Anterior Cervical Corpectomy Research Articles

Comparison of Complications between Anterior Cervical Diskectomy and Fusion versus Anterior Cervical Corpectomy and Fusion in Two- and Three-Level Cervical Spondylotic Myelopathy: A Meta-analysis.

In this study, we systematically analyze the differences in complications between anterior cervical diskectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) in two- and three-level cervical spondylotic myelopathy (CSM). We performed a systematic search in MEDLINE, EMBASE, PubMed, Web of Science, Cochrane databases, Chinese Biomedical Literature Database, CNKI, and Wan Fang Data for all relevant studies. All statistical analyses were performed using Review Manager version 5.3. A total of 11 articles with 849 study subjects were included, with 474 patients in the ACDF group and 375 patients in the ACCF group. The results of the meta-analysis showed that in C5 palsy (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.16-1.06), pseudarthrosis (OR: 1.07; 95% CI: 0.23-5.07), dysphagia (OR: 1.06; 95% CI: 0.60-1.86), infection (OR: 0.41; 95% CI: 0.16-1.09), cerebrospinal fluid leakage (OR: 1.21; 95% CI: 0.39-3.73), graft dislodgment (OR: 0.28; 95% CI: 0.06-1.37), and hematoma (OR: 0.32; 95% CI: 0.06-1.83), there are no significant differences between the ACDF and ACCF groups, whereas total complication (OR: 0.50; 95% CI: 0.31-0.80) showed that the ACDF group had a significantly lower morbidity than the ACCF group. Furthermore, the three-level subgroup of ACDF had significantly better results in C5 palsy (OR: 0.31; 95% CI: 0.11-0.88), infection (OR: 0.22; 95% CI: 0.05-0.94), graft dislodgment (OR: 0.07; 95% CI: 0.01-0.40), and total complication (OR: 0.37; 95% CI: 0.23-0.60) compared with the ACCF subgroup. In general, postoperative pseudarthrosis, dysphagia, cerebrospinal fluid leakage, hematoma, C5 palsy, infection, and graft dislodgment did not differ significantly between the two groups. Total complication was significantly less in the ACDF group compared to the ACCF group. In the three-level subgroup, the morbidity of C5 palsy, infection, and graft dislodgment was significantly lower in ACDF than in ACCF.

New anterior controllable antedisplacement and fusion surgery for cervical ossification of the posterior longitudinal ligament: a biomechanical study.

The traditional anterior approach for multilevel severe cervical ossification of the posterior longitudinal ligament (OPLL) is demanding and risky. Recently, a novel surgical procedure-anterior controllable antedisplacement and fusion (ACAF)-was introduced by the authors to deal with these problems and achieve better clinical outcomes. However, to the authors' knowledge, the immediate and long-term biomechanical stability obtained after this procedure has never been evaluated. Therefore, the authors compared the postoperative biomechanical stability of ACAF with those of more traditional approaches: anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF). To determine and assess pre- and postsurgical range of motion (ROM) (2 Nm torque) in flexion-extension, lateral bending, and axial rotation in the cervical spine, the authors collected cervical areas (C1-T1) from 18 cadaveric spines. The cyclic fatigue loading test was set up with a 3-Nm cycled load (2 Hz, 3000 cycles). All samples used in this study were randomly divided into three groups according to surgical procedures: ACDF, ACAF, and ACCF. The spines were tested under the following conditions: 1) intact state flexibility test; 2) postoperative model (ACDF, ACAF, ACCF) flexibility test; 3) cyclic loading (n = 3000); and 4) fatigue model flexibility test. After operations were performed on the cadaveric spines, the segmental and total postoperative ROM values in all directions showed significant reductions for all groups. Then, the ROMs tended to increase during the fatigue test. No significant crossover effect was detected between evaluation time and operation method. Therefore, segmental and total ROM change trends were parallel among the three groups. However, the postoperative and fatigue ROMs in the ACCF group tended to be larger in all directions. No significant differences between these ROMs were detected in the ACDF and ACAF groups. This in vitro biomechanical study demonstrated that the biomechanical stability levels for ACAF and ACDF were similar and were both significantly greater than that of ACCF. The clinical superiority of ACAF combined with our current results showed that this procedure is likely to be an acceptable alternative method for multilevel cervical OPLL treatment.

Biomechanical Effects of a Novel Anatomic Titanium Mesh Cage for Single-Level Anterior Cervical Corpectomy and Fusion: A Finite Element Analysis.

