer is a superior alternative invention for the treatment of multilevel CSM to reduce the risk of dysphagia.

Rigid-Plating and Cortico-Cancellous Allograft Are Effective for 3-Level Anterior Cervical Discectomy and Fusion: Radiographic and Clinical Outcomes

OBJECTIVE

To determine the risk factors associated with radiographic changes and clinical outcomes following 3-level anterior cervical discectomy and fusion (ACDF) using rigidplate constructs and cortico-cancellous allograft. ACDF has demonstrated efficacy for treatment of multilevel degenerative cervical conditions, but current data exists in small heterogeneous forms.

METHODS

A retrospective review included 98 patients with primary 3-level ACDF surgery at one institution from 2008 to 2013 with minimum 1-year follow-up. Cervical sagittal vertical axis (SVA), segmental height, fusion, and lordosis radiographs were measured preoperatively and at 2 postoperative periods.

RESULTS

Rates of asymptomatic pseudarthroses and total reoperations were 18% and 4%, respectively. Results demonstrated immediate improvements in cervical lordosis (5.5°, p < 0.01) and segmental height (5.0-mm increase, p < 0.01) with little changes in the cervical SVA (3.2-mm increase, p < 0.01). The segmental height decreased from immediate postoperative period to final follow-up (1.7-mm decrease, p < 0.01). Older age was protective against radiolucent lines (p < 0.05). Patient-reported outcomes significantly improved following surgery (p < 0.01). Current smoking status and diagnosis of diabetes mellitus had no impact on radiographic or clinical outcomes. Risk factors were not identified for the 5 reoperations (4%).

CONCLUSION

Three-level ACDF with rigid-plating and cortico-cancellous allograft is an effective procedure for degenerative diseases of the cervical spine without the application of additional adjuncts or combined anteriorposterior cervical surgeries. Significant improvements in cervical lordosis, segmental height, and segmental alignment can be achieved with little change in cervical SVA and a low rate of reoperations over short-term follow-up. Similarly, patient-reported outcomes show significant improvements.

Prevalence and risk factors of axial neck pain in patients undergoing multilevel anterior cervical decompression with fusion surgery

Objectives

The aim of this study was to explore the prevalence and risk factors for axial neck pain in patients undergoing multilevel anterior cervical decompression with fusion surgery.

Methods

In this study, 88 patients, who underwent multilevel anterior cervical decompression with fusion surgery from January 2012 to January 2017, were retrospectively reviewed. Based on the postoperative axial neck pain, the patients were classified into two groups: axial pain group and no axial pain group. The patients were followed up 3 weeks, 3 months, and 1 year after cervical anterior surgery for the early- and long-term clinical evaluation. The possible effect factors included demographic variables (age, sex, BMI, smoking, drinking, heart disease, hypertension, diabetes, preoperative kyphosis, preoperative axial neck pain, preoperative JOA scores, and ODI) and surgery-related variables (surgical option, vertebral lesions, spinal canal stenosis rate, superior fusion segment, presence of intramedullary high signal intensity).

Results

The prevalence of axial neck pain was 27.3% (24 cases of 88). Our results showed that preoperative axial neck pain (62% vs 23%, P < 0.001) and preoperative kyphosis (42% vs 21.9%, P < 0.001) were risk factors for axial pain after multilevel anterior cervical surgery. Additionally, for patients with preoperative cervical kyphosis, compared to no axial pain group, the axial neck group was significantly more likely to exist a higher preoperative angle of C2–7 (13.31 ± 2.33 vs 7.33 ± 2.56, P < 0.001) and a higher correction range for kyphosis (20.24 ± 4.12 vs 12.34 ± 3.12, P < 0.001). However, for all the patients with postoperative axial symptoms, the improvement rate of axial pain was significantly higher for patients without cervical kyphosis at the early-term follow-up (3 weeks) (P = 0.032), no significant differences were found at the medium-term (P = 0.554) and long-term follow-up (P = 0.902), and improvements of clinical symptom have no obvious difference at the last follow-up.

