Anterior Cervical Decompression Research Articles

The efficacy and safety of mini-open (air/water medium) endoscopy-assisted anterior cervical discectomy and fusion for the treatment of cervical spondylotic myelopathy.

To compare the clinical efficacy of mini-open (air/water medium) endoscopy-assisted anterior cervical discectomy and fusion (MOEA-ACDF) and anterior cervical decompression and fusion (ACDF) for cervical spondylotic myelopathy (CSM). This study retrospectively analysed the clinical data of CSM patients who received surgical treatment from January 1, 2020, to December 31, 2022. Patients were divided into two groups according to the surgical method: the MOEA-ACDF group and the ACDF group. The preoperative and postoperative imaging results at one week and the last follow-up examination were compared between the two groups. The Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) score and neck disability index (NDI) score were used to evaluate the clinical outcomes preoperatively, one week postoperatively and at the last follow-up examination. The minimum follow-up duration was 12 months. A total of 131 CSM patients who underwent surgery at our institution were included, including 61 patients in the MOEA-ACDF group and 70 patients in the ACDF group. In the MOEA-ACDF group, the postoperative C2-C7 Cobb angle and HAVB were significantly greater than the preoperative values (P < 0.05). In the ACDF group, the postoperative C2-C7 Cobb angle was also significantly greater than the preoperative value, and the C2-C7 ROM and HAVB significantly decreased (P < 0.05). The postoperative neurological function of the patients in both groups improved, and the postoperative VAS score and NDI score significantly decreased. Compared with ACDF, MOEA-ACDF is associated with a significantly larger postoperative C2-C7 Cobb angle and significantly better C2-C7 ROM and HAVB, as well as better clinical efficacy (P < 0.05). MOEA-ACDF combines endoscopic systems with ACDF technology to treat CSM, but its clinical efficacy is not inferior to that of ACDF in the short- to intermediate-term. It can effectively and safely restore the cervical intervertebral height, physiological curvature, and range of motion.

The Positive Side Effect of Anterior Cervical Decompression and Fusion on Axial Neck Pain.

Observational Cohort Study. This study aims to comprehensively assess the outcomes of anterior cervical spine surgery in patients who have undergone surgical intervention for radiculopathy or myelopathy, with a specific focus on the surgery's impact on axial neck pain. Data from an institutional spine surgery registry were analyzed for patients who underwent anterior cervical spine surgery between January 2016 and March 2022. Patient demographics, clinical variables, and outcome measures, including the Neck Disability Index (NDI), numeric rating scales for neck and arm pain (NRS-Neck and NRS-Arm), and 36-Item Short Form Health Survey (SF-36) scores, were collected. Statistical analysis included paired t-tests, chi-squared tests, and multivariate linear regression. Of 257 patients, 156 met the inclusion criteria. Patients showed significant improvement in NDI, NRS-Neck, NRS-Arm, SF-36 (Physical and Mental components), and all changes exceeded the minimum clinically important difference. Multivariate regression revealed that lower preoperative physical and mental component scores and higher preoperative NRS-Neck predicted worse NDI scores at follow-up. This study underscores that anterior cervical fusion not only effectively alleviates arm pain and disability but also has a positive impact on axial neck pain, which may not be the primary target of surgery. Our findings emphasize the potential benefits of surgical intervention when neck pain coexists with neurologic compression. This contribution adds to the growing body of evidence emphasizing the importance of precise diagnosis and patient selection. Future research, ideally focusing on patients with isolated neck pain, should further explore alternative surgical approaches to enhance treatment options.

Effect of Anterior Cervical Decompression and Fusion for Cervical Myelopathy Treatment

Background: Cervical myelopathy is a common cause for neurosurgical outpatient department visit, and a substantial proportion of patient suffering from myelopathy due to cervical spondylosis has to go through surgical management, commonly anterior cervical decompression and fusion in the form of Cloward’s procedure, Smith Robinson procedure, PEEK and Titanium cage implant and fusion. A total of 23 cases were selected according to predefined inclusion and exclusion criteria. Method: This is a prospective study that was conducted in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University. Patients with cervical myelopathy undergoing anterior cervical decompression and fusion, in the form of Cloward’s procedure, Smith Robinson procedure, or Anterior Cervical Discectomy with Poly Ether Ether Ketone (PEEK) and Titanium cage implants in a single level for inclusion and exclusion criteria. Results: This study found out that the Modified Nurick grading system is a useful tool to quantify the functional status of the patients suffering from cervical myelopathy and surgery in various forms of anterior cervical decompression and fusion has an impact on the functional status even at an early period of one month. 82.6% of the patients had functional improvement, whereas 13% remained the same. Only one out of the 23 patients deteriorated. Various methods of anterior cervical decompression and fusion or the levels of involvement did not have any statistically significant impact on improvement among the patients. Conclusion: Anterior cervical decompression and fusion is a time-proven treatment modality for the patients suffering from cervical myelopathy owed to external compression due to spondylotic changes and Ossified Posterior Longitudinal Ligament. The functional status of the patients that have been compromised due to the disease shows promising change even in the early period undergoing surgery. Bang. J Neurosurgery 2023; 13(1): 3-9

