Anterior Cervical Discectomy Fusion Research Articles

Management outcomes of cervical radiculopathy with conservative treatment, anterior cervical discectomy fusion (ACDF), and anterior cervical disc replacement (ACDR)—Retrospective single center matched cohort study

Abstract Background: Degenerative cervical radiculopathy results from nerve root compression in the cervical neural foramina, often due to a herniated disc, osteophyte, or facetal/ligamentum flavum hypertrophy. Typically, 80% of patients show improvement within the initial 12 weeks through nonoperative measures, with surgical intervention considered for non-responders. This study aimed to compare clinical and radiological outcomes in cervical radiculopathy patients undergoing prolonged conservative care, anterior cervical discectomy and fusion (ACDF), or anterior cervical disc replacement (ACDR) after a 1‐year follow‐up. Materials and Methods: Our study was a retrospective single‐center study involving 780 cervical radiculopathy patients from January 2012 to December 2021. About 80.12% found relief with conservative management within 12 weeks. Remaining 155 patients were offered surgery, with 73 opting for continued conservative care, and 82 undergoing surgery (55 with ACDF and 27 with ACDR). Evaluation was done using visual analogue scale (VAS), Neck Disability Index (NDI), and radiographic parameters. Results: The mean follow‐up was 11.58 ± 6.7 months. ACDR group: Mean age 43.38 ± 8.56, VAS 7.81 ± 1.04 preoperatively, improved significantly to 2.07 ± 1.34 (P < 0.05) at 1‐year follow‐up. ACDF group: Mean age 44.85 ± 10.65, VAS 8.22 ± 1.21 preoperatively, improved significantly to 2.09 ± 1.01 (P < 0.05) at 1‐year follow‐up. Conservative group: Mean age 45.04 ± 11.19, VAS 7.77 ± 1.86 preoperatively, improved significantly to 2.08 ± 1.40 (P < 0.05) at 1‐year follow‐up. Radiographic parameters significantly improved in all groups at 1‐year follow‐up (P < 0.05). Range of motion (ROM) changes varied across groups. Miyazaki’s grading and Kim’s score showed comparable results. Conclusion: Comparable clinical and radiological outcomes were observed among conservative, ACDF, and ACDR approaches. ACDR approach demonstrated a better NDI score outcome. Neck ROM was better maintained or improved in the ACDR approach, decreased in ACDF, and remained almost similar in the conservative group.

Comparison of Anterior Cervical Discectomy Fusion Combined with Lateral Mass Screw and with Cervical Pedicle Screw Fixation Surgery under O-Arm Navigation for Single-Stage Management of Severe Lower Cervical Fracture Dislocation.

The incidence of severe lower cervical fractures and dislocations due to trauma has increased significantly, and the optimal treatment remains controversial. This study compares the safety and efficacy of anterior cervical discectomy fusion (ACDF) combined with lateral mass screw (LMS) and with cervical pedicle screw (CPS) fixation surgery under O-arm navigation as single-stage treatments of severe lower cervical fracture dislocations. Data from 48 patients who underwent ACDF + CPS (Group A) or ACDF + LMS (Group B) for severe lower cervical fracture dislocation between January 2016 and September 2020 were retrospectively reviewed. Groups A and B comprised 25 and 23 cases, respectively. Clinical parameters, such as operative time, intraoperative blood loss, number of fixed segments, posterior incision length, operative complications, and hospitalization days were recorded. Preoperatively and postoperatively, the sub-axial injury classification (SLIC) score, the American Spinal Injury Association (ASIA) impairment scale, and the Japanese Orthopaedic Association (JOA) score were recorded and analyzed using Student's t-test. The SLIC scores were 7.1 ± 1.2 and 7.5 ± 1.1, ASIA were 1.5 ± 0.6 and 1.2 ± 0.6, JOA score improvements were 3.2 ± 2.4 and 3.0 ± 2.1, operative times were 282.1 ± 91.7 and 266.5 ± 88.2 min, intraoperative blood losses were 437.8 ± 118.5 and 418.7 ± 104.2 mL, fixed segments were 2.8 ± 0.7 and 4.8 ± 1.1, and lengths of posterior incisions were 12.7 ± 2.8 and 13.8 ± 3.2 cm in Groups A and B, respectively. There was no significant difference between the two groups in the operative time, intraoperative blood loss, incision length, and postoperative recovery; however, group A had more fixed segments. At the final follow-up, no intraoperative or postoperative complications directly caused by the implant were present. Throughout the follow-up, all cases showed recovery and progressive improvement. Both ACDF + LMS and ACDF + CPS under O-arm navigation can safely and effectively restore cervical vertebral sequence, fully release spinal canal compression, and promote patients' neurological recovery. Thus, both are effective treatments for severe lower cervical fracture dislocations. However, compared to LMS, CPS under O-arm navigation has shorter fixed segments and induces less trauma.

