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Expert Panel on Neurological Imaging, Eldaya RW, Parsons MS, Hutchins TA, Avery R, Burns J, Griffith B, Hassankhani A, Khan MA, Ng H, Raizman NM, Reitman C, Shah VN, Sliker C, Soliman H, Timpone VM, Tomaszewski CA, Yahyavi-Firouz-Abadi N, Policeni B. ACR Appropriateness Criteria® Cervical Pain or Cervical Radiculopathy: 2024 Update. J Am Coll Radiol 2025; 22:S136-S162. [PMID: 40409873 DOI: 10.1016/j.jacr.2025.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2025] [Accepted: 02/24/2025] [Indexed: 05/25/2025]
Abstract
Cervical spine pain is one of the most common reasons for seeking medical care as it ranks in the top 5 causes of global years lost to disability. The economic burden of cervical pain is also significant. Imaging is at the center of diagnosis of cervical pain and its causes. However, different symptoms and potential causes of cervical pain require different initial imaging to maximize the benefit of diagnostic usefulness of imaging. In this document we address different cervical pain variants with detailed assessment of the strengths and weaknesses of different modalities for addressing each specific variant. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Rami W Eldaya
- Washington University School of Medicine, Saint Louis, Missouri.
| | - Matthew S Parsons
- Panel Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | - Troy A Hutchins
- Panel Vice-Chair, University of Utah Health, Salt Lake City, Utah
| | - Ryan Avery
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | | | - Majid A Khan
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Henry Ng
- Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, Cleveland, Ohio; American College of Physicians
| | - Noah M Raizman
- The Centers for Advanced Orthopaedics, George Washington University, Washington, District of Columbia, and Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; American Academy of Orthopaedic Surgeons
| | - Charles Reitman
- Medical University of South Carolina, Charleston, South Carolina; North American Spine Society
| | - Vinil N Shah
- University of California, San Francisco, San Francisco, California
| | - Clint Sliker
- University of Maryland School of Medicine, Baltimore, Maryland; Committee on Emergency Radiology, Commission on General, Small, Rural and Emergency Radiology
| | - Hesham Soliman
- Northwell/Hofstra University Zucker School of Medicine, Manhasset, New York; American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | | | | | | | - Bruno Policeni
- Specialty Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Martin CT, Yoon ST, Alluri RK, Benzel EC, Bono CM, Cho SK, Chou D, Chen X, Cheung JP, Cabrera JP, Ćorluka S, Demetriades AK, Gary MF, Ghogawala Z, Hamouda W, Han I, Hauri D, Hsieh PC, Jain A, Kim JS, Le HV, Louie PK, Luo Z, Meisel HJ, Muthu S, Ryu DS, Sansur CA, Schoenfeld AJ, Scaramuzzo L, Schroeder GD, Rajasekaran S, Sotiris V, Vadalà G, Vergroesen PPA, Wang JC, Wu Y, Riew KD, AO Spine Knowledge Forum Degenerative. How Reliable is the Assessment of Fusion Status Following ACDF Using Dynamic Flexion-Extension Radiographs? Global Spine J 2025; 15:2450-2457. [PMID: 39639494 PMCID: PMC11622210 DOI: 10.1177/21925682241303107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2024] Open
Abstract
Study DesignReliability study.ObjectivesThe radiographic diagnosis of non-union is not standardized. Prior authors have suggested using a cutoff of <1 mm interspinous process motion (ISPM) on flexion-extension radiographs, but the ability of practicing surgeons to make these measurements reliably is not clear.Methods29 practicing spine surgeons measured ISPM on 19 levels of ACDF from 9 patients. Surgeons relied on these measurements to report on fusion status. Inter-observer correlation co-efficients (ICC), standard error (SEM) and the minimum detectable difference (MD) of these measurements were calculated. We screened for clerical errors by checking measurements more than one standard deviation from the group mean.ResultsThe ICC for ISPM was .76 (.64; .88) with a SEM of 1 mm and a MD of 2.76 mm. Agreement on fusion status was moderate, with an ICC of .6 (.44; .76). After screening for and removing clerical errors, the ICC improved to .82 (.71; .91), SEM improved to .83 mm, and MD improved to 2.29 mm. Six reviewers had an ICC >.9. The ICC from these high performing reviewers was .94 (.9; .97), SEM was .45 mm, and MD was 1.26 mm.ConclusionsThe MD of 2.29 mm in our study group was not precise enough to support a cutoff of <1 mm ISPM as the sole measurement technique in screening for non-union after ACDF, and there was only moderate agreement amongst surgeons on fusion status based on dynamic radiographs. More stringent techniques are necessary to avoid mis-diagnosing non-union in clinical studies. Future studies should consider auditing measurements to identify clerical errors.
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Affiliation(s)
| | | | - Ram Kiran Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Edward C. Benzel
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Chris M. Bono
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Samuel K. Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dean Chou
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Xiaolong Chen
- Department of Orthopedic Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jason P.Y. Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Juan P. Cabrera
- Department of Neurosurgery, Hospital Clínico Regional de Concepción, Concepción, Chile
- Faculty of Medicine, University of Concepción, Concepción, Chile
| | - Stipe Ćorluka
- Spinal Surgery Division, Department of Traumatology, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
- Department of Anatomy and Physiology, University of Applied Health Sciences, Zagreb, Croatia
| | - Andreas K. Demetriades
- Edinburgh Spinal Surgery Outcome Studies Group, Department of Neurosurgery, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Matthew F. Gary
- Department of Orthopaedics, Emory University, Atlanta, GA, USA
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Zoher Ghogawala
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Waeel Hamouda
- Department of Neurosurgery, Kasr Alainy Faculty of Medicine, Research, and Teaching Hospitals, Cairo University, Cairo, Egypt
- Neurological & Spinal Surgery Service, Security Forces Hospital, Dammam, Saudi Arabia
| | - Inbo Han
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
| | - Dimitri Hauri
- Clinical Science, AO Innovation Translation Center, AO Foundation, Davos, Switzerland
| | - Patrick C. Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jun S. Kim
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Hai V. Le
- Department of Orthopaedic Surgery, University of California, Sacramento, CA, USA
| | - Philip K. Louie
- Center for Neurosciences and Spine, Department of Neurosurgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Zhuojing Luo
- Department of Orthopaedic Surgery, Xijing Hospital, Forth Military Medical University, Xi’an, China
| | - Hans-Jörg Meisel
- Department of Neurosurgery, BG Klinikum Bergmannstrost, Halle, Germany
| | - Sathish Muthu
- Orthopaedic Research Group, Coimbatore, India
- Department of Orthopaedics, Government Medical College, Karur, India
- Department of Biotechnology, Karpagam Academy of Higher Education, Coimbatore, India
| | - Dal-Sung Ryu
- Department of Neurosurgery, College of Medicine, Inha University, Incheon, Korea
| | - Charles A. Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Laura Scaramuzzo
- Spine Surgery Unit, Department of Aging, Orthopaedic and Rheumatological Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Veranis Sotiris
- Department of Neurosurgery, 251 General Air Force and Reserve Hospital, Athens, Greece
| | - Gianluca Vadalà
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Jeffrey C. Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Yabin Wu
- Clinical Science, AO Innovation Translation Center, AO Foundation, Davos, Switzerland
| | - K. Daniel Riew
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA
- Department of Orthopedic Surgery, Columbia University, New York, NY, USA
| | - AO Spine Knowledge Forum Degenerative
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopaedics, Emory University, Atlanta, GA, USA
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, NY, USA
- Department of Orthopedic Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
- Department of Neurosurgery, Hospital Clínico Regional de Concepción, Concepción, Chile
- Faculty of Medicine, University of Concepción, Concepción, Chile
- Spinal Surgery Division, Department of Traumatology, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
- Department of Anatomy and Physiology, University of Applied Health Sciences, Zagreb, Croatia
- Edinburgh Spinal Surgery Outcome Studies Group, Department of Neurosurgery, Royal Infirmary Edinburgh, Edinburgh, UK
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA, USA
- Department of Neurosurgery, Kasr Alainy Faculty of Medicine, Research, and Teaching Hospitals, Cairo University, Cairo, Egypt
- Neurological & Spinal Surgery Service, Security Forces Hospital, Dammam, Saudi Arabia
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
- Clinical Science, AO Innovation Translation Center, AO Foundation, Davos, Switzerland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
- Department of Orthopaedic Surgery, University of California, Sacramento, CA, USA
- Center for Neurosciences and Spine, Department of Neurosurgery, Virginia Mason Medical Center, Seattle, WA, USA
- Department of Orthopaedic Surgery, Xijing Hospital, Forth Military Medical University, Xi’an, China
- Department of Neurosurgery, BG Klinikum Bergmannstrost, Halle, Germany
- Orthopaedic Research Group, Coimbatore, India
- Department of Orthopaedics, Government Medical College, Karur, India
- Department of Biotechnology, Karpagam Academy of Higher Education, Coimbatore, India
- Department of Neurosurgery, College of Medicine, Inha University, Incheon, Korea
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Spine Surgery Unit, Department of Aging, Orthopaedic and Rheumatological Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA, USA
- Department of Orthopaedics, Ganga Hospital, Coimbatore, India
- Department of Neurosurgery, 251 General Air Force and Reserve Hospital, Athens, Greece
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- Department of Orthopaedic Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA
- Department of Orthopedic Surgery, Columbia University, New York, NY, USA
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Zhao ER, Kamil R, Kaidi AC, Mok JK, Oquendo Y, Badejo O, Amen TB, Kazarian GS, Asada T, Omurzakov AM, Xu T, Subramanian T, Varady NH, Johnson MA, Zhang B, Fourman MS, Morse KW, Lovecchio FC, Iyer S, Dowdell JE, Kim HJ, Qureshi SA. Zero-Profile Stand-Alone Cages Versus Traditional Cage-and-Plate Constructs in Single and Multi-Level Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis Using Validated Fusion Assessment Methods. Global Spine J 2025:21925682251329228. [PMID: 40229971 PMCID: PMC11999997 DOI: 10.1177/21925682251329228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2024] [Revised: 02/13/2025] [Accepted: 03/07/2025] [Indexed: 04/16/2025] Open
Abstract
ObjectivesStand-alone (SA) and anterior cage-and-plate (ACP) have been studied in anterior cervical discectomy and fusion (ACDF). However, fusion assessment methods vary and existing studies are not propensitymatched and often lack patient-reported outcomes (PROMs). We compare fusion rates between propensity-matched single- and multi-level SA versus ACP using a method validated by intraoperative motion testing during revision surgery. We also compare sagittal alignment, perioperative outcomes, and PROMs.MethodsPatients >18 years who underwent primary ACDF were included. 2:1 propensity score matching was performed. Fusions were assessed using 1 year computer tomography and flexion/extension radiographs via validated fusion assessment methods. ALOD was assessed at least 6-months postoperatively. Sagittal alignment was assessed at preoperative, short-term postoperative (2-6 weeks), and long-term postoperative (6 months or more) time points. PROMs, operative time, blood loss, dysphagia, and complications were analyzed.Results153 patients (51 SA) were included after matching. There were no differences in fusion rates overall (P = .662), or by number of surgical levels. There were no differences in ALOD at upper or lower levels, nor was there a difference in ALOD grade. Regarding segmental lordosis, overall lordosis, T1 slope, TS-CL, and PROMs (NDI, SF-12 PCS, VAS neck and arm), there were no differences at preoperative or any postoperative time point. Operative time and blood loss were greater in the ACP cohort, with no differences in complications or postoperative dysphagia.ConclusionsFusion rates, PROMs, radiographic outcomes, complications, and dysphagia rates were all comparable following single and multi-level ACDF between SA and ACP.
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Affiliation(s)
- Eric R. Zhao
- Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | | | | | - Jung K. Mok
- Hospital for Special Surgery, New York, NY, USA
| | | | | | | | | | | | - Arsen M. Omurzakov
- Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Tim Xu
- Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Tejas Subramanian
- Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | | | | | - Bo Zhang
- Hospital for Special Surgery, New York, NY, USA
| | | | | | | | | | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
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El Yaagoubi Y, Lioret E, Thomas C, Loret JE, Simonneau A, Amelot A, Michaud-Robert AV, Pasquesoone H, Philippe L, Prunier-Aesch C. 18F-Naf PET/CT in pseudarthrosis after anterior cervical discectomy and fusion. Spine J 2025; 25:763-773. [PMID: 39615692 DOI: 10.1016/j.spinee.2024.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Revised: 09/23/2024] [Accepted: 11/05/2024] [Indexed: 12/20/2024]
Abstract
BACKGROUND CONTEXT Pseudarthrosis is a well-known cause of persistent or recurrent pain after anterior cervical discectomy and fusion (ACDF). Numerous radiographic criteria to determine the fusion status has been described in the literature, but their accuracies in clinical practice vary considerably and no 1 single method has proved superior. Fluorine-18 sodium fluoride (18F-NaF) positron emission tomography/computed tomography (PET/CT), depicting osteoblastic activity, might be useful to identify pseudarthrosis after ACDF. PURPOSE To investigate the ability of 18F-NaF PET/CT to identify pseudarthrosis after ACDF using surgical revision as the reference standard. STUDY DESIGN Retrospective observational study. PATIENTS SAMPLE A total of 30 patients consisting of 40 surgical levels. OUTCOME MEASURES For each level, the presence or absence of intragraft uptake (InGU) and extragraft uptake (ExGU) were recorded, as well as adjacent segment uptake (ASU). CT part of the scan was rated as "fused" or "nonfused." Results were correlated to the gold-standard of revision surgery. METHODS We retrospectively included consecutive patients who underwent revision surgery for suspicion of symptomatic pseudarthrosis after ACDF following 18F-NaF PET/CT performed between July 2019 and march 2023. 18F-NaF PET/CT results were compared with the gold standard of surgical evaluation of the stability of the fusion material. All patients underwent a systematic CT scan to evaluate the success of revision surgery 1 year postoperatively. We also investigated whether some patients underwent a repeated 18F-NaF PET/CT for persistent or recurrent pain after revision surgery. RESULTS Revision surgery demonstrated pseudarthrosis in 37 levels (93%) and excluded pseudarthrosis in 3 levels (7%). In the pseudarthrosis group (n=37), InGU was observed in all levels (100%) while ExGU was present in only 10 levels (27%). Fifteen levels (41%) with confirmed pseudarthrosis were rated as "fused" on CT scan preoperatively. In the nonpseudarthrosis group (n=3), InGU was observed in 2 levels (67%) while ExGU was never present. Two levels (67%) were rated as "fused" on fusion CT scan. One year postoperatively, fusion was successfully achieved on CT scan in 39 levels (98%). Seven patients (consisting of 8 levels) had been subsequently reexplored by 18F-NaF PET/CT for persistent or recurrent pain following revision surgery. PET/CT did not reveal any uptake (InGU or ExGU) in 7 levels, rated as "fused" on follow-up CT scan. PET/CT showed InGU in the only level rated as "nonfused" on CT scan. CONCLUSIONS 18F NaF PET/CT may be a useful adjunctive diagnostic tool to detect pseudarthrosis after ACDF surgery, especially in case of high clinical suspicion with standard conventional imaging not suggestive of nonunion. In our cohort, all levels (100%) with confirmed pseudarthrosis on revision surgery demonstrated InGU on PET/CT, while 41% of these levels were rated as "fused" on CT scan preoperatively. 18F NaF PET/CT might also be helpful after revision surgery to rule out repseudarthrosis and identify the pain generator. These promising data need to be confirmed in larger prospective studies.
