Anterior Cervical Corpectomy Research Articles

The Early Effects of Longus Colli Muscle and Anterior Longitudinal Ligament Reconstructions on Swallowing Function after Anterior Cervical Surgery: A Six-Month Follow-Up Study.

Anterior cervical discectomy and fusion (ACDF) is the gold standard surgery used to treat cervical degenerative disease. Dysphagia and hoarseness are the two most common complications that occur after anterior cervical surgery (ACS). In this study, we aim to evaluate the early effects of longus colli muscle (LCM) and anterior longitudinal ligament (ALL) reconstructions on swallowing function after ACS. We recruited 91 patients (35 males and 56 females; mean age: 49.41 ± 8.60 years [range: 26-72 years]) who have undergone either ACDF or anterior cervical corpectomy and fusion (ACCF) between August 2019 and October 2021. Patients were divided into LCM and ALL suture group (Group A), and LCM and ALL non-suture group (Group B). Assessments of the incidence of dysphagia and the swallowing quality of life (SWAL-QOL) were completed in 2 days, 1 week, 1 month, 3 months and 6 months after surgery. Average prevertebral soft tissue thickness (APSTT) were measured on lateral cervical spine radiographs taken with X-rays 2 days, 1 month, 3 months and 6 months after surgery. In the 2-day, 1-week and 1-month postoperative follow-up, the incidence of dysphagia in group A was significantly lower than that in group B (p < 0.05), and the SWAL-QOL scores of group A were significantly higher than those of group B (p < 0.05). In the 3-month and 6-month postoperative follow-up, no significant differences were found between groups A and B in terms of the incidence of dysphagia (p > 0.05). In the 6-month postoperative follow-up, no significant differences were found between the groups in terms of SWAL-QOL scores (p > 0.05). There were no significant differences in APSTT between groups during postoperative follow-up (p > 0.05). The reconstructions of LCM and ALL in ACS can effectively improve short-term postoperative swallowing function.

Biomechanical Effect of Osteoporosis on Adjacent Segments After Anterior Cervical Corpectomy and Fusion

Adjacent segmental degeneration (ASD) is one common long-term complication of anterior cervical corpectomy and fusion (ACCF), and osteoporosis is one basic disease in the elderly. After ACCF, patients may experience osteoporosis with age. However, the influence of osteoporosis on ASD remains unclear. The purpose of this study was to determine whether osteoporosis could affect the development of ASD following ACCF. Three finite element models of the cervical spine, including 1 normal model, 1 ACCF model, and 1 ACCF with osteoporosis model, were constructed. ACCF was simulated at the C4-C6 level. A 73.6N follower load and a 1 Nm moment were imposed on the normal model, and the same follower load together with an adjusted moment was applied to the ACCF model and the ACCF with osteoporosis model, to simulate movement in each direction. The range of motion, intradiscal pressure, shear stress on anulus fibrosus, and facet joint stress at C3-C4 and C6-C7 levels of the models were calculated. In this study, the normal model was well validated. In flexion, extension, right lateral bending, and right axial rotation, the overall range of motion was 8.92°, 19.7°, 15.37°, and 45.27° in the normal model, and the adjusted moment was 1.4 Nm, 2.7 Nm, 1.1 Nm, and 2.6 Nm in the ACCF model, and 1.3 Nm, 2.5 Nm, 1.1 Nm, and 2.4 Nm in the ACCF with osteoporosis model. Despite of a few exceptions, the maximum values of the outcome measurements were mostly found in the ACCF model, and the minimum values in the normal model. Compared with the ACCF model, most of the outcome measurements were decreased in the ACCF with osteoporosis model. Osteoporosis can retard the adverse influence of ACCF on adjacent segments.