59. The impact of insulin dependence on anterior cervical discectomy fusion surgery outcomes: an analysis of 75,808 patients

59. The impact of insulin dependence on anterior cervical discectomy fusion surgery outcomes: an analysis of 75,808 patients

Posterior endoscopic decompression combined with anterior cervical discectomy and fusion versus posterior laminectomy and fusion for multilevel cervical spondylotic myelopathy: a retrospective case-control study

ObjectiveTo compare the clinical efficacy of surgical treatment for multilevel cervical spondylotic myelopathy (MCSM) between the hybrid procedure, posterior endoscopic decompression (PED) combined with anterior cervical discectomy fusion (ACDF), and posterior cervical laminectomy and fusion (PCLF).MethodsA retrospective analysis was performed on 38 patients who received surgical treatment for MCSM from January 2018 to December 2021, including 19 cases in hybrid procedure group (13 males and 6 females), followed up for 10 to 22 (12.8 ± 10.3) months, and 19 cases in PCLF group (15 males and 4 females), followed up for 10 to 21 (11.7 ± 8.9) months. Perioperative information, including operation time, intraoperative blood loss, length of hospitalization, and complications, were compared between two groups. Visual analogue scale (VAS) of pain, neck disability index (NDI) and Japanese Orthopaedic Association (JOA) score were recorded to evaluate clinical efficacy. Cervical lordosis was calculated by radiographic examination.ResultsIntraoperative blood loss, length of hospital stay were less in hybrid group than PCLF group, while operation time is longer in hybrid group, with a statistically significant difference (p < 0.05). Increased lordosis was better in hybrid group. There was no significant difference in preoperative VAS, JOA and NDI at pre-operation and final follow-up between two groups. But at post-operation and final follow-up, VAS was less in hybrid group than PCLF group (p < 0.05). There were 2 cases of neurostimulation symptoms in hybrid group, 2 cases of C5 nerve root palsy, 2 cases of subcutaneous fat necrosis and 1 case of dural tear in PCLF group, and all patients relieved with symptomatic treatment.ConclusionThe hybrid procedure of PED combined with ACDF showed satisfied clinical outcome, with less intraoperative blood loss, shorter length of hospitalization and lower post-operative neck pain than PCLF. It is an effective surgical treatment for MCSM.

Modified ACDF Technique for the Treatment of Centrum Focal Ossification of the Posterior Longitudinal Ligament: A Case Report

Anterior cervical discectomy fusion (ACDF) is a surgical procedure used to treat cervical spondylosis with anterior spinal cord compression. However, there are limitations to traditional ACDF and posterior indirect decompression when the anterior source lesion is in the center of the cervical vertebra. On June 8, 2022, our department treated a patient with cervical spondylotic myelopathy-whose high posterior longitudinal ligament (OPLL) occupied the central position of the vertebral body-with modified ACDF. The preoperative surgical plan was designed based on the relevant imaging data and assay index. Also, the visual analogue scale (VAS), Japanese Orthopaedic Association (JOA) scores, and imaging parameters of neck pain were recorded and compared. Postoperative imaging data showed that cervical curvature was recovered and spinal canal compression was relieved. The VAS score for neck pain decreased from 7 preoperatively to 1.5 at the last follow-up, while the JOA score increased from 10 preoperatively to 29 at the last follow-up. The volume of the spinal canal was restored. Simultaneously, the patient's extremity muscle strength improved and muscle tension decreased. Modified ACDF may be an effective surgical method for resolving spinal cord compression in a specific location when bone mineral density is good. We can effectively avoid iatrogenic nerve injury and symptom recurrence by removing the vertebral body and the lesion directly.

