Strategies to Achieve Spinal Fusion in Multilevel Anterior Cervical Spine Surgery: An Overview.
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ABSTRACT: Background
Anterior cervical fusion offers surgeons a safe and reliable surgical option for single-level and multilevel pathology; however, multilevel fusions pose a higher risk of complications than single-level fusions, including possible pseudoarthrosis, adjacent segment disease, sagittal imbalance, and construct subsidence. Various techniques can be used to mitigate risk in multilevel anterior cervical fusion.Questions/purposes
We reviewed the literature to determine the best surgical strategies in multilevel anterior cervical fusion.Methods
We searched the PubMed database for articles published from January 1980 through July 2019. Two authors identified relevant articles and then manually screened them for others to include in this review.Results
We initially identified 1936 articles and included 48 in our review. We found that clinical outcomes of multilevel anterior cervical fusion can be optimized through the use of biologics and graft selection, the evaluation of pre-existing deformity, the assessment of comorbidities, and the selection of fusion levels. Meticulous surgical technique in conjunction with modern surgical tools, such as instrumentation and biologics, allow surgeons to address complex cervical problems while limiting morbidity and enhancing clinical outcomes.Conclusions
Multilevel anterior cervical fusions offer a relatively safe and reliable treatment option for both single-level and multilevel pathology.
SUBMITTER: McCarthy MH
PROVIDER: S-EPMC7253572 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundIn case of spinal cord compression behind the vertebral body, anterior cervical corpectomy and fusion (ACCF) proves to be a more feasible approach than cervical discectomy. The next step was the placement of an expandable titanium interbody in order to restore the vertebral height. The need for additional anterior plating with ACCF has been debatable and such technique has been evaluated by very few studies. The objective of the study is to evaluate radiographic and clinical outcomes in patients with multilevel degenerative cervical spine disease treated by stand-alone cages for anterior cervical corpectomy and fusion (ACCF).MethodsThirty-one patients (66.5 ± 9.75 years, range 53-85 years) were analyzed. Visual Analog Scale (VAS) and the 10-item Neck Disability Index (NDI) were assessed preoperatively and during follow-up on a regular basis after surgery and after one year at least. Assessment of radiographic fusion, subsidence, and lordosis measurement of Global cervical lordosis (GCL); fusion site lordosis (FSL); the anterior interbody space height (ant. DSH); the posterior interbody space height (post. DSH); the distance of the cage to the posterior wall of the vertebral body (CD) were done retrospectively. Mean clinical and radiographic follow-up was 20.0 ± 4.39 months.ResultsVAS-neck (p = 0.001) and VAS-arm (p < 0.001) improved from preoperatively to postoperatively. The NDI improved at the final follow-up (p < 0.001). Neither significant subsidence of the cages nor significant loss of lordotic correction were seen. All patients showed a radiographic union of the surgically addressed segments at the last follow up.ConclusionsApplication of a stand-alone expandable cage in the cervical spine after one or two-level ACCF without additional posterior fixation or anterior plating is a safe procedure that results in fusion. Neither significant subsidence of the cages nor significant loss of lordotic correction were seen.Trial registrationRetrospectively registered. According to the Decision of the ethics committee, Jena on 25th of July 2018, that this study doesn't need any registration. https://www.laek-thueringen.de/aerzte/ethikkommission/registrierung/ .
| S-EPMC8725343 | biostudies-literature
Project description:The objective of this meta-analysis is to compare hybrid surgery (HS) and cervical discectomy and fusion (ACDF) for multilevel cervical degenerative disc diseases (DDD). Systematic searches of all published studies through March 2015 were identified from Cochrane Library, Medline, PubMed, Embase, ScienceDirect, CNKI, WANFANG DATA and CQVIP. Randomized controlled trials (RCTs) and non-RCTs involving HS and ACDF for multilevel DDD were included. All literature was searched and assessed by two independent reviewers according to the standard of Cochrane systematic review. Data of functional and radiological outcomes in two groups were pooled, which was then analyzed by RevMan 5.2 software. One RCT and four non-RCTs encompassing 160 patients met the inclusion criteria. Meta-analysis revealed significant differences in blood loss (p = 0.005), postoperative C2-C7 ROM (p = 0.002), ROM of superior adjacent segment (p < 0.00001) and ROM of inferior adjacent segment (p = 0.0007) between the HS group and the ACDF group. No significant differences were found regarding operation time (p = 0.75), postoperative VAS (p = 0.18) and complications (p = 0.73) between the groups. Hybrid surgery demonstrated excellent clinical efficacy and radiological results. Postoperative C2-C7 ROM was closer to the physiological status. No decrease in the ROM of the adjacent segment was noted in the hybrid surgery group.