Factors affecting titanium mesh cage subsidence in single-level anterior cervical corpectomy and fusion for ossification of the posterior longitudinal ligament

PurposeTo analyze risk factors of titanium mesh cage (TMC) subsidence in single-level anterior cervical corpectomy and fusion (ACCF) for cervical ossification of the posterior longitudinal ligament (OPLL).MethodsTMC subsidence is defined as the reduction of the adjacent vertebral bodies by ≥ 2 mm. Patients with cervical OPLL who were treated with single-level ACCF between January 2019 and May 2021 were retrospectively analyzed in two groups: patients with TMC subsidence as Group S and patients with no TMC subsidence as Group N during the one-year follow-up period. The degree of distraction of surgical segment and correction of the cervical curvature was measured to analyze their relationship with TMC subsidence.ResultsA total of 128 patients were included in Group S, and 138 patients were included in Group N. There was no significant difference in patient demographics and complications between the two groups. The degree of distraction in Group S was significantly higher than that in Group N (11.4% ± 7.6% vs. 4.7% ± 9.7%, P < 0.01). The change of C2 to C7 Cobb angle (α) in Group S was significantly greater than that in Group N (5.7 ± 2.7 vs. 1.4 ± 4.7, P < 0.01), and the change of interspinous process distance (SPD) in Group S was also significantly greater than that in Group N (7.0 ± 4.2 vs. 4.1 ± 2.7, P < 0.01). The JOA score and JOA recovery rate were not statistically different between the two groups.ConclusionsIntraoperative selection of overlength TMC in single-level ACCF for OPLL, over-distraction and excessive correction of the cervical curvature may cause TMC subsidence after surgery. No significant impact of TMC subsidence on the surgical outcome was observed during the 1-year follow-up period.

Evaluating a paradigm shift from anterior decompression and fusion to muscle-preserving selective laminectomy: a single-center study of degenerative cervical myelopathy.

Muscle-preserving selective laminectomy (SL) is an alternative to conventional decompression surgery in patients with degenerative cervical myelopathy (DCM). It is less invasive, preserves the extensor musculature, and maintains the range of motion of the cervical spine. Therefore, the preferred treatment for DCM at the authors' institution has changed from anterior decompression and fusion (ADF), including anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF), toward SL. The aim of this study was to evaluate surgical outcomes before and after this paradigm shift with patient-reported outcome measures (PROMs), complications, reoperations, and cost-effectiveness. This study was a retrospective register-based cohort study. All patients with DCM who underwent ADF or SL at the authors' institution from 2008 to 2019 were reviewed. Using ANCOVA, changes in PROMs from baseline to the 2-year follow-up were compared between the two groups, adjusting for clinicodemographic parameters, baseline PROMs, number of decompressed levels, and MRI measurements (C2-7 Cobb angle, C2-7 sagittal vertical axis [SVA], and modified K-line interval [mK-line INT]). The PROMs, including the European Myelopathy Score (EMS), the Neck Disability Index (NDI), and the EQ-5D, were collected from the national Swedish Spine Register. Complications, reoperations, and in-hospital treatment costs were also compared between the two groups. Ninety patients (mean age 60.7 years, 51 men [57%]) were included in the ADF group and 63 patients (mean age 68.8 years, 41 men [65%]) in the SL group. The ADF and SL groups had similar PROMs at baseline. The preoperative MR images showed similar C2-7 Cobb angles (10.7° [ADF] vs 14.1° [SL], p = 0.12) and mK-line INTs (4.08 vs 4.88 mm, p = 0.07), but different C2-7 SVA values (16.2 vs 19.3 mm, p = 0.04). The comparison of ANCOVA-adjusted mean changes in PROMs from baseline to the 2-year follow-up presented no significant differences between the groups (EMS, p = 0.901; NDI, p = 0.639; EQ-5D, p = 0.378; and EQ-5D health, p = 0.418). The overall complication rate was twice as high in the ADF group (22.2% vs 9.5%, p = 0.049), while the reoperation rate was comparable (16.7% vs 7.9%, p = 0.146). The average in-hospital treatment cost per patient was $6617 (USD) for SL, $7046 for ACDF, and $12,000 for ACCF. SL provides similar PROMs after 2 years, a significantly lower complication rate, and better cost-effectiveness compared with ADF.

Short-term post-operative complications in 207 patients with multi-level degenerative cervical myelopathy: the effect of surgical approach.