Anterior cervical discectomy fusion versus posterior decompression and fusion in octogenarians with cervical myelopathy: Clinical outcomes and complications with a 3-year follow-up

IntroductionCervical stenosis and concurrent Cervical Spondylotic Myelopathy (CSM) are prevalent in the elderly. Treatment options include Anterior Cervical Discectomy Fusion (ACDF) and Posterior Decompression and Fusion (PDF). Research questionThis study aims to compare clinical outcomes and complications between ACDF and PDF in patients aged 80 and above. Material and methodsData from electronic medical records between 2005 and 2021 at a single institution were analyzed. Logistic and linear regression analyses were performed to explore risk factors and the relationship between comorbidities and neurological conditions. Results21 patients with ACDF and 26 with PDF were studied over 16 years. PDF patients had more operated levels, higher blood loss, and longer hospital stays, but mortality rates and mJOA improvements were similar in both groups. The presence of comorbidities was a unique risk factor for postoperative complications. Discussion and conclusionACDF and PDF led to neurological improvements in elderly CSM patients. However, the decision of surgical procedure should carefully consider the potential for postoperative complications, particularly in patients with comorbidities.

Application of “key and lock” principle in the treatment of traumatic cervical Spondyloptosis of c6-7: Case report and literature review

Purpose: Traumatic cervical spondyloptosis is a rare clinical pathology that often causes complete paralysis. When a patient presents neurologically intact or incomplete paralysis, the management becomes more complicated. Preservation of neural function and restoration of anatomic alignment collectively remain the golden goals of therapy. There are still few reports on this issue, however, the existing literature did not clearly define severity of injuries and the treatment strategy in such cases. On the occasion of reporting one treated traumatic C6-7 spondyloptosis case, we reviewed existing literatures. Material and Methods: The patient was a 48-year-old man who had motorcycle accident and was presented with post-operation for right frontal epidural hematoma in 3 days before admitting to hospital. Neurological assessment showed motor strength grade 3/5 in the proximal upper and lower-extremity muscle groups on the right side, and 1/5 on the left side with incontinence of sphincters. X-rays and computed tomography (CT) scan revealed a three-column ligamentous injury with complete anterior displacement of C6 to C7 vertebral body. We applied the “Key - Lock” principle for better understanding of the biomechanics of the injury and found out the favorable strategy. The patient underwent posterior approach with decompression and anterior approach with reduction and anterior cervical discectomy fusion for C6-7. Results: After 8 months follow-up, the patient had recovered muscular strength in bilateral upper and lower-extremities muscle groups, sphincter function had fully recovered, and he was able to ambulate by himself. Plain radiograph and CT scan showed good aligment and progressive maturation of his fusion procedure. Conclusion: Traumatic cervical spondyloptosis of C6-7 is a high-energy unstable fracture and rare. This report develops a new principle called “Key and Lock” for more understand the biomechanics of the injury and treatment. Our patient was successfully treated with open reduction, decompression, and anterior cervical discectomy fusion.

Evaluation of Topology Optimization Using 3D Printing for Bioresorbable Fusion Cages: A Biomechanical Study in a Porcine Model.

