Long-term clinical and radiological outcomes following anterior cervical discectomy and fusion by zero-profile anchored cage

Anterior cervical discectomy and fusion is more effective than cervical arthroplasty in relieving atypical symptoms in patients with cervical spondylosis

BACKGROUND AND PURPOSE

Patients with cervical spondylosis often present with concurrent 'atypical symptoms' of unknown etiology that have been associated with cervical spondylotic disease, including dizziness, headache, nausea, tinnitus, blurred vision, palpitations, and memory and gastrointestinal disturbances. Few studies have addressed whether surgical intervention to treat classic symptoms of cervical spondylosis can also effectively alleviate atypical symptoms. Accordingly, the purpose of this study is to compare the ability of cervical arthroplasty (CA) and anterior cervical discectomy and fusion (ACDF) to alleviate atypical symptoms associated with cervical spondylosis.

MATERIALS AND METHODS

A retrospective analysis of 140 patients with cervical spondylosis and associated atypical symptoms was performed. Atypical symptoms were defined vertigo, headache, nausea and vomiting, tinnitus, blur vision, palpitation, hypomnesia, and gastroenteric disturbances not otherwise explained by medical comorbidities. Seventy-eight patients (55.7%) underwent ACDF and 62 (44.3%) patients underwent CA. Demographics, surgical characteristics, patient reported outcome measures (PROMs), radiographs, complication rates, and resolution in atypical symptoms were recorded and compared between groups. Atypical symptoms were assessed using a 20-point system. All the patients had a minimum of five years follow-up.

RESULTS

VAS, SF-36, JOA, and NDI scores improved significantly in all the patients (p < 0.001). At the last follow-up, the fusion rate was 97% in the ACDF group. Atypical symptoms improved in both groups (p < 0.001), although the ACDF group demonstrated greater improvement in headache and vertigo resolution compared to the CA group (p < 0.0001).

CONCLUSIONS

While both ACDF and CA are effective in alleviating atypical symptoms associated with cervical spondylosis, ACDF demonstrated greater improvements in atypical symptoms.

Dysphagia as a Postoperative Complication of Anterior Cervical Discectomy and Fusion

Anterior cervical discectomy and fusion (ACDF), despite its possible complications, remains the gold standard for the surgical treatment of patients with radiculopathy and/or myelopathy caused by cervical intervertebral disc herniation or spondylosis. Despite its high rate of incidence, postoperative dysphagia following ACDF is still poorly understood; its pathogenesis remains relatively unknown, and its risk factors are still a subject of debate.

The aim of this study is to review the incidence, pathogenesis, diagnosis, and methods of prevention of dysphagia in ACDF patients. To this end, a literature review was conducted based on the PubMed internet database. Article titles were searched by using the following keywords: “dysphagia” and “anterior cervical discectomy and fusion” or “ACDF”. The search was limited to prospective clinical studies evaluating dysphagia after ACDF surgery. Studies published in non-English languages, retrospective studies, cadaveric studies, reviews, case reports, study protocols, and commentary studies were excluded.

Initially, 335 studies were identified after a primary search. After the application of the exclusion criteria, 73 studies remained for the final analysis. This literature review focused on identifying the rate of dysphagia and the various risk factors leading to this complication by comparing and evaluating the current literature with a wide spectrum of heterogeneity concerning patients, surgeons, and surgical techniques. A mean dysphagia rate of 19.4% (95% CI: 9.6%-29.1%) based on the findings of the included studies correlating dysphagia directly with ACDF procedures was calculated. Various established risk factors leading to dysphagia include the female sex, smoking, the surgical approach, rhBMP-2 use, and multilevel surgery, while zero-profile devices seem to reduce dysphagia risk. The diagnosis is based on clinical and radiological findings, especially prevertebral soft-tissue swelling. However, videofluoroscopic and endoscopic studies have been recently used for the evaluation of dysphagia. The role of local administration of steroids in the prevention of dysphagia has not yet been clarified. This review underscores the prevailing rudimentary understanding of the problem of dysphagia after ACDF procedures and highlights the need for more sensitive, factor-specific studies for understanding the impact of various risk factors on the incidence rate of dysphagia.