Background: The traditional titanium mesh cage (TTMC) has become common as a classical instrument for Anterior Cervical Corpectomy and Fusion (ACCF), but a series of complications such as cage subsidence, adjacent segment degeneration (ASD), and implant-related complications by using the TTMC have often been reported in the previous literature. The aim of this study was to assess whether a novel anatomic titanium mesh cage (NTMC) could improve the biomechanical condition after surgery. Methods: The NTMC model consists of two spacers located on both sides of the TTMC which match the anatomic structure between the endplates by measuring patient preoperative cervical computed tomography (CT) data. The ranges of motion (ROMs) of the surgical segments and the stress peaks in the C6 superior endplates, titanium mesh cage (TMC), screw–bone interface, anterior titanium plate, and adjacent intervertebral disc were compared. Results: Compared with the TTMC, the NTMC reduced the surgical segmental ROMs by 89.4% postoperatively. The C6 superior endplate stress peaks were higher in the TTMC (4.473–23.890 MPa), followed by the NTMC (1.923–5.035 MPa). The stress peaks on the TMC were higher in the TTMC (47.896–349.525 MPa), and the stress peaks on the TMC were lower in the NTMC (17.907–92.799 MPa). TTMC induced higher stress peaks in the screw–bone interface (40.0–153.2 MPa), followed by the NTMC (14.8–67.8 MPa). About the stress peaks on the anterior titanium plate, the stress of TTMC is from 16.499 to 58.432 MPa, and that of the NTMC is from 12.456 to 34.607 MPa. Moreover, the TTMC induced higher stress peaks in the C3/4 and C6/7 intervertebral disc (0.201–6.691 MPa and 0.248–4.735 MPa, respectively), followed by the NTMC (0.227–3.690 MPa and 0.174–3.521 MPa, respectively). Conclusion: First, the application of the NTMC can effectively decrease the risks of TMC subsidence after surgery. Second, in the NTMC, the stresses at the anterior screw-plate, bone–screw, and TMC interface are much less than in the TTMC, which decreased the risks of instrument-related complications after surgery. Finally, increases in IDP at adjacent levels are associated with the internal stresses of adjacent discs which may lead to ASD; therefore, the NTMC can effectively decrease the risks of ASD.

Symptomatic postoperative spinal epidural hematoma preferentially occurs after anterior cervical discectomy and fusion versus anterior cervical corpectomy and fusion: a retrospective study.

Cervical spondylotic myelopathy (CSM) is a common cause of neurological morbidity, which can have an impact on quality of life. Symptomatic postoperative spinal epidural hematoma (SPSEH) is a rare condition, but can cause permanent neurological deficits and disability if not managed properly. However, there are limited studies on the outcomes of SPSEH after anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) were performed for 2-level CSM. Therefore, the aim of the present study was to compare the clinical outcomes and incidence of SPSEH after ACDF compared with SPSEH after anterior cervical corpectomy and ACCF for 2-level CSM to reduce surgical complications of 2 level CSM. A total of 551 patients (261 males and 290 females) who underwent ACDF or ACCF for 2-level CSM from January 2009 to February 2015 were retrospectively reviewed. Preoperative indexes (age, sex, body mass index, bone mineral density, preoperative coagulation, and past medical history), perioperative indexes (length of hospital admission, blood loss, and operation times), preoperative and postoperative neurological statuses, complications, fusion rate, and the SPSEH incidence for ACDF or ACCF were compared simultaneously. With the exception of blood loss (P<0.001), no significant differences were observed between the 2 groups in terms of sex, prothrombin time, activated partial thromboplastin time, platelet count, length of hospital admission, operation time, the final follow-up Japanese Orthopedic Association score, visual analog scale score, fusion rate, and complications. The overall incidence rate for SPSEH after ACDF was 1.9%, while the rate for SPSEH after ACCF was 0.4%. Following hematoma removal, only one patient showed any improvement in neurological function, despite treatment with hyperbaric oxygen and neurotrophic drugs. The findings indicated that surgical management of 2-level CSM using ACDF or ACCF showed similar clinical outcomes, fusion rate, complications, and perioperative parameters, with the exception of blood loss. However, SPSEH preferentially occurs after surgery with ACDF. Therefore, whether ACCF surgery for 2-stage CSM is the superior treatment modality.

Wear assessment of a Ti–6Al–4V motion-preserving porous artificial-cervical-joint fabricated by SLM after surface carburization