Preclinical biomechanical study of topology optimization versus standard ring design for bioresorbable poly-ε-caprolactone (PCL) cervical spine fusion cages delivering bone morphogenetic protein-2 (BMP-2) using a porcine model. The aim was to evaluate range of motion (ROM) and bone fusion, as a function of topology optimization and BMP-2 delivery method. 3D printing technology enables fabrication of topology-optimized cages using bioresorbable materials, offering several advantages including customization, and lower stiffness. Delivery of BMP-2 using topology optimization may enhance the quality of fusion. Twenty-two 6-month-old pigs underwent anterior cervical discectomy fusion at one level using 3D printed PCL cages. Experimental groups (N=6 each) included: Group 1: ring design with surface adsorbed BMP-2, Group 2: topology-optimized rectangular design with surface adsorbed BMP-2, and Group 3: ring design with BMP-2 delivery via collagen sponge. Additional specimens, two of each design, were implanted without BMP-2, as controls. Complete cervical segments were harvested six months postoperatively. Nanocomputed tomography was performed to assess complete bony bridging. Pure moment biomechanical testing was conducted in all three planes, separately. Continuous 3D motions were recorded and analyzed. Three subjects suffered early surgical complications and were not evaluated. Overall, ROM for experimental specimens, regardless of design or BMP-2 delivery method, was comparable, with no clinically significant differences among groups. Among experimental specimens at the level of the fusion, ROM was <1.0° in flexion and extension, indicative of fusion, based on clinically applied criteria for fusion of <2 to 4°. Despite the measured biomechanical stability, using computed tomography evaluation, complete bony bridging was observed in 40% of the specimens in Group 1, 50% of Group 2, 100% of Group 3, and none of the control specimens. A topology-optimized PCL cage with BMP-2 is capable of resulting in an intervertebral fusion, similar to a conventional ring-based design of the same bioresorbable material.

Patient-specific numerical investigation of the correction of cervical kyphotic deformity based on a retrospective clinical case

Little research has been reported on evaluating the safety of the fixation construct in cervical kyphosis correction. In this study, we proposed a principal-strain criterion to evaluate the safety of the fixation construct and validated the modeling method against a retrospective case of anterior cervical discectomy fusion (ACDF). From C2 to T2 vertebra bodies, fixation instruments were reconstructed and positioned as per postoperative computed tomography (CT) scans. Head weight (HW) and various moments estimated from isometric strength data were imposed onto the C2. The postoperative stability of non-surgical segments, deformations surrounding the screw trajectories, and contact slipping on zygapophysial joints were analyzed. The model was validated against the reality that the patient had a good fusion and deformity correction. The ACDF restricted the range of motions (ROMs) of cervical segments and lent stability to vertebra fusion, no failure was found in the finite element (FE) model of cervical vertebrae. The deformation surrounding the screw trajectories were concentrated to the lateral sides of trajectories, recommending that the shape of the anterior cervical plate conforming to the curvature of the vertebra and screws fully inserted into vertebrae reduced the deformation concentration around the screw trajectories.