Does Hybrid Surgery Improve Quality of Life in Multilevel Cervical Degenerative Disk Disease? Five-Year Follow-up Study

BACKGROUND

Patient satisfaction is becoming an increasing factor worthy of consideration when evaluating the surgical quality. The correlation between patient satisfaction and surgical outcomes 5 years after cervical hybrid surgery (HS), which incorporates anterior cervical decompression and fusion and cervical disk arthroplasty techniques in multilevel cervical degenerative disk disease, has not been evaluated.

METHODS

The aim of this study was firstly to analyze prospectively collected data from a sample of patients (n = 50) treated with cervical HS for selected cases of radiculopathy and myelopathy in order to evaluate pain levels of patients, using the Neck and Arm Pain scale as an expression of visual analog scale. Secondly, we aimed to evaluate health-related quality of life, via the short-form 36, Neck Disability Index, and Japanese Orthopedic Association score. Patients were followed up for more than 5 years. Intraoperative parameters, clinical features, and outcome scores were recorded. Radiologic investigations including disk height and changes in adjacent disk spaces were assessed.

RESULTS

Clinical improvements were observed in all outcomes; significant improvements on the Neck Disability Index, visual analog scale, short-form 36, and Japanese Orthopedic Association scores were maintained at 5 years (P < 0.05). The mean disk height resulted restored in all the cases. Temporary dysphagia was rarely observed (3%). No surgery for adjacent-level disease was required. There was no significant difference in the outcomes between radiculopathy and myelopathy groups (P > 0.05).

CONCLUSIONS

HS is an effective and safe procedure for the treatment of multilevel cervical degenerative disk disease. Such a surgical construct offers postoperative improvement on pain levels and health-related quality of life.

Effectiveness of cervical zero profile integrated cage with and without supplemental posterior Interfacet stabilization

BACKGROUND

Conditions requiring cervical decompression and stabilization are commonly treated using anterior cervical discectomy and fusion using an anterior cage-plate construct. Anterior zero profile integrated cages are an alternative to a cage-plate construct, but literature suggests they may result in less motion reduction. Interfacet cages may improve integrated cage stability. This study evaluated the motion reduction of integrated cages with and without supplemental interfacet fixation. Motion reduction of integrated cages were also compared to published cage-plate results.

METHODS

Seven cadaveric (C2-T1) spines were tested in flexion-extension, lateral bending, and rotation. Specimens were tested: 1) intact, 2) C6-C7 integrated cage, 3) C6-C7 integrated cage + interfacet cages, 4) additional integrated cages at C3-C4 and C4-C5, 5) C3-C4, C4-C5 and C6-C7 integrated cages + interfacet cages. Motion, lordosis, disc and neuroforaminal height were assessed.

FINDINGS

Integrated cage at C6-C7 decreased flexion-extension by 37% (P = .06) and C3-C5 by 54% (P < .01). Integrated + interfacet cages decreased motion by 89% and 86% compared to intact (P < .05). Integrated cages increased lordosis at C4-C5 and C6-C7 (P < .01). Integrated + interfacet cages returned C3-C5 lordosis to intact values, while C6-C7 remained more lordotic (P = .02). Compared to intact, neuroforaminal height increased after integrated cages at C3-C5 (P ≤ .01) and at all levels after interfacet cages (P < .01).

INTERPRETATION

Anterior integrated cages provides less stability than traditional cage-plate constructs while supplemental interfacet cages improve stabilization. Integrated cages provide more lordosis at caudal levels and increase neuroforaminal height more at cranial levels. After interfacet cages, posterior disc height and neuroforaminal height increased more at the caudal segments.

Degenerative Cervical Myelopathy: Review of Surgical Outcome Predictors and Need for Multimodal Approach

Degenerative cervical myelopathy is the most common cause of spinal cord injury in the elderly population in the developed world, and it significantly affects the quality of life of patients and their caregivers. Surgery remains the only treatment option able to halt disease progression and provide neurological recovery for most patients. Although it has remained challenging to predict exactly who will experience improvement after surgery, increasingly it has been shown that clinical, imaging, and electrophysiological factors can predict, with relatively good capacity, those more likely to benefit. Clinically, the baseline neurological impairment appears to be strongly related to the outcome, and the magnetic resonance imaging findings of T1-weighted hypointensity and the length of T2-weighted hyperintensity appear to be the most prognostic. In this context, electrophysiology findings (both motor and sensory evoked potentials) have shown some predictive capacity. However, large studies are lacking. Although multivariate models have been conducted using clinical and magnetic resonance imaging data, no multimodal prediction models are available that encompass the predictive capacity of clinical, imaging, and electrophysiological data. In the present review, we examined the rationale for clinical, imaging, and electrophysiological usage in clinical practice and discussed a model of multimodal assessment for the management of degenerative cervical myelopathy.

