Can airway complications following multilevel anterior cervical surgery be avoided?

Postoperative Airway Management after Anterior Cervical Spine Surgery: Retrospective Neurosurgical Multicenter Study

Airway complications that occur after anterior cervical spine surgery pose a life-threatening risk, which encompasses complications including prolonged intubation, unplanned reintubation, and/or necessity of tracheostomy. The present study aimed to identify the surgical risks associated with postoperative airway complications in neurosurgical training institutes. A retrospective, multicenter, observational review of data from 365 patients, who underwent anterior cervical spine surgery between 2018 and 2022, at three such institutes was carried out. Postoperative airway complication was defined as either the need for prolonged intubation on the day of surgery or the need for unplanned reintubation. The perioperative medical information was obtained from their medical records. The average age of the cohort was over 60 years, with males comprising approximately 70%. Almost all surgeries predominantly involved anterior cervical discectomy and fusion or anterior cervical corpectomy and fusion, with most surgeries occurring at the level of C5/6. In total, 363 of 365 patients (99.5%) were extubated immediately after surgery, and the remaining two patients were kept under intubation because of the risk of airway complications. Of the 363 patients who underwent extubation immediately after surgery, two (0.55%) required reintubation because of postoperative airway complications. Patients who experienced airway complications were notably older and exhibited a significantly lower body mass index. The results of this study suggested that older and frailer individuals are at an elevated risk for postoperative airway complications, with immediate postoperative extubation generally being safe but requiring careful judgment in specific cases.

Effect of Furosemide on Prevertebral Soft Tissue Swelling after Anterior Cervical Fusion: A Comparative Study with Dexamethasone

STUDY DESIGN

Retrospective cohort study.

PURPOSE

This study aimed to investigate the effect of furosemide on prevertebral soft tissue swelling (PSTS) after anterior cervical fusion (ACF) and compare it with the effect of dexamethasone.

OVERVIEW OF LITERATURE

Postoperative PSTS is a common complication of ACF. Dexamethasone has been used for its treatment; however, its efficacy remains controversial. Furosemide may reduce PSTS if it is soft tissue edema; however, no studies have demonstrated the effect of furosemide on PSTS after ACF.

METHODS

The symptomatic PSTS group received intravenous (IV) administration of dexamethasone or furosemide. The asymptomatic PSTS group did not receive any medication. Patients were divided into the control (no medication, n=31), Dexa (IV dexamethasone, n=25), and Furo (IV furosemide, n=28) groups. PSTS was checked daily with simple radiographs and medication-induced reductions in PSTS from its peak or after medication.

RESULTS

The peak time (postoperative days) of PSTS in the control (2.27±0.47, p<0.05) and Dexa (1.91±0.54, p<0.01) groups were significantly later than that in the Furo group (1.38±0.74). PSTS was significantly lower in the Furo group than in the Dexa group from postoperative days 4 to 7 (p<0.05). PSTS reduction after the peak was significantly greater in the Furo group than in the control (p<0.01) and Dexa (p<0.01) groups. After starting the medication therapy, the Furo group showed a significantly greater reduction in PSTS than the Dexa group (p<0.01). No difference was found in symptom improvement among the three groups.

CONCLUSIONS

If furosemide is used to reduce PSTS after ACF, it can effectively reduce symptoms.

A Case Report Describing Three Cases of Challenging or Failed Intubation after Cervical Spine Surgery: A Peril of Early Extubation

Postoperative airway complications can be a common, yet perhaps underappreciated, complication in patients undergoing cervical spine surgery. Presented here are three cases in which patients experienced postoperative airway compromise, resulting in difficulty establishing a secure airway following cervical spine operations. Establishing factors that contribute to airway complications after cervical spine surgery can aid in early identification of high-risk patients to create an appropriate airway management strategy. Ultimately, the frequency of airway difficulty after removal of the endotracheal tube in patients undergoing cervical spine surgery should not be taken lightly.

