Controversies in Cervical Discectomy and Fusion: Practice Patterns Among Canadian Surgeons

A Canadian perspective on anterior cervical discectomies: practice patterns and preferences

Background

The purpose of this study is to elucidate the current practice patterns of Canadian neurosurgeons with regards to anterior cervical discectomy (ACD).

Methods

A one-page questionnaire was sent out using SurveyMonkey to all neurosurgeon members of the Canadian Neurological Sciences Federation (CNSF). End points were surgeon preference for ACD surgical method, graft source, the length of collar usage and the recommended time before returning to work.

Results

Response rate was 74.0%. Of the responders, 75.0% performed single level ACD and 18.3% had completed spine fellowships. The majority (68.2%) chose ACD with fusion and plating (ACDFP) as their preferred method with allograft being the most popular choice of fusion material (44.3%). Most of the respondents did not prescribe collars (60.9%) and when they did, hard collar was prescribed most often (76.9%) and Aspen^TM collar was the most popular choice (67.7%). The majority of surgeons chose 'other' as their response for length of time for collar use (40.0%) while allowing them to take their collars off at night (78.1%). Most of the surgeons recommended physiotherapy post-operatively (58.1%) and time to physiotherapy was 6-8 weeks. Recommended back to work time was 6 weeks for 44.9% of respondents. In the cross analysis, surgeons who performed ACDF were more likely to prescribe collars (50%, P=0.01) versus surgeons who performed ACDFP (21.7%, P=0.01).

Conclusions

Our survey is an up to date description of current practice patterns for ACD amongst Canadian neurosurgeons.

Are External Cervical Orthoses Necessary after Anterior Cervical Discectomy and Fusion: A Review of the Literature

Introduction & Background: The use of external cervical orthosis (ECO) after anterior cervical discectomy and fusion (ACDF) varies from physician to physician due to an absence of clear guidelines. Our purpose is to evaluate and present evidence answering the question, “Does ECO after ACDF improve fusion rates?” through a literature review of current evidence for and against ECO after ACDF. 

Review: A PubMed database search was conducted using specific ECO and ACDF related keywords. Our search yielded a total of 1,267 abstracts and seven relevant articles. In summary, one study provided low quality of evidence results supporting the conclusion that external bracing is not associated with improved fusion rates after ACDF.  The remaining six studies provide very low quality of evidence results; two studies concluded that external bracing after cervical procedures is not associated with improved fusion rates, one study concluded that external bracing after cervical procedures is associated with improved fusion rates, and the remaining three studies lacked sufficient evidence to draw an association between external bracing after ACDF and improved fusion rates.

Conclusion: We recommend against the routine use of ECO after ACDF due to a lack of improved fusion rates associated with external bracing after surgery.

Anterior Cervical Discectomy and Fusion: Practice Patterns Among Greek Spinal Surgeons

Background

A web-based survey was conducted among Greek spinal surgeons to outline the current practice trends in regard to the surgical management of patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine pathology. Various practice patterns exist in the surgical management of patients undergoing anterior cervical discectomy for degenerative pathology. No consensus exists regarding the type of the employed graft, the necessity of implanting a plate, the prescription of an external orthotic device, and the length of the leave of absence in these patients.

Methods

A specially designed questionnaire was used for evaluating the criteria for surgical intervention, the frequency of fusion employment, the type of the graft, the frequency of plate implantation, the employment of an external spinal orthosis (ESO), the length of the leave of absence, and the prescription of postoperative physical therapy. Physicians’ demographic factors were assessed including residency and spinal fellowship training, as well as type and length in practice.

Results

Eighty responses were received. Neurosurgeons represented 70%, and orthopedic surgeons represented 30%. The majority of the participants (91.3%) considered fusion necessary. Allograft was the preferred type of graft. Neurosurgeons used a plate in 42.9% of cases, whereas orthopedic surgeons in 100%. An ESO was recommended for 87.5% of patients without plates, and in 83.3% of patients with plates. The average duration of ESO usage was 4 weeks. Physical therapy was routinely prescribed postoperatively by 75% of the neurosurgeons, and by 83.3% of the orthopedic surgeons. The majority of the participants recommended 4 weeks leave of absence.

Conclusions

The vast majority of participants considered ACDF a better treatment option than an ACD, and preferred an allograft. The majority of them employed a plate, prescribed an ESO postoperatively, and recommended physical therapy to their patients.

Variations in Practice Patterns among Neurosurgeons and Orthopaedic Surgeons in the Management of Spinal Disorders

Study Design

This is a case series.

Purpose

We wanted to identify variations in the practice patterns among neurosurgeons and orthopedic surgeons for the management of spinal disorders.

Overview of Literature

Spinal disorders are common in the clinical practice of both neurosurgeons and orthopedic surgeons. It has been observed that despite the availability of various guidelines, there is lack of consensus among surgeons about the management of various disorders.