Degenerative cervical myelopathy (DCM) is a common condition often treated by surgical decompression and fusion. The objective of this paper was to compare short-term post-operative complication rates of patients with multi-level DCM treated with decompression and fusion using either an anterior or a posterior cervical approach. A retrospective evaluation of patients' charts, imaging studies and operative reports of patients operated for multilevel subaxial DCM from 2011 to 2016 at a single institution was performed. Patients who were operated upon for the treatment of three stenosed spinal levels or above and who underwent anterior cervical discectomy and fusion, or anterior cervical corpectomy and fusion, or posterior cervical laminectomy and fusion, were included. Short-term post-operative complications were compared between the anterior and posterior approaches. Overall, 207 patients were included in this study. 156 were operated via an anterior approach and 51 via a posterior approach. The mean number of treated levels was 3.4 and 4.3 for the anterior and posterior approach groups, respectively (p < 0.001). In the posterior approach group, the proportion of stenosed spinal levels within all operated levels was significantly lower than in the anterior approach group (p = 0.025). Early post-operative neurological status change was favourable for both groups. Deep wound infection rate was significantly higher in the posterior approach group (7.8% vs. none; p = 0.001). Posterior cervical laminectomy and fusion is significantly associated with an increased rate of deep wound infection and wound revision surgery compared to the anterior approach. We recommend the anterior approach as the valid option in treating multi-level DCM.

Pediatric Cervical Spine Injuries.

Objective Pediatric cervical spine injuries are rare and account for 1 to 2% of all pediatric spine injuries. There is a paucity of data on pediatric cervical spine injuries in developing countries like India. The purpose of this study is to review and analyze our 5 years of experience with pediatric cervical spine injuries. Methods All the available medical records over the 5 years were reviewed retrospectively. The data was analyzed to know the epidemiology, mechanism of injury, injury patterns, management, and outcome. The patients were divided into two groups: 0 to 9 years and 10 to 18 years. Results Seventy-five eligible records were included in our study. The incidence of cervical spine injuries was significantly lower in younger children than the older ones ( p < 0.042). The most common mechanism of injury was fall from height: 33 (44%) patients followed by road traffic accidents: 27 (36%) patients. The involvement of the upper cervical spine was significantly higher in younger children ( p < 0.001). Fractures with subluxation were the most common pattern of injury, observed in 35 (47%) patients. However, fractures with subluxation were uncommon in younger children compared with older children ( p < 0.04). Spinal cord injury without radiographic abnormality (SCIWORA) was observed in 42% of younger children compared with 8% of older children ( p < 0.02). Thirty (40%) patients were managed surgically; anterior cervical corpectomy with fusion was the most commonly performed procedure in 19 (63%) patients. The overall mortality was 20%. Conclusion The results of our study revealed predominant involvement of the upper cervical spine in children younger than 10 years of age. SCIWORA was documented in both the age groups with a significantly higher incidence in younger children. The instrumentation and fusion techniques in children are safe; however, developing pediatric spine needs special considerations.

THE BLEEDING MIGRATION: ESOPHAGEAL INJURY FROM CERVICAL HARDWARE

THE BLEEDING MIGRATION: ESOPHAGEAL INJURY FROM CERVICAL HARDWARE

The Efficacy of Anterior Cervical Corpectomy and Fusion and Posterior Total Laminectomy on Cervical Spinal Cord Injury and Quality of Life.

