A prospective randomized comparison of rectangular titanium cage fusion and iliac crest autograft fusion in patients undergoing anterior cervical discectomy

Abstract

The authors compare clinical outcome and fusion rates after iliac crest autograft (ICAG)- and rectangular titanium cage (RTC)-augmented fusion in patients undergoing anterior cervical discectomy (ACD). One hundred consecutive patients with 127 levels of cervical disc disease refractory to conservative treatment were randomized into one of the two treatment groups (ICAG/RTC fusion). The visual analog scale was used by the patient to rate overall pain and head, neck, arm, and donor site pain separately. Myelopathy was documented according to Japanese Orthopaedic Association and Nurick grading systems. Outcome was analyzed using Odom criteria, the 36-Item Short Form (SF-36), and Patient Satisfaction Index scales. Fusion rates were assessed on standard and flexion-extension radiographs. Follow-up data of at least 12 months' duration were available for 95 patients. More residual overall pain after 12 months was documented in patients who underwent ICAG fusion (3.3 +/- 2.5 [ICAG] and 2.2 +/- 2.4 [RTC]; p < 0.05). Although arm and head pain were minimal in both groups, neck pain proved to be the predominant symptom (2.7 +/- 2.5 [ICAG] and 1.9 +/- 2.1 [RTC]), which resolved in only 67 and 48% of RTC- and ICAG-treated patients, respectively (p < 0.05). Myelopathy improved comparably in both groups. Regardless of increased pain in ICAG-treated patients, PSI and SF-36 scores were not significantly different between groups (only four [8%] of 47 ICAG-treated patients and five [10%] of 48 RTC-treated patients were unsatisfied). Good to excellent functional recovery according to Odom criteria was observed in 75 and 79% of ICAG- and RTC-treated patients, respectively. Fusion rates were 81 and 74%, respectively (p = 0.51). Fusion rates and clinical outcome at 12 months after ACD were comparable between patients who underwent ICAG and RTC fusion. The use of rectangular cages, however, avoids donor site morbidity and reduces overall pain and, thus, seems to be an advantageous treatment alternative.