| S-EPMC4549689 | biostudies-other
Project description:Background and objectivesThe anterior approach for cervical discectomy and fixation is a valuable procedure for decompression of the spinal cord in patients with severe canal stenosis and stabilization of cervical vertebral column. Although some studies have investigated the thyroid complications especially in cervical cancer surgery or recently in tracheostomy, little research has been performed on the anterior spine surgery so far. The present study aimed to evaluate possible changes in the thyroid in patients experiencing anterior cervical approaches for degenerative diseases.Materials and methodsSeventy patients who were undergoing anterior cervical spine surgery were selected and their demographic information was recorded, including age, sex, weight, body mass index (BMI), and medical records. Thyroid hormones (TSH, free T4, and free T3) were measured before surgery and three months after surgery.ResultsMost patients had cervical disc herniation (60%). The mean duration of surgery was 71.9 ± 8.36 minutes (range: 60-90 minutes). Twenty-one patients (30%) had anterior plating while 49 patients (70%) did not. Spearman's correlation coefficient was used to examine the correlation of the following variables with TSH changes: Number of operated cervical levels, level of operated spine, incision type, duration of surgery, type of surgery (ACDF or ACCF). None of these variables showed a significant correlation. Meanwhile, a significant and direct correlation was observed between TSH changes and age.ConclusionsAlthough the results of our study did not show any signs of functional changes due to thyroid tissue injury during surgery, based on rare case reports and age-related laboratory changes, we recommend thyroid function tests for diagnosing subclinical thyroid dysfunction before anterior cervical spine surgery in patients with degenerative diseases and especially in older adults.
| S-EPMC8823493 | biostudies-literature
Project description:Study design:Single-center, retrospective case-control study. Objectives:This study aimed to determine the risk factors for progression of neurological symptoms after anterior fusion for cervical spine trauma with no or incomplete spinal cord injury. Setting:Community-based hospital with an acute care center in Japan. Methods:We retrospectively reviewed 54 consecutive unstable subaxial cervical spine fracture/dislocation cases that had undergone surgical treatment. A total of 20 patients with no or incomplete spinal cord injury who underwent anterior fusion were identified. Injury characteristics, bony spinal canal diameter (SCD) at the injured level on computed tomography (CT), diagnosis delay of more than 24?h, and other surgery-related parameters were documented as potential risk factors. Results:The study population included 16 male and 4 female patients. The median age was 71.5 (range: 20-88) years. Two cases of SCI progression were identified (AIS E to C5-8 C and AIS D to C5-8 C). Both cases occurred in men who were older than the average age of all the patients. Only delayed diagnosis was significantly associated with the progression of SCI (p?=?0.02). SCDs on CT demonstrated a tendency to be smaller than those of cases without progression, but this was not statistically significant (progression: median, 8.1 [7.2-8.9] mm; no progression: median, 10.1 [4.2-12.6] mm; p?=?0.21). Conclusion:Our results suggested that a delay in diagnosis was associated with neurological progression after ACF. Furthermore, imposing ligamentous flavum might become a compression factor if the diagnosis is delayed.