Methods

A questionnaire was distributed, either directly or via e-mail, to the both the neurosurgeons and orthopedic surgeons who worked at 5 tertiary care centers within a single region of Korea. The surgeons were working either in private practice or in academic institutions. The details of the questionnaire included demographic details and the specialty (orthopedic/neurosurgeon). The surgeons were classified according to the level of experience as up to 5 years, 6-10 years and > 10 years. Questions were asked about the approach to lumbar discectomy (fragmentectomy or aggressive disc removal), using steroids for treating discitis, the fusion preference for spondylolisthesis, the role of an orthosis after fusion, the preferred surgical approach for spinal stenosis, the operative approach for spinal trauma (early within 72 hours or late > 72 hours) and the role of surgery in complete spinal cord injury. The data was analyzed using SPSS ver 16. p-values < 0.05 were considered to be significant.

Results

Of the 30 surgeons who completed the questionnaire, 20 were neurosurgeons and 10 were orthopedic surgeons. Statistically significant differences were observed for the management of spinal stenosis, spondylolisthesis, using an orthosis after fusion, the type of lumbar discectomy and the value of surgical intervention after complete spinal cord injury.

Conclusions

Our results suggest that there continues to exist a statistically significant lack of consensus among neurosurgeons and orthopedic spine surgeons when considering using an orthosis after fusion, the type of discectomy and the value of intervention after complete spinal injury.

Introduction and methodology: guidelines for the surgical management of cervical degenerative disease

In March 2006, the Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons compiled an expert group to perform an evidence-based review of the clinical literature on management of cervical degenerative spine disease. This process culminated in the formation of the Guidelines for the Surgical Management of Cervical Degenerative Disease. The purpose of the Guidelines was to address questions regarding the therapy, diagnosis, and prognosis of cervical degenerative disease using an evidence-based approach. Development of an evidence-based review and recommendations is a multitiered process. Typical guideline development consists of 5 processes: 1) collection and selection of the evidence; 2) assessment of the quality and strength of the evidence; 3) analysis of the evidentiary data; 4) formulation of recommendations; and 5) guideline validation. This manuscript details the methodology in compiling the Guidelines for the Surgical Management of Cervical Degenerative Disease.

Agreement between orthopedic surgeons and neurosurgeons regarding a new algorithm for the treatment of thoracolumbar injuries: a multicenter reliability study

INTRODUCTION

Considerable variability exists in the management of thoracolumbar (TL) spine injuries. Although there are many influences, one significant factor may be the treating surgeon's specialty and training (ie, orthopedic surgery vs. neurosurgery). Our objective was to assess the agreement between spinal orthopedic and neurologic surgeons in rating the severity of TL spine injuries with a new treatment algorithm. This information could be important in establishing consensus-based protocols for managing these challenging injuries.

METHODS

Twenty-eight spinal surgeons (8 neurosurgeons and 20 orthopedic surgeons) reviewed 56 TL injury case histories. Each case was classified and scored according to the TL injury severity score (TLISS). The case histories were reordered and the physicians repeated the exercise 3 months later. At both intervals the surgeons were asked if they agreed with the final treatment recommendation of the TLISS algorithm. The reliability and decision validity of the TLISS was compared.

RESULTS

Between-group interrater reliability was similar to within group reliabilities. Intrarater reliability was also similar between groups. The between speciality interrater reliability of the TLISS management recommendation was moderate (74% agreement, kappa=0.532). Orthopedic and neurosurgeons agreed with the TLISS management recommendation 91.4% and 94.4% of the time, respectively.

CONCLUSIONS

The TLISS demonstrated good reliability in terms of intraobserver and interobserver agreement on the algorithmic treatment recommendations. The recommendation for operation seems to be consistent between fellowship-trained orthopedic and neurosurgical spine surgeons. This type of classification system may reduce the existing variability and initial management decision for treatment of TL injuries.

Surgical management of cervical myelopathy: indications and techniques for multilevel cervical discectomy

BACKGROUND CONTEXT

Surgery is usually required for treatment of cervical myelopathy to decompress the neural elements, restore lordosis, and stabilize the spine. By addressing these problems, the neurological deterioration may be halted.

PURPOSE

Multilevel cervical discectomy and fusion offers several advantages over other approaches. The authors describe the technique, discuss the indications, and present the potential complications associated with it.

METHODS

Decompression is achieved via discectomy and subsequent removal of the osteophytes using a curetting technique. Preparation of end plates in a parallel fashion allows for gapless grafting of allograft bone for enhancement of fusion. A dynamic plate and screw system strengthens the construct.

RESULTS

A high rate of fusion can be obtained using the technique of multilevel cervical discectomy and fusion with acceptable levels of complications. It is especially useful in cases of spondylosis that have a kyphotic deformity because, in addition to anterior decompression, it allows reconstruction of the spine to help restore a lordotic curvature.

CONCLUSIONS

Multilevel cervical discectomy and fusion has proven to be very effective in decompressing and stabilizing the spine for treatment of cervical myelopathy.