Effects of Anterior Plating on Achieving Clinically Meaningful Improvement Following Single-Level Anterior Cervical Discectomy and Fusion

A retrospective comparative analysis of anterior cervical discectomy and fusion using stand-alone titanium cage versus cage and plate fixation in two-level cervical disc herniation

BACKGROUND

This study aims to compare the outcomes of two-level anterior cervical discectomy and fusion (ACDF) procedures using stand-alone cages versus cage and plate fixation in patients diagnosed with cervical disc herniation (CDH).

MATERIALS AND METHODS

This retrospective analysis included 60 patients who underwent two-level ACDF procedures. Patients were divided into two groups: one treated with stand-alone cages and the other with cage and plate fixation. Data on surgical duration, blood loss, fusion stability, and complication rates were collected. Clinical outcomes, including neck pain and functional status, were assessed using standard scoring systems.

RESULTS

Plate fixation provided superior fusion stability but was associated with longer surgery durations, higher intraoperative blood loss, and increased complication rates. Stand-alone cages reduced intraoperative trauma but demonstrated higher subsidence rates and prolonged fusion times. Both techniques resulted in significant improvements in neck pain and disability scores.

DISCUSSION

While both approaches are effective for managing cervical disc herniation, each has distinct advantages and limitations. Surgical technique selection should be individualized, considering patient-specific anatomical factors, functional demands, and the risk-benefit profile of each approach.

Radiographic Characteristics of Caudal Segment in Multilevel Anterior Cervical Discectomy and Fusion: The Bony Buttress Formation

OBJECTIVE

Anterior cervical discectomy and fusion (ACDF) with anterior plating is a commonly performed procedure for cervical disc diseases. While the clinical outcomes of most reported multilevel ACDF cases are excellent, symptomatic pseudarthrosis remains a challenge, often requiring revision surgeries. This study aims to present the radiological characteristics of multilevel ACDF constructs, which can be considered during intraoperative management to prevent pseudarthrosis.

METHODS

This retrospective cohort study included patients who underwent multilevel (3 or 4 levels) ACDF with anterior plating between June 2010 and August 2022. Patients were regularly followed at 4 months, 12 months, and then annually postoperation. Fusion rates and characteristic radiological patterns, such as the formation of bony buttresses underneath the anterior plate, were graded and evaluated.

RESULTS

A total of 163 patients were included in the study. Overall fusion rates were 26.38%, 64.34%, and 81.58% at 4-month, 1-year, and the final follow-up, respectively. Nonunions at 4-month follow-up with tightly engaged anterior plate with bony buttress formation were more likely to fuse in the later period (Buttress grade 0 vs. 1; p=0.01, odds ratio [OR], 5.70, Buttress grade 1 vs. >2; p<0.01, OR, 12.00).

CONCLUSION

This study emphasizes the significance of pseudarthrosis following multilevel ACDF. Pseudarthrosis predominantly occurs in the caudal-most segment of the construct, particularly when it terminates at C7. Constructs that are not tightly engaged and lack bony buttress formation in the caudal part of multilevel ACDF are more likely to develop pseudarthrosis.

Comparative Radiological Outcomes of Stand-alone Cage versus Cage and Plate in Anterior Cervical Discectomy and Fusion: A Retrospective Cohort Study

Background  Anterior cervical discectomy and fusion (ACDF) is one of the most commonly used techniques for neural decompression in degenerative cervical radiculopathy and cervical myelopathy. Controversies regarding the superiority of cage augmentation with anterior cervical plate remain, yet several surgeons are still performing ACDF with a stand-alone cage (ACDF-SA). Our study aimed to compare the radiological outcomes between the ACDF augmented with anterior cervical plate (ACDF-CPA) and ACDF-SA in single-level cervical degenerative disc disease. Methods  A retrospective data review was conducted for patients who underwent ACDF between January 2011 and December 2019. All adult patients who underwent single-level ACDF for cervical radiculopathy and myelopathy with at least 12 months of follow-up were included in the study. Patients who had a systemic infection, trauma injury, history of malignancy, inadequate radiographs, and less than 12 months of follow-up were excluded from the study. Radiological outcomes, including cage subsidence, fusion rate, and adjacent segment degeneration, were assessed by two senior orthopaedic spine fellows. Adjusted risk ratios were used to compare the radiological outcomes of ACDF-SA and ACDF-CPA, adjusting for age and gender. Results  A total of 43 patients were included. Among them, 58% of the patients underwent a stand-alone cage ACDF, while 42% had anterior cervical plate augmentation. The overall fusion rate at 6 months was 76%. The ACDF-SA group's fusion rate was 88%, while that of the ACDF-CPA group was 61%. At 12 months, the overall fusion rate was 81% and was comparable between the two groups. Cage subsidence and adjacent segment degeneration rates were similar between the groups at 6 and 12 months. Adjusted relative risk analysis showed a 50% higher probability of fusion at 6 months in the ACDF-SA group compared with the ACDF-CPA group (95% confidence interval [CI]: 1.01-2.22) and a 22% higher probability at 12 months, though not statistically significant (95% CI: 0.90-1.64). Female gender was associated with higher fusion rates and lower subsidence risk at 12 months. Conclusion  Augmentation with the anterior cervical plate in ACDF did not show superiority to the conventional stand-alone cage in mono-segmental ACDF. Our study showed similar outcomes regarding cage subsidence, adjacent segment disease, and fusion rates at 12 months. However, the stand-alone cage achieved faster fusion at 6 months than the plate group.

