Utility of Cervical Collars Following Cervical Fusion Surgery. Does It Improve Fusion Rates or Outcomes? A Systematic Review

The Use of Osteobiologics in Single versus Multi-Level Anterior Cervical Discectomy and Fusion: A Systematic Review

STUDY DESIGN

Systematic literature review.

OBJECTIVES

In this study we assessed evidence for the use of osteobiologics in single vs multi-level anterior cervical discectomy and fusion (ACDF) in patients with cervical spine degeneration. The primary objective was to compare fusion rates after single and multi-level surgery with different osteobiologics. Secondary objectives were to compare differences in patient reported outcome measures (PROMs) and complications.

METHODS

After a global team of reviewers was selected, a systematic review using different repositories was performed, confirming to PRISMA and GRADE guidelines. In total 1206 articles were identified and after applying inclusion and exclusion criteria, 11 articles were eligible for analysis. Extracted data included fusion rates, definition of fusion, patient reported outcome measures, types of osteobiologics used, complications, adverse events and revisions.

RESULTS

Fusion rates ranged from 87.7% to 100% for bone morphogenetic protein 2 (BMP-2) and 88.6% to 94.7% for demineralized bone matrix, while fusion rates reported for other osteobiologics were lower. All included studies showed PROMs improved significantly for each osteobiologic. However, no differences were reported when comparing osteobiologics, or when comparing single vs multi-level surgery specifically.

CONCLUSION

The highest fusion rates after 2-level ACDF for cervical spine degeneration were reported when BMP-2 was used. However, PROMs did not differ between the different osteobiologics. Further blinded randomized trials should be performed to compare the use of BMP-2 in single vs multi-level ACDF specifically.

Cervical collar use following anterior cervical hybrid surgery: protocol for a prospective randomized, time-controlled trial

INTRODUCTION

Cervical hybrid surgery (HS) combines anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) to establish an individualized surgical plan for patients with multiple cervical disc degenerative diseases. In order to maintain the stability of the spine after HS, an external cervical collar is often used. However, there is still controversy regarding the importance of a cervical collar following surgery. This study aims to determine whether the cervical collar is effective and how long it should be worn after surgery.

METHODS

This is a randomized, single-center, prospective, parallel-controlled trial. Eligible participants will be selected according to the inclusion and exclusion criteria. The primary outcome is the neck disability index, which will be evaluated before surgery and at one week, 3 weeks, 6 weeks, 3 months, 6 months, and 12 months following surgery. The secondary outcomes consist of the Japanese Orthopedic Association Scores, MOS 36-item short-form health survey (SF-36), visual analog scale, Pittsburgh Sleep Quality Index (PSQI), Bazaz dysphagia scoring system, Falls Efficacy Scale, cervical collar satisfaction score, neck soft tissue assessment, and Braden Scale, as well as radiologic assessments for cervical lordosis, disc height of the operative levels, fusion rate, range of motion (ROM), and complications including anterior bone loss, prosthesis migration, and heterotopic ossification. The clinical and radiologic examinations were performed by investigators with no therapeutic relationship with the individual patient. All radiographs were examined by one independent radiologist.

ETHICS AND DISSEMINATION

The results of this study will be published in peer-reviewed journals and presented at conferences. Upon completion of this trial, our findings could provide an appropriate cervical collar-wearing guideline for patients receiving HS.

TRIAL REGISTRATION

ChiCTR.org.cn ChiCTR2000033002. Registered on 2020-05-17.

The Utility of Postoperative Bracing on Radiographic and Clinical Outcomes Following Cervical Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

To determine the radiographic and clinical utility of postoperative orthoses following cervical spine surgery.

METHODS

We performed a search of the PubMed, Cochrane Library, Medline Ovid, and SCOPUS databases from inception until November 2021. Eligible studies included outcomes of postoperative bracing vs no bracing following cervical spine surgery. The primary outcome of interest was fusion rates after cervical surgery in braced vs unbraced patients. Secondary outcomes included patient reported outcomes and complication rates.