Financial Aspects of Cervical Disc Arthroplasty: A Narrative Review of Recent Literature

Recently, there has been significant interest in understanding the cost-effectiveness of treatments in spine surgery as health care systems in the United States move toward value-based care and alternative payment models. Previous studies have shown comparable outcomes of cervical disc arthroplasty (CDA) and anterior cervical discectomy fusion; however, there is a lack of consensus on the cost-effectiveness of CDA to support full adoption. Evidence of the limitations of these cost-analysis studies also exists in the literature, including industry funding, potential selection bias, and varying methods of calculating value. The goal of this narrative review is to provide an overview of the cost-effectiveness of CDA compared with anterior cervical discectomy and fusion, and potential limitations with cost-analysis studies in spine surgery.

Multilevel cervical arthroplasty-clinical and radiological outcomes

BACKGROUND

Cervical disc arthroplasty (CDA) is a valid option for single-level cervical disc disease (CDD) as an alternative to fusion. However, the use in 3- and 4-level disc disease is under scrutiny with scarce data published so far. Our aim was to study clinical and radiological outcomes of arthroplasty in patients with multilevel CDD.

METHODS

Retrospective analysis of clinical records, pre- and post-operative neutral/dynamic X-rays of patients who underwent CDA in multilevel CDD (2-4 levels). We evaluated sagittal balance parameters (C2-7 and index angle, SVA), global and segmental range of motion (ROM)), neck and arm VAS, Odom's criteria, re-operation rate, adjacent segment disease (ASD), willingness to undertake the same procedure again. Rate of heterotopic ossification (HO) was studied for follow-up >2 years. A subgroup analysis was performed regarding 2-level versus 3- or 4-level arthroplasty.

RESULTS

Thirty-two patients were included, 6 males and 26 females, mean age of 46 years (range, 30-63). Seventy-seven cervical disc levels were treated with the same artificial disc. Twenty-one patients were operated on 2 levels, nine in 3 levels, and 2 patients in 4 levels. Post-operatively, there was a decrease in SVA (-2.2±8.36 mm, P=0.098) and an increase in global (3.7±9.6º, P=0.042) and index (1.3±6.1º, P=0.071) ROM. Mean nVAS and aVAS decreased (7.5±1.1 to 2.5±1.5; 6.3±1.9 to 2.2±1.7, P<0.05). Two-level versus 3-4 level patient subgroups showed a lower SVA (-1.3±8.1 mm P=0.47; -3.4±6.3 mm P=0.107), a slight increase in global (1.6±9.4º P=0.44; 7.2±11.7º P=0.07) and index (1.1±4.7º P=0.12; 1.3±8.1º P=0.35) ROM. HO was present in 9.9% (7/71) of disc levels operated, none of them with grade 3 or 4.

CONCLUSIONS

Multilevel CDA provides good clinical and radiological outcomes, preserving global and segmental cervical mobility, while having a beneficial effect on sagittal balance. These results hold for 2 to 4 levels, making this technique a valuable option in selected patients with cervical multilevel CDD.

Cervical disc herniation: which surgery?

PURPOSE

Cervical disc herniation is a common pathology. It can be treated by different surgical procedures. We aimed to list and analyzed every available surgical option. We focused on the comparison between anterior cervical decompression and fusion and cervical disc arthroplasty.

RESULTS

The anterior approach is the most commonly used to achieve decompression and fusion by the mean of autograft or cage that could also be combined with anterior plating. Anterior procedures without fusion have shown good outcomes but are limited by post-operative cervicalgia and kyphotic events. Posterior cervical foraminotomy achieved good outcomes but is not appropriate in a case of a central hernia or ossification of the posterior ligament. Cervical disc arthroplasty is described to decrease the rate of adjacent segment degeneration. It became very popular during the last decades with numerous studies with different implant device showing encouraging results but it has not proved its superiority to anterior cervical decompression and fusion. Anterior bone loss and heterotopic ossification are still to be investigated.

CONCLUSION

Anterior cervical decompression and fusion remain the gold standard for surgical treatment of cervical disc herniation.