Does Focal Kyphotic Deformity at Non-responsible Levels Affect the Outcomes of Anterior Cervical Decompression and Fusion?

Focal cervical kyphotic deformity (FCK) without neurologic compression is not uncommon in patients with cervical spondylotic myelopathy (CSM) who underwent anterior cervical decompression and fusion (ACDF) surgery. It remains unclear whether FCK at non-responsible levels needs to be treated simultaneously. This study aims to investigate whether FCK at non-responsible levels is the prognostic factor for CSM and elucidate the surgical indication for FCK. Patients with CSM who underwent ACDF between January 2016 and April 2021 were included. Patients were divided into two groups according to the presence of FCK and two classifications according to global cervical sagittal alignment. Clinical outcomes were compared using Japanese Orthopaedic Association (JOA) scores and recovery rate (RR) of neurologic function. Univariate and multivariate analysis based on RR assessed the relationship between various possible prognostic factors and clinical outcomes. The receiver operating characteristic curve (ROC) was used to determine the optimal cutoff value of the focal Cobb angle to predict poor clinical outcomes. A total of 94 patients were included, 41 with FCK and 53 without. Overall, the RR of neurologic function was significantly lower in the FCK than in the non-FCK group. Further analysis showed that the RR difference between the two groups was only observed in hypo-lordosis classification (kyphotic and sigmoid alignment), but not in the lordosis classification. Multivariate analysis showed that the preoperative focal Cobb angle in the FCK level (OR = 0.42; 95% CI = 0.18-0.97) was independently associated with clinical outcomes in the hypo-lordosis classification. The optimal cutoff point of the preoperative focal kyphotic Cobb angle was calculated at 4.05°. For CSM with hypo-lordosis, FCK was a risk factor for poor postoperative outcomes. Surgeons may consider treating the FCK simultaneously if the focal kyphotic Cobb angle of FCK is greater than 4.05° and is accompanied by cervical global kyphotic or sigmoid deformity.

Application and Advantages of the Trans-Unco-Discal (TUD) Approach for Cervical Spondylotic Myelopathy and Radiculopathy: Classification and Modification of Surgical Technique Based on the Location of Spinal Cord and/or Nerve Root Compression.

Purpose: We assess the application and advantages of modifying the trans-unco-discal (TUD) approach which we underwent for cervical myelo-radiculopathy. We present the surgical techniques of the modified TUD approach. Materials and Methods: The material was 180 cases where anterior cervical decompression (ACD) was performed by the modified TUD approach. We classified the material into four groups based on the location of the nerve root and/or spinal cord compression: I, compression of the root at intervertebral foramen (IVF); II, compression of the posterior margin of the vertebral body; III, compression of the IVF and posterior margin of the vertebral body; IV, compression of the bilateral IVF and posterior margin of the vertebral body. We applied the modified TUD approach to these four types. We present the surgical procedures and techniques for the modified TUD approach. The Japanese orthopedic association (JOA) score and neuroradiological alignment were examined. Results: The improvement rate of the JOA score was 78.4% at 6 months post-surgery and 77.5% in the most recent examinations. By the modified TUD approach, compressive lesions of the spinal cord and/or nerve roots were removed, and good alignment was acquired and sustained. Conclusions: ACD by the modified TUD approach safely achieved appropriate decompression for the spinal cord and/or nerve roots, and the patients had a high improvement rate and good alignment. Complications were less common than with other surgical procedures. If the TUD approach and endoscopic approaches can be combined, their application to new area is anticipated.