Conclusions

Overall, preoperative axial neck pain and kyphosis could predict axial neck pain for patients undergoing multilevel anterior cervical decompression with fusion surgery, and recovery of cervical kyphosis may contribute to the long-term recovery of neural function, but may also suffer from risk of short-term axial pain, which could be reduced through moderate cervical curvature recovery.

Comparison of laminectomy and fusion vs laminoplasty in the treatment of multilevel cervical spondylotic myelopathy: A meta-analysis

PURPOSE

The purpose of this study is to evaluate the clinical safety and efficacy between laminectomy and fusion (LF) versus laminoplasty (LP) for the treatment of multi-level cervical spondylotic myelopathy (CSM).

METHODS

The authors searched electronic databases using PubMed, MEDLINE, Embase, Cochrane Controlled Trial Register, and Google Scholar for relevant studies that compared the clinical effectiveness of LF and LP for the treatment of patients with multilevel CSM. The following outcome measures were extracted: the Japanese Orthopaedic Association (JOA) scores, cervical curvature index (CCI), visual analog scale (VAS), Nurich grade, reoperation rate, complications, rate of nerve palsies. Newcastle Ottawa Quality Assessment Scale (NOQAS) was used to evaluate the quality of each study. Data analysis was conducted with RevMan 5.3.

RESULTS

A total of 14 studies were included in our meta-analysis. No significant difference was observed in terms of postoperative Japanese Orthopaedic Association score (P = .29), visual analog scale neck pain (P = .64), cervical curvature index (P = .24), Nurich grade (P = .16) and reoperation rate (P = .21) between LF and LP groups. Compared with LP group, the total complication rate (OR 2.60, 95% CI 1.85, 3.64, I = 26%, P < .00001) and rate of nerve palsies (OR 3.18, 95% CI 1.66, 6.11, I = 47%, P = .0005) was higher in the LF group.

CONCLUSIONS

Our meta-analysis reveals that surgical treatments of multilevel CSM are similar in terms of most clinical outcomes using LF and LP. However, LP was found to be superior than LF in terms of nerve palsy complications. This requires further validation and investigation in larger sample-size prospective and randomized studies.

Placement of Titanium Mesh in Hybrid Decompression Surgery to Avoid Graft Subsidence in Treatment of Three-Level Cervical Spondylotic Myelopathy: Cephalad or Caudal?

Background

Hybrid decompression has been used to treat patients with cervical spondylotic myelopathy (CSM). However, no published study has investigated the effect of titanium mesh (TM) located cephalad or caudal in hybrid decompression surgery on the graft subsidence in treatment of three-level CSM.

Material/Methods

Forty-eight cases with three-level CSM who underwent the procedure of hybrid decompression from Jan 2014 to Jan 2017 were retrospectively reviewed. Radiological outcomes immediately postoperatively and at the final follow-up were compared between cases from group A (TM located cephalad, n=21) and group B (TM located caudal, n=27).

Results

No differences were observed in the 2 groups in terms of number, sex, or duration of follow-up. The average follow-up was 4.38±0.439 months in group A and 4.81±0.509 months in group B (p>0.05). The index loss of anterior (AIBH), middle (MIBH), and posterior interbody height (PIBH) in group A were 0.857±0.448/1.00±0.525/1.33±0.608, respectively, which were all lower than that in group B (P<0.05), as was the occurrence of TM subsidence. However, there was no significance difference in height loss of adjacent intervertebral space between groups. All angles were decreased at the final follow-up in both groups (p<0.05). More decrease of C2–C7 angle occurred in group B (p>0.05), and segmental angle in group A decreased more than in group B (p>0.05).

Conclusions

TM inferior to intervertebral cage (IC) in hybrid decompression has a higher risk for developing subsidence, and when the choice of the position of TM is available in hybrid decompression surgery, TM located cephalad was recommend to alleviate TM subsidence.