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Affiliation(s)
| | - Eric Lioret
- Department of Neurosurgery, Vinci Clinic, Tours, France
| | | | | | | | - Aymeric Amelot
- Department of Neurosurgery, Bretonneau University Hospital, Tours, France
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Hipp JA, Mikhael MM, Reitman CA, Buser Z, Patel VV, Chaput CD, Ghiselli G, DeVine J, Berven S, Nunley P, Grieco TF. Diagnosis of spine pseudoarthrosis based on the biomechanical properties of bone. Spine J 2024:S1529-9430(24)00935-5. [PMID: 39154949 DOI: 10.1016/j.spinee.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 07/15/2024] [Accepted: 08/09/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND CONTEXT Failure to fuse following anterior cervical discectomy and fusion (ACDF) may result in symptomatic pseudoarthrosis. Traditional diagnosis involves computerized tomography to detect bridging bone and/or flexion-extension radiographs to assess whether segmental motion is above specific thresholds; however, there are currently no well-validated diagnostic tests. We propose a biomechanically rational approach to achieve a reliable diagnostic test for pseudoarthrosis. PURPOSE Develop and test a biomechanically based approach to the diagnosis of pseudoarthrosis. STUDY DESIGN Literature review, development of theory, re-analysis of a previously published study with surgical exploration as the gold-standard, and retrospective analysis of pooled studies to understand time to fusion. METHODS Fully automated methods were used to measure disc space strains (change in disc space height divided by initial height). Measurement error combined with the reported failure strain of trabecular bone led to a proposed strain threshold for diagnosis of pseudoarthrosis following ACDF. We reanalyzed previously reported flexion-extension radiographs for asymptomatic volunteers to assess whether flexion-extension radiographs, in the absence of fusion surgery, can be expected to provide sufficient stress on motion segments to allow for reliable strain-based fusion assessment. The sensitivity and specificity of strain- and rotation-based pseudoarthrosis diagnosis were assessed by reanalysis of previously reported post-ACDF flexion-extension radiographs, where intraoperative fusion assessments were also available. Finally, we assessed changes in strain over time using 9,869 flexion-extension radiographs obtained 6 weeks to 84 months post-ACDF surgery from 1,369 patients. RESULTS The estimated error in automated measurement of disc space strain from radiographs was approximately 3%, and the reported failure strain of bridging bone was less than 2.5%. On that basis, we propose a 5% strain threshold for pseudoarthrosis diagnosis. Reanalysis of a study in which intraoperative fusion assessments were available revealed 67% sensitivity and 82% specificity for strain-based diagnosis of pseudoarthrosis, which was comparable to rotation-based diagnosis. Analysis of post-ACDF flexion-extension radiographs revealed rapid strain reduction for up to 24 months, followed by a slower decrease for up to 84 months. When rotation is less than 2 degrees, the strain-based diagnosis differed from the rotation-based diagnosis in approximately 14% of the cases. CONCLUSIONS We propose steps for standardizing diagnosis of pseudoarthrosis based on the failure strain of bone, measurement error, and retrospective data. These steps include obtaining high-quality flexion-extension studies, the application of proposed diagnostic thresholds, and the use of image stabilization for conclusive diagnosis, when motion is near thresholds. The necessity for an accurate diagnosis with minimal radiation exposure underscores the need for further optimization and standardization in diagnosing pseudoarthrosis following ACDF surgery. CLINICAL SIGNIFICANCE In a symptomatic postspine fusion patient, it is important to diagnose or rule-out pseudoarthrosis. There are currently no well-validated diagnostic tests for this condition. Incorporating strain-based intervertebral motion analysis into the diagnosis could lead to a standardized and validated test for detecting spine pseudoarthrosis.
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Affiliation(s)
| | - Mark M Mikhael
- Orthopaedic Spine Surgery, Illinois Bone and Joint Institute, Glenview, IL, USA
| | - Charles A Reitman
- Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Zorica Buser
- The Gerling Institute and NYU Grossman School of Medicine, New York, NY USA
| | - Vikas V Patel
- Department of Orthopedic Surgery, University of Colorado, Denver, CO, USA
| | - Christopher D Chaput
- Department of Orthopedics, University of Texas Health San Antonio, San Antonio, TX, USA
| | | | - John DeVine
- Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Sigurd Berven
- Orthopedic Surgery, UCSF Spine Center, San Francisco, CA, USA
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Redaelli A, Stephan SR, Riew KD. Is neck pain treatable with surgery? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1137-1147. [PMID: 38191741 DOI: 10.1007/s00586-023-08053-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/05/2023] [Accepted: 11/14/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION Neck pain is one of the most common complaints in clinical practice and can be caused by a wide variety of conditions. While cervical spine surgery is a well-accepted option for radicular pain and myelopathy, surgery for isolated neck pain is controversial. The identification of the source of pain is challenging and subtle, and misdiagnosis can lead to inappropriate treatment. MATERIALS AND METHODS AND RESULTS: We conducted a thorough literature review to discuss and compare different causes of neck pain. We then supplemented the literature with our senior author's expert analysis of treating cervical spine pathology. CONCLUSIONS This study provides an in-depth discussion of neck pain and its various presentations, as well as providing insight into treatment strategies and diagnostic pearls that may prevent mistreatment of cervical spine pathology.
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Affiliation(s)
- Andrea Redaelli
- GSpine4, IRCCS Ospedale Galeazzi-Sant'Ambrogio, Milan, Italy
| | - Stephen R Stephan
- Department of Orthopaedic Surgery, San Diego Spine Foundation, San Diego, USA
| | - K Daniel Riew
- Department of Neurological Surgery, Weill-Cornell Medical Center, New York, USA
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, USA
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7
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Jain A, Dhanjani S, Harris A, Cartagena M, Babu J, Riew D, Shin J, Wang JC, Yoon ST, Buser Z, Meisel HJ. Structural Allograft Versus Mechanical Interbody Devices Augmented With Osteobiologics in Anterior Cervical Discectomy and Fusion: A Systematic Review. Global Spine J 2024; 14:34S-42S. [PMID: 38421329 PMCID: PMC10913916 DOI: 10.1177/21925682231171857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
STUDY DESIGN Systematic Literature Review. OBJECTIVE Perform a systematic review evaluating postoperative fusion rates for anterior cervical discectomy and fusion (ACDF) using structural allograft vs various interbody devices augmented with different osteobiologic materials. METHODS Comprehensive literature search using PubMed, Embase, The Cochrane Library, and Web of Science was performed. Included studies were those that reported results of 1-4 levels ACDF using pure structural allograft compared with a mechanical interbody device augmented with an osteobiologic. Excluded studies were those that reported on ACDF with cervical corpectomy; anterior and posterior cervical fusions; circumferential (360° or 540°) fusion or revision ACDF for nonunion or other conditions. Risk of bias was determined using the Cochrane review guidelines. RESULTS 8 articles reporting fusion rates of structural allograft and an interbody device/osteobiologic pair were included. All included studies compared fusion rates following ACDF among structural allograft vs non-allograft interbody device/osteobiologic pairs. Fusion rates were reported between 84% and 100% for structural allograft, while fusion rates for various interbody device/osteobiologic combinations ranged from 26% to 100%. Among non-allograft cage groups fusion rates varied from 73-100%. One study found PEEK cages filled with combinations of autograft, allograft, and demineralized bone matrix (DBM) to have an overall fusion rate of 26%. In one study comparing plate and zero-profile constructs, there was no difference in fusion rates for two-level fusions. CONCLUSION There was limited data comparing fusion outcomes of patients undergoing ACDF using structural allograft vs interbody devices augmented with osteobiologic materials to support superiority of one method.
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Affiliation(s)
- Amit Jain
- Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
| | | | - Andrew Harris
- Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
| | | | - Jacob Babu
- Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Daniel Riew
- Weill Cornell Brain and Spine Center, New York, NY, USA
| | - John Shin
- Mass General Brigham Inc, Boston, MA, USA
| | | | - S Tim Yoon
- Orthopedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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8
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Peng Z, Liu L, Sheng X, Liu H, Ding C, Wang B, Hong Y, Pan X, Meng Y. Risk Factors of Nonfusion after Anterior Cervical Decompression and Fusion in the Early Postoperative Period: A Retrospective Study. Orthop Surg 2023; 15:2574-2581. [PMID: 37538029 PMCID: PMC10549804 DOI: 10.1111/os.13835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/16/2023] [Accepted: 06/24/2023] [Indexed: 08/05/2023] Open
Abstract
OBJECTIVE Although high fusion rates have been reported for anterior cervical decompression and fusion (ACDF) in the medium and long term, the risk of nonfusion in the early period after ACDF remains substantial. This study investigates early risk factors for cage nonfusion in patients undergoing single- or multi-level ACDF. METHODS This was a retrospective study. From August 2020 to December 2021, 107 patients with ACDF, including 197 segments, were enrolled, with a follow-up of 3 months. Among the 197 segments, 155 were diagnosed with nonfusion (Nonfusion group), and 42 were diagnosed with fusion (Fusion group) in the early period after ACDF. We assessed the significance of the patient-specific factors, radiographic indicators, serum factors, and clinical outcomes. The Wilcoxon rank sum test, t-tests, analysis of variance, and stepwise multivariate logistic regression were used for statistical analysis. RESULTS Univariate analysis showed that smoking, insufficient improvement in the C2-7 Cobb angle (p = 0.024) and the functional spinal unit Cobb angle (p = 0.022) between preoperative and postoperative stages and lower serum calcium (fusion: 2.34 ± 0.12 mmol/L; nonfusion: 2.28 ± 0.17 mmol/L, p = 0.003) β-carboxyterminal telopeptide end of type 1 collagen (β-CTX) (fusion: 0.51 [0.38, 0.71]; nonfusion: 0.43 [0.31, 0.57], p = 0.008), and N-terminal fragment of osteocalcin (N-MID-BGP) (fusion: 18.30 [12.15, 22.60]; nonfusion: 14.45 [11.65, 18.60], p = 0.023) are risk factors for nonfusion in the early period after ACDF. Stepwise logistic regression analysis revealed that poor C2-7 Cobb angle improvement (odds ratio [OR], 1.107 [1.019-1.204], p = 0.017) and lower serum calcium (OR, 3.700 [1.138-12.032], p = 0.030) are risk factors. CONCLUSIONS Patients with successful fusion after ACDF had higher preoperative serum calcium and improved C2-7 Cobb angle than nonfusion patients at 3 months. These findings suggest that serum calcium could be used to identify patients at risk of nonfusion following ACDF and that correcting the C2-7 Cobb angle during surgery could potentially increase fusion in the early period after ACDF.
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Affiliation(s)
- Zihan Peng
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Li Liu
- Department of Orthopedics, West China Hospital/West China School of NursingSichuan UniversityChengduChina
| | - Xiaqing Sheng
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Hao Liu
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Chen Ding
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Beiyu Wang
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Ying Hong
- Department of Operating Room, West China Hospital/West China School of NursingSichuan UniversityChengduChina
| | - Xiaoli Pan
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Yang Meng
- Department of Orthopedics, Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
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Hasan S, Babrowicz J, Waheed MA, Piche JD, Patel R, Aleem I. The Utility of Postoperative Bracing on Radiographic and Clinical Outcomes Following Cervical Spine Surgery: A Systematic Review. Global Spine J 2023; 13:512-522. [PMID: 35499300 PMCID: PMC9972282 DOI: 10.1177/21925682221098361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Sazid Hasan
- Oakland University William Beaumont
School of Medicine, Rochester, MI, USA
| | - Joseph Babrowicz
- College of Literature, Science and
the Arts, University of Michigan, Ann Arbor, MI, USA
| | - Muhammad A. Waheed
- Oakland University William Beaumont
School of Medicine, Rochester, MI, USA
| | - Joshua David Piche
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Rakesh Patel
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ilyas Aleem
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA,Ilyas Aleem, MD, MS, FRCSC, Department of
Orthopedic Surgery, University of Michigan, 1500 East Medical Center Drive, 2912
Taubman Center, SPC 5328, Ann Arbor, MI 48109, USA.
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10
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Xu Q, Lu Z, Chen P, Li B, Zheng X, Jiang S, Jiang L. Acceptable Fusion Rate of Single-Level OLIF Using Pure Allograft Combined with Posterior Instrumentation through the Wiltse Approach: A 2-Year Follow-Up Study. Orthop Surg 2023; 15:801-809. [PMID: 36718553 PMCID: PMC9977589 DOI: 10.1111/os.13657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Autogenic bone grafts have shown successful fusion rates in the treatment of degenerative lumbar disorders, but taking too many autogenic bones may result in donor site ischemia or infection. This study aimed to evaluate the outcomes of single-level oblique lumbar interbody fusion (OLIF) using pure allograft combined with posterior pedicle screw instrumentation through the Wiltse approach. METHODS A retrospective case analysis was performed on a series of consecutive patients who received a single-level OLIF procedure combined with posterior pedicle screw instrumentation through the Wiltse approach between July 1, 2017, and December 31, 2019, in which pure allogenic bone graft was used and filled in the large window of the cage. The patients were followed up as scheduled at 1 day and 3, 6, 12, 24 months after operation. Clinical outcome was assessed by multiple questionnaires, including Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) score rating system, short form-36 health survey (SF-36), and visual analog scale (VAS) for low back pain. Radiographic outcome was evaluated by measuring the parameters such as disc height, lumbar lordosis, and segmental angle on the standard standing lateral radiographs, and the space angle of the fusion level on the dynamic views of the lateral radiographs. Subsidence of the cage and intervertebral fusion status were evaluated on both the radiographic and CT scan images. RESULTS A total of 34 patients were finally included in this study. At 2-year follow-up, the VAS for low back pain, ODI, JOA, and SF-36 scores all had significant improvement (p < 0.001). Substantial increase of anterior and posterior disc heights was observed (p < 0.001). Both lumbar lordosis and segmental angle became larger (p < 0.05). No visible change of the space angle of the fusion level was found on the dynamic views. The 1-year fusion rate of 73.5% on CT scans proceeded to 82.4% at 2-year follow-up. The fusion rate was as high as 91.2% according to Bridwell interbody fusion grading system on radiographic images. The clinical outcomes in patients with incomplete fusion were just as good as those with complete fusion. The six patients with cage subsidence had higher ODI (p < 0.001) and lower JOA (p < 0.001) and SF-36 PCS (p = 0.011) scores than those without cage subsidence. CONCLUSION The use of pure allograft in single-level OLIF resulted in an acceptable fusion rate and satisfactory clinical effect at 2-year follow-up. Supplementation of posterior pedicle screw through the minimally invasive Wiltse approach ensured the favorable outcomes both clinically and radiographically.