Disability and pain after anterior cervical decompression and fusion: A group-based trajectory analysis

Disability and pain after anterior cervical decompression and fusion: A group-based trajectory analysis

Age is Associated with Level of First-Time Anterior Cervical Discectomy and Fusion: An Ordinal Analysis of Factors Influencing Timing of Cervical Degeneration

Symptomatic cervical spondylosis is often treated with anterior cervical decompression and fusion (ACDF). However, few factors can predict which cervical level will degenerate and require intervention. This analysis evaluates pre-procedural factors associated with level of first-time single-level ACDF. We performed a retrospective analysis of patients who underwent single-level ACDF without prior history of spine surgery. Mann Whitney U-tests and Spearman rank-order correlation were performed for analyses of associations between variables of interest and ACDF level. Adjusted odds-ratios were calculated by proportional-odds logistic regression, with age, sex, body mass index (BMI), current tobacco use, history of neck trauma, preoperative radicular symptoms, and preoperative myelopathic symptoms as covariates. 141 patients met inclusion criteria, and age demonstrated a negative correlation with ACDF level, such that younger patients tended to have ACDF performed at inferior subaxial levels (p=0.0006, rho = -0.31, moderately strong relationship). Patients with pre-operative radicular symptoms and myelopathic symptoms were more likely to have ACDF performed at inferior (p=0.0001) and superior (p<0.0001) levels, respectively. Patient sex, BMI, current tobacco use, and history of neck trauma were not predictive of ACDF level. When adjusting for the above variables in a proportional-odds ordinal logistic regression model, a one year increase in age conferred a 4% increase in the odds of requiring an ACDF at a given superior level compared to the adjacent inferior level. Age is correlated with level of first-time single level ACDF. Individual subaxial levels may have unique biomechanical properties that influence degeneration.

Effect of Intelligent Health Education Based on Health Belief Model on Patients With Kinesophobia After Surgical Treatment of Cervical Spondylosis

To explore the application effect of intelligent health education based on the health belief model on patients with postoperative kinesophobia after surgical treatment of cervical spondylosis. A prospective cohort study was conducted with patients who underwent anterior cervical discectomy, decompression, and fusion surgery with a single central nerve and spine center, and who had postoperative kinesophobia, ie, fear of movement. The patients made voluntary decisions concerning whether they would receive the intervention of intelligent health education. The patients were divided into a control group and an intelligent education group and the intervention started on the second day after the surgery. The intelligent education group received intelligent education starting from the second day after surgery through a WeChat widget that used the health belief model as the theoretical framework. The intelligent health education program was designed according to the concept of patient problems, needs, guidance, practice, and feedbacks. It incorporated four modules, including knowledge, intelligent exercise, overcoming obstacles, and sharing and interaction. It had such functions as reminders, fun exercise, shadowing exercise, monitoring, and documentation. Health education for the control group also started on the second day after surgery and was conducted by a method of brochures of pictures and text and WeChat group reminder messages. The participants were surveyed before discharge and 3 months after their surgery. The primary outcome measure compared between the two groups was the degree of kinesophobia. Secondary outcome measures included differences in adherence to functional exercise (Functional Exercise Adherence Scale), pain level (Visual Analogue Scale score), degree of cervical functional impairment (Cervical Disability Index), and quality of life (primarily assessed by the Quality of Life Short Form 12 [SF-12] scale for psychological and physiological health scores). A total of 112 patients were enrolled and 108 patients completed follow-up. Eventually, there were 53 cases in the intelligent education group and 55 cases in the control group. None of the patients experienced any sports-related injuries. There was no statistically significant difference in the primary and secondary outcome measures between the two groups at the time of discharge. At the 3-month follow-up after the surgery, the level of kinesophobia in the intelligent education group (25.72±3.90) was lower than that in the control group (29.67±6.16), and the difference between the two groups was statistically significant (P<0.05). In the intelligent education group, the degree of pain (expressed in the median [25th percentile, 75th percentile]) was lower than that of the control group (0 [0, 0] vs. 1 [1, 2], P<0.05), the functional exercise adherence was better than that of the control group (63.87±7.26 vs. 57.73±8.07, P<0.05), the psychological health was better than that of the control group (40.78±3.98 vs. 47.78±1.84, P<0.05), and the physical health was better than that of the control group (43.16±4.41 vs. 46.30±3.80, P<0.05), with all the differences being statistically significant. There was no statistically significant difference in the degree of cervical functional impairment between the two groups (1 [1, 2] vs. 3 [2, 7], P>0.05). Intelligent health education based on the health belief model can help reduce the degree of kinesophobia in patients with postoperative kinesophobia after surgical treatment of cervical spondylosis and improve patient prognosis.

A Comparison of Short-Term Outcomes after Surgical Treatment of Multilevel Degenerative Cervical Myelopathy in the Geriatric Patient Population: An Analysis of the National Surgical Quality Improvement Program Database 2010-2020.

