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      Stand-Alone Cervical Cages in 2-Level Anterior Interbody Fusion in Cervical Spondylotic Myelopathy: Results from a Minimum 2-Year Follow-up

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          Abstract

          Study Design

          A retrospective review of patients who underwent 2-level anterior cervical discectomy and fusion (ACDF) with standalone polyetheretherketone (PEEK) cages for cervical spondylotic myelopathy (CSM).

          Purpose

          To evaluate the efficacy of stand-alone PEEK cage in 2-level cervical interbody fusion for CSM.

          Overview of Literature

          ACDF is a standard surgical procedure to treat degenerative disc disease. However, the use of additional anterior plating for 2-level ACDF remains controversial.

          Methods

          We reviewed outcomes of patients who underwent 2-level ACDF with stand-alone PEEK cages for CSM over a 7-year period (2007–2015) in a regional hospital. Japanese Orthopaedic Association (JOA) score, fusion rate, subsidence rate, cage migration, and cervical alignment by the C2–7 angle as well as the local segmental angle (LSA) of the cervical spine were assessed.

          Results

          In total, 31 patients (mean age, 59 years; range, 36–87 years) underwent 2-level ACDF with a cage-only construct procedure between 2007 and 2015. The minimum follow-up was 24 months; mean follow-up was 51 months. C3–5 fusion was performed in 45%, C4–6 fusion in 32%, and C5–7 fusion in 23%. Mean JOA score improved from 10.1±2.2 to 13.9±2.1 ( p<0.01) at the 24-month follow-up. Fusion was achieved in all patients. Subsidence occurred in 22.5% of the cages but was not associated with differences in JOA scores, age, sex, or levels fused. Lordosis of the C2–7 angle and LSA increased after surgery, which were maintained for up to 1 year but subsequently disappeared after 2 years, yet the difference was not statistically significant. No cage migration was noted; two patients developed adjacent segment disease requiring posterior laminoplasty 3 years after ACDF.

          Conclusions

          The use of a stand-alone PEEK cage in a 2-level cervical interbody fusion achieves satisfactory improvements in both clinical outcomes and fusion.

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          Most cited references20

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          The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion.

          G. W Smith, R A Robinson (1958)
          Article 0 comments Cited 342 times – based on 0 reviews     Review now
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            Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion.

            J Martin Leland, Alan Hilibrand, Alexander Vaccaro … (2003)
            This retrospective, questionnaire-based investigation evaluated iliac crest bone graft (ICBG) site morbidity in patients having undergone a single-level anterior cervical discectomy and fusion (ACDF) procedure performed by a single surgeon (T.J.A.). To evaluate acute and chronic problems associated with anterior ICBG donation, particularly long-term functional outcomes and impairments caused by graft donation. Anterior cervical discectomy and fusion procedures frequently use autologous anterior ICBG to facilitate osseous union. Although autologous ICBG offers several advantages over alternative grafting materials, donor site morbidity can be significant. Acute and chronic complications of donor sites have been reported, yet there are currently no reports of long-term functional outcomes after autologous anterior ICBG donation after single-level ACDF. A questionnaire was mailed to 187 consecutive patients who were retrospectively identified to have undergone autologous anterior ICBG harvest for single-level ACDF between 1994 and 1998. The questionnaire divided items into symptomatic (acute and chronic) and functional assessments. Patients answered yes, no, or not applicable; pain was assessed with a Visual Analogue Scale (VAS). Surveys were completed either by mail or follow-up telephone interview by 134 patients (71.6%). Average follow-up was 48 months (range, 24-72 months). Acute symptoms were reported at the following rates: ambulation difficulty, 50.7%; extended antibiotic usage, 7.5%; persistent drainage, 3.7%; wound dehiscence, 2.2%; and incision and drainage, 1.5%. The chronic symptom questionnaire demonstrated a high degree of satisfaction with the cosmetic result (92.5%). Pain at the donor site was reported by 26.1% of patients with a mean VAS score of 3.8 in 10, and 11.2% chronically use pain medication. Twenty-one patients (15.7%) reported abnormal sensations at the donor site, but only 5.2% reported discomfort with clothing. A unique functional assessment revealed current impairments at the following rates: ambulation, 12.7%; recreational activities, 11.9%; work activities, 9.7%; activities of daily living, 8.2%; sexual activity, 7.5%; and household chores, 6.7%. A large percentage of patients report chronic donor site pain after anterior ICBG donation, even when only a single-level ACDF procedure is performed. Moreover, long-term functional impairment can also be significant. Patients should be counseled regarding these potential problems, and alternative sources of graft material should be considered.
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              Subsidence of stand-alone cervical cages in anterior interbody fusion: warning.