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Affiliation(s)
- Qingyin Xu
- Spine CenterXinhua Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
| | - Zeyu Lu
- Spine CenterXinhua Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
| | - Pengbo Chen
- Spine CenterXinhua Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
| | - Bo Li
- Spine CenterXinhua Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
| | - Xinfeng Zheng
- Spine CenterXinhua Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
| | - Shengdan Jiang
- Spine CenterXinhua Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
| | - Leisheng Jiang
- Spine CenterXinhua Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
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11
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Pinter ZW, Skjaerlund J, Michalopoulos GD, Nathani KR, Bydon M, Nassr A, Sebastian AS, Freedman BA. Dynamic Radiographs Are Unreliable to Assess Arthrodesis Following Cervical Fusion: A Modeled Radiostereometric Analysis of Cervical Motion. Spine (Phila Pa 1976) 2023; 48:127-136. [PMID: 36083848 DOI: 10.1097/brs.0000000000004470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/12/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN In vitro study. OBJECTIVE The purpose of the present study was to utilize an idealized cervical spine model to determine whether the parallax effect or changes in the position of the spine relative to the x-ray generator influence intervertebral motion parameters on dynamic cervical spine radiographs. SUMMARY OF BACKGROUND DATA The utility of flexion-extension radiographs in clinical practice remains in question due to poor reliability of the parameters utilized to measure motion. MATERIALS AND METHODS A cervical spine model with tantalum beads inserted into the tip of each spinous process was utilized to measure interspinous process distance (IPD) on plain radiographs. The model was then manipulated to alter the generator angle and generator distance, and the IPD was measured. The impact of individual and combined changes in these parameters on IPD was assessed. Multivariate analysis was performed to identify independent drivers of variability in IPD measurements. RESULTS Isolated changes in the generator distance and generator angle and combined changes in these parameters led to significant changes in the measured IPD at each intervertebral level in neutral, flexion, and extension, which, in many instances, exceeded an absolute change of >1 mm or >2 mm. Multivariate analysis revealed that generator distance and generator angle are both independent factors impacting IPD measurements that have an additive effect. CONCLUSIONS In an idealized cervical spine model, small clinically feasible changes in spine position relative to the x-ray generator produced substantial variability in IPD measurements, with absolute changes that often exceeded established cutoffs for determining the presence of pathologic motion across a fused segment. This study further reinforces that motion assessment on dynamic radiographs is not a reliable method for determining the presence of an arthrodesis unless these sources of variability can be consistently eliminated. LEVEL OF EVIDENCE 3.
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Affiliation(s)
| | | | | | - Karim R Nathani
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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12
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Suk KS, Jimenez KA, Jo JH, Kim HS, Lee HM, Moon SH, Lee BH. Anterior Plate-Screws and Lower Postoperative T1 Slope Affect Cervical Allospacer Failures in Multi-Level ACDF Surgery: Anterior Versus Posterior Fixation. Global Spine J 2023; 13:89-96. [PMID: 33648356 PMCID: PMC9837507 DOI: 10.1177/2192568221991515] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
STUDY DESIGN Prospective observational study. OBJECTIVE In ACDF, graft failure and subsidence are common complications of surgery. Depending on the cervical fixation, different biomechanical characteristics are applied on the grafts. This aims to describe the incidence of cervical spacer failure in patients with cervical degenerative condition according to the cervical fixation method and sagittal balance. METHOD From November 2011 to December 2015, 262 patients who underwent cervical spine surgery were enrolled prospectively. Patients were divided into 3 groups based on fixation method: anterior plate/screw (APS), posterior lateral mass screw (LMS), pedicle screw (PPS) groups. Serial X-rays and CT scans were utilized to evaluate radiologic outcomes. RESULTS Mean patient ages were 56.1 years in the APS group, 61.5 years in the LMS group, and 57.6 years in the PPS group (P = 0.002). Allospacer failure was most common in the APS group, compared to the LMS and PPS groups (chi-square, P = 0.038). Longer fusion level was associated with greater allospacer failure (Baseline 2 level surgery; Odds ratio (OR) 3.4 in 3 level, 15.2 in 4 level, P = 0.036,0.013). Higher T1 slope was correlated with less allospacer failure (OR 0.875, P = 0.001). ORs of allospacer failure in the LMS and PPS groups were 0.04 and 0.02, respectively, (P = 0.01, 0.01), compared with the APS group. CONCLUSION This study was able to show that allospacer failure in multi-level ACDF surgery is more common with a longer fusion length, less postoperative T1 slope, and an anterior plate-screws technique. Pedicle screws provided the best biomechanical stability among the 3 constructs.
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Affiliation(s)
- Kyung-Soo Suk
- Department of Orthopedic Surgery, Yonsei
University College of Medicine, Seoul, Korea
| | - Kathryn Anne Jimenez
- Department of Orthopedic Surgery, Yonsei
University College of Medicine, Seoul, Korea
| | - Je Hyung Jo
- Department of Orthopedic Surgery, Yonsei
University College of Medicine, Seoul, Korea
| | - Hak-Sun Kim
- Department of Orthopedic Surgery, Yonsei
University College of Medicine, Seoul, Korea
| | - Hwan-Mo Lee
- Department of Orthopedic Surgery, Yonsei
University College of Medicine, Seoul, Korea
| | - Seong-Hwan Moon
- Department of Orthopedic Surgery, Yonsei
University College of Medicine, Seoul, Korea
| | - Byung Ho Lee
- Department of Orthopedic Surgery, Yonsei
University College of Medicine, Seoul, Korea,Byung Ho Lee, Department of Orthopedic
Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,
Seoul, 120-752, Korea.
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13
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Godlewski B, Bebenek A, Dominiak M, Bochniak M, Cieslik P, Pawelczyk T. Reliability and Utility of Various Methods for Evaluation of Bone Union after Anterior Cervical Discectomy and Fusion. J Clin Med 2022; 11:jcm11206066. [PMID: 36294384 PMCID: PMC9605251 DOI: 10.3390/jcm11206066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/09/2022] [Accepted: 10/13/2022] [Indexed: 11/25/2022] Open
Abstract
Most surgical procedures performed on account of degenerative disease of the cervical spine involve a discectomy and interbody fixation. Bone fusion at the implant placement site is evaluated post-operatively. It is agreed that computed tomography is the best modality for assessing bone union. We evaluated the results obtained with various methods based solely on conventional radiographs in the same group of patients and compared them with results obtained using a method that is a combination of CT and conventional radiography, which we considered the most precise and a reference method. We operated on a total of 170 disc spaces in a group of 104 patients. Fusion was evaluated at 12 months after surgery with five different and popular classifications based on conventional radiographs and then compared with the reference method. Statistical analyses of test accuracy produced the following classification of fusion assessment methods with regard to the degree of consistency with the reference method, in descending order: (1) bone bridging is visible on the anterior and/or posterior edge of the operated disc space on a lateral radiograph; (2) change in the value of Cobb's angle for a motion segment on flexion vs. extension radiographs (threshold for fusion vs. pseudoarthrosis is 2°); (3) change in the interspinous distance between process tips on flexion vs. extension radiographs (threshold of 2 mm); (4) change in the value of Cobb's angle of a motion segment (threshold of 4°); (5) change in the interspinous distance between process bases on flexion vs. extension radiographs (threshold of 2 mm). When bone union is evaluated on the basis on radiographs, without CT evidence, we suggest using the "bone bridging" criterion as the most reliable commonly used approach to assessing bone union.
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Affiliation(s)
- Bartosz Godlewski
- Department of Orthopaedics and Traumatology, with spinal Surgery Ward, Scanmed—St. Raphael Hospital, ul. Adama Bochenka 12, 04-141 Cracow, Poland
- Correspondence: ; Tel./Fax: +48-12-3855634
| | - Adam Bebenek
- Department of Orthopaedics and Traumatology, with spinal Surgery Ward, Scanmed—St. Raphael Hospital, ul. Adama Bochenka 12, 04-141 Cracow, Poland
| | - Maciej Dominiak
- Department of Orthopaedics and Traumatology, with spinal Surgery Ward, Scanmed—St. Raphael Hospital, ul. Adama Bochenka 12, 04-141 Cracow, Poland
| | - Marcin Bochniak
- Department of Orthopaedics and Traumatology, with spinal Surgery Ward, Scanmed—St. Raphael Hospital, ul. Adama Bochenka 12, 04-141 Cracow, Poland
| | - Piotr Cieslik
- Department of Orthopaedics and Traumatology, Military Institute of Medicine, 04-141 Warsaw, Poland
| | - Tomasz Pawelczyk
- Department of Affective and Psychotic Disorders, Medical University of Lodz, 92-213 Lodz, Poland
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14
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Yu H, Zhou Z, Yu B, Sun T, Tang Q, Jia Y. The efficacy of platelet-rich plasma applicated in spinal fusion surgery: A meta-analysis. Front Surg 2022; 9:924753. [PMID: 36211298 PMCID: PMC9537823 DOI: 10.3389/fsurg.2022.924753] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The purpose of this meta-analysis is to evaluate the effect of the application of platelet-rich plasma (PRP) in spinal fusion surgery on the fusion rate of the spine. Methods A comprehensive search of the PubMed, Embase, Cochrane Library, and Science Direct databases was conducted to identify randomized control trials (RCTs) or observational cohort studies that evaluated the efficacy and safety of PRP in spinal fusion. Data on final fusion rate, changes in the visual analog scale (VAS), estimated blood loss (EBL), and operative time was collected from the eligible studies for meta-analysis. Patients were divided into PRP and non-PRP groups according to whether PRP was used during the spinal fusion procedure. Results According to the selection criteria, 4 randomized controlled trials and 8 cohort studies with 833 patients and 918 levels were included. The outcomes indicated that PRP application is associated with a lower fusion rat (OR = 0.62, 95% CI: (0.43, 0.89), P = 0.009) at final follow-up (>24 months). Subgroup analysis showed a lower rate of spinal fusion in the PRP group compared to the non-PRP group (OR = 0.35, 95% CI: (0.21, 0.58), P < 0.001) when spinal fusion was assessed using only anterior-posterior radiographs. When the bone graft material was a combination of autologous bone + artificial bone, the spinal fusion rate was lower in the PRP group than in the non-PRP group (OR = 0.34, 95% CI: (0.16, 0.71), P = 0.004). The PRP and non-PRP groups showed no significant differences in VAS changes at the 24th postoperative month (WMD = 0.36, 95% CI: (−0.37, 1.09), P = 0.33); Application of PRP does not reduce the estimated blood loss (WMD = −86.03, 95% CI: (−188.23, 16.17), P = 0.10). In terms of operation time, using PRP does not prolong operation time (WMD = −3.74, 95% CI: (−20.53, 13.04), P = 0.66). Conclusion Compared with bone graft fusion alone, PRP cannot increase the rate of spinal fusion. Inappropriate methods of spinal fusion assessment or mixing PRP with artificial/allograft bone may have been responsible for the lower rate of spinal fusion in the PRP group. Systematic Review Registration doi: 10.37766/inplasy2022.5.0055
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Affiliation(s)
- Hongwei Yu
- School of Medicine, Nankai University, Tianjin, China
- Department of Spinal Surgery, Tian-jin Union Medical Centre, Nankai University People’s Hospital, Tianjin, China
| | - Zhaohong Zhou
- School of Medicine, Nankai University, Tianjin, China
- Department of Spinal Surgery, Tian-jin Union Medical Centre, Nankai University People’s Hospital, Tianjin, China
| | - Bin Yu
- Department of Spinal Surgery, Tian-jin Union Medical Centre, Nankai University People’s Hospital, Tianjin, China
- Correspondence: Bin Yu
| | - Tianwei Sun
- Department of Spinal Surgery, Tian-jin Union Medical Centre, Nankai University People’s Hospital, Tianjin, China
| | - Qiong Tang
- Department of Respiratory Medicine, Tian-jin Union Medical Centre, Nankai University People’s Hospital, Tianjin, China
| | - Yutao Jia
- Department of Spinal Surgery, Tian-jin Union Medical Centre, Nankai University People’s Hospital, Tianjin, China
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15
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Balouch E, Burapachaisri A, Woo D, Norris Z, Segar A, Ayres EW, Vasquez-Montes D, Buckland AJ, Razi A, Smith ML, Protopsaltis TS, Kim YH. Assessing Postoperative Pseudarthrosis in Anterior Cervical Discectomy and Fusion (ACDF) on Dynamic Radiographs Using Novel Angular Measurements. Spine (Phila Pa 1976) 2022; 47:1151-1156. [PMID: 35853174 DOI: 10.1097/brs.0000000000004375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/28/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective review of operative patients at a single institution. OBJECTIVE The aim was to validate a novel method of detecting pseudarthrosis on dynamic radiographs. SUMMARY OF BACKGROUND DATA A common complication after anterior cervical discectomy and fusion is pseudarthrosis. A previously published method for detecting pseudarthrosis identifies a 1 mm difference in interspinous motion (ISM), which requires calibration of images and relies on anatomic landmarks difficult to visualize. An alternative is to use angles between spinous processes, which does not require calibration and relies on more visible landmarks. MATERIALS AND METHODS ISM was measured on dynamic radiographs using the previously published linear method and new angular method. Angles were defined by lines from screw heads to dorsal points of spinous processes. Angular cutoff for fusion was calculated using a regression equation correlating linear and angular measures, based on the 1 mm linear cutoff. Pseudarthrosis was assessed with both cutoffs. Sensitivity, specificity, inter-reliability and intrareliability of angular and linear measures used postoperative computed tomography (CT) as the reference. RESULTS A total of 242 fused levels (81 allograft, 84 polyetheretherketone, 40 titanium, 37 standalone cages) were measured in 143 patients (mean age 52.0±11.5, 42%F). 36 patients (66 levels) had 1-year postoperative CTs; 13 patients (13 levels) had confirmed pseudarthrosis. Linear and angular measurements closely correlated ( R =0.872), with 2.3° corresponding to 1 mm linear ISM. Potential pseudarthroses was found in 28.0% and 18.5% levels using linear and angular cutoffs, respectively. Linear cutoff had 85% sensitivity, 87% specificity; angular cutoff had 85% sensitivity, 96% specificity for detecting CT-validated pseudarthrosis. Interclass correlation coefficients were 0.974 and 0.986 (both P <0.001); intrarater reliability averaged 0.953 and 0.974 ( P <0.001 for all) for linear and angular methods, respectively. CONCLUSIONS The angular measure for assessing potential pseudarthrosis is as sensitive as and more specific than published linear methods, has high interobserver reliability, and can be used without image calibration. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Eaman Balouch
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | | | - Dainn Woo
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Zoe Norris
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Anand Segar
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Ethan W Ayres
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | | | - Aaron J Buckland
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- Melbourne Orthopaedic Group, Melbourne Australia
- Spine and Scoliosis Research Associates, Melbourne Australia
| | | | | | | | - Yong H Kim
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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16
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PEEK versus titanium-coated PEEK cervical cages: fusion rate. Acta Neurochir (Wien) 2022; 164:1501-1507. [PMID: 35471708 DOI: 10.1007/s00701-022-05217-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/17/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed procedures for degenerative cervical disease. The evaluation of fusion status is still not fully standardized, and a variety of measurement methods are used. This study presents our own evaluation of fusion by comparing two types of implants. METHODS A total of 170 disc spaces were operated on in 104 patients using PEEK (polyetheretherketone) cages and titanium-coated (TC) PEEK cages. Patients were assigned to a specific implant using a randomisation table. Fusion status was evaluated based on functional radiographs and CT scans obtained at 12 months post-surgery. Multivariate mixed-effects logistic regression models were performed to assess the association of type of implant with different fusion rates. RESULTS At 12 months post-surgery, CT scans were performed in 86 patients (a total of 144 disc spaces) and conventional radiographs were obtained in 102 (a total of 166 disc spaces). Complete fusion was demonstrated in 101 cases (71.1%), partial fusion in 43 cases (29.9%). There were no cases of absence of fusion. A total of 85 PEEK cages (59%) and 59 TC-PEEK cages (41%) were implanted. For PEEK cages, complete fusion was seen in 75 (88.2%) disc spaces, compared to 26 (44.1%) achieved with TC-PEEK cages. A significantly higher proportion of complete fusions (B = 15.58; P < 0.0001) after 12 months was observed with PEEK implants compared to TC-PEEK implants. CONCLUSION Complete fusion was noted at 12 months post-surgery significantly more frequently with PEEK implants compared to TC-PEEK implants.