Retrospective review of the American College of Surgeons-National Surgical Quality Improvement Program database from 2010 to 2020. To compare the short-term complication rates of anterior cervical decompression and fusion (ACDF), posterior cervical laminoplasty (LP), and posterior cervical laminectomy and fusion (PCF) in a geriatric population. The geriatric population in the United States has increased significantly. Degenerative cervical myelopathy (DCM) is caused by cervical spinal stenosis, and its prevalence increases with age. Therefore, the incidence of multilevel DCM requiring surgical intervention is likely to increase. ACDF, LP, and PCF are the most commonly used surgical techniques for treating multilevel DCM. However, there is uncertainty regarding the optimal surgical technique for the decompression of DCM in geriatric patients. Patients aged 65 years who had undergone either multilevel ACDF, LP, or PCF for the treatment of DCM were analyzed. Additional analysis was performed by standardizing the data for the American Society of Anesthesiologists classification scores and preoperative functional status. A total of 23,129 patients were identified. Patients with ACDF were younger, more often female, and preoperatively healthier than those in the other two groups. The estimated postoperative mortality and morbidity, mean operation time, and length of hospital stay were the lowest for ACDF, second lowest for LP, and highest for PCF. The readmission and reoperation rates were comparable between ACDF and LP; however, both were significantly lower than PCF. PCF is associated with the highest risk of mortality, morbidity, unplanned reoperation, and unplanned readmission in the short-term postoperative period in patients aged 65 years. In contrast, ACDF carries the lowest risk. However, some disease-specific factors may require posterior treatment. For these cases, LP should be included in the preoperative discussion when determining the ideal surgical approach for geriatric patients.

Resource Utilization following Anterior Versus Posterior Cervical Decompression and Fusion for Acute Central Cord Syndrome.

Retrospective cohort study. The purpose of this study is to compare the impact of anterior cervical decompression and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for the treatment of acute traumatic central cord syndrome (CCS) on hospital episodes of care in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination. Acute traumatic CCS is the most common form of spinal cord injury in the United States. CCS is commonly treated with surgical decompression and fusion. Hospital resource utilization based on surgical approach remains unclear. Patients undergoing ACDF and PCDF for acute traumatic CCS were identified using the 2019 Medicare Provider Analysis and Review Limited Data Set and Centers for Medicare and Medicaid Services 2019 Impact File. Multivariate models for hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. Subanalysis of accommodation and revenue center cost drivers was performed. There were 1474 cases that met inclusion criteria: 673 ACDF (45.7%) and 801 PCDF (54.3%). ACDF was independently associated with a decreased cost of $9802 (P<0.001) and a 59.2% decreased risk of discharge to nonhome destinations (adjusted odds ratio: 0.408, P<0.001). The difference in length of stay was not statistically significant. On subanalysis of cost drivers, ACDF was associated with decreased charges ($55,736, P<0.001) compared with PCDF, the largest drivers being the intensive care unit ($15,873, 28% of total charges, P<0.001) and medical/surgical supply charges ($19,651, 35% of total charges, P<0.001). For treatment of acute traumatic CCS, ACDF was associated with almost $10,000 less expensive cost of care and a 60% decreased risk of discharge to nonhome destination compared with PCDF. The largest cost drivers appear to be ICU and medical/surgical-related. These findings may inform value-based decisions regarding the treatment of acute traumatic CCS. However, injury and patient clinical factors should always be prioritized in surgical decision-making, and increased granularity in reimbursement policies is needed to prevent financial disincentives in the treatment of patients with CCS better addressed with posterior approach-surgery.

Clinical Outcomes of Anterior Cervical Decompression and Fusion Therapy for Patients With Hirayama Disease

To investigate the clinical outcomes of anterior cervical decompression and fusion (ACDF) surgery for the treatment of Hirayama disease (HD). In this study, 15 patients with HD who underwent ACDF operation between March 2022 and March 2023 with complete data were retrospectively analyzed. Following the diagnosis, conservative treatment was ineffective, and thus, disease progression severely affected the quality of life of patients. ACDF was performed in the China-Japan Friendship Hospital, and patients were regularly followed up postoperatively. The cervical range of motion (ROM), the anteroposterior and transverse diameter of the spinal cord, and their ratio were measured before and after the operation. The neurological function of patients before and after the last follow-up was evaluated using the selected brief-Michigan Hand Questionnaire (sb-MHQ), whilst the overall therapeutic effect after the operation was evaluated using Odom's criteria. All patients were followed up for an average of 12 ±4.5 (6-18) months. Dynamic X-ray displayed that the ROM of cervical vertebrae decreased from 72.73 ±12.72 ° (53-97 °) to 33.53 °±10.34 ° (15-54 °) (P < 0.001). Moreover, flexion cervical MRI performed after the operation revealed that spinal cord compression was markedly relieved, and the ratio of the anteroposterior diameter of the spinal cord to the transverse diameter increased from 0.27 ±0.09 to 0.43 ±0.03 (P < 0.001). At the last follow-up visit, finger extension tremor symptoms were alleviated, although they did not completely disappear. Contrastingly, muscle atrophy showed no significant improvement. Finally, the sb-MHQ score significantly increased from 17.33 ±1.76 preoperatively to 24.80 ±1.78 at the last follow-up (P < 0.001). Our results collectively highlighted the efficacy of ACDF for the treatment of HD. This procedure can limit excessive cervical flexion and repeated compression of the spinal cord during cervical movement and considerably improve upper limb functions.