This study is aimed at investigating the efficacy of anterior cervical corpectomy and fusion and posterior total laminectomy in the treatment of cervical spinal cord injury and assessing the impact of the two approaches on cervical spine function and patient quality of life. Retrospectively analyze the clinical data from 180 patients with cervical spinal cord injury who were admitted to the First Affiliated Hospital of Hebei North University from June 2019 to June 2021. The patients were divided into an anterior approach group (n = 89, treated with anterior cervical corpectomy and fusion) and a posterior approach group (n = 91, treated with posterior total laminectomy). The amount of blood loss in the posterior approach group was larger compared to the anterior approach group. Patients in the posterior approach group had higher wound diameters and operation times compared to the anterior approach group, as well as the operation cost. The visual analogue scale (VAS) scores of patients in the posterior approach group were significantly higher than in the anterior approach group one month after operation. The Japanese Orthopaedic Association (JOA), neck disability index (NDI), and American Spinal Injury Association (ASIA) scores of patients in both groups at 1, 6, and 9 months after surgery were higher compared to those before surgery, yet no significant differences were observed between the two groups. Also, no significant difference was observed in the incidence of complication and the quality of life between the two groups before and after treatment. Anterior cervical corpectomy and fusion and posterior total laminectomy can effectively restore the cervical nerve function in the treatment of cervical spinal cord injury. However, anterior subtotal vertebral resection is associated with improved perioperative indicators compared to posterior total laminectomy. Clinically, surgical methods can be selected according to imaging findings, the general condition of patients, and individual economic status.

Biomechanics of a novel artificial cervical vertebra from an in vivo caprine cervical spine non-fusion model.

ObjectiveAnterior cervical corpectomy and fusion (ACCF) has been widely used in the treatment of cervical spondylotic myelopathy (CSM) but is accompanied by unavoidable motion loss and destruction of vertebra. We aim to evaluate the range of motion (ROM) of caprine cervical spine constructs implanted with cervical artificial disc and vertebra system (ADVS). The purpose of this study was to investigate the biomechanical properties of the ADVS from an in vivo caprine cervical spine non-fusion model.MethodsTwelve goats were randomly divided into ADVS or control group, with 6 animals in each group. The animals in the ADVS group were implanted with ADVS at the C4 level. The cervical spine constructs were harvested 6 months after the operation. The ROM of cervical spine specimens in the ADVS group was recorded. Biomechanical testing of the specimens in the control group were conducted to evaluate the ROM of the cervical spine specimens under intact and fixed condition (C3-C5) by an anterior plate, respectively.ResultsThe biomechanical outcomes showed that the ROM of the levels (C3-C5) implanted with ADVS was maintained. The ROM in the adjacent level (C2-3) did not increase significantly comparing with intact group.ConclusionsIn general, ADVS could preserve the ROM of operative levels and could reconstruct the height of the vertebra. ADVS did not increase the ROM of upper adjacent level. This device provides a non-fusion method for the treatment of patients suffering from CSM. However, improvements on the design of ADVS are still needed.Translational potential statementThis study introduced a novel cervical spinal implant, which was designed to have the ability of motion preservation and vertebra construction. Our study provided a non-fusion procedure in the treatment of CSM after ACCF.

Is Anterior Trans‐Intervertebral Space Decompression Important in Treating Cervical Spondylosis with Severe Intervertebral Space Narrowing? A Retrospective Cohort Study

To evaluate the clinical efficacy and practicality of anterior trans-intervertebral space decompression and fusion (ATIDF) by comparing radiological and clinical outcomes between ATIDF and traditional anterior cervical corpectomy and fusion (ACCF) in cervical spondylosis patients with severe disc space narrowing. Seventy-one cervical spondylosis patients with severe disc space narrowing underwent anterior cervical spine surgery were included in this retrospective study. Thirty-seven patients underwent ATIDF and 34 patients underwent ACCF. The neck disability index (NDI), Japan Orthopaedic Association (JOA) score and the Hirabayashi improvement rate were used to evaluate patient neurological status. Cervical sagittal alignment (C2-C7 Cobb angle), surgical segment sagittal alignment (Cobb angle of surgical segment) and disc space height were also compared between the two groups. There were 39 males and 32 females; mean age was 63.72 ± 6.36 years (range, 39-81 years). Mean follow-up was 22.4 months (range, 6-45 months). All patients achieved an adequate neurological improvement. There were no significant differences in NDI, JOA scores and Hirabayashi improvement rate between the two groups. The change of C2-7 Cobb angle and surgical segment Cobb angle were both greater in the ATIDF group. The average intervertebral height ratio of the patients in the ATIDF group increased significantly after surgery (0.38 ± 0.17 before surgery to 1.13 ± 0.32 after surgery, P < 0.01). The overall complication rate was lower in the ATIDF group than the ACCF group (35.14% and 44.12%). At 6 months follow-up, three patients in the ACCF group presented with subsidence of the titanium mesh cage. ATIDF is an effective technique for treating cervical spondylosis with severe disc space narrowing; it can achieve adequate decompression and improve sagittal alignment while avoiding and reducing the implant-related complications inherent to traditional ACCF.