Adjacent segment degenerative diseases are a major clinical concern for anterior cervical corpectomy with fusion surgery. In this study, a hybrid motion-preserving cervical prosthesis consists of two articulating joints and one porous fusion body is designed to provide motion ability and reduce the occurrence of degenerative diseases. The hybrid design is fabricated from Ti–6Al–4V (TC4) alloy using selective laser melting (SLM) technology. After carburization pretreatment, two types of bearing couple SLM-TC4 self-mating and SLM-TC4/UHMWPE were studied in terms of lubrication regime, contact mechanics and wear performance. According to the ISO 18192-1 standard, five million cycles (Mc) of in vitro spine simulator wear tests were conducted in bovine serum lubricated condition.Hamrock-Dawson minimum lubrication film thickness analysis stated that both bearing was likely under boundary lubrication only, with extensive surface asperities contact. And, the contact stress encountered during in vitro condition was not enough to cause surface fatigue failure of any bearing couple. In term of wear performance, the obtained steady state wear rates were 0.160 ± 0.004 mm3/Mc for SLM-TC4 self-mating and 8.57 ± 0.06 mm3/Mc for SLM-TC4/UHMWPE bearing couples, respectively. According to these outcomes, SLM-TC4 self-mating couple was more promising for the articulating joint bearing design.For SLM-TC4 self-mating couple, the initial wear mechanism was abrasion with potential third-body abrasion wear. As the wear cycle proceeding, the TiC cermet layer was gradually damaged and exposed the local bare metal. Under this circumstance, material loss was consisted of abrasion wear, adhesion wear, and tribo-corrosion. In comparison, the wear mechanism of SLM-TC4/UHMWPE bearing was always abrasion-adhesion of UHMWPE. The surface of UHMWPE socket was severely plowed by the hard micro bulge of the TiC layer, and material loss and plastic deformation occurred only on the UHMWPE socket. In conclusion, carburization pre-treatment causes a hard TiC cermet layer formation on the SLM-TC4, which enhance its hardness and protect underling material from corrosion damage. The thickness and quality of the TiC layer directly affect the longevity of the joint prosthesis in vivo.

Risk Factors for Predicting Increased Surgical Drain Output in Patients After Anterior Cervical Decompression and Fusion

Tje objective of this study was to identify factors that are independently associated with increased surgical drain output (ISDO) in patients who have undergone anterior cervical decompression (discectomy/corpectomy) and fusion (anterior cervical discectomy and fusion [ACDF]/anterior cervical corpectomy and fusion [ACCF]). Consecutive patients who underwent ACDF/ACCF with surgical drain placement at a single academic institution between January 2013 and December 2017 were identified from the medical records. Patients were categorized into normal or ISDO groups, with ISDO defined as a total drain output of 100ml or more. The demographic distribution and clinical data of these 2 groups were incorporated into univariate and multivariate analyses to investigate the predictive factors of ISDO. A total of 791 patients with ACDF/ACCF met the inclusion criteria. The average drain output for this cohort was 104.9±55.9ml. Among all patients in the study, 378 patients had ISDO (drain output >100ml). Our analysis identified the following independent predictors of ISDO in all patients: male sex (P < 0.001), age 50years or older (P= 0.018), the number of discs involved (P < 0.001), and C3 involvement (P= 0.002). Among the patients undergoing ACDF, male sex (P < 0.001), the number of discs involved (P < 0.001), and C3 involvement (P= 0.004) were significant predictors of ISDO. Among those undergoing ACCF, male sex (P < 0.001) and the number of discs involved (P < 0.001) were significant predictors of ISDO. Male sex, age 50years or older, the number of discs involved, and C3 involvement were significant risk factors for ISDO following anterior cervical decompression and fusion. Patients with these risk factors may benefit from surgical drain placement.

Undifferentiated presentation of unilateral agenesis of a cervical pedicle and a contiguous vertebral hemangioma: illustrative case.

BACKGROUNDUnilateral agenesis of a cervical pedicle is a known rare entity that has been well described over the past 70 years. It is usually an incidental or minimally symptomatic presentation with no significant clinical repercussion. No previous report has described concurrent non-osseous developmental abnormalities alongside this unique pathology.OBSERVATIONSThis case reported a cervical hemangioma with associated unilateral pedicle agenesis and an incidental finding of callosal dysgenesis and lipoma. The initial presentation consisted solely of persistent neck pain, with cervical radiography illustrating significant kyphotic deformity secondary to apparent anterolisthesis of C3-C4. The patient underwent a combined approach: anterior cervical corpectomy at C4-C5 with supplemental posterior fusion. The authors provided a review of the literature concerning developmental pedicle abnormalities and vertebral hemangioma. Pedicle agenesis is known to be associated with multiple pathologies, but the authors have not found evidence of a clinical paradigm consisting of a vertebral hemangioma in the presence of cervical pedicle agenesis, callosal dysgenesis, or callosal lipoma.LESSONSCareful evaluation of radiographs with appropriate subsequent multimodal imaging is key to identifying unique pathologies in the spine that complement a patient’s history and clinical findings. If multiple abnormalities are noted, a novel clinical etiology or syndrome must be considered.

Anterior Cervical Controllable Antedisplacement and Fusion (ACAF): Improving Outcomes for Severe Cervical Ossification of the Posterior Longitudinal Ligament.