| S-EPMC6173744 | biostudies-literature
Project description:Study Design Review. Objective Postoperative oropharyngeal dysphagia is one of the most common complications following anterior cervical spine surgery (ACSS). We review and summarize recent literature in order to provide a general overview of clinical signs and symptoms, assessment, incidence and natural history, pathophysiology, risk factors, treatment, prevention, and topics for future research. Methods A search of English literature regarding dysphagia following anterior cervical spine surgery was conducted using PubMed and Google Scholar. The search was focused on articles published since the last review on this topic was published in 2005. Results Patients who develop dysphagia after ACSS show significant alterations in swallowing biomechanics. Patient history, physical examination, X-ray, direct or indirect laryngoscopy, and videoradiographic swallow evaluation are considered the primary modalities for evaluating oropharyngeal dysphagia. There is no universally accepted objective instrument for assessing dysphagia after ACSS, but the most widely used instrument is the Bazaz Dysphagia Score. Because dysphagia is a subjective sensation, patient-reported instruments appear to be more clinically relevant and more effective in identifying dysfunction. The causes of oropharyngeal dysphagia after ACSS are multifactorial, involving neuronal, muscular, and mucosal structures. The condition is usually transient, most often beginning in the immediate postoperative period but sometimes beginning more than 1 month after surgery. The incidence of dysphagia within one week after ACSS varies from 1 to 79% in the literature. This wide variance can be attributed to variations in surgical techniques, extent of surgery, and size of the implant used, as well as variations in definitions and measurements of dysphagia, time intervals of postoperative evaluations, and relatively small sample sizes used in published studies. The factors most commonly associated with an increased risk of oropharyngeal dysphagia after ACSS are: more levels operated, female gender, increased operative time, and older age (usually >60 years). Dysphagic patients can learn compensatory strategies for the safe and effective passage of bolus material. Certain intraoperative and postoperative techniques may decrease the incidence and/or severity of oropharyngeal dysphagia after ACSS. Conclusions Large, prospective, randomized studies are required to confirm the incidence, prevalence, etiology, mechanisms, long-term natural history, and risk factors for the development of dysphagia after ACSS, as well as to identify prevention measures. Also needed is a universal outcome measurement that is specific, reliable and valid, would include global, functional, psychosocial, and physical domains, and would facilitate comparisons among studies. Results of these studies can lead to improvements in surgical techniques and/or perioperative management, and may reduce the incidence of dysphagia after ACSS.
| S-EPMC3854602 | biostudies-other
Project description:IntroductionAuthors aim to demonstrate the surgical technique and outcomes of using a platysma sparing approach to anterior cervical spine surgery.MethodsMedical records of 496 prospective patients, group 1 (259 patients) with an outpatient platysma muscle-sparing approach. Group 2 (237 patients) with inpatient standard muscle-splitting approach.ResultsIntergroup comparison showed statistical significant improvement in VAS neck and NDI scores p = 0.009 and p = 0.012 and surgical operative time and estimated blood loss, p = 0.003 and p = 0.006 respectively.ConclusionThis anatomy sparing technique demonstrates a safe, effective and reproducible approach to cervical spine surgery which is a goal of less exposure surgery philosophy.
| S-EPMC6807304 | biostudies-literature
Project description:Background: Intraoperative neuromonitoring (IONM) is frequently used during spine surgery to mitigate the risk of neurological injuries. Yet, its role in anterior cervical spine surgery remains controversial. Without consensus on which anterior cervical spine surgeries would benefit the most from IONM, there is a lack of standardized guidelines for its use in such procedures. Purpose: We sought to assess the alerts generated by each IONM modality for 4 commonly performed anterior cervical spinal surgeries: anterior cervical diskectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), cervical disk replacement (CDR), or anterior diskectomy. In doing so, we sought to determine which IONM modalities (electromyography [EMG], motor evoked potentials [MEP], and somatosensory evoked potentials [SSEP]) are associated with alert status when accounting for procedure characteristics (number of levels, operative level). Methods: We conducted a retrospective review of IONM data collected by Accurate Neuromonitoring, LLC, a company that supports spine surgeries conducted by 400 surgeons in 8 states, in an internally managed database from December 2009 to September 2018. The database was queried for patients who underwent ACCF, ACDF, anterior CDR, or anterior diskectomy in which at least 1 IONM modality was used. The IONM modalities and incidence of alerts were collected for each procedure. The search identified 8854 patients (average age, 50.6 years) who underwent ACCF (n = 209), ACDF (n = 8006), CDR (n = 423), and anterior diskectomy (n = 216) with at least 1 IONM modality. Results: Electromyography was used in 81.3% (n = 7203) of cases, MEP in 64.8% (n = 5735) of cases, and SSEP in 99.9% (n = 8844) of cases. Alerts were seen in 9.3% (n = 671), 0.5% (n = 30), and 2.7% (n = 241) of cases using EMG, MEP and SSEP, respectively. In ACDF, a significant difference was seen in EMG alerts based on the number of spinal levels involved, with 1-level ACDF (6.9%, n = 202) having a lower rate of alerts than 2-level (10.0%, n = 272), 3-level (15.2%, n = 104), and 4-level (23.4%, n = 15). Likewise, 2-level ACDF had a lower rate of alerts than 3-level and 4-level ACDF. A significant difference by operative level was noted in EMG use for single-level ACDF, with C2-C3 having a lower rate of use than other levels. Conclusions: This retrospective review of anterior cervical spinal surgeries performed with at least 1 IONM modality found that SSEP had the highest rate of use across procedure types, whereas MEP had the highest rate of nonuse. Future studies should focus on determining the most useful IONM modalities by procedure type and further explore the benefit of multimodal IONM in spine surgery.