Discrepancies in recommendations for return to regular activities after cervical spine surgery: A survey study

BackgroundThe recommended timing for returning to common activities after cervical spine surgery varies widely among physicians based on training background and personal opinion, without clear guidelines or consensus. The purpose of this study was to analyze spine surgeons’ responses about the recommended timing for returning to common activities after different cervical spine procedures. MethodsThis was a survey study including 91 spine surgeons. The participants were asked to complete an anonymous online survey. Questions regarding their recommended time for returning to regular activities (showering, driving, biking, running, swimming, sedentary work, and nonsedentary work) after anterior cervical decompression and fusion (ACDF), cervical disc replacement (CDR), posterior cervical decompression and fusion (PCDF), and laminoplasty were included. Comparisons of recommended times for return to activities after each surgical procedure were made based on surgeons’ years in practice. ResultsFor ACDF and PCDF, there were no statistically significant differences in recommended times for return to any activity when stratified by years in practice. When considering CDR, return to non-sedentary work differed between surgeons in practice for 10 to 15 years, who recommended return at 3 months, and all other groups of surgeons, who recommended 6 weeks. Laminoplasty surgery yielded the most variability in activity recommendations, with earlier recommended return (6 weeks) to biking, non-sedentary work, and sedentary work in the most experienced surgeon group (>15 years in practice) than in all other surgeon experience groups (3 months). ConclusionsWe observed significant variability in surgeon recommendations for return to regular activities after cervical spine surgery.

Elective Single-Level Primary Anterior Cervical Decompression and Fusion for Degenerative Spondylotic Cervical Myelopathy is Associated With Decreased Resource Utilization Versus Posterior Cervical Decompression and Fusion.

Retrospective cohort study. To compare elective single-level anterior cervical discectomy and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for degenerative cervical myelopathy (DCM) in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination in Medicare patients. A sub-analysis of potential cost drivers was also performed. In the era of value-based medicine, there is substantial interest in reducing the cost of care. Both ACDF and PCDF are used to treat DCM but carry different morbidity and risk profiles that can impact hospital resource utilization. However, this has not been assessed on a national level. Patients undergoing single-level elective ACDF and PCDF surgery were identified using the 2019 Medicare Provider Analysis and Review (MedPAR) Limited Data Set (LDS) and Centers for Medicare and Medicaid Services (CMS) 2019 Impact File. Multivariate models of hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. A univariate sub-analysis of 9 revenue centers was performed. In all, 3942 patients met the inclusion criteria. The mean cost of elective single-level cervical fusion for myelopathy was $18,084±10,783, and the mean length of stay was 2.45±2.95d. On multivariate analysis, ACDF was independently associated with decreased cost of $5,814 (P<0.001), shorter length of stay by 1.1 days (P<0.001), and decreased risk of nonhome discharge destination by 58% (adjusted odds ratio: 0.422, P<0.001).On sub-analysis of 9 revenue centers, medical/surgical supply ($10,497, 44%), operating room charges ($5401, 23%), and accommodations ($3999, 17%) were the largest drivers of charge differences. Single-level elective primary ACDF for DCM was independently associated with decreased cost, decreased hospital length of stay, and a lower rate of nonhome discharge compared with PCDF. Medical and surgical supply, operating room, and accommodation differences between ACDF and PCDF are potential areas for intervention. Increased granularity in reimbursement structures is warranted to prevent the creation of disincentives to the treatment of patients with DCM with pathology that is better addressed with PCDF. Level-III Retrospective Cohort Study.

Anatomical Brushite-Coated Mg-Nd-Zn-Zr Alloy Cage Promotes Cervical Fusion: One-Year Results in Goats.