The detailed steps to perform ACAF have been described previously1. Briefly, following induction of general endotracheal anesthesia, a standard right- or left-sided Smith-Robinson incision is made. Discectomies are performed at the involved levels. By measuring the thickness of the OPLL on an axial preoperative computed tomography scan at each compressed level, the amount of each anterior vertebral body to be resected can be calculated preoperatively. This was, in general, equal to the thickness of the ossified mass at the same level. The previously calculated portion of each involved body in the vertebral body-OPLL complex is resected. Following the creation of a contralateral longitudinal osseous trough, the prebent anterior cervical plate is then placed, and the screws are installed after proper drilling and taping on the remaining vertebral bodies. The screws utilized in this procedure should not be too short to achieve adequate purchase in the vertebral body. Subsequently, the intervertebral cages are inserted. Thus, the vertebral body-OPLL complex is temporarily stabilized for the next procedure. Next, an ipsilateral longitudinal osseous trough is created to completely isolate the vertebral body-OPLL complex. Notably, the objective of complete isolation of the vertebral body-OPLL complex is to further anteriorly hoist the complex to decompress the spinal cord. Finally, screws are inserted through the plate and into each vertebral body and are gradually tightened to displace the bodies anteriorly. Allogenic iliac bone graft is placed in the longitudinal bone troughs to promote fusion. Nonoperative treatment is frequently ineffective. Traditional surgical interventions have included anterior cervical corpectomy and fusion (ACCF), posterior laminoplasty, and laminectomy2,3. ACCF focuses on resecting the ventral ossified mass in order to obtain direct decompression; however, this technique is very technically demanding, with a high risk of complications. In addition, the clinical benefits of ACCF will be limited when the OPLL extends over >3 levels. Posterior decompression can achieve indirect decompression by allowing the spinal cord to float away from the ossified mass. This technique depends largely on the preoperative presence of cervical lordosis and is contraindicated in patients with kyphosis or severe OPLL. In addition, posterior decompression surgery has been associated with a high incidence of late neurological deterioration and even revision surgery2. ACAF combines the advantages of direct decompression as occurs with ACCF with the limited manipulation of the canal contents as occurs with the posterior approach4-6. The procedure considers the ossified mass and the vertebral body as a single unit. Decompression is accomplished by moving the vertebral body with the OPLL ventrally away from the spinal cord. The preserved part of the vertebral body-OPLL complex becomes part of the anterior wall of the spinal canal. Without direct instrument manipulation inside the canal, the occurrence of cerebrospinal fluid leakage, hemorrhage, and intraoperative neural injury can be minimized5. Compared with a posterior approach, ACAF can achieve more decompression of the cord, especially in patients with cervical kyphosis and those with >60% of the spinal canal occluded6. This procedure can yield satisfactory clinical outcomes with fewer surgery-related complications1,4-6,9. A single-center, prospective, randomized controlled study showed significantly better Japanese Orthopaedic Association scores and recovery rates at 1 year for ACAF compared with laminoplasty for the treatment of multilevel OPLL in cases in which the occupying ratio of the canal was >60% occluded or the K-line (i.e., a virtual line between the midpoints of the anteroposterior canal diameter at C2 and C7) was negative9. In addition, patients who underwent ACAF had better preservation of cervical lordosis and sagittal balance9. The cervical segments to be treated should include all of the segments with OPLL that are causing spinal cord compression.The uncinate process can be utilized as a safe anatomical landmark for the longitudinal osteotomies in order to avoid vertebral artery injury, even in cases with severely ossified masses.Careful evaluation of the vertebral artery on preoperative magnetic resonance imaging or computed tomography is of great importance.Appropriately increasing the curvature of the cervical plate can further enlarge the space for the following antedisplacement of the vertebral body-OPLL complex.The location of the uncinate processes must be confirmed before the creation of the 2 longitudinal osseous troughs7,8.The preserved superior and inferior vertebral end plates should be made as smooth and mutually parallel as possible.The thickness of the anterior part of the vertebral bodies to be resected should be calculated preoperatively.The posterior longitudinal ligament behind the involved segments should not be resected. ACAF = anterior cervical controllable antedisplacement and fusionACCF = anterior cervical corpectomy and fusionOPLL = ossification of the posterior longitudinal ligamentCT = computed tomographyJOA = Japanese Orthopaedic AssociationMRI = magnetic resonance imagingOR = occupying rate of the spinal canalVOC = vertebral bodies-OPLL complexRR = recovery rateCSF = cerebrospinal fluidUP = uncinate processTF = transverse foramen.

Anterior cervical corpectomy for the treatment of spondylotic myelopathy: results of a prospective double-armed study with a three-year follow-up.