Treatment of three-level cervical spondylotic myelopathy using ACDF or a combination of ACDF and ACCF.

ObjectivesThis study aims to compare the outcomes between two anterior decompression and fusion techniques to treat multilevel cervical spondylotic myelopathy (MCSM).MethodsAfter the screening for eligibility, a total of 66 patients were admitted to this study. These participants underwent anterior surgeries due to MCSM in our hospital between June 2016 and July 2018. All participants underwent either the anterior cervical discectomy and fusion (ACDF) surgery (ACDF group) or the combination of ACDF and anterior cervical corpectomy and fusion (ACCF), which was the anterior cervical hybrid decompression and fusion (ACHDF) surgery group. All the patients were followed up ≥18 months, the average latest followed up time was 23.64 (±2.69) months. The length of hospitalization, operation time, blood loss, visual analog scale (VAS), Japanese Orthopaedic Association (JOA) score, improvement rate, Hounsfield units (HU) of C3–C7, cobb angle, and anterior column height of fusion levels pre and post operation were analyzed.ResultsThere were no statistical differences between the ACDF and ACHDF groups regarding the length of hospitalization, operation time, blood loss, HU of C3–C7, VAS, JOA score, improvement rate, cobb angle, and anterior column height in fusion levels in pre-operation and 3 months after operation (all P > 0.05). However, compared with the ACHDF group, the ACDF group achieved significantly better improvement in the anterior column height of fusion levels in the final 18–29 months post-operatively (P < 0.05).ConclusionsBoth approaches of ACDF alone and a combination of ACDF and ACCF can achieve satisfactory outcomes in the treatment of MCSM, but ACDF has better outcomes in maintaining anterior column height of fusion levels.

Risk Factors, Incidence and Mortality of Vertebral Artery Injury in Patients Undergoing Anterior Cervical Corpectomy: A Retrospective Large National Data Base Study.

Retrospective Cohort Study. To determine the incidence of vertebral artery injury (VAI), risk factors, intervention, associated complications, and mortality in patients undergoing anterior cervical corpectomy. We performed a retrospective review of the incidence of VAI during anterior cervical corpectomy using the PearlDiver database from 2010-2017. The CPT code 63081 to identify corpectomy patients. Patient data extracted included, incidence of VAI, demographic factors, intervention, and future complications of death and stroke. The risk were calculated compared with those patients who did not have VAI. 26126 patients were identified to have undergone cervical corpectomy. Multivariate analysis of risk factors showed that younger age and male sex were associate with higher rate of injury (t = -11.5; P < .0001 and t = 3.8; P = .0001, respectively). Vertebral artery injuries occurred in 78 patients at an incidence of .3%. 11 (14%) VAI patients had a cerebral infarction compared with 1705 (7%) for non-VAI patients (OR = 2.13; 95% CI = [1.18 - 3.85; P = .0179]) during the follow up period. 1-year mortality rates were higher in patients who suffered a VAI (14%) compared to those who did not suffer a VAI (4%; OR = 3.85; CI = [2.04 - 7.14]; P < .0001). Consequence of VAI may not be known for months following the injury. Although the same admission mortality is rare with this injury, there is a significant increase in post-discharge complications. This study suggests that further investigations into long term health risk of VAI is needed.

Comparison of Two Anterior Reconstructive Techniques in the Treatment of 3-Level and 4 Level Cervical Spondylotic Myelopathy: A Meta-analysis of Last Decade.