RESULTS

A total of 3232 titles were initially screened. After inclusion criteria were applied, 7 studies (550 patients) were included, which compared results of braced vs unbraced patients after cervical spine surgery. These studies showed acceptable reliability for inclusion based on the Methodical Index for Non-Randomized studies and Critical Appraisal Skills Programme assessment tools. There were no significant differences in fusion rates or complications between braced vs unbraced patients identified in any study. Patient reported pain and quality of life measures between braced and unbraced groups varied amongst studies, without any clear overall advantages favoring either method.

CONCLUSIONS

This systematic review found that external bracing, though widely used following cervical spine surgery, may not offer any advantages in patient-reported outcomes, as compared to not bracing. In regard to the effect of bracing on fusion rates, no strong consensus can be made as the methods of fusion assessment in the included studies were heterogenous and suboptimal. Future high-quality studies using recommended methods of fusion assessment are needed to adequately address this important question.

Post-operative Use of Cervical Orthoses for Subaxial Cervical Spine Injuries - a Survey-based Analysis at German Spine Care Centres

INTRODUCTION

There are no evidence-based recommendations for the post-operative treatment and application of soft or rigid cervical collars after operative treatment of injuries of the subaxial cervical spine. Cervical collars can restrict peak range of motion and serve as a reminder to the patient. However, they can also cause pressure ulcers. The aim of this online-based survey among German spine centres was to gain an overview of post-operative treatment and the application of soft or rigid cervical collars after surgical treatment of injuries of the subaxial cervical spine.

MATERIALS AND METHODS

An online-based survey was conducted among 59 spine centres certified by the German Spine Society. It comprised seven items and the option of adding remarks in the form of open-ended responses.

RESULTS

The return rate was 63% (37 out of 59). Of the 37 analysed spine centres, 51% routinely apply a cervical collar post-operatively, 27% apply a soft and 16% a rigid cervical collar, 8% sequentially apply first a rigid and later a soft cervical collar. Less than half of the spine centres (43%) routinely use no cervical collar. Rigid collars are applied for more than 6 weeks and soft collars up to 6 weeks at some spine centres. Standardised post-operative treatment plans are common. The selection of the post-operative treatment plan depends primarily on the type of injury and method of operation and partly on patient age and bone quality. The satisfaction of German spine centres with the current handling of post-operative treatment of subaxial cervical spine injuries is high.

DISCUSSION

The post-operative treatment of injuries of the subaxial cervical spine at German spine centres is heterogeneous, and the evidence on advantages and disadvantages of the post-operative application of cervical collars is insufficient. Planning and implementation of randomised controlled clinical trials in subaxial cervical spine injuries is challenging.

Postoperative Restrictions After Anterior Cervical Discectomy and Fusion

No scientific evidence on restrictions for patients following an anterior cervical discectomy and fusion (ACDF) is available. The goal of this study is to assess the practice and patterns of restrictions after single-level and multilevel ACDF at an academic institution. We submitted two questionnaires, for restrictions after single-level and multilevel ACDF, to 18 spine surgeons at our institution. Questions included length of time in practice, use of cervical collar, postoperative restrictions and practices. We received 10 complete responses. Four (40%) of the respondents were in practice for less than 5 years; 3 (30%) 5 or more years, but less than 10; 1 (10%) 10 or more years, but less than 20; 2 (20%) 20 or more years. Only two (20%) surgeons recommend a cervical collar after a single-level ACDF, while seven (70%) do so after a multilevel ACDF, for an average of 9.1 weeks and standard deviation (SD) of 2.8. Nine surgeons (90%) reported providing lifting restrictions after a single-level and multilevel ACDF, with a mean of 10 kg and SD of 2.5 in both cases. 5 (50%) give driving restrictions after a single-level ACDF, eight (80%) do so after a multilevel. eight (80%) recommend physical therapy after both single-level and multilevel ACDF. three (30%) obtain a CT to confirm fusion at one year. Only two (20%) recommend a bone stimulator. Significant variability exists among surgeons in regards to restrictions following ACDF, but some areas of consensus emerged: 90% of respondents give lifting restrictions, with a mean of 10 kg, 80% recommend physical therapy for a range of motion and muscle strengthening.