Since the first description in the 1950s, cervical spondylotic myelopathy (CSM) has posed many challenges to neurosurgeons and spine surgeons. Direct comparison among different operative approaches has failed to produce valuable results due to either an insufficient number of enrolled patients or a lack of standardization of baseline conditions. This prospective double-armed non-randomized study with a 3-year follow-up involved 80 patients with degenerative cervical myelopathy surgically and conservatively treated. The primary aim was to determine the efficacy of corpectomy in mild-moderate and severe CSM and to compare the outcomes of conservative and surgical treatment. Eighty patients were stratified into two arms, on the basis of the mJOA score: mild-moderate (mJOA ≥12) and severe myelopathy (mJOA score <12). Each arm was subdivided into two treatment groups (operative or conservative): A1, mild-moderate myelopathy treated with corpectomy; A2, mild-moderate myelopathy treated conservatively; B1, severe myelopathy treated with corpectomy; B2, severe cervical myelopathy treated conservatively. The clinical outcome was evaluated with the modified JOA score, timed 10-meter walk, Mehalic grade, motor evoked potentials, the SF-12, and further assessed by external observers blinded to the type of treatment. No significant differences in the recovery rates were found between the A1 and A2 groups at 6 months, although better results were recorded in the surgical groups (A1 and B1) at 12 months and at the final follow-up, as suggested by the significantly higher recovery rates. Multivariate analysis showed an inverse correlation between the duration of symptoms and the recovery rate (P<0.0001). Moreover, the preoperative timed 10-meter walk (P<0.004), the preoperative hypointensity on T1-weighted MR images (P<0.001), a higher Mehalic grade (P<0.02), the pre-treatment MEP (P<0.002), and the preoperative spinal canal diameter (P<0.004) significantly influenced the recovery rate. This prospective double-armed non-randomized study demonstrates that corpectomy is an effective and safe treatment, especially for severe forms of myelopathy. In mild-moderate conditions, a discrepancy between neurological improvement and expressed level of satisfaction was found. The present results also show that a multiparametric evaluation is crucial for proper patient selection for corpectomy.

Simulated Bundled Payments for 4 Common Surgical Approaches to Treat Degenerative Cervical Myelopathy: A Consideration to Break the Clinical Equipoise.

Retrospective cohort study. The aim was to compare 90-day and 2-year reimbursements for ≥2-level anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior laminectomy and fusion (LF) and laminoplasty (LP) done for degenerative cervical myelopathy (DCM). In DCM pathologies where there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes over posterior approaches. In the era of value and bundled payments initiatives, cost profile of various approaches will form an important consideration for decision making. IBM MarketScan Research Database (2005-2018) was used to study beneficiaries (30-75 y) who underwent surgery (mACDF, ACCF, LF, LP) for DCM. Index hospital stay (operating room, surgeon, hospital services) and postdischarge inpatient, outpatient and prescription medication payments have been used to simulate 90-day and 2-year bundled payment amounts, along with their distribution for each procedure. A total of 10,834 patients with median age of 54 years were included. The median 90-day payment was $46,094 (interquartile range: $34,243-$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital was 62.4% (operating room: 46.6) and surgeon payments were 17.5% of the average 90-day bundle. There was significant difference in the index, 90-day and 2-year reimbursements and their distribution among procedures. In a national cohort of patients undergoing surgery for DCM, LP had the lowest complication rate, and simulated bundled reimbursements at 90 days and 2 years postoperatively. The lowest quartile 90-day payment for LF was more expensive than median amounts for mACDF, ACCF, and LP. If surgeons encounter scenarios of clinical equipoise in practice, LP is likely to result in maximum value as it is on an average 70% less expensive than LF over 90 days.

Anterior cervical discectomy and fusion in the era of motion preserving surgery

Background. Anterior cervical discectomy and fusion is accepted as the standard surgical treatment of cervical spondylotic myelopathy. Cervical disc arthroplasty has gained widespread acceptance as an alternate choice for ACDF. We intend to present the clinical and radiologic outcomes of patients who underwent ACDF in our department. Methods. Designed as a retrospective study, the primary objective was to assess the nonunion in patients undergoing ACDF and Anterior cervical Corpectomy and fusion. The article discusses the outcome for the discectomy group. All patients who underwent ACDF for CSM from January 2014 to December 2018 were included. Patients who underwent posterior fusion in addition to anterior approach, revision surgery and congenital anomalies of the spine were excluded. Of the 230 eligible patients,46 subjects were part of the study. They underwent neurologic and radiographic examination and their past records were examined. Neurologic outcome was assessed using Nurick grade and mJOA score. Dysphagia was assessed using the Bazaz score. Neck radiographs were analysed for fusion, Adjacent segment Disease, subsidence, cervical and segmental lordosis. Results. The overall response rate was 25.65%. The mean follows up duration was 4 years. The mean age of the population was 47.1 years. The most common operating level was C5/6. The neurologic status of patients improved from the baseline. There was mild transient dysphagia in 5(10.9%) patients. The overall rate of fusion was 91.3%. Subsidence was seen in 10.9%. Degenerative changes were noted in postop x rays of 67.4% of patients. There was no mortality. Conclusion. ACDF achieves thorough decompression thereby resulting in neurologic improvement. It produces effective and sustained neurologic improvement. Preoperative adjacent segment degenerative changes were significantly associated with the development of ASD during follow up. This is can due to the progression of the disease. Though the procedure improves the lordosis, it tends to decrease with follow up.