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Abstract
Pseudarthrosis of the cervical spine represents a common and challenging problem for spine surgeons. Rates vary greatly from as low as 0%-20% to >60% and depend heavily on patient factors, approach, and number of levels. While some patients remain asymptomatic from pseudarthrosis, many require revision surgery due to instability, continued neck pain, or radiculopathy/myelopathy. We aimed to provide a practical, narrative review of cervical pseudarthrosis to address the following areas: (1) definitions, (2) incidence, (3) risk factors, (4) presentation and workup, (5) treatment decision-making, and (6) postoperative care. It is our hope the current review provides a concise summary for how to diagnose and treat challenging cervical nonunions.
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Affiliation(s)
- Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
| | - Clinton J Devin
- Steamboat Orthopedic and Spine Institute, Steamboat Springs, CO
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Diagnosis of reoperated cervical non-union: Multicenter retrospective study about 45 patients. Orthop Traumatol Surg Res 2021; 107:102924. [PMID: 33845177 DOI: 10.1016/j.otsr.2021.102924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 09/04/2020] [Accepted: 09/15/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Non-union is one of the main complications of single- or multi-level cervical spine fusion, considerably impairing functional results. The aim of this study was to evaluate the respective contributions of imaging examinations in the diagnostic process, the challenge being to avoid inappropriate surgery and unnecessary complementary examinations. MATERIAL AND METHOD A retrospective multicenter study included all patients managed for cervical spine non-union between 2008 and 2018. We evaluated the imaging examinations performed on each patient and determined signs of non-union in each image. RESULTS The study included 45 patients in 4 centers: 55% female; mean age, of 48±8.0 years; 57% smokers. Systematic static radiography showed signs of non-union in 55% of cases. Dynamic X-ray was performed in 34% of patients, and showed hypermobility of the level in 80% of cases. CT supported diagnosis of non-union in 97% of cases, and MRI in 48%. SPECT-CT was positive in all cases of non-union. DISCUSSION Dynamic X-ray is rarely prescribed, but frequently provided an objective measure of hypermobility of the level in non-union, justifying first-line use. Millimetric-slice CT was reliable for diagnosis. MRI is relevant only once diagnosis has been made, as part of preoperative work-up. Nuclear imaging can be useful in order to solve doubtful cases. CONCLUSION In suspected cervical spine non-union, we recommend dynamic X-rays (flexion/extension) and CT-scan as first-line diagnosis examinations. LEVEL OF EVIDENCE IV.
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Shen YW, Yang Y, Liu H, Wu TK, Ma LT, Chen L, Hu LY, Ding C, Rong X, Wang BY, Meng Y, Hong Y. Preliminary results in anterior cervical discectomy and fusion with the uncovertebral joint fusion cage in a goat model. BMC Musculoskelet Disord 2021; 22:628. [PMID: 34273965 PMCID: PMC8286593 DOI: 10.1186/s12891-021-04412-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/28/2021] [Indexed: 02/08/2023] Open
Abstract
Objective To preliminarily evaluate the safety and efficacy of the uncovertebral joint fusion cage in a goat model of cervical spine interbody fusion. Methods Twenty-four healthy adult goats were randomly assigned to one of the two following groups: Group A, goats were implanted with an uncovertebral joint fusion cage combined with a local autograft and Group B, goats were implanted with a non-profile cage filled with a local autograft. The goats were prospectively evaluated for 24 weeks and then were sacrificed for evaluation. X-rays, CT and micro-CT scanning, and undecalcified bone histological analysis were used for the evaluation of fusion. Results 75.0% (9/12) of the goats in Group A were evaluated as having fusion at 12 weeks, compared to 41.7% (5/12) in Group B. 83.3% (10/12) of the goats in Group A were evaluated as having fusion at 24 weeks compared to 58.3% (7/12) in Group B. The fusion grading scores in Group A were significantly higher than that in Group B both at 12 weeks and 24 weeks (P < 0.05). Micro-CT scanning and undecalcified bone histological analysis showed that new bone formation can be obviously found in the bilateral uncovertebral joint. The bone volume fraction (BV/ TV) in Group A (23.59 ± 4.43%) was significantly higher than Group B (16.16 ± 4.21%), with P < 0.05. Conclusions Preliminary results of this study demonstrated that uncovertebral joint fusion cage is effective for achieving early bone formation and fusion without increase of serious complications.
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Affiliation(s)
- Yi-Wei Shen
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
| | - Yi Yang
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
| | - Hao Liu
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China.
| | - Ting-Kui Wu
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
| | - Li-Tai Ma
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
| | - Lin Chen
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
| | - Ling-Yun Hu
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
| | - Chen Ding
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
| | - Xin Rong
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
| | - Bei-Yu Wang
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
| | - Yang Meng
- Department of Orthopedic surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
| | - Ying Hong
- Department of Operation Room and Anesthesia Center, West China Hospital, Sichuan University, No. 37 Guo Xue Rd, Chengdu, 610041, China
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Kanna RM, Perambuduri AS, Shetty AP, Rajasekaran S. A Randomized Control Trial Comparing Local Autografts and Allografts in Single Level Anterior Cervical Discectomy and Fusion Using a StandAlone Cage. Asian Spine J 2020; 15:817-824. [PMID: 33189111 PMCID: PMC8696067 DOI: 10.31616/asj.2020.0182] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/21/2020] [Indexed: 11/23/2022] Open
Abstract
Study Design Randomized controlled trial. Purpose To compare the functional and radiological outcomes of anterior cervical discectomy and fusion (ACDF) using local graft and allograft Overview of Literature The choice of bone grafts for ACDF varies among different types: iliac crest, allograft, and substitutes. Availability, cost, and donor site morbidity are potential disadvantages. Local osteophyte grafts are then advantageous and shows to have good fusion. Methods We randomly sampled participants requiring a single level ACDF for degenerative conditions (n=27) between allograft (n=13) and local graft (n=14) groups. Follow-up of patients occurred at 6 weeks, 3 months, 6 months, and 1 year using Numerical Pain Rating Scale (NPRS) scores for arm and neck pain, Neck Disability Index (NDI), 2-item Short Form Health Survey (SF-12), and lateral disk height. We then assessed radiological fusion using computed tomography (CT) scan at 12 months, and graded as F− (no fusion), F (fusion seen through the cage), F+ (fusion seen through the cage, with bridging bone at one lateral edge), and F++ (fusion seen through cage with bridging bone bilaterally). Results There were no significant differences in the age, sex, duration of intervention, blood loss, and hospital stay between the two groups (p>0.05). Both groups showed significant improvements in all functional outcome scores including NPRS for arm and neck pain, NDI, and SF-12 at each visit (p<0.01). We observed a marked improvement in disk height in both groups (p<0.05), but at 1 year of follow-up, there was a significant though slight subsidence (p=0.47). CT at 1 year showed no non-unions. We recorded F, F+, and F++ grades of fusion in 23.2%, 38.4%, and 38.4% in allograft group and 28.6%, 42.8%, and 28.6% in local graft group, respectively, though no significant differences observed (p=0.73). Conclusions Marginal osteophytes are effective as graft inside cages for ACDF, since they provide similar radiological outcomes, and equivalent improvements in functional outcomes, as compared to allografts.
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Affiliation(s)
- Rishi Mugesh Kanna
- Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, India
| | | | - Ajoy Prasad Shetty
- Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, India
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Kroeze RJ, Verberne SJ, Graat H, Slot K, Pluymakers WJ, Temmerman O. Mid-Term and Long-Term Clinical and Radiological Outcomes of a Carbon I/F Stand-Alone Cage in Anterior Lumbar Interbody Fusion. Int J Spine Surg 2020; 14:665-670. [PMID: 33046539 DOI: 10.14444/7097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The current study was undertaken to determine the midterm and long-term radiological outcomes, complications and functional status of patients who underwent a single-level anterior interbody lumbar fusion (ALIF) procedure. SUMMARY OF BACKGROUND DATA Low back pain affects 70%-90% of the general population at some point in their life, and in general, the majority are best treated by nonsurgical therapy. However, a lumbar fusion can be considered in selected cases. In previous decades, lumbar interbody fusion procedures have gained popularity. Despite the approach used, stand-alone interbody fusion is becoming less popular due to poor fusion rates. When studying ALIF procedures, the addition of instrumentation results in higher fusion rates. Nevertheless, long-term follow-up can give either unexpected or similar insights into certain procedures that should be available in the current literature. Therefore, the current study was undertaken to determine the midterm and long-term radiological outcomes, complications, and functional status of patients who underwent a single-level ALIF procedure. METHODS A cohort of 50 patients was studied following stand-alone ALIF for midterm and long-term follow-up of 6.6 years and 19.7 years, respectively. Primary outcome measurements were disability using the Oswestry Disability Index (ODI) score and pain scores using the visual analog scale, and the MOS 36-item Short-Form Health Survey (SF-36) was used to evaluate the quality of life. In addition, radiographic assessment was performed to indicate the number of solid fusions. RESULTS After a mean of 19.7 years, we had a loss to follow-up of 34%. Functional measurements revealed an ODI of 41 for both time points and an SF-36 physical component score around 41.4 and 40.8 for the midterm and long-term follow-up, respectively. The mental component of the SF-36 was 48.7 and 49.9, respectively. The assessment of interbody fusion revealed only 66% and 70% solid fusion after 6.6 years and 19.7 years, respectively. CONCLUSIONS In concordance with previous studies, the outcome of midterm and long-term results in this study showed that the I/F cage in ALIF procedures is a safe treatment option for single-level interbody fusion. The radiological results corroborate literature regarding stand-alone interbody fusion, and additional instrumentation is likely to increase fusion rates. However, functional measurements reveal that the postsurgical situation remains likely worse than patients in a healthy Dutch population but possibly better that in a back pain population.
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Affiliation(s)
- R J Kroeze
- Department of Orthopaedic Surgery, St. Maartenskliniek, Nijmegen, The Netherlands
| | - S J Verberne
- Department of Orthopaedic Surgery, NWZ, Alkmaar, The Netherlands
| | - Hca Graat
- Department of Orthopaedic Surgery, NWZ, Alkmaar, The Netherlands
| | - K Slot
- Department of Orthopaedic Surgery, NWZ, Alkmaar, The Netherlands
| | - W J Pluymakers
- Department of Orthopaedic Surgery, NWZ, Alkmaar, The Netherlands
| | - Opp Temmerman
- Department of Orthopaedic Surgery, NWZ, Alkmaar, The Netherlands
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Dong C, Yang F, Wei H, Tan M. Anterior release without odontoidectomy for irreducible atlantoaxial dislocation: transoral or endoscopic transnasal? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:507-516. [PMID: 32654012 DOI: 10.1007/s00586-020-06527-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/30/2020] [Accepted: 07/01/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare transoral and endoscopic transnasal anterior release without odontoidectomy and posterior reduction and fixation to treat irreducible atlantoaxial dislocation (IAAD). METHODS From June 2006 to January 2017, 35 consecutive patients with IAAD underwent transoral (Tr-Oral group) or endoscopic transnasal (Tr-Nasal group) release and posterior fixation and fusion in our department. Clinical neurological recovery (Japanese Orthopedic Association (JOA) score) and radiological reduction parameters including atlantodontoid interval (ADI), space available for the cord (SAC) and cervicomedullary angle (CMA) were analyzed and compared. The operation duration, blood loss, length of intensive care unit (ICU)/hospital stay and complications were recorded. RESULTS All 35 patients (18 and 17 patients in the Tr-Oral and Tr-Nasal groups, respectively) were followed up for a mean of 36.4 months (range, 21-60 months). All patients achieved excellent anatomical reduction and clinical neurological recovery, with no significant differences between the two groups. The JOA score, ADI, SAC and CMA were not significantly different between the two groups at various postoperative points. Although the Tr-Oral group had shorter operation time and less blood loss than the Tr-Nasal group, the Tr-Nasal group tended to have a significantly shorter hospital/ICU stay, earlier extubation and earlier oral intake than the Tr-Oral group. CONCLUSION The transoral and endoscopic transnasal approaches can achieve equivalent release and reduction effects when treating IAAD. Compared to the transoral approach, the endoscopic transnasal route is less invasive with earlier extubation and oral intake, shorter hospital/ICU stays and lower medical costs, which is conducive to enhanced recovery after surgery.