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

STUDY DESIGN

Systematic review.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Anterior cervical corpectomy and fusion : Spinal cord compression caused by buckled ligamentum flavum

Anterior cervical corpectomy and fusion (ACCF) is a commonly performed surgical procedure for cervical spondylotic myelopathy (CSM). Various complications associated with ACCF have been reported; however, spinal cord compression caused by buckling of the ligamentum flavum (LF) after ACCF has not yet been well recognized. This article describes the case of a 59-year-old man who underwent ACCF at C5 for treatment of CSM. Although numbness and weakness of the upper extremities were relieved 2 weeks after the operation, gait imbalance persisted and worsened at 7 months. Magnetic resonance imaging (MRI) performed at 12 months revealed buckling of the LF into the spinal canal at the C5/6 level, compressing the spinal cord; moreover, high signal intensity in the spinal cord was observed beneath the buckling area on T2-weighted images. The secondary laminoplasty at C5 and C6 was performed 13 months after primary surgery and MRI showed that the spinal canal was widened at the C5 and C6 levels and the spinal cord was decompressed.

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of the Prognostic Value of Different Quantitative Measurements of Increased Signal Intensity on T2-Weighted MRI in Cervical Spondylotic Myelopathy

OBJECTIVE

To investigate whether different quantitative measurements of increased signal intensity (ISI) on T2-weighted magnetic resonance imaging are useful for predicting surgical outcome in patients with cervical spondylotic myelopathy (CSM).

METHODS

We retrospectively reviewed 108 patients with ISI who underwent surgery for CSM. Clinical outcome was evaluated via the Japanese Orthopaedic Association (JOA) score and the recovery rate. Patients were divided into 2 groups based on the JOA recovery rate: good (≥50%) and fair (<50%). The quantitative measurements of ISI included the maximum vertical length and the signal change ratio (SCR). C2-C7 sagittal alignment, C2-C7 sagittal vertical axis, C2-C7 range of motion, maximum spinal cord compression, and maximum canal compromise also were assessed.

RESULTS

There were no significant differences in cervical sagittal alignment parameters between the groups. Multivariate analysis showed that a longer duration of symptoms, a lower preoperative JOA score, a longer preoperative ISI length, and a greater preoperative SCR were negatively associated with clinical outcomes. Receiver operating characteristic curve analysis showed that the best cutoff values of ISI length and SCR as negative predictors of surgical outcome were 15.50 mm and 1.56, respectively, and the areas under the receiver operating characteristic curve of preoperative ISI length, SCR that discriminate recovery rate of JOA score (≥50%, <50%) were 0.8507, 0.8422, respectively, and was 0.8903 for a combination of the 2.

CONCLUSIONS

Duration of symptoms, preoperative JOA score, preoperative ISI length, and SCR can reflect surgical outcome in patients with CSM; however, cervical sagittal alignment may not affect surgical outcome. Combining ISI length and SCR to depict ISI on T2-weighted magnetic resonance imaging is optimal and accurate. Patients with ISI length >15.50 mm and SCR >1.56 have fair surgical recovery.

National Trends in Demographics and Outcomes Following Cervical Fusion for Cervical Spondylotic Myelopathy

STUDY DESIGN

Retrospective trends analysis.

OBJECTIVES

Cervical fusion is a common adjunctive surgical modality used in the treatment of cervical spondylotic myelopathy (CSM). The purpose of this study was to quantify national trends in patient demographics, hospital characteristics, and outcomes in the surgical management of CSM.

METHODS

This was a retrospective study that used the National Inpatient Sample. The sample included all patients over 18 years of age with a diagnosis of CSM who underwent cervical fusion from 2003 to 2013. The outcome measures were in-hospital mortality, length of stay, and hospital charges. Chi-square tests were performed to compare categorical variables. Independent t tests were performed to compare continuous variables.

RESULTS

We identified 62 970 patients with CSM who underwent cervical fusion from 2003 to 2013. The number of fusions performed per year in the treatment of CSM increased from 3879 to 8181. The average age of all fusion patients increased from 58.2 to 60.6 years (P < .001). Length of stay did not change significantly from a mean of 3.7 days. In-hospital mortality decreased from 0.6% to 0.3% (P < .01). Hospital charges increased from $49 445 to $92 040 (P < .001).