Anterior 1-2 Level Cervical Corpectomy and Fusion for Degenerative Cervical Disease: A Retrospective Study With Lordotic Porous Tantalum Cages. Long-Term Changes in Sagittal Alignment and Their Clinical and Radiological Implications After Cage Subsidence.

Despite the advances in anterior cervical corpectomy and fusion (ACCF) as a reconstructive surgical technique, the rate of complications related to artificial implants remains high. The purpose of this study was to investigate the long-term clinical course of ACCF with tantalum trabecular metal (TTM)-lordotic implants. Focus is placed on the relevance and influence of implant subsidence on sagittal alignment and the related clinical implications. Retrospective, observational study of prospectively collected outcomes including 56 consecutive patients with degenerative cervical disc disease (myelopathy and/or radiculopathy). All patients underwent 1-level or 2-level ACCF with TTM-lordotic implants. The mean duration of follow-up was 4.85 years. The fusion rate at the end of follow-up was 98.11% (52/53). Implant subsidence occurred in 44 (83.01%) cases, including slight subsistence (<3 mm) in 37 (69.81%) and severe subsidence (>3 mm) in 7 cases (13.2%). The greatest degree of subsidence developed in the first 3 months postoperatively (P = 0.003). No patients presented a significant increase in implant subsidence beyond the second year of follow-up. The most common site of severe subsidence was the anterior region of the cranial end plate (4/7). At the end of follow-up, C1-C7 lordosis and segmental-Cobb angle of the fused segment increased on average by 5.06 ± 8.26 and 1.98 ± 6.02 degrees, respectively, though this difference failed to reach statistical significance (P > 0.05). Visual analog scale and Neck Disability Index scores improved at the conclusion of follow-up (P < 0.05). ACCF with anterior cervical reconstruction using TTM-lordotic implants and anterior cervical plating for treatment of cervical degenerative disease has high fusion rates and good clinical outcome. The osteoconductive properties of TTM provide immediate stabilization and eliminate the need for bone grafts to ensure solid bone fusion. Before fusion occurs, asymptomatic implant settlement into the vertebral body is inevitable. However, lack of parallelism and reduced contact surface between the implant and the vertebral end plate are major risk factors for severe further subsidence, which may negatively affect the clinical outcomes.

Anterior cervical pseudomeningocele causing syncope after spinal surgery: A case report.

Introduction and importancePseudomeningocele formation from incidental durotomy is a known risk in spine surgery. We present a case of incidental durotomy leading to anterior neck pseudomeningocele, compressing the carotid body (CB) resulting in syncopal episodes. To our knowledge, this is the first case report implicating syncopal episodes to CB compression via a pseudomeningocele.Case presentationA mid sixty-year-old patient with history of obesity, hypertension, and diabetes presented with gait impairment and hand weakness. Ossification of posterior longitudinal ligament (OPLL) was diagnosed with computed tomography imaging (CT) and magnetic resonance imaging (MRI). Elective surgery was completed with an anterior and posterior approach for decompression and fusion. Hospital course (San Jose, CA, USA) was complicated by respiratory depression and incomplete tetraplegia. On post-operative day (POD) six, CT revealed anterolateral soft tissue neck swelling; subsequent CT and MRI showed fluid collection expansion, with associated syncopal episodes on POD thirty-nine. Despite interventional radiology drainage, the fluid collection and symptoms returned five days later. The patient ultimately underwent durotomy revision and repair with muscle patch.Clinical discussionThis case highlights the challenges in managing anterior cervical dural tears resulting in pseudomeningocele. Risk factors include anterior cervical corpectomy and decompression, as well as an underlying diagnosis of OPLL. Untreated dural tears may develop into pseudomeningoceles which can contribute to life-threatening outcomes.ConclusionThis case report presents the serious consequences of incidental durotomy, the unique post-surgical complication of syncope due to compression of the CB from a pseudomeningocele, and the challenges of managing a persistent pseudomeningocele.