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Affiliation(s)
- Chunke Dong
- Beijing University of Chinese Medicine, 11 North Third Ring Road East, Chaoyang District, Beijing, 100029, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Feng Yang
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Hongyu Wei
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Mingsheng Tan
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China.
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van Bilsen MWT, Ullrich C, Ferraris L, Hempfing A, Hitzl W, Mayer M, Koller H. Diagnostic accuracy of CT scan-based criteria compared with surgical exploration for the analysis of cervical fusion and nonunion. J Neurosurg Spine 2020; 33:51-57. [PMID: 32114527 DOI: 10.3171/2019.12.spine191011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/05/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Computed tomography (CT) scans are accepted as the imaging standard of reference to define union after anterior cervical discectomy and fusion (ACDF). However, ideal CT criteria to diagnose union have not been identified or validated. The objective of this study was to analyze the diagnostic value of 9 CT-based criteria and identify the ideal criteria among them to assess cervical fusion after ACDF using surgical exploration as the standard of reference. METHODS The authors performed a retrospective radiographic study of a single surgeon's prospective assessment of osseous fusion during cervical revision surgery by analyzing complete radiographic data in 44 patients who underwent anterior cervical revision surgery due to symptomatic suspected nonunion or adjacent level disease. All patients received standard preoperative CT scans, which were assessed by an independent radiologist to evaluate 9 diagnostic criteria for osseous union. During revision surgery, scar tissue was removed and manual segmental translation tests were performed. Nonunion was defined by visualized motion at the treated ACDF level. RESULTS In total, 44 patients were included in the study (30 men; patient age 54 ± 6 years, BMI 28 ± 5 kg/m2). For analysis of fusion, 75 cervical levels were explored, of which 61 levels (81%) showed intraoperative movement indicating nonunion. Statistical analysis showed that of the 9 parameters used to diagnose bone union, "bridging bone on ≥ 3 CT slices" yielded the highest sensitivity (100%) and specificity (58%). Multivariate analysis revealed that prediction accuracy was not increased if several criteria were combined to determine fusion. CONCLUSIONS The authors found that the best indicator of bone union was the item bridging bone on ≥ 3 CT slices. Combining the scoring of more than one criterion did not increase the diagnostic accuracy.
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Affiliation(s)
- Martine W T van Bilsen
- 1Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Christopher Ullrich
- 3Charlotte Radiology PA and Department of Radiology, Carolinas Medical Center, Charlotte, North Carolina
| | | | | | - Wolfgang Hitzl
- 6Research Office, Paracelsus Medical University, Salzburg, Austria; and
| | - Michael Mayer
- 7Wirbelsäulenzentrum am Stiglmaierplatz, Munich, Germany
| | - Heiko Koller
- 2Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Germany
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Dang L, Zhu J, Liu Z, Liu X, Jiang L, Wei F, Song C. A new approach to the treatment of spinal instability: Fusion or structural reinforcement without surgery? Med Hypotheses 2020; 144:109900. [PMID: 32562916 DOI: 10.1016/j.mehy.2020.109900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/24/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
Spinal instability related low back pain is a common condition resulting from degeneration and loss of stiffness of the intervertebral joint. In order to restore stability, highly invasive surgical fusion is needed for patients who are not responding to conservative treatment. Given the risk and complications of surgery, there has been the urge for improvement with a less invasive solution. Formation of vertebral body osteophytes is a common observation that has been treated as a degenerative condition. However, recent studies have associated it with reduced motion of spinal segments. Unlike the traditional view, we regard it as adaptive reactions aiming to repair and hypothesize that the spinal segments could be stabilized or fused by intentionally induced osteophytes growth at the mobile parts of the intervertebral joint. This could be achieved by injecting Bone Morphogenetic Proteins to the anterior ends of the vertebral bodies and/or the facet joints on both sides of two consecutive vertebrae percutaneously. If verified, it would be the first time that fusion could be achieved without surgery. Hence it would provide a valuable alternative to current treatments of spinal instability. Preliminary test in favor of this hypothesis is presented and we recommend that a formal study with sufficient number of samples is needed for verification.
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Affiliation(s)
- Lei Dang
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China
| | - Jinglin Zhu
- Department of Orthopedics, Beijing Shijitan Hospital, No. 10 Tieyi Rd., Yangfangdian Subdistrict, Haidian District, Beijing, PR China
| | - Zhongjun Liu
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China
| | - Xiaoguang Liu
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China
| | - Liang Jiang
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China
| | - Feng Wei
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China
| | - Chunli Song
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China.
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O'Donohoe TJ, Mililli L, Magee A, Thien C, Wang YY. Effect of the Presence and Type of Plate Augmentation on Postoperative Dysphagia Among Adult Patients Undergoing Elective Anterior Cervical Discectomy and Fusion for Spondylosis: A Randomized Trial. Neurospine 2020; 17:174-183. [PMID: 32252167 PMCID: PMC7136120 DOI: 10.14245/ns.1938446.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/28/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To determine the effect of anterior plating on postoperative dysphagia (POD) among adult patients undergoing elective anterior cervical discectomy and fusion (ACDF) for cervical spondylosis and determine the potential role of demographic and clinical characteristics in the development of POD. METHODS Consecutive adults undergoing an elective, single-level, ACDF were randomly assigned to receive a stand-alone CoRoent Cage or a CoRoent Cage with a Helix, or HelixMini plate. Patients with a history of cervical spine surgery were excluded. M. D. Anderson Dysphagia Inventory and Bazaz questionnaires were completed at regular intervals for 12 months postoperatively. RESULTS Twenty-five patients were recruited over a 2-year period, with 8 allocated to receive a stand-alone cage, 5 to receive a cage and Helix Mini plate, and 12 to receive a cage and Helix plate. The POD rate was 68% at 48 hours, before falling to 16% at 6 and 12 months. A longer retraction time was observed in the Helix plate group compared to the stand-alone cage group (7.88; 95% confidence interval, 0.12-15.63; p = 0.046), although there was no difference in the incidence or severity of dysphagia between cohorts at any timepoint. With the exception of body mass index, there was no difference in patients with and without dysphagia, and each of the interventions was equally efficacious with respect to clinical and radiological endpoints. CONCLUSION Dysphagia is a common consequence of ACDF and, while the placement of a large plate results in longer retraction time, it was not associated with higher rates of dysphagia. Further research is required to identify both patient-specific and surgical contributors to this complication.
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Affiliation(s)
- Tom J O'Donohoe
- Department of Neurosurgery, St. Vincent's Hospital, Fitzroy, VIC, Australia.,National Trauma Research Institute, Prahran, VIC, Australia
| | | | | | - Christopher Thien
- Department of Neurosurgery, St. Vincent's Hospital, Fitzroy, VIC, Australia
| | - Yi Yuen Wang
- Department of Neurosurgery, St. Vincent's Hospital, Fitzroy, VIC, Australia.,Keyhole Neurosurgery, Fitzroy, VIC, Australia
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Role of MRI in the assessment of interbody fusion with tantalum intervertebral implant. Orthop Traumatol Surg Res 2020; 106:285-289. [PMID: 32169395 DOI: 10.1016/j.otsr.2019.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 11/14/2019] [Accepted: 11/19/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Radiologic assessment of interbody fusion (IF) is controversial; thin-slice CT is the present gold standard despite artifacts due to the metal implant that hinder interpretation. The present study aimed to assess the contribution of MRI in IF assessment after instrumented posterior lumbar interbody fusion (PLIF) using tantalum intervertebral implants. The study hypothesis was that fusion following PLIF can be assessed on MRI. MATERIALS AND METHOD A single-center retrospective study included 52 single-level PLIF procedures (42 for degenerative disc disease and 10 for isthmic spondylolisthesis) using 2 tantalum intervertebral cages without interbody bone graft. Fusion was assessed at 1 year on static and dynamic X-ray and on MRI with a dedicated protocol. Two senior osteoarticular radiologists screened frontal and sagittal MRI slices for continuous cancellous interbody bridges. Consolidation was considered acquired (grade I) in case of continuous bridges on at least 2 successive frontal or sagittal slices, possible (grade II) in case of continuous bridge on just 1 slice, or absent (grade III) in case of no or discontinuous bridge. RESULTS Forty-eight patients were included, with a mean 55 months' follow-up (range, 25-74 months). There were no hardware failures. Intervertebral mobility on dynamic X-ray was systematically less than 5°. Fusion on MRI was grade I in 71% of cases, grade II in 8% and grade III in 21%. Interobserver agreement was 100% on X-ray and 81% on MRI, with kappa coefficient=0.56 (range, 0.35-0.77). DISCUSSION Tantalum implants without bone autograft enabled satisfactory standard radiographic study. MRI provided imperfect assessment of fusion, being contributive only in case of positive findings (71% in the present study); when no bridge is detected on MRI, no conclusion can be drawn. Progress in CT to reduce artifacts may improve fusion assessment, unless bone integration on both sides of the implant is considered to be sufficient for interbody continuity, without a continuous bone bridge between endplates being a requirement. LEVEL OF EVIDENCE IV.
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Structural Allograft versus Polyetheretherketone Implants in Patients Undergoing Spinal Fusion Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2020; 136:101-109. [DOI: 10.1016/j.wneu.2020.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 12/30/2022]
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Gandhi SD, Wahlmeier ST, Louie P, Sauber R, Tooley TR, Baker KC, Park DK. Effect of local retropharyngeal steroids on fusion rate after anterior cervical discectomy and fusion. Spine J 2020; 20:261-265. [PMID: 31505302 DOI: 10.1016/j.spinee.2019.08.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/27/2019] [Accepted: 08/27/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) is considered the gold standard surgical intervention for cervical myelopathy and radiculopathy. Obtaining a solid fusion is an important goal of ACDF, and doing so has correlated with favorable clinical outcomes. A common complication after surgery is postoperative dysphagia. Multiple techniques have been utilized in attempt to prevent and treat dysphagia, including use of retropharygeal steroids. PURPOSE To examine the effects of retropharyngeal steroids on fusion rate in ACDF. STUDY DESIGN Case control METHODS: Forty-two patients who received local retropharyngeal steroids during ACDF surgery were the sample patient population. The control group consisted of matched cases based on number of spinal levels treated and age at approximately 1:2 case to control ratio. Data were collected on demographic variables, as well as operative and postoperative courses. Radiographic data were collected and fusion determined by <2 mm motion on flexion/extension views and bridging bone. Data were compared between case and control populations. Continuous variables were compared using Student's t test and nominal/ordinal values were compared using Z-test. Fusion status was assessed using Pearson chi-squared test. RESULTS A total of 121 patients were reviewed based on matching status and sufficient follow-up. The case and control groups were successfully matched based on age, spinal levels treated, and smoking status. The case group had an overall fusion rate of 64.7%, whereas the control group had a fusion rate of 91%. When analyzed at each level of attempted fusion, the case group had a fusion rate of 81% compared to 93% in the control group. There was a single patient in the case group that developed esophageal rupture and retropharygeal abscess requiring surgical intervention with irrigation, debridement and repair at 8 months after index operation. CONCLUSIONS The use of retropharyngeal steroids to mitigate postoperative dysphagia is associated with a decreased rate of radiographic fusion in ACDF surgery.
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Affiliation(s)
- Sapan D Gandhi
- Department of Orthopaedic Surgery, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073, USA
| | - Steven T Wahlmeier
- Department of Orthopaedic Surgery, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073, USA.
| | - Philip Louie
- Department of Orthopaedic Surgery, Rush University, 1611 W. Harrison St, Suite 201, Chicago, IL 60612, USA
| | - Ryan Sauber
- Department of Orthopaedic Surgery, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073, USA; Department of Orthopaedic Surgery, Allegheny Health Network, Pittsburg, PA, USA
| | - Trevor R Tooley
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
| | - Kevin C Baker
- Department of Orthopaedic Surgery, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073, USA
| | - Daniel K Park
- Department of Orthopaedic Surgery, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073, USA
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Obermueller T, Wagner A, Kogler L, Joerger AK, Lange N, Lehmberg J, Meyer B, Shiban E. Radiographic measurements of cervical alignment, fusion and subsidence after ACDF surgery and their impact on clinical outcome. Acta Neurochir (Wien) 2020; 162:89-99. [PMID: 31758260 DOI: 10.1007/s00701-019-04139-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/04/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Some recent studies indicate correlations between cervical alignment and clinical outcome after anterior cervical discectomy and fusion (ACDF) surgery. However, there still are no established criteria for the interpretation of alignment, fusion and subsidence in relation to clinical outcome. METHODS A retrospective analysis of 208 radiographs of patients following ACDF with stand-alone PEEK cage implantation was performed. The measurements were obtained on plain radiographs in lateral and anteroposterior projections as well as flexion/extension radiographs. Cervical alignment was measured using the Gore, Laing and Cobb methods; fusion was evaluated by an assortment of radiographic hallmarks: the presence of bridging bone, the Cobb angle and the distances between the tips and bases of the spinous processes of the operated segments, respectively. For assessment of subsidence, we used the Mochida method in addition to ventral and dorsal segmental height reduction. Correlation analysis between the different radiological characteristics and clinical outcome at a minimum follow-up of 12 months was conducted. RESULTS Two hundred and eight patients were evaluated for alignment, fusion and subsidence. Cervical alignment using the Gore and Cobb methods correlated among each other, but failed to exhibit significant correlation with clinical outcome. Interpretation of fusion rates varied greatly (43.9 to 89.4%) depending on the criteria used. Pearson coefficients between radiographic presence of pseudarthrosis and the measurements of the spinous process distances (0.595; p < 0.001), the Cobb angles (0.187; p = 0.007) and the presence of bridging bone (0.224; p < 0.001) each exhibited statistical significance. None of the methods employed significantly correlated with clinical outcome. Regarding subsidence, we found rates of 62%, 48% and 27% using the Mochida, ventral and dorsal segmental height reduction assessment methods, respectively. Pearson correlations between pairs of Mochida/ventral (r = 0.39; p = 0.66) and Mochida/dorsal (r = 0.007; p = 0.921) height reduction assessment methods were weak and no significant correlation between subsidence rates and clinical outcome was shown. CONCLUSION All measured parameters varied depending in the measurement method used. This was most pronounced for fusion. There was a moderate positive correlation between neck pain and subsidence as measured by the Mochida method.