Study DesignA meta-analysis.ObjectiveAnterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) are widely used in the treatment of cervical spondylotic myelopathy (CSM). However, the clinical outcomes and complications between ACDF and ACCF treating multi-level CSM remain poorly understood. Thus, we performed a meta-analysis to compare the clinical outcomes and complications of the two procedures in the treatment of 3-level and 4-level CSM.MethodsAn extensive search of the literature was performed in the English databases of PubMed, Embase, and Cochrane Library and the Chinese databases of CNKI and WANFANG. We collected factors, including demographic data, surgical factors, and complications. Data analysis was conducted with RevMan 5.3 and STATA 12.0.ResultsFinally, 14 articles (5429 patients) were included in our study. No significant difference was found in preoperative and 3-month follow-up Japanese Orthopedic Association (JOA) scores, neck disability index, preoperative C2-C7, segmental angle, operation time, as well as the number of dysphagia, hoarseness, cerebral fluid leakage, infection, epidural hematoma, axial pain, hardware breakage, and pseudarthrosis between ACDF and ACCF. However, our findings showed that blood loss (P < 0.00001), the number of total complications (P < 0 .00001), C5 palsy (P = 0.0004), graft dislodgement (P = 0.02), graft subsidence (P = 0.0003), and revision surgery (P = 0.0008) in ACDF were significantly less than in ACCF. Additionally, postoperative and change of C2-C7 (P < 0.00001), segment angle (P < 0.00001), and fusion rate (P = 0.001) in ACDF were significantly higher than in ACCF. Post-operative JOA in ACDF was significantly higher than in ACCF (P = 0.02).ConclusionsAlthough the clinical efficacy of both surgeries was similar, ACDF was superior to ACCF in the reconstruction of cervical lordosis and the number of complications in the treatment of 3-level and 4-level CSM.

The Pre-Operative Duration of Symptoms: The Most Important Predictor of Post-Operative Efficacy in Patients with Degenerative Cervical Myelopathy.

Objective. To explore the most important predictors of post-operative efficacy in patients with degenerative cervical myelopathy (DCM). Methods. From January 2013 to January 2019, 284 patients with DCM were enrolled. They were categorized based on the different surgical methods used: single anterior cervical decompression and fusion (ACDF) (n = 80), double ACDF (n = 56), three ACDF (n = 13), anterior cervical corpectomy and fusion (ACCF) (n = 63), anterior cervical hybrid decompression and fusion (ACHDF) (n = 25), laminoplasty (n = 38) and laminectomy and fusion (n = 9). The follow-up time was 2 years. The patients were divided into two groups based on the mJOA recovery rate at the last follow-up: Group A (the excellent improvement group, mJOA recovery rate >50%, n = 213) and Group B (the poor improvement group, mJOA recovery rate ≤50%, n = 71). The evaluated data included age, gender, BMI, duration of symptoms (months), smoking, drinking, number of lesion segments, surgical methods, surgical time, blood loss, the Charlson Comorbidity Index (CCI), CCI classification, imaging parameters (CL, T1S, C2-7SVA, CL (F), T1S (F), C2-7SVA (F), CL (E), T1S (E), C2-7SVA (E), CL (ROM), T1S (ROM) and C2-7SVA (ROM)), maximum spinal cord compression (MSCC), maximum canal compromise (MCC), Transverse area (TA), Transverse area ratio (TAR), compression ratio (CR) and the Coefficient compression ratio (CCR). The visual analog score (VAS), neck disability index (NDI), modified Japanese Orthopedic Association (mJOA) and mJOA recovery rate were used to assess cervical spinal function and quality of life. Results. We found that there was no significant difference in the baseline data among the different surgical groups and that there were only significant differences in the number of lesion segments, C2–7SVA, T1S (F), T1S (ROM), TA, CR, surgical time and blood loss. Therefore, there was comparability of the post-operative recovery among the different surgical groups, and we found that there were significant differences in age, the duration of symptoms, CL and pre-mJOA between Group A and Group B. A binary logistic regression analysis showed that the duration of the symptoms was an independent risk factor for post-operative efficacy in patients with DCM. Meanwhile, when the duration of symptoms was ≥6.5 months, the prognosis of patients was more likely to be poor, and the probability of a poor prognosis increased by 0.196 times for each additional month of symptom duration (p < 0.001, OR = 1.196). Conclusion. For patients with DCM (regardless of the number of lesion segments and the proposed surgical methods), the duration of symptoms was an independent risk factor for the post-operative efficacy. When the duration of symptoms was ≥6.5 months, the prognosis of patients was more likely to be poor, and the probability of a poor prognosis increased by 0.196 times for each additional month of symptom duration (p < 0.001, OR = 1.196).