Effectiveness of nasotracheal intubation in anterior cervical surgery including C3 lesions

Objective Anterior approach cervical surgery is widely used for accessing C3 lesions. When operating with an anterior approach, the surgical field is obstructed by mandible. Neck extension is popular method to secure better surgical field but risk devastating neurological damage. To overcome this limited surgical field without neck extension, we adopted nasotracheal intubation and evaluated its efficiency. Methods We retrospectively analyzed 16 patients who underwent anterior cervical discectomy or corpectomy of C3 lesions via nasotracheal intubation. We enrolled an additional 29 patients who underwent anterior cervical discectomy or corpectomy of C3 lesions via orotracheal intubation as a control group. All patients had been diagnosed with cervical spondylotic myelopathy or ossification of the posterior longitudinal ligament. We measured the mandibular-cervical angle, which is the angle between the lower mandibular line and anterior vertebral line. Results The mandibular-cervical angle was increased by 7.3 with nasotracheal intubation compared to orotracheal intubation. Conclusions Nasotracheal intubation is an effective surgical option for securing the surgical field without neck extension in anterior cervical surgery including C3 lesions.

Anterior cervical corpectomy and fusion with stand-alone cages in patients with multilevel degenerative cervical spine disease is safe

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/.

Is 3D-printed off-the-shelf prosthesis more capable of reducing implant subsidence than titanium mesh cage in anterior cervical corpectomy and fusion?

Is 3D-printed off-the-shelf prosthesis more capable of reducing implant subsidence than titanium mesh cage in anterior cervical corpectomy and fusion?

Outcome of ACCF in Multilevel Cervical Spondylotic Myelopathy with OPLL and Kyphotic Deformity

Purpose: To evaluate the Outcome of Anterior cervical corpectomy &amp; Fusion in multilevel Cervical Spondylotic Myelopathy with Ossification Posterior Longitudinal Ligament &amp; kyphotic deformity. Background: Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in the adult. Ossification of the posterior longitudinal ligament (OPLL) is a hyperostotic condition of the spine, where the PLL becomes progressively calcified, leading to spinal canal stenosis. Anterior decompression by corpectomy and removal of ossified posterior longitudinal ligament is a well-recognized technique for decompressing the cervical spine. The involved vertebral body/bodies are removed and after assuring adequate decompression, titanium mesh cage filled with autogenous bone graft is placed in the gap with reinforcement by anterior cervical locking plate and screw. Materials &amp; Method: Retrospectively we reviewed 15 cases from 2010 to 2021 of CSM with OPLL and kyphotic deformity. All the patients with positive MRI &amp; CT scan findings and underwent ACCF by mesh cage with bone graft. Neurological improvement was assessed by the Nurick Score , improvement of pain control by VAS score, fusion rate by Bridwell’s criteria &amp; Overall functional assessment by modified Odom’s score . Results: Total number of patients was 15. Average age was 60 years (range 35-85). Average follow-up period was 18 months. Post-operatively, Nurick scores improved by grade 1 in 7 patients, grade 2 in 5 patients, grade 3 in 2 patients, and grade 4 in 1 patient. In our series we have no chair bound or bedridden patients after surgery. There was no difference in myelopathy outcomes comparing patients older and younger than 75 years . There was no radiographic progression after surgery. But, more than 90% patients had kyphotic correction of 10-20ͦ respectively. Conclusion: ACCF is a safe and effective method in treating the CSM with correction of few degrees of kyphotic deformity. Keywords: ACCF, Mesh cage, Locking plate

Anatomical Evaluation of Spinal Nerve and Cervical Intervertebral Foramina in Anterior Controllable Antedisplacement and Fusion Surgery: A Cadaveric and Radiologic Study.

ObjectiveTo achieve the anatomical evaluation of spinal nerve and cervical intervertebral foramina in anterior controllable antedisplacement and fusion (ACAF) surgery, a novel surgical technique with the wider decompression, through a cadaveric and radiologic study.MethodsRadiographic data of consecutive 47 patients (21 by ACAF and 26 by anterior cervical corpectomy and fusion [ACCF]) who have accepted surgery for treatment of cervical ossification of the posterior longitudinal ligament(OPLL) and stenosis from March 2017 to March 2018 were retrospectively reviewed and compared between an ACAF group and ACCF group. Three postoperative radiographic parameters were evaluated: the decompression width and the satisfaction rate of decompression at the entrance zone of intervertebral foramina on computed tomography (CT), and the transverse diameter of spinal cord in the decompression levels on magnetic resonance imaging (MRI). In the anatomic study, three fresh cadaveric spines (death within 3 months) undergoing ACAF surgery were also studied. Four anatomic parameters were evaluated: the width of groove, the distance between the bilateral origins of ventral rootlets, the length of ventral rootlet from their origin to the intervertebral foramina, the descending angle of ventral rootlet.ResultsThe groove created in ACAF surgery included the bilateral origins of ventral rootlets. The rootlets tended to be vertical from the rostral to the caudal direction as their takeoff points from the central thecal sac became higher and farther away from their corresponding intervertebral foramina gradually. No differences were identified between left and right in terms of the length of ventral rootlet from the origin to the intervertebral foramina and the descending angle of ventral rootlet. The decompression width was significantly greater in ACAF group (19.2 ± 1.2 vs 14.7 ± 1.2, 21.3 ± 2.2 vs 15.4 ± 0.9, 21.5 ± 2.1 vs 15.7 ± 1.0, 21.9 ± 1.6 vs 15.9 ± 0.8, from C3 to C6). The satisfactory rate of decompression at the entrance zone of intervertebral foramina tended to be better in the left side in ACAF group (significant differences were identified in the left side at C3/4, C4/5, C6/7 level, and in the right side at C4/5 level when compared with ACCF). And decompression width was significantly greater than the transverse diameter of spinal cord in ACAF group. Comparatively, there existed no significant difference in the ACCF group besides the C5 level.ConclusionACAF can decompress the entrance zone of intervertebral foramina effectively and its decompression width includes the origins and massive running part of bilateral ventral rootlets. Due to its wider decompression range, ACAF can be used as a revision strategy for the patients with failed ACCF.