In this study, an anatomical brushite-coated Mg-Nd-Zn-Zr alloy cage was fabricated for cervical fusion in goats. The purpose of this study was to investigate the cervical fusion effect and degradation characteristics of this cage in goats. The Mg-Nd-Zn-Zr alloy cage was fabricated based on anatomical studies, and brushite coating was prepared. Forty-five goats were divided into three groups, 15 in each group, and subjected to C2/3 anterior cervical decompression and fusion with tricortical bone graft, Mg-Nd-Zn-Zr alloy cage, or brushite-coated Mg-Nd-Zn-Zr alloy cage, respectively. Cervical radiographs and computed tomography (CT) were performed 3, 6, and 12 months postoperatively. Blood was collected for biocompatibility analysis and Mg2+ concentration tests. The cervical spine specimens were obtained at 3, 6, and 12 months postoperatively for biomechanical, micro-CT, scanning electron microscopy coupled with energy dispersive spectroscopy, laser ablation-inductively coupled plasma-time-of-flight mass spectrometry, and histological analysis. The liver and kidney tissues were obtained for hematoxylin and eosin staining 12 months after surgery for biosafety analysis. Imaging and histological analysis showed a gradual improvement in interbody fusion over time; the fusion effect of the brushite-coated Mg-Nd-Zn-Zr alloy cage was comparable to that of the tricortical bone graft, and both were superior to that of the Mg-Nd-Zn-Zr alloy cage. Biomechanical testing showed that the brushite-coated Mg-Nd-Zn-Zr alloy cage achieved better stability than the tricortical bone graft at 12 months postoperatively. Micro-CT showed that the brushite coating significantly decreases the corrosion rate of the Mg-Nd-Zn-Zr alloy cage. In vivo degradation analysis showed higher Ca and P deposition in the degradation products of the brushite-coated Mg-Nd-Zn-Zr alloy cage, and no hyperconcentration of Mg was detected. Biocompatibility analysis showed that both cages were safe for cervical fusion surgery in goats. To conclude, the anatomical brushite-coated Mg-Nd-Zn-Zr alloy cage can promote cervical fusion in goats, and the brushite-coated Mg-Nd-Zn-Zr alloy is a potential material for developing absorbable fusion cages.

Biomechanical Comparison of Anterior Cervical Corpectomy Decompression and Fusion, Anterior Cervical Discectomy and Fusion, and Anterior Controllable Antedisplacement and Fusion in the Surgical Treatment of Multilevel Cervical Spondylotic Myelopathy: A Finite Element Analysis.

Multilevel cervical spondylotic myelopathy poses significant challenges in selecting optimal surgical approaches, warranting a comprehensive understanding of their biomechanical impacts. Given the lack of consensus regarding the most effective technique, this study aims to fill this critical knowledge gap by rigorously assessing and comparing the biomechanical properties of three distinct surgical interventions, including anterior controllable antedisplacement and fusion (ACAF), anterior cervical corpectomy decompression and fusion (ACCF), and anterior cervical discectomy and fusion (ACDF). The study offers pivotal insights to enhance treatment precision and patient outcomes. The construction of the cervical spine model involved a detailed process using CT data, specialized software (Mimics, Geomagic Studio, and Hypermesh) and material properties obtained from prior studies. Surgical instruments were modeled (titanium mesh, anterior cervical plate, interbody cage, and self-tapping screws) to simulate three surgical approaches: ACAF, ACCF, and ACDF, each with specific procedures replicating clinical protocols. A 75-N follower load with 2 Nm was applied to simulate biomechanical effects. The range of motion decreased more after surgery for ACAF and ACDF than for ACCF, especially in flexion and lateral bending. ACCF have higher stress peaks in the fixation system than those of ACAF and ACDF, especially in flexion. The maximum von Mises stresses of the bone-screw interfaces at C3 of ACCF were higher than those of ACAF and ACDF. The maximum von Mises stresses of the bone-screw interfaces at C6 of ACDF were much higher than those of ACAF and ACCF. The maximum von Mises stresses of the grafts of ACCF and ACAF were much higher than those of ACDF. The maximum von Mises stresses of the endplate of ACCF were much higher than those of ACAF and ACDF. The ACAF and ACDF models demonstrated superior cervical reconstruction stability over the ACCF model. ACAF exhibited lower risks of internal fixation failure and cage subsidence compared to ACCF, making it a promising approach. However, while ACAF revealed improved stability over ACCF, higher rates of subsidence and internal fixation failure persisted compared to ACDF, suggesting the need for further exploration of ACAF's long-term efficacy and potential improvements in clinical outcomes.

