Anterior cervical discectomy and fusion may be more effective than anterior cervical corpectomy and fusion for the treatment of cervical spondylotic myelopathy

A Meta-Analysis of Surgical Outcomes in 25727 Patients Undergoing Anterior Cervical Discectomy and Fusion or Anterior Cervical Corpectomy and Fusion for Cervical Deformity

STUDY DESIGN

Systematic Review.

OBJECTIVES

To evaluate which cervical deformity correction technique between anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) produces better clinical, radiographic, and operative outcomes.

METHODS

We conducted a meta-analysis comparing studies involving ACDF and ACCF. Adult patients with either original or previously treated cervical spine deformities were included. Two independent reviewers categorized extracted data into clinical, radiographic, and operative outcomes, including complications. Clinical assessments included patient-reported outcomes; radiographic evaluations examined C2-C7 Cobb angle, T1 slope, T1-CL, C2-7 SVA, and graft stability. Surgical measures included surgery duration, blood loss, hospital stay, and complications.

RESULTS

26 studies (25727 patients) met inclusion criteria and were extracted. Of these, 14 studies (19077 patients) with low risk of bias were included in meta-analysis. ACDF and ACCF similarly improve clinical outcomes in terms of JOA and NDI, but ACDF is significantly better at achieving lower VAS neck scores. ACDF is also more advantageous for improving cervical lordosis and minimizing the incidence of graft complications. While there is no significant difference between approaches for most surgical complications, ACDF is favorable for reducing operative time, intraoperative blood loss, and length of hospital stay.

CONCLUSIONS

While both techniques benefit cervical deformity patients, when both techniques are feasible, ACDF may be superior with respect to VAS neck scores, cervical lordosis, graft complications and certain perioperative outcomes. Further studies are recommended to address outcome variability and refine surgical approach selection.

Quality assessment of systematic reviews of surgical treatment of cervical spine degenerative diseases: an overview

OBJECTIVE

To gather all systematic reviews of surgical treatment of degenerative cervical diseases and assess their quality, conclusions and outcomes.

METHODS

A literature search for systematic reviews of surgical treatment of degenerative cervical diseases was conducted. Studies should have at least one surgical procedure as an intervention. Included studies were assessed for quality through Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) and Assessment of Multiple Systematic Reviews (AMSTAR) questionnaires. Quality of studies was rated accordingly to their final score as very poor (<30%), poor (30%-50%), fair (50%-70%), good (70%-90%), and excellent (>90%). If an article reported a conclusion addressing its primary objective with supportive statistical evidence for it, they were deemed to have an evidence-based conclusion.

RESULTS

A total of 65 systematic reviews were included. According to AMSTAR and PRISMA, 1.5% to 6.2% of studies were rated as excellent, while good studies counted for 21.5% to 47.7%. According to AMSTAR, most studies were of fair quality (46.2%), and 6.2% of very poor quality. Mean PRISMA score was 70.2%, meaning studies of good quality. For both tools, performing a meta-analysis significantly increased studies scores and quality. Cervical spondylosis studies reached highest scores among diseases analyzed. Authors stated conclusions for interventions compared in 70.7% of studies, and only two of them were not supported by statistical evidence.

CONCLUSION

Systematic reviews of surgical treatment of cervical degenerative diseases present "fair" to "good" quality in their majority, and most of the reported conclusions are supported by statistical evidence. Including a meta-analysis significantly increases the quality of a systematic review.

Risk Factors and Radiologic Changes in Subsidence after Single-Level Anterior Cervical Corpectomy: A Minimum Follow-Up of 2 Years

Objective

Anterior cervical corpectomy using a titanium mesh cage may result in delayed nonunion and thus a change in cervical alignment, and patients may require revision surgery. We investigated the radiologic and clinical outcomes of cervical corpectomy and the risk factors for subsidence.

Methods

We studied 74 patients who underwent single-level anterior cervical corpectomy for cervical spondylotic myelopathy with or without ossification of the posterior longitudinal ligament between 2007 and 2014. Graft subsidence was considered present when there was a reduction in the anterior and posterior heights by an average of 4 mm or more 2 years after the operation. We measured cervical parameters before surgery, immediately after surgery, and 6, 12, and 24 months after surgery. The clinical outcomes were the neck and arm visual analog scale scores and reoperation rate.

Results

In the subsidence group, these values gradually decreased over the 24 months. The radiologic parameters did not differ between the 2 groups for 24 months after the onset of subsidence. There were no differences in clinical outcome or reoperation rate. In the analysis of the risk factors, subsidence occurred with a large T1 slope and a large change in the C27 Cobb angle (p=0.020 and p=0.026, respectively).