CONCLUSIONS

This study showed a dramatic increase in cervical fusions to treat CSM from 2003 to 2013 concomitant with increasing age of the patient population. Despite increases in average age and number of comorbidities, length of stay remained constant and a decrease in mortality was seen across the study period. However, hospital charges increased dramatically.

Anterior cervical corpectomy and fusion versus discectomy and fusion for the treatment of two-level cervical spondylotic myelopathy: analysis of sagittal balance and axial symptoms

PURPOSE

To compare the postoperative sagittal balance and occurrence of axial symptoms between anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF) for the treatment of two-level cervical spondylotic myelopathy (CSM).

METHODS

A total of 71 consecutive patients who underwent ACCF or ACDF for two-level CSM in our institution from January 2014 to December 2016 were retrospectively reviewed. Of these patients, 30 (17 males, 13 females) were subjected to ACCF, and 41 (20 males, 21 females) were treated with ACDF. Perioperative data, radiographic parameters, clinical outcomes, and axial symptom occurrence were compared between the two groups.

RESULTS

The average follow-up durations were 13.7 ± 3.9 months in the ACCF group and 13.4 ± 3.3 months in the ACDF group. The volume of blood loss was significantly lower in the ACDF group than in the ACCF group, and the operation time of the former was significantly shorter than that of the latter. The postoperative global lordotic angle and T1 slope were significantly larger in the ACCF group than in the ACDF group in each follow-up. The occurrence of postoperative axial symptoms was significantly lower in the ACDF group than in the ACCF group.

CONCLUSION

The volume of blood loss was lower and the operation time was shorter in ACDF than in ACCF for the treatment of two-level CSM. Sagittal balance was better in the ACDF group than in the ACCF group, and this observation may lead to a reduced occurrence of axial symptoms.

Clinical and Radiologic Features of 3 Reconstructive Procedures for the Surgical Management of Patients with Bilevel Cervical Degenerative Disc Disease at a Minimum Follow-Up Period of 5 Years: A Comparative Study

OBJECTIVE

To assess the mid-long-term follow-up of the safety and efficacy of anterior cervical discectomy and fusion (ACDF), cervical artificial disc replacement (CADR) and hybrid surgery (HS) for bilevel cervical degenerative disc disease (cDDD).

METHODS

77 patients who underwent ACDF, HS, and CADR were retrospectively reviewed. Clinical effects were evaluated based on Neck Disability Index (NDI), Visual Analog Scale (VAS), and Japanese Orthopedic Association (JOA) scores and the Odom criteria. Radiographic outcomes were evaluated, including cervical range of motion (ROM), ROM in the operative and adjacent segments, incidence of degeneration in the adjacent segments (ASD), and heterotopic ossification (HO).

RESULTS

NDI, VAS, and JOA scores significantly improved in all patients after surgery without significant differences between groups. The excellent-to-good ratio in the Odom scale was 28/30 for the HS group, 30/33 for the ACDF group, and 13/14 for the CADR group. No significant differences in clinical outcomes or complication were found between groups (P > 0.05). Furthermore, the HS and CADR groups had less decreased ROM in the cervical and operative segments and less compensatory ROM in adjacent segments (P < 0.05). By contrast, the ACDF group had decreased ROM in the cervical and operative segments and significantly increased ROM in adjacent segments (P < 0.05). Moreover, the incidence of ASD was higher in the ACDF group, but the difference was not statistically significant (P > 0.05). HO was found in 10 patients (33.3%) in the HS group and 5 patients (35.7%) in the CADR group.

CONCLUSION

HS was superior to ACDF with regard to equivalent clinical outcomes in the mid-long-term follow-up. Furthermore, HS was superior in the maintenance of ROM and had less impact on its adjacent segments. The efficacy of HS is similar to that of CADR.

