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      The efficacy of anchored stand-alone spacers in comparison to conventional cage and plate in anterior cervical discectomy and fusion surgery: A meta-analysis of randomised controlled trials for clinical and radiological outcomes


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          Anterior cervical discectomy and fusion (ACDF) is commonly performed with cage and plate constructs to stabilise diseased or injured cervical segments. Despite it being a commonly performed procedure, there are notable rates of associated morbidity reported in the literature. Stand-alone spacers represent a novel form of instrumentation to conventional cage and plate constructs.

          Research question

          Do stand-alone spacers have improved operative characteristics and postoperative outcomes in ACDF cohorts when compared to cage and plate constructs?


          A systematic review and meta-analysis was conducted of PubMed/Medline, Embase and Google Scholar databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. Studies of interest included cage and plate instrumentation versus anchored stand-alone spacers for patients undergoing ACDF. Pre- and post-operative clinical and radiological outcomes were collated and compared for significance between cohorts.


          10 RCTs were identified and included with 779 patients total. Mean age of the entire cohort was 50.1 years. 62% (483/779) of the cohort were male. 384 patients underwent ACDF with stand-alone cage, while 395 had ACDF with conventional cage and plate. Stand-alone spacers significantly outperformed conventional instrumentation in terms of estimated blood loss (p < 0.01), total postoperative complications (p < 0.01), dysphagia rates (p = 0.04) and adjacent segment disease (p = 0.04). Non-inferiority was evident in both patient reported outcome measures and radiological outcomes.


          This meta-analysis highlights the efficacy of stand-alone spacers for the management of primarily cervical spondylitic disease for both single-level and multi-level pathology, and thus presents an attractive alternative to conventional instrumentation for patients undergoing ACDF surgery.


          • Cage and plate constructs have notable rates of associated morbidity with ACDF.

          • Stand-alone spacers are a novel form of instrumentation to be used in ACDF.

          • Stand-alone spacers are an attractive alternative to cage and plate constructs.

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          Most cited references31

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          RoB 2: a revised tool for assessing risk of bias in randomised trials

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            The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration

            Systematic reviews and meta-analyses are essential to summarise evidence relating to efficacy and safety of healthcare interventions accurately and reliably. The clarity and transparency of these reports, however, are not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users. Since the development of the QUOROM (quality of reporting of meta-analysis) statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realising these issues, an international group that included experienced authors and methodologists developed PRISMA (preferred reporting items for systematic reviews and meta-analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions. The PRISMA statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this explanation and elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA statement, this document, and the associated website (www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
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              Anterior cervical discectomy and fusion associated complications.

              Retrospective review study with literature review. The goal of our current study is to raise awareness on complications associated with anterior cervical discectomy and fusion (ACDF) and their early detection and proper management. It is known that ACDF constitutes one of the most commonly performed spinal procedures. Its outcome is quite satisfactory in the majority of cases. However, occasional complications can become troublesome, and in rare circumstances, catastrophic. Although there are several case reports describing such complications, their rate of occurrence is generally underreported, and data regarding their exact incidence in large clinical series are lacking. Meticulous knowledge of potential intraoperative and postoperative ACDF-related complications is of paramount importance so as to avoid them whenever possible, as well as to successfully and safely manage them when they are inevitable. In a retrospective study, 1015 patients undergoing first-time ACDF for cervical radiculopathy and/or myelopathy due to degenerative disc disease and/or cervical spondylosis were evaluated. A standard Smith-Robinson approach was used in all our patients, while an autologous or allograft was used, with or without a plate. Operative reports, hospital and outpatient clinic charts, and radiographic studies were reviewed for procedure-related complications. Mean follow-up time was 26.4 months. The mortality rate in our current series was 0.1% (1 of 1015 patients, death occurred secondary to an esophageal perforation). Our overall morbidity rate was 19.3% (196 of 1015 patients). The most common complication was the development of isolated postoperative dysphagia, which observed in 9.5% of our patients. Postoperative hematoma occurred in 5.6%, but required surgical intervention in only 2.4% of our cases. Symptomatic recurrent laryngeal nerve palsy occurred in 3.1% of our cases. Dural penetration occurred in 0.5%, esophageal perforation in 0.3%, worsening of preexisting myelopathy in 0.2%, Horner's syndrome in 0.1%, instrumentation backout in 0.1%, and superficial wound infection in 0.1% of our cases. Meticulous knowledge of the ACDF-associated complications allows for their proper management. Postoperative dysphagia, hematoma, and recurrent laryngeal nerve palsy were the most common complications in our series. Management of complications was successful in the vast majority of our cases.

                Author and article information

                Brain Spine
                Brain Spine
                Brain & Spine
                18 January 2024
                18 January 2024
                : 4
                : 102748
                [a ]National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
                [b ]Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity, Ireland
                [c ]School of Medicine, University of College Dublin, Belfield, Dublin, Ireland
                [d ]Orthopaedic Resident, University of Toronto, Canada
                [e ]School of Medicine, University of Galway, Galway, Ireland
                [f ]Department of Orthopaedics, Tallaght University Hospital, Tallaght, Dublin, Ireland
                [g ]Department of Orthopaedics, St. Vincent's University Hospital, Dublin, Ireland
                Author notes
                []Corresponding author. National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland. jakemcdonnell@ 123456rcsi.com
                S2772-5294(24)00004-3 102748
                © 2024 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                : 30 August 2023
                : 27 December 2023
                : 17 January 2024

                cervical spine,acdf,spine surgery,cage,spacer,outcomes
                cervical spine, acdf, spine surgery, cage, spacer, outcomes


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