Conclusion

Subsidence gradually occurred after single-level anterior cervical corpectomy for up to 24 months. However, the presence of subsidence did not affect the radiologic and clinical outcomes. When the T1 slope was large and the C27 Cobb angle change was severe, more subsidence occurred.

Comparison of Postoperative Complications and Reoperation Rates Following Surgical Management of Cervical Spondylotic Myelopathy in the Privately Insured Patient Population

STUDY DESIGN

This was a large database study.

OBJECTIVE

The objective of this study was to compare the incidence of complications and reoperation rates between the most common surgical treatments for cervical spondylotic myelopathy (CSM): anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and posterior laminectomy and fusion (Lamifusion).

SUMMARY OF BACKGROUND DATA

CSM is a major contributor to disability and reduced quality of life worldwide.

METHODS

Humana insurance database was queried for CSM diagnoses between 2007 and 2016. The initial population was divided based on the surgical treatment and matched for age, sex, and Charlson Comorbidity index. Specific postoperative complications or revisions were analyzed at individual time points. Pearson χ2 analysis with Yate continuity correction was used.

RESULTS

Lamifusion had significantly higher rates of wound infection/disruption than ACDF or ACCF (5.03%, 2.19%, 2.29%; P=0.0008, 0.002, respectively) as well as iatrogenic deformity (4.75%, 2.19%, 2.10%; P=0.0036, 0.0013). Lamifusion also had a significantly higher rate of shock and same-day transfusion than ACDF (4.75%, 2.01%, P=0.0005), circulatory complications (2.01%, <1%, P=0.0183), and C5 palsy (4.84%, 1.74%, P≤0.0001). Compared with ACDF, Lamifusion had higher rates of hardware complication (3.29%, 2.01%, P=0.0468), and revision surgery (8.23% 5.85%, P=0.0395). Lamifusion had significantly lower rates of dysphagia than either ACDF (3.93% vs. 6.58%, P=0.0089) or ACCF (3.93% vs. 8.59%, P<0.0001). When comparing ACCF to ACDF, ACCF had significantly higher rates of circulatory complications (2.38%, <1%, P=0.0053), shock/same-day transfusion (3.2%, 2.0%, P=0.59), C5 palsy (3.47%, 1.74%, P=0.0108), and revision surgery (9.51%, 5.85%, P=0.0086).

CONCLUSIONS

The data shows that posterior Lamifusion has higher overall rate of complications compared with ACDF or ACCF. Furthermore, when comparing the anterior approaches, ACDF was associated with lower rate of complication and revision. ACCF had the highest overall rate of revision surgery.

A novel anatomic titanium mesh cage for reducing the subsidence rate after anterior cervical corpectomy: a finite element study

Fusion with a titanium mesh cage (TMC) has become popular as a conventional method after cervical anterior corpectomy, but postoperative TMC subsidence has often been reported in the literature. We designed a novel anatomic cervical TMC to reduce the postoperative subsidence rate. According to the test process specified in the American Society of Testing Materials (ASTM) F2267 standard, three-dimensional finite element analysis was used to compare the anti-subsidence characteristics of a traditional TMC (TTMC) and novel TMC (NTMC). Through analysis, the relative propensity values of a device to subside (Kp) of the TTMC and NTMC were 665.5 N/mm and 1007.2 N/mm, respectively. A higher Kp measurement is generally expected to indicate that the device is more resistant to subsidence into a vertebral body. The results showed that the novel anatomic titanium mesh cage (NTMC) significantly improved the anti-subsidence performance after anterior cervical corpectomy and fusion (ACCF), which was approximately 51.3% higher than that of the traditional titanium mesh cage.

Early Recurrent Symptoms After Anterior Cervical Discectomy and Fusion Done for Myelopathy

We present a unique case with early recurrent myelopathic clinical manifestations following anterior cervical discectomy and fusion; however, he had an eventual diagnosis of multiple sclerosis rather than any residual cord compression on repeat imaging.

Perioperative Outcomes in 17,947 Patients Undergoing 2-Level Anterior Cervical Discectomy and Fusion Versus 1-Level Anterior Cervical Corpectomy for Treatment of Cervical Degenerative Conditions: A Propensity Score Matched National Surgical Quality Improvement Program Analysis

Objective

To compare the perioperative morbidity of 2-level anterior cervical discectomy and fusion (ACDF) with that of 1-level anterior cervical corpectomy and fusion (ACCF) for the treatment of cervical degenerative conditions.