Longitudinal Spinous-Splitting Laminoplasty with Coral Bone for the Treatment of Cervical Adjacent Segment Degenerative Disease: A 5-Year Follow-up Study.

This study was designed to analyze the causes of cervical adjacent segment degenerative disease (ASDis), evaluate the surgical outcomes of longitudinal spinous‐splitting laminoplasty with coral bone (SLAC) during cervical reoperation, and accumulate data on reoperation with SLAC in a primary hospital. Based on the inclusion and exclusion criteria, we conducted a retrospective study involving 52 patients who underwent cervical reoperation for ASDis using SLAC at the spinal surgery department of the Beijing Jishuitan Hospital from 1998 to 2014. Among them, 39 were treated with anterior cervical fusion and internal fixation during the first operation (anterior cervical corpectomy with fusion [ACCF], n = 24; anterior cervical discectomy and fusion [ACDF], n = 11; and cervical disc arthroplasty [CDA], n = 4). Outcomes were the Japanese Orthopaedic Association (JOA) score, neck disability index (NDI) score, upper limb/neck and shoulder evaluated using a visual analogue scale (VAS), and rates of ASDis. In patients who underwent an anterior cervical approach in the first instance, the incidence of ASDis was significantly higher in the C3/4 gap than in the other gaps. In the ACCF group, the lateral radiograph of the cervical spine revealed that the distance between the anterior cervical plate and the adjacent segment disc was <5 mm in 15 (62.5%) cases and five (12.8%) cases, respectively, the internal fixation screws broke into the annulus of the adjacent segment. After the first SLAC, ASDis developed at C2/3 and C3/4 in four (30.8%) and eight (61.5%) cases, respectively. After reoperation, all cases were followed up for >5 (average, 6.2) years. The pre‐reoperation and last follow‐up values were as follows: mean Japanese Orthopaedic Association score, 10.2 ± 1.5 vs 15.5 ± 0.7 (P = 0.03); neck disability index, 26.2 vs 13.6 points (P = 0.01); upper‐limb visual analog scale (VAS) score, 6.1 vs 2.6 points (P = 0.04); and neck and shoulder VAS score, 6.6 vs 2.1 points (P = 0.03). SLAC is a simple technique in which the local anatomy is clearly visible and satisfactory clinical outcomes are obtained.

Anterior Corpectomy and Plating with Carbon-PEEK Instrumentation for Cervical Spinal Metastases: Clinical and Radiological Outcomes

Background: Anterior cervical corpectomy and plating has been recognized as a valuable approach for the surgical treatment of cervical spinal metastases. This study aimed to report the surgical, clinical and radiological outcomes of anterior carbon-PEEK instrumentations for cervical spinal metastases. Methods: Demographical, clinical, surgical and radiological data were collected from 2017 to 2020. The Neck Disability Index (NDI) questionnaire for neck pain, EORTC QLQ-C30 questionnaire for quality of life, Nurick scale for myelopathy and radiological parameters (segmental Cobb angle and cervical lordosis) were collected before surgery, at 6 weeks postoperatively and follow-up. Results: Seventeen patients met inclusion criteria. Mean age was 60.9 ± 7.6 years and mean follow-up was 12.9 ± 4.0 months. The NDI (55.4 ± 11.7 to 25.1 ± 5.4, p < 0.001) scores and the EORTC QLQ-C30 global health/QoL significantly improved postoperatively and at the last follow-up. The segmental Cobb angle (10.7° ± 5.6 to 3.1° ± 2.2, p < 0.001) and cervical lordosis (0.9° ± 6.7 to −6.2 ± 7.8, p = 0.002) significantly improved postoperatively. Only one minor complication (5.9%) was recorded. Conclusions: Carbon/PEEK implants represent a safe alternative to commonly used titanium ones and should be considered in cervical spinal metastases management due to their lower artifacts in postoperative imaging and radiation planning. Further larger comparative and cost-effectiveness studies are needed to confirm these results.