Development of an International AO Spine Guideline for the Use of Osteobiologics in Anterior Cervical Fusion and Decompression (AO-GO).

Methodological study for guideline development. AO Spine Guideline for Using Osteobiologics (AO-GO) project for spine degenerative pathologies was an international, multidisciplinary collaborative initiative to identify and evaluate evidence on existing use of osteobiologics in Anterior Cervical Fusion and Decompression (ACDF). The aim was to formulate precisely defined, clinically relevant and internationally applicable guidelines ensuring evidence-based, safe and effective use of osteobiologics, considering regional preferences and cost-effectiveness. Guideline was completed in two phases: Phase 1- evidence synthesis; Phase 2- recommendation development based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. In Phase 1, key questions identified by a panel of experts were addressed in a series of systematic reviews of randomized and non-randomized studies. In Phase 2, the GRADE approach was used to formulate a series of recommendations, including expert panel discussions via web calls and face-to-face meetings. AO-GO aims to bridge an important gap between evidence and use of osteobiologics in spine fusion surgeries. Owing to differences in osteobiologics preparation and functional characteristics, regulatory requirements for approval may vary, therefore it is highly likely that these products enter market without quality clinical trials. With a holistic approach the guideline aims to facilitate evidence-based, patient-oriented decision-making processes in clinical practice, thus stimulating further evidence-based studies regarding osteobiologics usage in spine surgeries. In Phase 3, the guideline will be disseminated and validated using prospectively collected clinical data in a separate effort of the AO Spine Knowledge Forum Degenerative in a global multicenter clinical study.

Comparison of laminoplasty and posterior segment fusion with laminoplasty and anterior segment fusion for treating acute extensional cervical spinal cord injury in pre-existing canal stenosis: a multicenter retrospective study

Background: Patients with pre-existing cervical spinal canal stenosis (CSCS) are more likely to suffer from an extensional spinal cord injury (SCI). However, the appropriate surgical alternatives for extended cervical SCIs in individuals with pre-existing CSCS remain unknown. The purpose of this study was to evaluate the clinical efficacies of laminoplasty and posterior short-segment fusion (PSF) with laminoplasty and anterior short-segment fusion (ASF) in the treatment of these patients. Methods: The clinical data of 258 patients from six spine centers were included in this retrospective study. Patients were divided into two different groups based on the surgical approach: laminoplasty and PSF (PSF group) and laminoplasty and ASF (ASF group). ASIA grades and JOA scores were obtained before and after surgery to assess neurological function. Results: There were 116 patients in the PSF group and 142 patients in the ASF group. The average operation time, intraoperative blood loss, and hospital stay were 188 min, 298 ml, and 7.6 days, respectively, in PSF group, compared to 245 min, 366 ml, and 10.4 days in PSF group, respectively. Complete decompression was achieved in all patients, and fusion was achieved 6 months after surgery. A post-operative computed tomography scan revealed that 39/464 (8.4%) screws had perforated, but no neurovascular complications occurred. Both surgical strategies improved the ASIA grade and there was no significant difference between the two groups (P = 0.926). The JOA score improved from 6.21 ± 1.85 to 10.90 ± 3.56 in the PSF group and from 6.45 ± 2.17 to 11.48 ± 3.62 in the ASF group, but at the final follow-up, there was no significant difference between the two groups (P = 0.134). The incidence of post-operative complications in the ASF group (24/142, 16.9%) (P = 0.043) was higher than that in the PSF group (6/116, 5.17%). Conclusions: Cervical laminoplasty combined with short-segment transpedicular screw fixation is a reliable option to treat extensional cervical SCIs in patients with CSCS. This surgical strategy is beneficial for achieving sufficient cervical spinal cord decompression, preserving cervical spine stability, and avoiding extra anterior cervical decompression and fusion, thereby reducing surgery time, intraoperative blood loss volume, post-operative complication rate, and length of hospital stay. Relevance for Patients: Cervical laminoplasty combined with posterior segmental fusion (PSF) reduces operative time, bleeding, and complications and achieves adequate spinal cord decompression in the treatment of extension cervical SCI in patients with CSCS.