Posterior or Single-stage Combined Anterior and Posterior Approach Decompression for Treating Complex Cervical Spondylotic Myelopathy Coincident Multilevel Anterior and Posterior Compression

STUDY DESIGN

A single-center, retrospective, longitudinal matched cohort clinical study of prospectively collected outcomes.

OBJECTIVE

To compare retrospectively the clinical outcomes and complications of the posterior approach laminoplasty and single-stage anterior approach laminoplasty combined with anterior cervical corpectomy and fusion and anterior cervical discectomy and fusion for treating patients with cervical spondylotic myelopathy coincident multilevel anterior and posterior compression, known as complex cervical spondylotic myelopathy (cCSM) here.

SUMMARY OF BACKGROUND DATA

The optimal surgical management of this type of cCSM remains controversial.

METHODS

Sixty-seven patients with multilevel cCSM underwent decompression surgery from 1996 to 2007. Among these patients, 31 underwent a single-stage combined approach with decompression (combined approach group) and 36 underwent laminoplasty for posterior approach (posterior approach group). Average operative duration, operative estimated blood loss, surgical costs, and cervical alignment were measured.

RESULTS

Average operative duration, operative estimated blood loss, and surgical costs were significantly lower in the posterior approach group than those in the combined approach group (P<0.001). Visual analog scale and modified Japanese Orthopedic Association scale were insignificantly different at each data collection period (P>0.05). No statistical difference was observed in the preoperative Cobb angle (P>0.05), whereas a significant statistical difference was observed for the postoperative Cobb angle (P<0.05) and variation of Cobb angle (P<0.05) between the 2 groups. The surgical incidences of complications were 22.2% and 48.4% in the posterior and combined approach groups (P<0.05), respectively.

CONCLUSIONS

For treating multilevel cCSM, both the posterior approach laminoplasty and single-stage combined approach led to significant neurological improvement and pain reduction in the majority of patients. Both approaches showed similar results in terms of decompression and neurological improvement. The posterior approach was superior to the combined approach in terms of surgical costs, surgical time, blood loss, and complication rate.

Pedicled Vascularized Clavicular Graft for Anterior Cervical Arthrodesis: Cadaveric Feasibility Study, Technique Description, and Case Report

STUDY DESIGN

Cadaveric feasibility study.

OBJECTIVE

To assess the anatomic and technical feasibility of rotating a clavicular segment on a sternocleidomastoid muscle (SCM) pedicle into the ventral cervical spine using a cadaveric model and to provide the first clinical case description of performing this procedure.

SUMMARY OF BACKGROUND DATA

Reconstruction of the anterior cervical spine in patients with a high risk of pseudoarthrosis may require the use of a vascularized bone graft (VBG). A vascularized clavicular graft rotated on an SCM pedicle would afford all the benefits of a VBG without the added morbidity of free-tissue transfer; however, this technique has not been described.

METHODS

A multidisciplinary team hypothesized that it would be anatomically and technically feasible to rotate a pedicled clavicular bone graft from the bottom of C2 to the top of T2 via an anterior approach. Five cadavers underwent bilateral anterior neck dissections for a total of 10 clavicular graft assessments. A case report describes the use of a clavicular VBG in a patient with a 3-level corpectomy defect and a history of failed fusion.

RESULTS

Ten clavicles were rotated on an SCM pedicle. The grafts were either harvested as an entire segment or as the superior two-thirds of clavicle, leaving the inferior one-third in situ with pectoralis attachments intact. All grafts reached from the bottom of C2 to the top of T2. When the entire length of exposed clavicle was mobilized, it could cover five to six levels. The case report highlights technical challenges of this procedure in a living patient and provides the clinical context for its potential utility in the reconstruction of the ventral cervical spine.

CONCLUSION

This surgical technique is best suited for patients with long-segment cervical defects and an increased risk of pseudarthrosis. Further clinical experience with this technique is required before definitive conclusions can be made.

LEVEL OF EVIDENCE

5.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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