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Affiliation(s)
- Thomas Obermueller
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Lorenz Kogler
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ann-Kathrin Joerger
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Nicole Lange
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jens Lehmberg
- Department of Neurosurgery, Städtisches Klinikum München Bogenhausen, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ehab Shiban
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Tang X, Wu X, Tan M, Yi P, Yang F, Hao Q. Endoscopic transnasal anterior release and posterior reduction without odontoidectomy for irreducible atlantoaxial dislocation. J Orthop Surg Res 2019; 14:119. [PMID: 31060590 PMCID: PMC6501461 DOI: 10.1186/s13018-019-1167-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 04/26/2019] [Indexed: 11/16/2022] Open
Abstract
Background To investigate the efficacy and safety of endoscopic transnasal anterior release and posterior reduction without odontoidectomy to treat irreducible atlantoaxial dislocation (IAAD). Methods A series of 9 patients with IAAD underwent endoscopic transnasal anterior release and posterior reduction without odontoidectomy. Etiology, instrumentation, fusion rate, and complications were documented. All patients were assessed clinically and radiologically for neurological recovery using the Japanese Orthopedic Association (JOA) score, atlantodontoid interval (ADI), and cervicomedullary angle (CMA). Results The mean age of the patients was 41.6 years, ranging from 14 to 60 years. Pathology showed os odontoideum in 3 patients, old traumatic dens fracture in 3 patients, occipitalization of C1 in 2 patients, and rheumatoid arthritis in 1 patient. Seven patients underwent C1–C2 pedicle screw fixations, and 2 patients required occipitocervical fixation. Eight cases resulted in complete reduction and 1 in partial reduction. Complications included one superficial infection related to the posterior approach. All patients were followed up for an average of 17 (range 13–32) months. Bony fusion was confirmed in all cases under radiologic assessment at 1 year postoperatively, and the bony fusion rate reached 100%. Moreover, no instrumental failure occurred during the entire follow-up period. The JOA score improved from 7.21 ± 1.62 to 12.28 ± 0.81 at the last follow-up. The ADI of 9 cases was 7.06 ± 0.85 mm preoperatively, which decreased to 2.26 ± 0.56 mm at the final follow-up. CMA improved from 103.80° ± 4.16° to 143.23° ± 7.47° postoperatively. Conclusion With transnasal approach and lack of odontoidectomy, this method could not only treat IAAD safely and effectively, but also reduce the possibility of many complications associated with the traditional transoral approach and odontoidectomy.
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Affiliation(s)
- Xiangsheng Tang
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Xinjie Wu
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China.,Graduate School of Peking Union Medical College, Beijing, 100730, People's Republic of China
| | - Mingsheng Tan
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China. .,Graduate School of Peking Union Medical College, Beijing, 100730, People's Republic of China.
| | - Ping Yi
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Feng Yang
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Qingying Hao
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
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McDonald MA, Kirsch CF, Amin BY, Aulino JM, Bell AM, Cassidy RC, Chakraborty S, Choudhri AF, Gemme S, Lee RK, Luttrull MD, Metter DF, Moritani T, Reitman C, Shah LM, Sharma A, Shih RY, Snyder LA, Symko SC, Thiele R, Bykowski J. ACR Appropriateness Criteria® Cervical Neck Pain or Cervical Radiculopathy. J Am Coll Radiol 2019; 16:S57-S76. [DOI: 10.1016/j.jacr.2019.02.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 12/12/2022]
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Riew KD, Yang JJ, Chang DG, Park SM, Yeom JS, Lee JS, Jang EC, Song KS. What is the most accurate radiographic criterion to determine anterior cervical fusion? Spine J 2019; 19:469-475. [PMID: 29990594 DOI: 10.1016/j.spinee.2018.07.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/30/2018] [Accepted: 07/02/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The accuracy of radiographic criteria for determining anterior cervical fusion remains controversial, and inconsistency in the literature makes a comparison of published clinical results problematic. The descriptions of bridging bone are still lacking and subjective, and the interpretation of images can be influenced by the type of graft or cage used. PURPOSE To assess and validate the diagnostic accuracies of four radiographic fusion criteria using the results of surgical exploration. STUDY DESIGN Retrospective, radiographic, and comparative study. PATIENT SAMPLE This study included patients who required anterior or posterior exploration of a previous anterior cervical arthrodesis level(s) ranging from C3-C4 to C7-T1 for suspected pseudarthrosis or adjacent-segment pathologies. They underwent radiologic examinations to determine the four fusion criteria. We included patients whose images were taken at least 1 year after the index surgery, and 82 patients with 151 cervical segments were enrolled. OUTCOME MEASURES The inter- and intra-rater reliabilities and validity that correlated with the results of surgical exploration for the four fusion criteria were assessed using data (fusion or not) that were collected by two raters. METHODS The four published radiographic fusion criteria were interspinous motion (ISM) < 1 mm and superjacent ISM ≥ 4 mm, seen on dynamic radiographs; conventional bridging bone, as seen on computed tomography (CT) scans; and extra-graft bridging bone (ExGBB) and intragraft bridging bone (InGBB), observed on multi-axial reconstructed CT scans. The criteria were evaluated by two raters (spine surgeons with 5 and 7 years of experience). The raters evaluated each criterion twice at two different time points, 3 to 4 weeks apart. First, ISM and conventional bridging bone on CT scans were evaluated, followed by ExGBB and InGBB, with a time interval of 4 months. This Research was supported by the Chung-Ang University Research Grants (less than 5,000 US dollars) in 2016. RESULTS The inter- and intra-rater reliability values of the ExGBB (0.887-0.933) criteria were the highest, followed by those for the ISM (0.860-0.906), bridging bone (0.755-0.907), and InGBB (0.656-0.695) criteria. The validity values that correlated with the exploration results were the highest for the ExGBB criteria (k=0.889), followed by the ISM (k=0.776), bridging bone (k=0.757), and InGBB (k=0.656) criteria and ExGBB showed the highest sensitivity (91.7%) and specificity (98.4%). Regarding the graft materials that were used, all criteria had the highest values in the auto-cortical group and lowest values in the cage group. Of note, sensitivity and specificity of ExGBB were 100% in autocortical group. In the cage group, the validity values for the ExGBB (k=0.663) and ISM (k=0.666) criteria were higher than those for the bridging bone (k=0.504) and InGBB (k=0.308) criteria CONCLUSION: The presence of ExGBB (anterior, posterior, or lateral to the graft or cage) correlated the best with surgical exploration. The ISM criteria demonstrated a similar accuracy to that of conventional bridging bone criteria on CT scans. In arthrodesed segments with auto-cortical bone, criteria showed the highest validity values. In cage group, ISM and ExGBB had acceptable accuracy, but the conventional bridging bone and InGBB were worse than guessing. We recommend that ISM and ExGBB criteria should be used to increase accuracy in patients who undergo arthrodesis with cages.
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Affiliation(s)
- K Daniel Riew
- Department of Orthopedic Surgery, The Spine Hospital, Columbia University Medical Center, NY, USA
| | - Jae Jun Yang
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Republic of Korea
| | - Sang-Min Park
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jin S Yeom
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Sung Lee
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Eui-Chan Jang
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Kwang-Sup Song
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea.
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Radiographic and Clinical Outcomes following Combined Oblique Lumbar Interbody Fusion and Lateral Instrumentation for the Treatment of Degenerative Spine Deformity: A Preliminary Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5672162. [PMID: 30729127 PMCID: PMC6341239 DOI: 10.1155/2019/5672162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/27/2018] [Accepted: 12/16/2018] [Indexed: 11/18/2022]
Abstract
Objective The authors recently used a combination of minimally invasive oblique lumbar interbody fusion (OLIF) and lateral fixation for the treatment of degenerative spine deformity. The early results were promising. Radiographic and clinical results as well as complications were retrospectively assessed in the current study. Methods Eleven patients with degenerative spine deformity underwent combined OLIF and lateral instrumentation without real-time electromyography (EMG) monitoring. Radiographic measurements including coronal Cobb angle, central sacral vertebral line (CSVL), lumbar lordosis (LL), sagittal vertebral axis (SVA), pelvic tilt (PT), and LL-PI (pelvic incidence) mismatch were taken preoperatively and at last follow-up postoperatively in all patients. Concurrently, the visual analog score (VAS) for back pain and the Oswestry Disability Index (ODI) score were used to assess clinical outcomes. The fusion rate of OLIF cage, total blood loss, operation time, hospital stay, and complications were also evaluated. Results At last follow-up, all patients who underwent combined OLIF and lateral instrumentation achieved statistically significant improvement in coronal Cobb angle (from 15.3±4.7° to 5.9±3.1°, p < 0.01), LL (from 34.3±9.0° to 48.2±8.5°, p < 0.01), PT (from 24.2±9.6° to 16.2±6.0°, p < 0.01), LL-PI mismatch (from 15.4±8.7° to 7.0±3.7°, p < 0.01), CSVL (from 2.1±2.2cm to 0.7±0.9cm, p = 0.01), and SVA (from 7.0±3.9cm to 2.9±1.8cm, p < 0.01). VAS for back pain (from 6.9±1.4 to 2.0±0.9, p < 0.05) and ODI (from 39.5±3.1 to 21.9±3.6, p < 0.01) improved significantly after surgery. Conclusions A combination of OLIF and lateral instrumentation is an effective and safety means of achieving correction of both coronal and sagittal deformity, resulting in improvement of quality of life in patients with degenerative spine deformity. It is a promising way to treat patients with moderate degenerative spine deformity.
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Liu G, Tan JH, Yang C, Ruiz J, Wong HK. A Computed Tomography Analysis of the Success of Spinal Fusion Using Ultra-Low Dose (0.7 mg per Facet) of Recombinant Human Bone Morphogenetic Protein 2 in Multilevel Adult Degenerative Spinal Deformity Surgery. Asian Spine J 2018; 12:1010-1016. [PMID: 30322256 PMCID: PMC6284119 DOI: 10.31616/asj.2018.12.6.1010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 05/22/2018] [Indexed: 01/08/2023] Open
Abstract
Study Design Retrospective cohort study. Purpose To report on spinal fusion assessment using computed tomography (CT) after adult spinal deformity (ASD) surgery using ultra-low dose recombinant human bone morphogenetic protein 2 (RhBMP-2). Overview of Literature The reported dose of RhBMP-2 needed for successful spinal posterolateral fusion in ASD ranges from 10 to 20 mg per spinal level. This study reports the use of ultra-low dose of RhBMP-2 (0.07 mg per facet) to achieve spinal fusion in multilevel ASD surgery. Methods Consecutive patients who underwent ASD surgery using ultra-low dose RhBMP-2 were recruited. Routine postoperative CT analysis for spinal fusion was performed by two spine surgeons. Inter-observer agreement was calculated for facet fusion (FF) and interbody fusion (IBF) at 6 and 12 months after the procedure. Results Six consecutive ASD patients with a mean age of 62 years (28–72 years) were examined. Each patient received a total dose of 12 mg with an average dose of 0.69±0.2 mg (0.42–1 mg) per single FF and 1.38±0.44 mg (0.85–2 mg) for IBF. Total 131 FF and 15 IBF were examined in the study, with 88 FFs and nine IBFs being analyzed specifically at 6 months after the surgery. FF and IBF reported by surgeons A and B at 6 months were 97.7% vs. 91.9% FF, respectively (κ=0.95) and 100% vs. 100% IBF, respectively (κ=1). Two patients underwent longitudinal follow-up CT at 12 months, and the FF rates reported by surgeons A and B were 100% vs. 95.8%, respectively (κ=0.96). Five out of nine facet (56%) non-unions were identified at the cross-links. The remaining four facet pseudarthrosis were noted at 1–2 spinal levels caudal to the cross-links. At the final clinical follow-up, there was no rod breakage, deformity progression, neurological deficit, or symptom recurrence. The Oswestry Disability Index improved by an average of 32.8±6.3, while the mental component summary of the 36-item Short-Form Health Survey improved by an average of 4.7±2.1, and physical component summary improved by an average of 10.5±2.1. Conclusions To our knowledge, this is the first study to report a CT that defined 92%–98% FF and 100% IBF using the lowest reported dose of RhBMP-2 in multilevel ASD surgery. The use of ultra-low dose RhBMP-2 reduces the RhBMP-2 related complications and healthcare costs.
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Affiliation(s)
- Gabriel Liu
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Jun Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Changwei Yang
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - John Ruiz
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
| | - Hee-Kit Wong
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
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Lin W, Ha A, Boddapati V, Yuan W, Riew KD. Diagnosing Pseudoarthrosis After Anterior Cervical Discectomy and Fusion. Neurospine 2018; 15:194-205. [PMID: 31352693 PMCID: PMC6226130 DOI: 10.14245/ns.1836192.096] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 09/19/2018] [Indexed: 12/18/2022] Open
Abstract
Radiographic confirmation of fusion after anterior cervical discectomy and fusion (ACDF) surgery is a critical aspect of determining surgical success. However, there is a lack of established diagnostic radiographic parameters for pseudoarthrosis. The purpose of this study is to summarize the findings of previous studies, review the advantages and disadvantages of frequently employed diagnostic criteria, and present our recommended protocol of fusion assessment. This study identified randomized controlled trials, case-control studies, and prospective and retrospective cohort studies reporting on spinal fusion and how successful fusion after ACDF. Among the 39 articles reviewed, bridging bone across the operated levels on static radiographs was the most commonly used criteria to confirm fusion (31 of 39, 79%). Dynamic flexion-extension radiographs were used to assess for interspinous movement (ISM) (22 of 39, 56.4%) and change in Cobb angle (12 of 39, 30.8%). Computed tomography (CT) based findings (21 of 39, 53.8%) were employed in ambiguous cases with improved sensitivity and specificity. Reconstructed CT scans were used to assess for intragraft bridging bone and extragraft bridging bone (ExGBB). ExGBB were proved to have the highest diagnostic sensitivity and specificity for pseudoarthrosis detection when compared to all other radiographic criteria. The ISM <1 mm on dynamic flexion-extension radiographs had high diagnostic sensitivity and specificity as well. After our reviewing, we recommend using dynamic lateral flexion-extension cervical spine radiographs at 150% magnificationin which the interspinous motion <1 mm and superjacent interspinous motion ≥4 mm confirms fusion. In ambiguous cases, we recommend using reconstructed CT scans to evaluate for ExGBB.