Acute post-operative airway complications following anterior cervical spine surgery and the role for cricothyrotomy

Anterior cervical spine surgery (ACSS) is a common procedure, but not without its own risks and complications. Complications that can cause airway compromise occur infrequently, but can rapidly lead to respiratory arrest, leading to severe morbidity or death. Knowing emergent post-operative airway management including surgical airway placement is critical. We aim to review the different etiologies of post-operative airway compromise following ACSS, the predictable timeline in which they occur, and the most appropriate treatment and management for each. We place special emphasis on the timing and proper surgical technique for an emergent cricothyrotomy. Angioedema is seen the earliest as a cause of post-operative airway compromise, typically within 6-12 hours. Retropharyngeal hematomas can be seen between 6-24 hours, most commonly within 12 hours. Pharyngolaryngeal edema is seen within 24-72 hours. After 72 hours, retropharyngeal abscess is the most likely etiology. Several studies have utilized delayed extubation protocols following ACSS based on patient risk factors and found reduced postoperative airway complications and reintubation rates. The administration of perioperative corticosteroids continues to be controversial with high-level studies recommending both for and against their use. Animal studies showed that after cardiac arrest, the brain can recover if oxygenation is restored within 5 minutes, but this time is likely shorter with asphyxia prior to cardiac arrest. Experience and training are essential to reduce the time for successful cricothyrotomy placement. Physicians must be prepared to diagnose and treat acute postoperative airway complications following ACSS to prevent anoxic brain injury or death. If emergent intubation cannot be accomplished on the first attempt, physicians should not delay placement of a surgical airway such as cricothyrotomy.

Analysis of the Risk Factors Associated with Prolonged Intubation or Reintubation after Anterior Cervical Spine Surgery

BACKGROUND

Standardized postoperative airway management is essential for patients undergoing anterior cervical spine surgery (ACSS). The paucity of clinical series evaluating these airway complications after ACSS has been resulted in a significant limitation in statistical analyses.

METHODS

A retrospective cohort study was performed regarding airway distress (intubation for more than 24 hours or unplanned reintubation within 7 days of operation) developed after ACSS. If prevertebral soft tissue swelling was evident after the operation, patients were managed with prolonged intubation (longer than 24 hours). Preoperative and intraoperative patient data, and postoperative outcome (time to extubation and reintubation) were analyzed.

RESULTS

Between 2008 and 2016, a total of 400 ACSS were performed. Of them, 389 patients (97.25%) extubated within 24 hours of surgery without airway complication, but 11 patients (2.75%) showed postoperative airway compromise; 7 patients (1.75%) needed prolonged intubation, while 4 patients (1.00%) required unplanned reintubation. The mean time for extubation were 2.75 hours (range: 0-23 hours) and 50.55 hours (range: 0-250 hours), respectively. Age (P = 0.015), diabetes mellitus (P = 0.003), operative time longer than 5 hours (P = 0.048), and estimated blood loss (EBL) greater than 300 mL (P = 0.042) were associated with prolonged intubation or reintubation. In prolonged intubation group, all patients showed no airway distress after extubation.

CONCLUSION

In ACSS, postoperative airway compromise is related to both patients and operative factors. We recommend a prolonged intubation for patients who are exposed to these risk factors to perform a safe and effective extubation.

Validity and reliability of a novel patient reported outcome tool to evaluate post-operative dysphagia, odynophagia, and voice (DOV) disability after anterior cervical procedures

Background

Existing evaluative instruments for dysphagia, odynophagia, and voice disturbance are cumbersome, focus pre-dominately on dysphagia, and often require administration by a certified Speech Pathologist. This study was conducted to utilize widely accepted instruments such as the American Speech and Hearing Association's National Outcomes Measurement System (NOMS) and VAS pain scales to validate a novel, patient-reported instrument that quantifies the severity of post-operative dysphagia, odynophagia, and voice disabilities (DOV).

Methods

The DOV was developed and subjected to multiple rounds of face and content validation by representative patient cohorts and a panel of clinical experts. An established, prospective clinical registry was utilized to collect pre and post-operative VAS-swallow related pain and DOV measurements for subjects with recent anterior cervical procedures (n=25 content validation, n=20 criterion validation), or recent lumbar decompressions (n=33). NOMS evaluations were performed by a certified Speech Language Pathologist on the first post-operative day after minimally invasive anterior approaches to cervical reconstruction were performed in the criterion validation cohort.