Anterior cervical decompression and fusion at one and two levels: trends and factors associated with structural allograft versus synthetic cages

BackgroundFollowing decompression in anterior cervical discectomy and fusion (ACDF), reconstruction is typically done with structural allograft or a synthetic cage. Relative trends and factors associated with utilizing these implants have not been well characterized. MethodsThe PearlDiver 2011 to 2021 M157 database was used to identify adult patients undergoing 1- or 2-level ACDF. The incidence of structural allograft versus synthetic cage utilized was compared by year. Patient factors predictive of synthetic cage use as the structural interbody for ACDF were assessed with multivariable analysis. Further, the use of anterior plates was trended to provide a measure of usage of stand-alone devices (this comparison was made beginning with 2016 based on coding limitations). ResultsOf 173,833 isolated 1- or 2-level ACDF cases identified, structural allograft was used for 63,029 (36.3%) and synthetic cages were used for 110,804 (63.8%). The use of synthetic cages increased from 51.1% of cases in 2011 to 75.8% of cases in 2021 (p < 0.0001). Independent clinical predictors of synthetic cage use were: older age (odds ratio [OR] 1.02 per decade), female sex (OR 1.04), and greater ECI (OR 1.09 per 2-point increase).Independent non-clinical predictors of synthetic cage use were: geographic region (Northeast OR 1.11, South OR 1.85, and West 2.08, each relative to Midwest), and provider specialty (orthopedic OR 1.06 relative to neurosurgeons). There was an increase in the percent of synthetic cases without separately coded plate (“stand-alone” interbody cages: 21.7% in 2016 to 35.3% in 2021, p < 0.001). ConclusionsThe usage of synthetic cages in 1- and 2- level ACDF has increased relative to structural allograft between 2011 and 2021 in the United States and more recently the use of “stand-alone” synthetic cages has been on the rise. Non-clinical as well as clinical factors were associated with implant choice, suggesting room for more consistent care algorithms.

The Modified 5-Factor Frailty Score May Not be Useful in Predicting Complications and Unplanned Readmission After 1-Level or 2-Level Anterior Cervical Decompression and Fusion

Background: The modified frailty index (mFI-5) has been shown to be a reliable risk stratification tool in different spine procedures. Its usefulness to predict complications after 1-level or 2-level anterior cervical decompression and fusion (ACDF) has not been studied extensively. Purpose: We aimed to assess the usefulness of the mFI-5 in 1-level or 2-level ACDF surgery by asking the following questions: (1) Is the mFI-5 a reliable tool to predict complications after 1-level or 2-level ACDF? (2) Is the mFI-5 useful in predicting prolonged hospital stay after 1-level or 2-level ACDF? (3) Is the mFI-5 useful in predicting readmission after 1-level or 2-level ACDF? Methods: We performed a retrospective analysis of the medical records of patients who underwent 1-level or 2-level ACDF at our institution. The mFI-5 was calculated based on the presence of 5 comorbidities: (1) congestive heart failure, (2) diabetes mellitus, (3) chronic obstructive pulmonary disease, (4) partially or totally dependent functional status, and (5) hypertension requiring medication. Patients were classified in 3 groups: not frail (mFI-5 items = 0), pre-frail (mFI-5 items = 1), and frail (mFI-5 items ≥2). Postoperative complications, length of stay, and readmission were recorded. Results: In the 662 patients included (mean age 51.4 ± 10.4 years), surgical and medical complications were not significantly different among groups. Lengths of stay and readmission rates were both significantly higher in the pre-frail group. Conclusion: Our study findings suggest that the mFI-5 might not be reliable to assess preoperative risk after 1-level or 2-level ACDF.

Outpatient Spine Surgery: A Narrative Review

In recent years, outpatient spine surgery has gained momentum as a promising approach to improve healthcare value by reducing costs and enhancing patient outcomes. This narrative review presents an updated summary of studies exploring the clinical outcomes and cost savings associated with outpatient spine surgery. Our review highlights the growing acceptance of outpatient spine surgery, which is driven by advancements in surgical techniques, anesthesia protocols, and perioperative care pathways. Several procedures, including lumbar discectomy, lumbar laminectomy plus/minus fusion, anterior cervical decompression and fusion (ACDF), and cervical disc arthroplasty (CDA), have shown success in the outpatient setting. A search strategy was employed to identify relevant studies from the MEDLINE database. Seventeen retrospective cohort studies met the inclusion criteria. Outpatient spine surgery demonstrated favorable clinical outcomes, including lower readmission and reoperation rates, shorter hospital stays, and comparable mortality rates. Additionally, analysis of feasibility outcomes revealed significant cost reductions and decreased operative timing with outpatient procedures. Despite its benefits, challenges persist in implementing outpatient spine surgery. Careful patient selection, standardized protocols, and appropriate financial planning are essential to ensure safe and successful integration into healthcare systems. Patient education and engagement are also crucial for promoting optimal outcomes.