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Affiliation(s)
- Wenbo Lin
- Department of Orthopedic, Changzheng Hospital, Second Military Medical University, Shang Hai, China
| | - Alex Ha
- Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital, New York-Presbyterian Healthcare System, New York, NY, USA
| | - Venkat Boddapati
- Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital, New York-Presbyterian Healthcare System, New York, NY, USA
| | - Wen Yuan
- Department of Orthopedic, Changzheng Hospital, Second Military Medical University, Shang Hai, China
| | - K Daniel Riew
- Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital, New York-Presbyterian Healthcare System, New York, NY, USA
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Kitchen D, Rao PJ, Zotti M, Woodman R, Sampson MJ, Allison D, Phan K, Selby M. Fusion Assessment by MRI in Comparison With CT in Anterior Lumbar Interbody Fusion: A Prospective Study. Global Spine J 2018; 8:586-592. [PMID: 30202712 PMCID: PMC6125925 DOI: 10.1177/2192568218757483] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES To evaluate the role of magnetic resonance imaging (MRI) in evaluation of fusion status following anterior lumbar interbody fusion (ALIF) and compare agreement and confidence in assessing fusion or its absence on MRI to the current standard computed tomography (CT). METHODS A prospective follow up of patients undergoing surgery by 2 spine surgeons between 2012 and 2015 at a single institution. Fusion was assessed at different time points in these patients by 2 independent musculoskeletal radiologists. Fusion was analyzed in coronal and sagittal planes using both imaging modalities, with confidence being attributed on a scale of 0 to 3. Assessors were blinded to patient data. RESULTS Fourteen patients (25 levels) with mean follow-up of 10.2 months (range 2.4-20.3 years) and age of 41 years (range 20.7-61.5 years) were assessed. MRI within the interbody cage in coronal (κ = .58) and sagittal (κ = .50) planes had the highest interobserver agreement. CT anterior to the cage in coronal (κ = .48) and sagittal (κ = .44) planes, as well as within the cage in coronal (κ = .50) and sagittal planes (κ = .44) showed moderate agreement. Confidence anterior to the interbody cage using MRI scan was reduced when compared with remaining angles and imaging modalities. CONCLUSIONS The study demonstrates that MRI may be a useful tool in the assessment of fusion following ALIF with results comparable to CT, and that it may have a useful role in select patients especially considering marked radiation exposure reduction.
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Affiliation(s)
- David Kitchen
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanth J. Rao
- Neurospine Research Group, Adelaide, South Australia, Australia,Westmead Hospital, Westmead, Australia,University of Sydney, Sydney, Australia,Prashanth J. Rao, Royal Adelaide Hospital, Suite 3, Level 3, 20-22 Mons Road Westmead, Sydney, Australia, 2145.
| | - Mario Zotti
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Matthew J. Sampson
- Flinders University, Adelaide, South Australia, Australia,Benson Radiology, Adelaide, South Australia, Australia
| | - Dale Allison
- Benson Radiology, Adelaide, South Australia, Australia,Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Kevin Phan
- Neurospine Research Group, Adelaide, South Australia, Australia
| | - Michael Selby
- Royal Adelaide Hospital, Adelaide, South Australia, Australia,Queen Elizabeth Hospital, Adelaide, South Australia, Australia,University of Adelaide, Adelaide, South Australia, Australia
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Wu X, Li Y, Tan M, Yi P, Yang F, Tang X, Hao Q. Long-Term Clinical and Radiologic Postoperative Outcomes After C1-C2 Pedicle Screw Techniques for Pediatric Atlantoaxial Rotatory Dislocation. World Neurosurg 2018; 115:e404-e421. [PMID: 29678707 DOI: 10.1016/j.wneu.2018.04.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/08/2018] [Accepted: 04/09/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although C1-C2 pedicle screw techniques have been extensively reported in pediatric series, reports on their use have examined only small series with short follow-up periods. The aim of this study was to report pediatric patients with atlantoaxial rotatory dislocation treated with these techniques with a minimum 5-year follow-up. METHODS Retrospective review was performed of 27 pediatric patients with atlantoaxial rotatory dislocation who underwent C1-C2 pedicle screw fixation between 2004 and 2012. Clinical and radiographic outcomes were collected and compared with a control group. RESULTS Follow-up period was 60-142 months (mean 84 months). Torticollis was completely corrected postoperatively in all but 1 patient. All patients experienced significant pain relief and improvement in range of motion, and 6 patients with neurologic deficits experienced significant improvement postoperatively. Both atlantodental interval and space available for the cord were significantly improved compared with preoperative values. At final follow-up, curvature was lordotic in 20 cases and straight in 7 cases. Compared with the control group, range of motion of the patient group was not significantly different in any direction except in flexion and rotation. Mean anteroposterior diameters of the spinal canal at C1 and C2 levels were not significantly different from the control group. CONCLUSIONS C1-C2 pedicle screw techniques are safe and effective for treatment of atlantoaxial rotatory dislocation and result in no obvious limitation on growth in older children.
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Affiliation(s)
- Xinjie Wu
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China; Graduate School of Peking Union Medical College, Beijing, China
| | - Yafeng Li
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Mingsheng Tan
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China; Graduate School of Peking Union Medical College, Beijing, China.
| | - Ping Yi
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Feng Yang
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xiangsheng Tang
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Qingying Hao
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China
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Implantation of an empty polyetheretherketone cage in anterior cervical discectomy and fusion: a prospective randomised controlled study with 2 years follow-up. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1358-1364. [PMID: 29322313 DOI: 10.1007/s00586-017-5450-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 12/25/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To compare the clinical outcomes, radiographic results and fusion rate of ACDF between empty PEEK cages and PEEK cages packed with β-tricalcium phosphate. METHODS Forty-five patients were prospectively enrolled with cervical degenerative disc disease who requiring ACDF with a PEEK cage. 23 patients were randomised to the study group (empty cages) and 22 patients were in the control group (cages filled with β-tricalcium phosphate). Both patient groups were fixed with a cervical locking plate. A CT scan was performed 12 months postoperatively and 24 months if not confirmed fused at 12 months to evaluate the status of fusion. Clinical status was evaluated using the Japanese Orthopaedic Association (JOA) score, the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS). RESULTS 46 levels (97.88%) in the study group and 44 levels (97.77%) in the control group were confirmed as fused at 24 months. There was no significant difference between the fusion rates observed in the study and control groups (p = 0.82). There was no significant difference in JOA, ODI, or VAS scores at 24 months follow-up. The results showed that the members of the non-fusion group tended to be older than the individuals in the fusion group at 12 months, but was not significant in statistics. CONCLUSIONS Similar fusion rates and clinical outcomes were achieved when using ACDF with PEEK cages and instrumentation, regardless of whether the cage was filled with bone substitute at 24 months follow-up. Fusion rates improved over time and are comparable between both groups. These slides can be retrieved under Electronic Supplementary material.
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Kani KK, Chew FS. Anterior cervical discectomy and fusion: review and update for radiologists. Skeletal Radiol 2018; 47:7-17. [PMID: 29058045 DOI: 10.1007/s00256-017-2798-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 10/06/2017] [Accepted: 10/11/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The goals of this article are to describe the various types of interbody grafts and anterior cervical plating systems, techniques for optimizing evaluation of cervical spine metallic implants on CT and MR imaging, expected appearance and complications of ACDF on postoperative imaging and imaging assessment of fusion. Optimization for optimizing metal induced artifacts. CONCLUSION Currently, ACDF is the most commonly performed surgical procedure for degenerative cervical spine disease. Interbody fusion is performed with bone grafts or interbody spacers, and may be supplemented with anterior cervical plating. Compressive pathologies at the vertebral body level may be addressed by simultaneous corpectomy. Postoperatively, imaging plays an integral role in routine screening of asymptomatic individuals, fusion assessment and evaluation of complications.
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Affiliation(s)
- Kimia Khalatbari Kani
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Felix S Chew
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
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Preoperative Radiographic Parameters to Predict a Higher Pseudarthrosis Rate After Anterior Cervical Discectomy and Fusion. Spine (Phila Pa 1976) 2017; 42:1772-1778. [PMID: 28459780 DOI: 10.1097/brs.0000000000002219] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To determine whether postoperative pseudarthrosis can be predicted from specific preoperative radiograph measurements. SUMMARY OF BACKGROUND DATA Various factors reportedly influence the occurrence of pseudarthrosis after anterior cervical discectomy and fusion (ACDF). However, to our knowledge, there are no reports on the relationships between preoperative radiographic parameters and pseudarthrosis. METHODS We analyzed 84 consecutive patients (45 males, 39 females, mean age, 58.9 ± 11.2 yrs) who underwent ACDF. In all patients, allografts filled with local chip bone were inserted after discectomy and anterior plating was performed. On preoperative plain radiographs, we analyzed C2-C7 sagittal vertical axis, T1 sagittal slope, segmental motion, global cervical motion, and location of fusion segments. Pseudarthrosis was diagnosed as interspinous motion >1 mm with superjacent interspinous motion ≥4 mm on magnified dynamic lateral radiographs. Multivariate logistic regression was used to analyze the risk factors for pseudarthrosis and the receiver operating characteristic (ROC) curve was used to define a cutoff value. RESULTS One hundred and twenty-five segments from 84 patients were included. The pseudarthrosis rate was 29% based on number of patients (24/84) and 20% based on number of segments (25/125). Multilevel surgery and segments at the lowest levels showed higher pseudarthrosis rates (P = 0.01). Per multivariate logistic regression analysis, greater preoperative segmental motion, greater preoperative T1 sagittal slope, and C6-7 segments were associated with a higher risk of pseudarthrosis (all P < 0.05). A segmental motion cutoff value of 12° demonstrated pseudarthrosis with sensitivity of 87%, specificity of 84%, and area under the curve of 0.899, indicating moderate accuracy. CONCLUSION Greater preoperative segmental motion, greater preoperative T1 sagittal slope, and lower fusion levels could be risk factors for pseudarthrosis following ACDF. Preoperative segmental motion >12° is likely to be an important indicator of the development of pseudarthrosis. LEVEL OF EVIDENCE 3.
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Kwon SW, Kim CH, Chung CK, Park TH, Woo SH, Lee SJ, Yang SH. The Formation of Extragraft Bone Bridging after Anterior Cervical Discectomy and Fusion: A Finite Element Analysis. J Korean Neurosurg Soc 2017; 60:611-619. [PMID: 29142619 PMCID: PMC5678065 DOI: 10.3340/jkns.2017.0178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/05/2017] [Accepted: 07/20/2017] [Indexed: 11/27/2022] Open
Abstract
Objective In addition to bone bridging inside a cage or graft (intragraft bone bridging, InGBB), extragraft bone bridging (ExGBB) is commonly observed after anterior cervical discectomy and fusion (ACDF) with a stand-alone cage. However, solid bony fusion without the formation of ExGBB might be a desirable condition. We hypothesized that an insufficient contact area for InGBB might be a causative factor for ExGBB. The objective was to determine the minimal area of InGBB by finite element analysis. Methods A validated 3-dimensional, nonlinear ligamentous cervical segment (C3-7) finite element model was used. This study simulated a single-level ACDF at C5-6 with a cylindroid interbody graft. The variables were the properties of the incorporated interbody graft (cancellous bone [Young's modulus of 100 or 300 MPa] to cortical bone [10000 MPa]) and the contact area between the vertebra and interbody graft (Graft-area, from 10 to 200 mm2). Interspinous motion between the flexion and extension models of less than 2 mm was considered solid fusion. Results The minimal Graft-areas for solid fusion were 190 mm2, 140 mm2, and 100 mm2 with graft properties of 100, 300, and 10000 MPa, respectively. The minimal Graft-areas were generally unobtainable with only the formation of InGBB after the use of a commercial stand-alone cage. Conclusion ExGBB may be formed to compensate for insufficient InGBB. Although various factors may be involved, solid fusion with less formation of ExGBB may be achieved with refinements in biomaterials, such as the use of osteoinductive cage materials; changes in cage design, such as increasing the area of polyetheretherketone or the inside cage area for bone grafts; or surgical techniques, such as the use of plate/screw systems.
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Affiliation(s)
- Shin Won Kwon
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Clinical Research Institute, Seoul National University Hospital, Seoul, Korea.,Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Korea
| | - Tae Hyun Park
- Department of Biomedical Engineering, Inje University, Gimhae, Korea.,R&D Center, Medyssey Co., Ltd, Jecheon, Korea
| | - Su Heon Woo
- Department of Biomedical Engineering, Inje University, Gimhae, Korea.,R&D Center, Medyssey Co., Ltd, Jecheon, Korea
| | - Sung-Jae Lee
- Department of Biomedical Engineering, Inje University, Gimhae, Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
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Street M, Gao R, Martis W, Munro J, Musson D, Cornish J, Ferguson J. The Efficacy of Local Autologous Bone Dust: A Systematic Review. Spine Deform 2017. [PMID: 28622897 DOI: 10.1016/j.jspd.2017.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
STUDY DESIGN A systematic review of bone dust as an autologous bone graft to encourage osseous fusion. OBJECTIVE To identify and review studies that report on the therapeutic potential of bone dust. The research question was structured as follows: populations-animal and human sources of bone dust harvested using burrs; interventions-autologous bone dust compared with other clinically utilized bone graft options; outcomes assessed-(1) in vitro cell viability, cell differentiation, and osteogenic potential and (2) clinical efficacy in the form of fusion rates as assessed using plain radiographs; study designs-in vitro, preclinical in vivo and clinical studies investigating the therapeutic potential of bone dust, harvested by burring, are included in this systematic review. SUMMARY OF BACKGROUND DATA Little is known about the efficacy of bone dust, generated during burring of local bone in spine surgery, as a bone graft to encourage osseous union. METHODS A systematic search was conducted in Medline, PubMed, OVID, Scopus, and Cochrane library. The following key words were used: bone dust, bone burring, bone paste, bone pate. RESULTS A total of 285 studies were reviewed. Fourteen articles were identified as relevant for inclusion in this systematic review. Current evidence suggests that bone dust retains osteogenic properties, but limited information is available regarding the osteoinductive potential of bone dust. CONCLUSION Bone dust represents a free source of autologous bone, which can be easily collected during the time of surgery and used as an augment to aid osseous fusion. Further research is required to evaluate the osteoinductive potential of bone dust. The retained growth factors in bone dust may potentially induce local osteoprogenitor cells to proliferate and mineralize to form new bone.