Results

Content validity: Subjects with a recent anterior cervical procedure reported a significant increase in post-operative dysphagia (pre-op: 0.13±0.35, post-op: 1.08±1.41, p=0.01), odynophagia (pre-op: 0.24±0.69, post-op: 0.84±0.90, p=0.001), and voice (pre-op: 0.10±0.41, post-op: 0.88±0.92, p=0.0004) disturbance. In contrast, subjects with a recent lumbar procedure did not demonstrate a significant increase in post-operative dysphagia, odynophagia, or voice disturbance (p>0.05).Criterion validity: Chi-squared contingency testing for independence between converted NOMS and DOV instrument scores accepted linkage between the two instruments for dysphagia X2(DF: 12, n=20, Expected: 21.03, Observed: 24.4, p: 0.02) and voice X2(DF: 6, n=20, Expected: 12.60, Observed: 21.28, p: 0.002) dimensions. Similarly, converted swallow related VAS and DOV odynophagia instruments demonstrated linkage X2(DF: 9, n=20, Expected: 16.92, Observed: 24.21, p: 0.004).Internal Reliability: Chronbach's alpha coefficient of reliability was 0.74 between all DOV survey dimensions.

Conclusions

The DOV survey is a valid patient-reported instrument to rapidly and reliably detect post-operative swallow and voice dysfunction.

Prevalence and Outcomes in Patients Undergoing Reintubation After Anterior Cervical Spine Surgery: Results From the AOSpine North America Multicenter Study on 8887 Patients

STUDY DESIGN

A multicenter, retrospective cohort study.

OBJECTIVE

To evaluate clinical outcomes in patients with reintubation after anterior cervical spine surgery.

METHODS

A total of 8887 patients undergoing anterior cervical spine surgery were enrolled in the AOSpine North America Rare Complications of Cervical Spine Surgery study. Patients with or without complications after surgery were included. Demographic and surgical information were collected for patients with reintubation. Patients were evaluated using a variety of assessment tools, including the modified Japanese Orthopedic Association scale, Nurick score, Neck Disability Index, and Short Form-36 Health Survey.

RESULTS

Nine cases of postoperative reintubation were identified. The total prevalence of this complication was 0.10% and ranged from 0% to 0.59% across participating institutions. The time to development of airway symptoms after surgery was within 24 hours in 6 patients and between 5 and 7 days in 3 patients. Although 8 patients recovered, 1 patient died. At final follow-up, patients with reintubation did not exhibit significant and meaningful improvements in pain, functional status, or quality of life.

CONCLUSIONS

Although the prevalence of reintubation was very low, this complication was associated with adverse clinical outcomes. Clinicians should identify their high-risk patients and carefully observe them for up to 2 weeks after surgery.

A microsurgical anterior cervical approach and the immediate impact of mechanical retractors: A case control study

Introduction:

A microsurgical anterior cervical approach with discectomy and fusion (MACDF) is one of the most widely used procedures for treating radicular disorders. This approach is highly successful; however, it is not free from complications. These can be associated with soft tissue injuries.

Aim of the Study:

The recognition of the risks for these complications should be identified for timely prevention and safe treatment.

Materials and Methods:

Study Design: Retrospective case control study. This study includes a retrospective case series of 37 patients, paying special attention to immediate complications related to the use of mechanical retraction of soft tissue (dysphagia, dysphonia, esophageal lesions and local hematoma); and a comparative analysis of the outcomes after changes in the retraction method.

Results:

All selected cases had a positive neurological symptom response in relation to neuropathic pain. Dysphagia and dysphonia were found during the first 72 h in 94.1% of the cases in which automatic mechanical retraction was used for more than one hour during the surgical procedure. A radical change was noted in the reduction of the symptoms after the use of only manual protective blades without automatic mechanical retraction: 5.1% dysphagia and 0% dysphonia in the immediate post-operative period, P = 0.001.

Conclusions:

Soft tissue damage due to the use of automatic retractors in MACDF is not minor and leads to general discomfort in the patient in spite of good neurological results. These problems most often occur when automatic retractors are used continuously for more than 1 hour, as well as when they are used in multiple levels. Dysphagia, dysphonia and local pain decreased with the use of transient manual blades for retraction, and with intermittent release following minimally invasive principles.

Factors that correlate with the decision to delay extubation after multilevel prone spine surgery

BACKGROUND

Multilevel spinal decompressions and fusions often require long anesthetic and operative times, which may result in airway edema and prolonged postoperative intubation. Delayed extubation can lead to bronchopulmonary infections and other complications. This study analyzed which factors correlated with the decision to delay extubation after multilevel spine surgery.