              Dante Marchesi, Vincent Arlet, E Gercek … (2003)
              Anterior cervical decompression and fusion with anterior plating of the cervical spine is a well-accepted treatment for cervical radiculopathy. Recently, to minimise the extent of surgery, anterior interbody fusion with cages has become more common. While there are numerous reports on the primary stabilising effects of the different cervical cages, little is known about the subsidence behaviour of such cages in vivo. We retrospectively reviewed eight patients with cervical radiculopathy operated upon with anterior discectomy and fusion with a stand-alone titanium cervical cage. During surgery, only the cartilage portion of the end plate was removed and the cages were filled with autologous cancellous bone graft from the iliac crest. To assess possible subsidence or migration, three different radiographic measurements in the sagittal plane were taken for each case, postoperatively and at the latest follow-up. Subsidence was defined as any change in at least one of our parameters of at least 3 mm. Follow-up time was 12-18 months (average 15 months). Five of the nine fused levels had radiological signs of cage subsidence. No posterior or anterior migration was observed. However, subsidence did not correlate with clinical symptoms in four of the five patients. The remaining patient with signs of subsidence, whose neck pain and neurologic symptoms had regressed in the early postoperative course, suffered recurrence of radiculopathy 6 months after the surgery. Her symptoms were explained by the subsidence of the cage and the subsequent foraminal stenosis observed on the magnetic resonance imaging (MRI) scan. At 15 months' follow-up, her cage was broken. Our preliminary results, so far limited in number, represent a serious warning to the proponents of stand-alone cervical cages
              Article 0 comments Cited 74 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Asian Spine J
                Journal ID (iso-abbrev): Asian Spine J
                Journal ID (publisher-id): ASJ
                Title: Asian Spine Journal
                Publisher: Korean Society of Spine Surgery
                ISSN (Print): 1976-1902
                ISSN (Electronic): 1976-7846
                Publication date (Print): April 2019
                Publication date (Electronic): 27 November 2018
                Volume: 13
                Issue: 2
                Pages: 225-232
                Affiliations
                Department of Orthopaedics and Traumatology, Kwong Wah Hospital, Hong Kong
                Author notes
                Corresponding author: Eugene Pak-Lin Ng Department of Orthopaedics & Traumatology, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong Tel: +852-35177877, Fax: +852-35177201, E-mail: npl566@ 123456ha.org.hk
                Article
                Publisher ID: asj-2018-0193
                DOI: 10.31616/asj.2018.0193
                PMC ID: 6454285
                PubMed ID: 30472820
                SO-VID: 924cb1e0-8a40-4039-9341-14d2a7f943dd
                Copyright © Copyright © 2019 by Korean Society of Spine Surgery
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 2 August 2018
                Date revision received : 26 August 2018
                Date accepted : 6 September 2018
                Categories
                Subject: Clinical Study

                ScienceOpen disciplines: Orthopedics
                Keywords: cervical spondylotic myelopathy,anterior cervical discectomy and fusion,stand-alone cage,two level fusion
                Data availability:
                ScienceOpen disciplines: Orthopedics
                Keywords: cervical spondylotic myelopathy, anterior cervical discectomy and fusion, stand-alone cage, two level fusion

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