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Affiliation(s)
- Matthew Street
- Auckland Bone and Joint Research Group, Bone and Joint Research Group, 85 Park Road, Grafton, Auckland 1023, New Zealand.
| | - Ryan Gao
- Auckland Bone and Joint Research Group, Bone and Joint Research Group, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Waldron Martis
- University of Auckland Medical School, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Jacob Munro
- Department of Orthopedic Surgery, Auckland District Health Board, Auckland 1023, New Zealand
| | - David Musson
- Auckland Bone and Joint Research Group, Bone and Joint Research Group, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Jillian Cornish
- Auckland Bone and Joint Research Group, Bone and Joint Research Group, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - John Ferguson
- Department of Orthopedic Surgery, Auckland District Health Board, Auckland 1023, New Zealand
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Analysis of the Fusion and Graft Resorption Rates, as Measured by Computed Tomography, 1 Year After Posterior Cervical Fusion Using a Cervical Pedicle Screw. World Neurosurg 2017; 99:171-178. [DOI: 10.1016/j.wneu.2016.12.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/07/2016] [Accepted: 12/08/2016] [Indexed: 11/22/2022]
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Pseudarthrosis of the Cervical Spine: Risk Factors, Diagnosis and Management. Asian Spine J 2016; 10:776-86. [PMID: 27559462 PMCID: PMC4995265 DOI: 10.4184/asj.2016.10.4.776] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 10/13/2015] [Indexed: 01/11/2023] Open
Abstract
Cervical myelopathy and radiculopathy are common pathologies that often improve with spinal decompression and fusion. Postoperative complications include pseudarthrosis, which can be challenging to diagnose and manage. We reviewed the literature with regard to risk factors, diagnosis, controversies, and management of cervical pseudarthrosis.
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Liu Y, Luo X, Zhou J, Li N, Peng S, Rong P, Wang W. Prognosis of posterior osteophyte after anterior cervical decompression and fusion in patients with cervical spondylotic myelopathy using three-dimensional computed tomography study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:1861-8. [PMID: 26931332 DOI: 10.1007/s00586-016-4390-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 01/11/2016] [Accepted: 01/15/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Inadequacy of posterior osteophyte resection in anterior cervical decompression and fusion (ACDF) surgery has long been a clinical concern as it may influence surgical outcome. There has been no agreement on the prognosis in the presence of remnant posterior osteophytes. METHODS This study retrospectively investigated 26 cervical spondylotic myelopathy patients after ACDF in whom a remnant posterior osteophyte was identified by long-term follow-up CT scans (minimum of 2 years). Remnant posterior osteophytes and osseous spinal canal were measured and compared between pre-operation CT and long-term post-operation CT. The post-operative clinical outcomes were also studied. RESULTS The remnant osteophytes did not obviously decrease in size in any patient and significantly enlarged in 10 patients, with a new posterior osteophyte developing in one patient. In patients whose remnant osteophyte is enlarged, the incidence of pseudoarthrosis, as well as clinical deterioration during follow-up was significantly higher than patients with stable osteophytes. CONCLUSION Contrary to previous reports, none of the remnant posterior osteophytes decreased obviously in size during follow up. Despite the persistence of posterior osteophytes, ACDF is still effective in CSM treatment. Posterior osteophyte enlargement at fused segment appears to be associated with symptomatic pseudoarthrosis and clinical deterioration after surgery.
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Affiliation(s)
- Yin Liu
- Department of Radiology, The Third Xiangya Hospital, Central South University, Tongzipo Road 138, Changsha, 410013, Hunan, People's Republic of China
| | - Xianming Luo
- Department of Radiology, The Third Xiangya Hospital, Central South University, Tongzipo Road 138, Changsha, 410013, Hunan, People's Republic of China
| | - Jiahui Zhou
- Department of Orthopeadics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Na Li
- Department of Radiology, The Third Xiangya Hospital, Central South University, Tongzipo Road 138, Changsha, 410013, Hunan, People's Republic of China
| | - Song Peng
- Department of Radiology, The Third Xiangya Hospital, Central South University, Tongzipo Road 138, Changsha, 410013, Hunan, People's Republic of China
| | - Pengfei Rong
- Department of Radiology, The Third Xiangya Hospital, Central South University, Tongzipo Road 138, Changsha, 410013, Hunan, People's Republic of China
| | - Wei Wang
- Department of Radiology, The Third Xiangya Hospital, Central South University, Tongzipo Road 138, Changsha, 410013, Hunan, People's Republic of China.
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Derakhshan A, Lubelski D, Steinmetz MP, Benzel EC, Mroz TE. Utility of Computed Tomography following Anterior Cervical Diskectomy and Fusion. Global Spine J 2015; 5:411-6. [PMID: 26430596 PMCID: PMC4577315 DOI: 10.1055/s-0035-1554773] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 03/16/2015] [Indexed: 11/22/2022] Open
Abstract
Study Design Retrospective case series. Objective To assess the utility of postoperative computed tomography (CT) following anterior cervical diskectomy and fusion (ACDF) and to determine the clinical circumstances most likely to lead to an abnormal CT scan. Methods Patients who underwent ACDF at a tertiary center over a span of 5 years were investigated. Only patients who had a minimum of 6 months' postoperative follow-up and a CT within 2 years after the surgery were included in the study group. All the postoperative notes were reviewed to determine indications for the CT, abnormalities identified, and whether the scan led to an alteration in the treatment course. Results The charts of 690 patients who underwent ACDF were reviewed. Of the 690 patients, 45 (7%) had postoperative CTs. These patients accounted for 53 postoperative CT scans, 45 (85%) of which were taken for patients who expressed persistent postoperative symptoms and/or had abnormal imaging. There were no indications for 8 (15%) of the CTs. Patients who had a CT for persistent symptoms and/or abnormal preliminary imaging were significantly more likely to have an abnormal CT (p = 0.03) and/or an alteration in treatment course (p = 0.04) compared with those with no symptomatic or radiologic indication for CT. Conclusions CT is associated with minimal utility regarding the alteration of treatment course when employed in asymptomatic patients. Postoperative CT should be ordered solely for symptomatic patients or those with other abnormal preliminary imaging. Judicious use of postoperative CT will limit the radiation exposure and cost.
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Affiliation(s)
- Adeeb Derakhshan
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Daniel Lubelski
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Michael P. Steinmetz
- Department of Neurosciences and Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, United States
| | - Edward C. Benzel
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Thomas E. Mroz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States,Address for correspondence Thomas E. Mroz, MD Departments of Orthopaedic and Neurological SurgeryCenter for Spine Health, The Cleveland Clinic, 9500 Euclid Avenue, S-40, Cleveland, OH 44195United States
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Abstract
STUDY DESIGN Systematic review. OBJECTIVE To determine best criteria for radiological determination of postoperative subaxial cervical fusion to be applied to current clinical practice and ongoing future research assessing fusion to standardize assessment and improve comparability. SUMMARY OF BACKGROUND DATA Despite availability of multiple imaging modalities and criteria, there remains no method of determining cervical fusion with absolute certainty, nor clear consensus on specific criteria to be applied. METHODS A systematic search in MEDLINE/Cochrane Collaboration Library (through March 2014). Included studies assessed C2 to C7 via anterior or posterior approach, at 12 weeks or more postoperative, with any graft or implant. Overall body of evidence with respect to 6 posited key questions was determined using Grading of Recommendations Assessment, Development and Evaluation and Agency for Healthcare Research and Quality precepts. RESULTS Of plain radiographical modalities, there is moderate evidence that the interspinous process motion method (<1 mm) is more accurate than the Cobb angle method for assessing anterior cervical fusion. Of the advanced imaging modalities, there is moderate evidence that computed tomography (CT) is more accurate and reliable than magnetic resonance imaging in assessing anterior cervical fusion. There is insufficient evidence regarding the optimal modality and criteria for assessing posterior cervical fusions and insufficient evidence to support a single time point after surgery as being optimal for determining fusion, although some evidence suggest that reliability of radiography and CT improves with increasing time postoperatively. CONCLUSION We recommend using less than 1-mm motion as the initial modality for determining anterior cervical arthrodesis for both clinical and research applications. If further imaging is needed because of indeterminate radiographical evaluation, we recommend CT, which has relatively high accuracy and reliability, but due to greater radiation exposure and cost, it is not routinely suggested. We recommend that plain radiographs also be the initial method of determining posterior cervical fusion but suggest a lower threshold for obtaining CT scans because dynamic radiographs may not be as useful if spinous processes have been removed by laminectomy. LEVEL OF EVIDENCE 1.
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Osteocel Plus cellular allograft in anterior cervical discectomy and fusion: evaluation of clinical and radiographic outcomes from a prospective multicenter study. Spine (Phila Pa 1976) 2014; 39:E1331-7. [PMID: 25188591 DOI: 10.1097/brs.0000000000000557] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, multicenter, nonrandomized, institutional review board-approved clinical and radiographic study. OBJECTIVE To evaluate and summarize the 2-year outcomes of patients treated with Osteocel Plus cellular allograft as part of an anterior cervical discectomy and fusion procedure. SUMMARY OF BACKGROUND DATA Osteocel Plus is an allograft cellular bone matrix containing native mesenchymal stem cells and osteoprogenitor cells that is intended to mimic the performance of iliac crest autograft without the morbidity associated with its harvest. METHODS A total of 182 patients were treated with anterior cervical discectomy and fusion using Osteocel Plus in a polyetheretherketone cage and anterior plating at 1 or 2 consecutive levels. Clinical outcomes included visual analogue scale for neck and arm pain, neck disability index, and SF-12 physical and mental component scores. Computed tomography and plain film radiographic measures included assessment of bridging bone, disc height, disc angle, and segmental range of motion. RESULTS A total of 249 levels were treated in 182 patients. Mean procedure time was 100 minutes, blood loss was less than 50 mL in 93% of patients, and hospital stay was 1 day or less in 84% of patients. Significant (P<0.05) average improvements in clinical outcomes from preoperatively to 24 months included the following: neck disability index: 21.5%; visual analogue scale neck: 34 mm; visual analogue scale arm: 35 mm; SF-12 physical component score: 11.2; SF-12 mental component score: 6.8. At 24 months, 93% of patients were satisfied with their outcome. In patients treated at a single level with a minimum of 24-month follow-up, 92% (79/86) of levels achieved solid bridging and 95% of levels demonstrated range of motion of less than 3°. In combined single- and 2-level procedures, 87% (157/180) of levels achieved solid bridging and 92% (148/161) had range of motion of less than 3° at 24 months. No patient required revision for pseudarthrosis. CONCLUSION Improvements in clinical results at 2 years, high patient satisfaction, and high radiographic and clinical fusion rates provide confidence in Osteocel Plus as an effective alternative to structural allograft or autograft in anterior cervical discectomy and fusion procedures. LEVEL OF EVIDENCE 4.
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Song KS, Piyaskulkaew C, Chuntarapas T, Buchowski JM, Kim HJ, Park MS, Kang H, Riew KD. Dynamic radiographic criteria for detecting pseudarthrosis following anterior cervical arthrodesis. J Bone Joint Surg Am 2014; 96:557-63. [PMID: 24695922 DOI: 10.2106/jbjs.m.00167] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND While interspinous motion analysis is commonly used to determine the status of an anterior cervical fusion, the accuracy of this technique is unclear. We believed that three questions needed to be answered. What degree of image magnification is ideal? How much motion should be considered "adequate" for making dynamic radiographs? What is the optimal amount of interspinous motion for detecting pseudarthrosis? METHODS We performed a retrospective study of 125 patients (109 fused segments and 153 pseudarthrotic segments) who had undergone reexploration with confirmation of fusion status. Interspinous motion at each operatively treated level and one superjacent level was measured by two independent investigators twice. Reliabilities of interspinous motion analysis at different magnification rates (25%, 100%, 150%, and 200%) were evaluated for fifty randomly selected segments to determine the optimal magnification, which we used for the remainder of the measurements. Fusion status was also determined on computed tomography (CT) by two other raters. We compared the intraoperative findings with those based on dynamic radiographs (with use of cutoff values of 1 and 2 mm of interspinous motion as the indication of pseudarthrosis) and CT. RESULTS On radiographs, both 150% and 200% magnification yielded higher interobserver and intraobserver reliabilities compared with 25% and 100% magnification, and the reliabilities at 150% and 200% were similar to each other, so subsequent measurements were made at 150%. The cutoff value of interspinous motion for detecting pseudarthrosis was 0.9 mm as determined with receiver operating characteristic curve analysis. Compared with CT, interspinous motion of ≥ 1 mm showed relatively low sensitivity (79.5%) and negative predictive value (77.1%) and similar specificity (97.0%) and positive predictive value (97.4%). Using interspinous motion of ≥ 2 mm as the cutoff decreased the sensitivity and negative predictive value to 46.6% and 56.8%, respectively. Our evaluation of what constituted adequate dynamic motion for making the radiographs showed that, with use of interspinous motion of ≥ 1 mm as the cutoff for detecting pseudarthrosis, superjacent interspinous motion of ≥ 4 mm increased the sensitivity and negative predictive value (86.3% and 83.4%) compared with those associated with alternative cutoffs of superjacent interspinous motion (≥ 3.5, ≥ 5, and ≥ 6 mm), and the specificity (96.1%) and positive predictive value (96.9%) were reasonable. CONCLUSIONS Use of interspinous motion of ≥ 1 mm as the cutoff for detection of anterior cervical pseudarthrosis on radiographs magnified 150% and made with superjacent interspinous motion of ≥ 4 mm yielded accuracies comparable with those of CT.
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Affiliation(s)
- Kwang-Sup Song
- Departments of Orthopaedic Surgery (K.-S.S.) and Anesthesiology (H.K.), Chung-Ang University, College of Medicine, Heukseok-dong, Dongjak-gu, 224-1, Seoul, South Korea. E-mail address for K.-S. Song:
| | - Chaiwat Piyaskulkaew
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63144. E-mail address for K.D. Riew:
| | - Tapanut Chuntarapas
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63144. E-mail address for K.D. Riew:
| | - Jacob M Buchowski
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63144. E-mail address for K.D. Riew:
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63144. E-mail address for K.D. Riew:
| | - Moon Soo Park
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63144. E-mail address for K.D. Riew:
| | - Hyun Kang
- Departments of Orthopaedic Surgery (K.-S.S.) and Anesthesiology (H.K.), Chung-Ang University, College of Medicine, Heukseok-dong, Dongjak-gu, 224-1, Seoul, South Korea. E-mail address for K.-S. Song:
| | - K Daniel Riew
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63144. E-mail address for K.D. Riew:
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