METHODS

We reviewed the records of 289 patients who underwent multilevel spine surgery lasting ≥8 hours in the prone position from 2006 to 2012. Variables hypothesized to affect the decision of the anesthesiologist to delay extubation at the end of the surgery were collected. These included preoperative factors (age, sex, ASA class, history of obstructive sleep apnea, BMI, previous spine surgery, current cervical surgery, anterior in addition to posterior spine surgery, emergency surgery) and intraoperative factors (difficult intubation, number of surgical levels, case time, estimated blood loss, fluid and blood administration, attending handoff and resident handoff, and case end time). We also compared the incidence of pulmonary postoperative complications between patients extubated at the end of the case to patients who had a delayed extubation.

RESULTS

A total of 126 patients (44%) were kept intubated after multilevel spine surgery. Multiple linear regression analysis showed factors that correlated with prolonged intubation which included age, ASA class, procedure duration, extent of surgery, total crystalloid volume administered, total blood volume administered, and the case end time. Patients who had a delayed extubation had a 3-fold higher rate of postoperative pneumonia.

CONCLUSIONS

Our study found that age, ASA class, procedure duration, extent of surgery, and total crystalloid and blood volume administered correlate with the decision to delay extubation in multilevel prone spine surgery. It also finds that the time the case ends is an independent variable that correlates with the decision not to extubate at the end of a long multilevel spinal surgery. The incidence of postoperative pneumonia is higher in patients who had a delayed extubation after surgery.

Endotracheal tube intubation with the aid of a laryngeal mask airway, a fiberoptic bronchoscope, and a tube exchanger in a difficult airway patient: a case report

A 28-year-old male patient with occipito-atlanto-axial instability underwent a cervical fusion with posterior technique. Post-operatively, the endotracheal tube (ETT) was removed, and the patient was transferred to the intensive care unit. After transfer, an upper airway obstruction developed and reintubations with a laryngoscope were attempted but failed. We inserted a #4 proseal laryngeal mask airway (LMA) and passed a 5.0 mm ETT through the LMA with the aid of a fiberoptic bronchoscope. We passed a tube exchanger through the 5.0 mm ETT and exchanged it with a 7.5 mm ETT. This method may be a useful alternative for difficult tracheal intubations.

Cervical decompression and unexpected soft tissue oedema: case report

Abstract

Acute upper airway obstruction (UAO) is a life threatening complication that is well recognized after carotid endarterectomy, thyroidectomy and pharyngeal area intervention. It is not widely acknowledged that airway obstruction can occur after cervical spinal fusion surgery which was first described in 1955. There are a number of common postoperative problems which may become apparent in the short to medium term. These include: sore throat, dysphagia, hoarseness, dysphonia, recurrent laryngeal nerve palsy and soft tissue swelling.

The need to add motor evoked potential monitoring to somatosensory and electromyographic monitoring in cervical spine surgery

Intraoperative neural monitoring (IONM), utilizing somatosensory evoked potentials (SEP) and electromyography (EMG), was introduced to cervical spine surgery in the late 1980's. However, as SEP only provided physiological data regarding the posterior cord, new motor deficits were observed utilizing SEP alone. This prompted the development of motor evoked potential monitoring (MEP) which facilitated real-time assessment of the anterior/anterolateral spinal cord. Although all three modalities, SEP, EMG, and MEP, are routinely available for IONM of cervical spine procedures, MEP are not yet routinely employed. The purpose of this review is to emphasize that MEP should now routinely accompany SEP and EMG when performing IONM of cervical spine surgery. Interestingly, one of the most common reasons for malpractice suits involving the cervical spine, is quadriparesis/quadriplegia following a single level anterior cervical diskectomy and fusion (ACDF). Previously, typical allegations in these suits included; negligent surgery, lack of informed consent, failure to diagnose/treat, and failure to brace. Added to this list, perhaps, as the 5(th) most reason for a suit will be failure to monitor with MEP. This review documents the value of MEP monitoring in addition to SEP and EMG monitoring in cervical spine surgery. The addition of MEP0 should minimize major motor injuries, and more accurately and reliably detect impending anterior cord deterioration that may be missed with SEP monitoring alone.

Risk factors for delayed extubation in thoracic and lumbar spine surgery: a retrospective analysis of 135 patients

PURPOSE

Extubation may be delayed after spine surgery mainly for the concerns of airway safety. Risk factors for delayed extubation in cervical spine surgery have been described to include prolonged surgery time and amount of crystalloids or blood transfused. To date, risk factors for delayed extubation in thoracic or lumbar spine surgery have not been investigated. We retrospectively reviewed 135 consecutive patients from 2006 to 2009 who underwent thoracic or lumbar spine surgery by one particular surgeon to identify risk factors for delayed extubation.