Methods

A retrospective study of the 2005–2016 National Surgical Quality Improvement Program database for patients undergoing 2-level ACDF and 1-level ACCF was performed. Patient data included: age, sex, body mass index (BMI), functional status, and American Society of Anesthesiologists (ASA) physical status (PS) classification. Hospital data included: operative time and length of hospital stay (LOS). Thirty-day outcome data included: any, serious, and minor adverse events, return to the operating room, readmission, and mortality. After propensity matching for age, sex, ASA PS classification, functional status, and BMI, multivariate logistic regression analysis was used to compare outcomes between the 2 propensity-matched subcohorts. Finally, multivariate logistic regression that additionally controlled for operative time was performed to compare the 2 propensity-matched subcohorts.

Results

A total of 17,497 cases were identified, with 90.20% undergoing 2-level ACDF and 9.80% undergoing 1-level ACCF. Patients undergoing 2-level ACDF were younger, more likely to be female, had higher functional status, and had shorter operative time and LOS (p < 0.001). After propensity score matching, cases undergoing 1-level ACCF had a statistically significant higher rate of serious adverse events (p = 0.005). This difference was no longer significant after controlling for operative time.

Conclusion

While there was noted to be additional morbidity in 1-level ACCF cases relative to 2-level ACDF cases, the lack of difference once controlling for the surgical time supports using the procedure that best accomplishes the surgical objectives.

[Spondylotic cervical myelopathy : Indication of surgical treatment]

BACKGROUND

The pathogenesis of cervical spondylotic myelopathy (CSM) is often multifactorial. Hence, the treatment of this disease requires a differentiated surgical approach in order to adequately address the underlying pathology.

PURPOSE

The aim of this review is to identify factors that influence the choice of treatment strategy and to summarize them in an algorithm that serves as a decision aid in choosing the optimal indication for surgical treatment. An attempt is made to define the threshold values for the indication of surgical treatment and to discuss the ideal timing for performing surgery.

MATERIALS AND METHODS

On the basis of the published data, the influencing factors on the prognosis of CSM, as well as surgical approaches are discussed.

RESULTS

Circumferential spinal cord compression, a sharply defined myelopathy signal in the T2-weighted MRI sequence, and segmental instability at the level of the myelopathy signal mean an unfavorable prognosis for the worsening of CSM. The most important factors that influence the choice of the surgical access point are the sagittal profile of the cervical spine, the extent of myelopathy, the extent of stenosis, and the location of the myelopathy-inducing pathology. Previously existing neck pain and prior cervical surgery must also be considered.

DISCUSSION

On the basis of the research carried out, we developed an algorithm that could serve as an aid in choosing the right treatment in the setting of cervical spondylotic myelopathy.

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.

Plasma VDBP, 25(OH)D, and GSH levels predict surgical outcome in patients with cervical spondylotic myelopathy

This study intends to investigate the predictive values of plasma Vitamin D-binding protein (VDBP), 25-hydroxyvitamin D [25(OH)D], and glutathione (GSH) levels in the outcome of cervical spondylotic myelopathy (CSM) surgery. Surgery outcomes of 236 CSM patients were determined. Recovery rate was calculated according to Japanese Orthopaedic Association (JOA) scores during follow-up. CSM patients with a recovery rate >50% were assigned with good prognosis and the rest were with fair prognosis. Preoperative and postoperative neurologic function scores were compared among groups. Plasma VDBP and 25(OH)D levels, as well as GSH levels were measured by ELISA and glutathione reductase recycling assay, respectively. Pearson's correlation coefficient was performed to analyze the correlation among plasma VDBP, 25(OH)D, and GSH levels. Receiver operating characteristic (ROC) curve was applied to evaluate the predictive value of plasma VDBP, 25(OH)D, and GSH levels for surgical outcome. Logistic regression model was used to analyze risk factors for surgical outcome. Compared with those with fair prognosis, CSM patients with good prognosis group exhibited higher postoperative neurologic function scores, plasma VDBP, 25(OH)D, and GSH levels, and better improvements in spinal cord compression and motions of the cervical vertebra. Plasma VDBP, 25(OH)D, and GSH levels were favorable prognostic factors for CSM surgical outcome. The sensitivity and specificity of plasma VDBP, plasma 25(OH)D, and plasma GSH were 89.8% and 91.7%, 85.8% and 84.4%, and 79.5% and 91.7%, respectively. Our study provides evidence that higher plasma VDBP, 25(OH)D, and GSH levels may predict better surgical outcome in CSM patients.

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.

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.