The Role of Intraoperative Neuromonitoring Modalities in Anterior Cervical Spine Surgery.

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.

Low cervical vertebral CT value increased early subsidence of titanium mesh cage after anterior cervical corpectomy and fusion

Study designThis study was a retrospective review.ObjectiveTo study the predictive effect of Hounsfield units (HU) value in the cervical vertebral body derived from computed tomography (CT) on the early titanium mesh cage (TMC) subsidence after anterior cervical corpectomy and fusion (ACCF).MethodsThis retrospective study was conducted on patients who underwent ACCF at one institution between January 2014 and December 2018. We collected date included age, gender, body mass index (BMI), disease type, surgical segment, whether merge ACDF, HU value of the vertebral body and endplate, vertebral body height loss, cervical lordosis angle, and cervical sagittal alignment. VAS, JOA, and NDI were used to assess clinical efficacy. Univariate analysis was performed to screen the influencing factors of TMC subsidence, and then logistic regression was used to find out the independent risk factors. The ROC curve and area under curve (AUC) were used to analyze the HU value to predict the TMC subsidence.ResultsA total of 85 patients who accepted ACCF were included in this study, and early titanium mesh cage subsidence was demonstrated in 29 patients. The subsidence rate was 34.1%. The JOA, VAS, and NDI scores significantly improved in both groups after the operation. Between the subsidence and non-subsidence groups, there were significant differences in age, intervertebral distraction height, and HU value in both upper and lower vertebral body and endplate. The logistic regression analysis proved that the HU value of the lower vertebral body was an independent risk of TMC subsidence, the AUC was 0.866, and the most appropriate threshold of the HU value was 275 (sensitivity: 87.5%, specificity: 79.3%).ConclusionPreoperative cervical CT value is an independent correlative factor for early TMC subsidence after ACCF, and patients with a low CT value of the inferior vertebral body of the operative segment have a higher risk of TMC subsidence in the early postoperative period.Trial registration: This study is undergoing retrospective registration.

Simulated bundled payments for four common surgical approaches to treat degenerative cervical myelopathy: a consideration to break the clinical equipoise.

In degenerative cervical myelopathy (DCM) pathologies in which there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes compared with posterior approaches. In this era of value and bundled payment initiatives, the cost profiles of various surgical approaches will form an important consideration in decision-making. The objective of this study was to compare 90-day and 2-year reimbursements for ≥ 2-level (multilevel) anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior cervical laminectomy and fusion (LF), and cervical laminoplasty (LP) performed for DCM. The IBM MarketScan research database (2005-2018) was used to study beneficiaries 30-75 years old who underwent surgery using four approaches (mACDF, ACCF, LF, or LP) for DCM. Demographics, index surgery length of stay (LOS), complications, and discharge disposition were compared. Index admission (surgeon, hospital services, operating room) and postdischarge inpatient (readmission, revision surgery, inpatient rehabilitation), outpatient (imaging, emergency department, office visits, physical therapy), and medication-related payments were described. Ninety-day and 2-year bundled payment amounts were simulated for each procedure. All payments are reported as medians and interquartile ranges (IQRs; Q1-Q3) and were adjusted to 2018 US dollars. A total of 10,834 patients, with a median age of 54 years, were included. The median 90-day payment was $46,094 (IQR $34,243-$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital payment was 62.4% (surgery/operating room 46.6%) and surgeon payments were 17.5% of the average 90-day bundle. There were significant differences 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 because it is 70% less expensive on average than LF over 90 days.

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.