METHODS

Data including patient factors, surgical time, anesthetic technique, blood loss, crystalloid and colloid administration, transfusion requirements, time to transfusion, and time to extubation were collected and analyzed. Delayed extubation was defined as the patient was not extubated in the operating room at completion of the surgery.

RESULTS

One hundred and eight patients were extubated in the OR. Delayed extubation occurred in 27 patients. Delayed extubation was significantly related to total operative time (6.6 ± 0.4 vs. 5.2 ± 0.1 h), volume of crystalloid replacement (6,018 ± 408 vs. 4,186 ± 130 cm3), volume of total colloids infused (787 ± 93 vs. 442 ± 36 cm3), intraoperative blood transfused (3.7 ± 0.5 vs. 0.7 ± 0.1 units); blood loss (2,137 ± 286 vs. 832 ± 50 cm3), and time to starting blood transfusion (106 ± 12 vs. 199 ± 9 min).

CONCLUSIONS

Our study suggests that intraoperative factors including prolonged surgical time, significant blood loss, larger volume of crystalloid and colloid infusion, and blood transfusion may be risk factors for delayed extubation following thoracic or lumbar spine surgery. Early blood transfusion may also increase the risk of delayed extubation. Patient factors did not affect extubation time.

Neuroimaging for the anesthesiologist

This article provides an overview of neuroimaging modalities of particular interest to the anesthesiologist caring for neurosurgical patients. Imaging characteristics of neuropathologies and considerations for anesthetic management of diagnostic procedures are discussed.

Efficacy of postoperative radiograph for evaluating the prevertebral soft tissue swelling after anterior cervical discectomy and fusion

BACKGROUND

After surgery for degenerative spinal disease by the anterior approach, the degree of soft tissue swelling can be assessed simply using plain radiographs. However, there are little studies according to the surgical methods or extent of surgery, and no study had addressed the clinical meaning of swelling determined by plain radiography. The purpose of this study was to evaluate the clinical significance of prevertebral soft tissue swelling (PSTS) after anterior cervical fusion with plate fixation for the treatment of degenerative cervical spinal disorders.

METHODS

One hundred and thirty-five patients that underwent anterior cervical fusion with plate augmentation for degenerative cervical spondylosis were included in this study. PSTS differences were analyzed with respect to numbers of fusion segments and location of fusion. Cases were divided into two groups based on the amount of PSTS, and incidences of dyspnea, dysphagia, dysphonia were evaluated.

RESULTS

PSTS increments were significantly greater in patients that had undergone multi-level or high-level fusion. Complications of dyspnea, dysphagia and dysphonia were found more frequently in patients with marked PSTS group.

CONCLUSIONS

Increments of PSTS after anterior cervical fusion for degenerative spinal disorders are greater and incidences of complications are higher in patients that undergo multi-level or high-level fusion. Thus, measurement of PSTS using consecutive cervical lateral radiographs after anterior cervical surgery is clinically meaningful procedure.

Cervical total disk replacement: complications and avoidance

Anterior cervical diskectomy and fusion for neurologic deficits, radicular arm pain, and neck pain refractory to conservative management are successful. The approach and procedure were first described in 1955 and have become the anterior cervical standard of care for orthopedic surgeons and neurosurgeons. Advancements and innovations have addressed disease processes of the cervical spine with motion-preserving technology. The possibility of obtaining anterior cervical decompression while maintaining adjacent segment motion led to the advent of cervical total disk replacement. The Food and Drug Administration has approved 3 cervical devices with other investigational device exemption trials under way.

Surgical management of complex spinal deformity

Surgical treatment of complex cervical spinal deformities can be challenging operations. Patients often present with debilitating conditions ranging from generalized decreased quality of life to quadriplegia. Surgical treatment can be divided into anterior, posterior, or combined procedures. A thorough understanding of anatomy, pathology, and treatment options is necessary. This article focuses on the surgical treatment of complex spinal deformity.

Prolonged airway obstruction after posterior occipitocervical fusion: a case report and literature review

The purpose of this paper was to inform the reader that prolonged upper airway obstruction after posterior cervical spine surgery is a possible complication for patients with metastatic tumor of upper cervical spine. A 49-year-old man presented severe neck pain during posture changes due to metastatic spinal tumor of C2. Occipitocervical fusion following removal of the posterior arch of C1 and laminectomy of C2 via the single posterior approach was performed 2 weeks after radiation therapy. After the surgery, life-threatening airway obstruction due to pharyngeal oedema occurred immediately after extubation that required emergency tracheostomy. The airway obstruction did not improve well during the patient's postoperative course. Once pharyngeal oedema occurs in patients with metastatic tumor of upper cervical spine who undergo posterior cervical spine surgery following radiation therapy to the neck, the pharyngeal oedema may be constant for a long period of time.

