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      Single-level Anterior Cervical Discectomy and Fusion Results in Lower Five-year Revisions than Posterior Cervical Foraminotomy in a Large National Cohort

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          Abstract

          Study Design.

          A retrospective cohort study using the 2010–2020 MSpine PearlDiver administrative data set.

          Objective.

          To compare perioperative adverse events and five-year revisions for single-level anterior cervical discectomy and fusion (ACDF) versus posterior cervical foraminotomy (PCF).

          Summary of Background Data.

          Cervical disk disease can often be treated surgically using single-level ACDF or PCF. Prior studies have suggested that posterior approaches provide similar short-term outcomes as ACDF; however, posterior procedures may have an increased risk of revision surgery.

          Materials and Methods.

          The database was queried for patients undergoing elective single-level ACDF or PCF (excluding cases performed for myelopathy, trauma, neoplasm, and/or infection). Outcomes, including specific complications, readmission, and reoperations, were assessed. Multivariable logistic regression was used to ascertain odds ratios (OR) of 90-day adverse events controlling for age, sex, and comorbidities. Kaplan-Meier survival analysis was performed to determine five-year rates of cervical reoperation in the ACDF and PCF cohorts.

          Results.

          A total of 31,953 patients treated by ACDF (29,958, 93.76%) or PCF (1995, 6.24%) were identified. Multivariable analysis, controlling for age, sex, and comorbidities, demonstrated that PCF was associated with significantly greater odds of aggregated serious adverse events (OR 2.17, P<0.001), wound dehiscence (OR 5.89, P<0.001), surgical site infection (OR 3.66, P<0.001), and pulmonary embolism (OR 1.72, P=0.04). However, PCF was associated with significantly lower odds of readmission (OR 0.32, P<0.001), dysphagia (OR 0.44, P<0.001), and pneumonia (OR 0.50, P=0.004). At five years, PCF cases had a significantly higher cumulative revision rate compared with ACDF cases (19.0% vs. 14.8%, P<0.001).

          Conclusions.

          The current study is the largest to date to compare short-term adverse events and five-year revision rates between single-level ACDF and PCF for nonmyelopathy elective cases. Perioperative adverse events differed by procedure, and it was notable that the incidence of cumulative revisions was higher for PCF. These findings can be used in decision-making when there is clinical equipoise between ACDF and PCF.

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          Most cited references32

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          Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial.

          Risk factors for nosocomial pneumonia, such as gastro-oesophageal reflux and subsequent aspiration, can be reduced by semirecumbent body position in intensive-care patients. The objective of this study was to assess whether the incidence of nosocomial pneumonia can also be reduced by this measure. This trial was stopped after the planned interim analysis. 86 intubated and mechanically ventilated patients of one medical and one respiratory intensive-care unit at a tertiary-care university hospital were randomly assigned to semirecumbent (n=39) or supine (n=47) body position. The frequency of clinically suspected and microbiologically confirmed nosocomial pneumonia (clinical plus quantitative bacteriological criteria) was assessed in both groups. Body position was analysed together with known risk factors for nosocomial pneumonia. The frequency of clinically suspected nosocomial pneumonia was lower in the semirecumbent group than in the supine group (three of 39 [8%] vs 16 of 47 [34%]; 95% CI for difference 10.0-42.0, p=0.003). This was also true for microbiologically confirmed pneumonia (semirecumbent 2/39 [5%] vs supine 11/47 [23%]; 4.2-31.8, p=0.018). Supine body position (odds ratio 6.8 [1.7-26.7], p=0.006) and enteral nutrition (5.7 [1.5-22.8], p=0.013) were independent risk factors for nosocomial pneumonia and the frequency was highest for patients receiving enteral nutrition in the supine body position (14/28, 50%). Mechanical ventilation for 7 days or more (10.9 [3.0-40.4], p=0.001) and a Glasgow coma scale score of less than 9 were additional risk factors. The semirecumbent body position reduces frequency and risk of nosocomial pneumonia, especially in patients who receive enteral nutrition. The risk of nosocomial pneumonia is increased by long-duration mechanical ventilation and decreased consciousness.
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            Full-endoscopic cervical posterior foraminotomy for the operation of lateral disc herniations using 5.9-mm endoscopes: a prospective, randomized, controlled study.