| S-EPMC9837402 | biostudies-literature
Project description:IntroductionIn managing cervical disc herniation, several treatment options are available. Anterior cervical decompression and fusion (ACDF) remain the gold standard in symptomatic cervical disc herniation. However, multilevel ACDF could diminish the motion of the segment. We planned to salvage the movement by only using single-level ACDF in our patient and osteophyte removal to reduce compression caused by spurs formation related to the herniated nucleus.MethodsA male patient, 43 years old, came with a chief complaint of neck pain three months ago. The pain was intermittent, radiated into both hands. There was midline tenderness, and his sensation was decreased from the level of C5 below. We managed to diagnose the patient with Cervical Herniated Disc (CHD) using MRI and performed single-level ACDF.ResultsAfter the operation, osteophyte formation was safely removed, the pain and the tingling sensation was no longer felt. The VAS score was reduced from 4 to 1. We observed good spinal fusion in the post x-ray imaging.ConclusionAnterior cervical discectomy and fusion after osteophyte removal proved successful for our patient treatment, with improvement from neck and arms symptoms. However, longer-term evaluation needs to be planned further to assess the result and possible complications of single-level ACDF.
| S-EPMC7779959 | biostudies-literature
Project description:Background:As the frequency of adult deformity surgery (ADS) continues to increase, our understanding of techniques that enhance fusion must continue to evolve because pseudarthrosis can be a serious and costly event. Purposes/Questions:We sought to conduct a review of the literature investigating techniques that can enhance outcomes of ADS. Methods:Two databases were searched for keywords such as "advances in spinal fusion," "new technology in adult spinal deformity," "interbody devices for adult spinal deformity," "adult spinal deformity rods," and "screw design in adult spinal deformity" to examine recent literature and trends in ADS. Results:We identified 45 articles for our review. Topics studied include the use of multiple rods, interbody fusion, distal fixation techniques, and bone morphogenetic protein or iliac crest bone graft. Conclusions:Many recent innovations in treatments to enhance fusion in ADS have been studied, some more controversial than others. Further research into the efficacy of these techniques may increase fusion rates in ADS.
| S-EPMC7253541 | biostudies-literature
Project description:We aimed to identify independent psychological predictors of quality of life (QOL) and functional outcome after anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease. We prospectively included patients undergoing ACDF for degenerative cervical disc herniation and stenosis. Patients completed a structured psychological assessment including the Center for Epidemiological Studies Depression Scale (ADS-K), Post-Traumatic Stress Scale-10 (PTSS-10), State Trait Anxiety Inventory-State Anxiety and - Trait Anxiety (STAI-S and STAI-T) and Anxiety Sensitivity Index-3 (ASI-3) before surgery, after 3 and 12 months. Outcome measures included EuroQol-5D (EQ), Short Form-36 (SF-36) and Oswestry Disability Index (ODI) scores. Of 104 included patients who underwent ACDF between March 2013 and November 2017, 92 completed follow-up after 3 and 12 months. The mean Visual Analogue Scale (VAS) scores for neck pain (- 1.4; p?<?.001) and arm pain (- 1.8; p?=?.031) significantly decreased by 12 months. QOL scores significantly increased by 3 months (EQ:?+?0.2; p?<?.001; SF-36 PCS:?+?6.2; p?<?.001; SF-36 MCS:?+?2.5; p?=?.044), a benefit which was retained at 12 months. Linear regression analyses identified statistically significant predictors in preoperative ASI-3, SF-36 MCS and STAI-S for postoperative QOL and ODI scores. There is a benefit for patients in terms of quality of life and function after undergoing surgery for degenerative cervical spine disease. With the ASI-3, SF-36 MCS and STAI-S there exist some predictors for postoperative QOL and ODI scores.
| S-EPMC7414876 | biostudies-literature