Upper airway obstruction associated with flexed cervical position after posterior occipitocervical fusion

Upper airway obstruction resulting from overflexion fixation of the cervical spine is a rare but life-threatening complication after cervical spine surgery. There are few reports of dyspnea after a posterior cervical fusion. We present the case of a 63-year-old woman with rheumatoid arthritis who developed an upper airway obstruction immediately after an O-C4 fusion. She was reintubated with a fiberoptic scope. Revision surgery allowing the angle to return to the neutral position was performed to ameliorate the overflexion of the cervical spine fixation and the consequent upper airway obstruction. After revision surgery, the upper airway obstruction disappeared. Our experience suggests that intraoperative use of fluoroscopy and extubation with a tube exchanger are recommended to avoid this complication, especially in patients at high risk of upper airway obstruction.

Prevertebral soft tissue swelling after anterior cervical discectomy and fusion with plate fixation

Airway complications after anterior cervical surgery are rare but potentially lethal. The purpose of this study was to identify the natural course of prevertebral soft tissue swelling after one- or two-level anterior cervical discectomy and fusion (ACDF) in order to prevent lethal airway obstruction after ACDF. Eighty-seven patients scheduled for one- or two-level ACDF were studied prospectively. Lateral radiographs of the cervical spine were taken preoperatively, postoperatively on the day of surgery and on the first, second, third, fourth, and fifth days after operation. Prevertebral soft tissue was measured from C2 to C6 on cervical spine lateral radiographs. The anteroposterior (AP) thickness of the prevertebral soft tissue was measured at each cervical level from C2 to C6. Prevertebral soft tissue swelling occurred postoperatively and increased markedly on the second day after operation. The maximum swelling was found on the second and third days. In fusions above C5 swelling was most prominent at C2, 3. Gradual decrease in swelling was observed after the fourth postoperative day. Prominent swelling was noted at the second, third, and fourth cervical levels. There was no significant difference in swelling when comparing one-level and two-level ACDF. Only one patient required reintubation (1.1%). In conclusion, in this prospective study of 87 patients fused at one or two levels in the cervical spine peak prevertebral soft tissue swelling was observed on the second and third days after the surgery.

Anterior approaches to cervical spondylosis and ossification of the posterior longitudinal ligament: review of operative technique and assessment of 65 multilevel circumferential procedures

BACKGROUND

Multilevel anterior cervical corpectomy with fusion (ACF) offers direct resection of spondylostenosis and ossification of the posterior longitudinal ligament (OPLL) with immediate stabilization. Ideal candidates for multilevel ACF include younger patients (<65 years of age), or older individuals (>65 years of age) with loss or reversal of the cervical lordosis (kyphosis).

METHODS

Sixty-five patients, averaging 56 years of age and including 40 males and 25 females, with multilevel MR- and CT-documented spondylostenosis and OPLL were studied. Preoperatively, patients exhibited moderate to severe myelopathy (average Nurick grade 3.8), and were managed with 2- to 4-level ACF with posterior wiring and fusion (PWF) procedures with halo application. The first 22 patients had no plate instrumentation, the next 22 had constrained (Orion) plates applied followed sequentially by the application of 13 semi-constrained (Atlantis) plates, and finally, 8 dynamic (ABC Aesculap) plates.

RESULTS

Patients improved an average of three postoperative Nurick grades. None exhibited new cord injuries, whereas three had transient C5 root paresis. Graft/plate or vertebral fracture with extrusion were observed in 3/22 nonplated patients, 2/22 constrained-plated patients, 3/13 semi-constrained-plated patients, and 0/8 dynamic-plated patients. Fusion was documented on dynamic radiographs and 2D-CT or 3D-CT studies obtained 3 and 6 months postoperatively, or later where indicated.

CONCLUSIONS

Multilevel ACF/PWF offers direct resection of spondylostenosis and OPLL with immediate maximal stabilization. Thus far, no graft/plate or vertebral body fracture or extrusions have been seen with dynamic plates, whereas the absence of plating and constrained and semi-constrained plating systems have failed.