            Prospective, randomized, controlled study of patients with lateral cervical disc herniations, operated either in a full-endoscopic posterior or conventional microsurgical anterior technique. Comparison of results of cervical discectomies in full-endoscopic posterior foraminotomy technique with the conventional microsurgical anterior decompression and fusion. Anterior cervical decompression and fusion is the standard procedure for operation of cervical disc herniations with radicular arm pain. Mobility-preserving posterior foraminotomy is the most common alternative in the case of lateral localization of the pathology. Despite good clinical results, problems may arise due to traumatization of the access. Endoscopic techniques are considered standard in many areas, since they may offer advantages in surgical technique and rehabilitation. These days, all disc herniations of the lumbar spine can be operated in full-endoscopic technique. With the full-endoscopic posterior cervical foraminotomy a procedures is available for cervical disc operations. One hundred and seventy-five patients with full-endoscopic posterior or microsurgical anterior cervical discectomy underwent follow-up for 2 years. In addition to general and specific parameters, the following measuring instruments were used: VAS, German version North American Spine Society Instrument, Hilibrand Criteria. After surgery 87.4% of the patients no longer had arm pain, and 9.2% had occasional pain. The clinical results were the same in both groups. There were no significant difference between the groups in the revision or complication rate. The full-endoscopic technique brought advantages in operation technique, preserving mobility, rehabilitation, and traumatization. The recorded results show that the full-endoscopic posterior foraminotomy is a sufficient and safe supplement and alternative to conventional procedures when the indication criteria are fulfilled. At the same time, it offers the advantages of a minimally invasive intervention.
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              A Review of Complication Rates for Anterior Cervical Diskectomy and Fusion (ACDF)

              Background: There are multiple complications reported for anterior cervical diskectomy and fusion (ACDF), one of the most common cervical spine operations performed in the US (e.g. estimated at 137,000 ACDF/year). Methods: Multiple studies analyzed the risks and complications rates attributed to ACDF. Results: In multiple studies, overall morbidity rates for ACDF varied from 13.2% to 19.3%. These included in descending order; dysphagia (1.7%-9.5%), postoperative hematoma (0.4%-5.6% (surgery required in 2.4% of 5.6%), with epidural hematoma 0.9%), exacerbation of myelopathy (0.2%-3.3%), symptomatic recurrent laryngeal nerve palsy (0.9%-3.1%), cerebrospinal fluid (CSF) leak (0.5%-1.7%), wound infection (0.1-0.9%-1.6%), increased radiculopathy (1.3%), Horner’s syndrome (0.06%-1.1%), respiratory insufficiency (1.1%), esophageal perforation (0.3%-0.9%, with a mortality rate of 0.1%), and instrument failure (0.1%-0.9%). There were just single case reports of an internal jugular veing occlusion and a phrenic nerve injury. Pseudarthrosis occurred in ACDF and was dependant on the number of levels fused; 0-4.3% (1-level), 24% (2-level), 42% (3 level) to 56% (4 levels). The reoperation rate for symptomatic pseudarthrosis was 11.1%. Readmission rates for ACDF ranged from 5.1% (30 days) to 7.7% (90 days postoperatively). Conclusions: Complications attributed to ACDF included; dysphagia, hematoma, worsening myelopathy, recurrent laryngeal nerve palsy, CSF leaks, wound infection, radiculopathy, Horner’s Syndrome, respiratory insufficiency, esophageal perforation, and instrument failure. There were just single case reports of an internal jugular vein thrombosis, and a phrenic nerve injury. As anticipated, pseudarthrosis rates increased with the number of ACDF levels, ranging from 0-4.3% for 1 level up to 56% for 4 level fusions.
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                Author and article information

                Journal
                Spine
                Ovid Technologies (Wolters Kluwer Health)
                0362-2436
                2023
                September 15 2023
                June 19 2023
                : 48
                : 18
                : 1266-1271
                Article
                10.1097/BRS.0000000000004754
                37339256
                f400a5f3-6b0d-4968-b12d-c3029ceb401f
                © 2023
                History

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