Assessing Surgical Outcomes for Cage Plate System versus Stand-Alone Cage in Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) is a common surgical procedure for addressing cervical spine conditions. It involves the utilization of either cage plate system (CPS) or stand-alone cage (SC). The objective of our study is to compare perioperative complications, patient-reported clinical outcomes measures, and radiographic outcomes of SC versus CPS in ACDF.

METHODS

We carried out a literature search in PubMed, Embase, Cochrane library, Web of science, Medline, and Google Scholar. All studies comparing the outcomes between CPS versus SC in ACDF were included.

RESULTS

Forty-one studies, 33 observational and 8 randomized clinical trials met the inclusion criteria. We found that both devices demonstrated comparable effectiveness in monosegmental ACDF with respect to Japanese Orthopedic Association Score, Neck Disability Index score, visual analog score, and fusion rates. CPS demonstrated superior performance in maintaining disc height, cervical lordosis, and exhibited lower incidence rates of cage subsidence. SC showed significant advantages over CPS in terms of shorter surgical duration, less intraoperative bleeding, shorter duration of hospitalization, as well as lower incidence rates of early postoperative dysphagia and adjacent segment disease.

CONCLUSIONS

Most of the included studies had monosegmented fusion, and there wasn't enough data to set recommendations for the multisegmented fusions. Larger studies with longer follow-up are necessary to draw more definitive conclusions to provide evidence for clinicians to make clinical decisions.

Comparing zero-profile and conventional cage and plate in anterior cervical discectomy and fusion using finite-element modeling

Conventional cage and plate (CCP) implants usually used in ACDF surgery, do have limitations such as the development of postoperative dysphagia, adjacent segment degeneration, and soft tissue injury. To reduce the risk of these complications, zero-profile stand-alone cage were developed. We used finite-element modeling to compare the total von Mises stress applied to the bone, disc, endplate, cage and screw when using CCP and ZPSC implants. A 3-dimensional FE (Finite element) analysis was performed to investigate the effects of the CCP implant and ZPSC on the C3 ~ T1 vertebrae. We confirmed that the maximum von Mises stress applied with ZPSC implants was more than 2 times greater in the endplate than that applied with CCP implants. The 3D analysis of the ZPSC model von Mises stress measurements of screw shows areas of higher stress in red. Although using ZPSC implants in ACDF reduces CCP implant-related sequalae such as dysphagia, we have shown that greater von Mises stress is applied to the endplate, and screw when using ZPSC implants. This may explain the higher subsidence rate associated with ZPSC implant use in ACDF. When selecting an implant in ACDF, surgeons should consider patient characteristics and the advantages and disadvantages of each implant type.

Self-locking stand-alone cage versus cage-plate fixation in monosegmental anterior cervical discectomy and fusion with a minimum 2-year follow-up: a systematic review and meta-analysis

BACKGROUND

Currently, self-locking stand-alone cages (SSC) are commonly applied in anterior cervical discectomy and fusion (ACDF), as are cage-plate constructs (CPC). However, it remains controversial concerning the long-term effectiveness of both apparatuses. Our purpose is to compare long-term effectiveness of SSC with CPC in monosegmental ACDF.

METHODS

Four electronic databases were queried to identify studies comparing SSC versus CPC in monosegmental ACDF. The meta-analysis was carried out with the use of the Stata MP 17.0 software package.

RESULTS

Ten trials with 979 patients were included. Compared to CPC, SSC significantly reduced operative time, intraoperative blood loss, duration of hospitalisation, cervical Cobb angle at final follow-up, 1-month postoperative dysphagia rate, and incidence of adjacent segment degeneration (ASD) at final follow-up. No significant difference was found regarding 1-month postoperative cervical Cobb angle, JOA scores, NDI scores, fusion rate and cage subsidence rate at final follow-up.

CONCLUSION

Both devices achieved similar long-term effectiveness in monosegmental ACDF regarding JOA scores, NDI scores, fusion rate and cage subsidence rate. SSC had significant advantages over CPC in reducing surgical duration, intraoperative bleeding, duration of hospitalisation, as well as rates of dysphagia and ASD after surgery. Therefore, SSC is a better option than CPC in monosegmental ACDF. However, SSC is inferior to CPC in maintaining cervical curvature at long-term follow-up. Whether radiological changes affect clinical symptoms needs confirmation in trials with longer follow-up.

The Effect of Subsidence on Segmental and Global Lordosis at Long-term Follow-up After Anterior Cervical Discectomy and Fusion

OBJECTIVE

Subsidence following anterior cervical discectomy and fusion (ACDF) may lead to disruptions of cervical alignment and lordosis. The purpose of this study was to evaluate the effect of subsidence on segmental, regional, and global lordosis.

METHODS

This was a retrospective cohort study performed between 2016-2021 at a single institution. All measurements were performed using lateral cervical radiographs at the immediate postoperative period and at final follow-up greater than 6 months after surgery. Associations between subsidence and segmental lordosis, total fused lordosis, C2-7 lordosis, and cervical sagittal vertical alignment change were determined using Pearson correlation and multivariate logistic regression analyses.

RESULTS

One hundred thirty-one patients and 244 levels were included in the study. There were 41 one-level fusions, 67 two-level fusions, and 23 three-level fusions. The median follow-up time was 366 days (interquartile range, 239-566 days). Segmental subsidence was significantly negatively associated with segmental lordosis change in the Pearson (r = -0.154, p = 0.016) and multivariate analyses (beta = -3.78; 95% confidence interval, -7.15 to -0.42; p = 0.028) but no associations between segmental or total fused subsidence and any other measures of cervical alignment were observed.

CONCLUSION

We found that subsidence is associated with segmental lordosis loss 6 months following ACDF. Surgeons should minimize subsidence to prevent long-term clinical symptoms associated with poor cervical alignment.