34. The effect of screw length on single-level anterior cervical fusion using finite element

<h3>BACKGROUND CONTEXT</h3> Anterior cervical discectomy fusion and plating (ACDFP) is one of the most common neurosurgical procedures performed. Early in the use of plates to minimize postoperative orthosis duration and to increase healing rates, there was an attempt to use a bicortical screw purchase. Over time, we have typically converted to a lesser screw length to decrease any additional risks from the bicortical technique. Our study looks at the biomechanical effect of screw length at a single-level ACDFP and the effect on adjacent levels in flexion and extension using finite element modeling. <h3>PURPOSE</h3> To determine the effect of screw length on single-level anterior cervical discectomy, fusion and plating, and its clinical application. <h3>STUDY DESIGN/SETTING</h3> Finite element model. <h3>METHODS</h3> A previously validated three-dimensional osteoligamentous finite element model (FEM) of the cervical spine column (C2-T1) was used. The FEM simulated the vertebra of the body, posterior elements, intervertebral disc and ligaments. Each vertebral body consisted of a thin cortical shell, a softer cancellous bone, endplate, and a posterior bony structure. The cortical bone was modeled as a linear isotropic material of 0.5mm thick shell surrounding the cancellous bone and a 0.2mm thick endplate was placed on the superior and inferior surface of the intervertebral disc. Each single motion segment of the FEM consists of vertebral bodies, intervertebral disc and five major vertebral ligaments. The intervertebral disc was modeled and composed of the nucleus pulposus, annulus ground substance and annulus fibrosus. Material property parameters from literature were used as definitions in the model. The intact spine was modified at the C5-C6 functional spine unit level to simulate the biomechanics of ACDF with different screw lengths (12mm, 14mm, 16mm, 18mm). The standard surgical procedure was used to simulate ACDFP with different length screws at the C5-C6 level. The ALL was removed. The disc properties were altered at the surgical level to simulate the trabecular bone, and this represented complete fusion. The plate was placed at the C5-C6 level, and 4 titanium screws were simulated. All FEM were fixed at the first thoracic vertebra in all degrees of freedom, and load was applied at the C2 superior endplate vertebra. Bending moment (1.5 Nm) combined with a follower load (75N) magnitude under flexion and extension was applied to the intact model. The ROM was measured at each level and across the C3-C7 levels. The variable moment loading protocol (otherwise known as hybrid loading) was next applied. The bending moment was varied until the ACDF with different length screw models displayed the same total range of motion across the C3-C7 levels (although individual segments could have different range of motion). The ROM was obtained at the segmental levels under the same loading mode. <h3>RESULTS</h3> The C5-6 area of fusion demonstrated the least flexion (0.17°) and extension (0.36°) with the 18mm screw and the most flexion (0.75°) and extension (1.06°) with the 12 mm screws. The length of the screw effects the adjacent levels of the spine throughout with the largest increase in ROM in flexion (11.51° -11.98° with 12mm and 18mm screw length respectively) and extension (6.71°- 7.71° with 12mm and 18mm screw length respectively occurring at the cephalad C4-5 level. The caudal C6-7 adjacent level was more pronounced with an increase in flexion ROM with 12mm screws with 12.04° vs 11.88° with 18mm screws and increased but less pronounced ROM in extension with 6.34° with 18mm screws and 5.72° with 12mm screws. <h3>CONCLUSIONS</h3> Increased screw length results in higher flexion ROM at the C4-5 level. An inverse relationship is noted with 12mm screws at the C6-7 adjacent levels demonstrating more ROM than the 18mm screws in flexion. In extension both C4-5 and C6-7 demonstrate that increasing screw length results in increased ROM as compared to 12mm screws. This increased ROM would be expected to increase adjacent segment degeneration more prominently at the C4-5 level as compared to C6-7. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

CLINICAL RESULTS OF EVOLUTIONAL CHANGE OF PRACTICE FROM OPEN TO ENDOSCOPIC SURGERY FOR CERVICAL DISC HERNIATION AND FORAMINAL STENOSIS

Objective: Limited literature on the effect on clinical and radiological outcomes in cervical endoscopic spine surgery replacing a large percentage of open and microscopic minimally invasive surgery on outcomes in patients for cervical disc herniations and foraminal pathologies. Methods: Retrospective comparative cohort study of two periods of 2015 to 2017 (first generation) is compared to 2018–2020 (second generation) on surgical treatment of degenerative cervical spinal conditions for 132 spinal cases. Basic demographics, preoperative, post-operative 1 week, 3 months and final follow-up of patients’ clinical outcomes in terms of Visual Analog Scale Pain Score, Neck Disability Index, Japanese Orthopaedic Association Score and MacNab’s Criteria were evaluated. Results: In the first generation, 50 cases of cervical disc herniation and foraminal stenosis with 70% open anterior cervical discectomy fusion or disc replacement 30% of the cases underwent posterior cervical endoscopic procedures with complication rate of 2%. In the second generation, 82 cases of cervical disc herniation and foraminal stenosis with 7% open anterior cervical discectomy fusion or disc replacement 93% of the cases underwent posterior cervical endoscopic procedures with complication rate of 6%. Compared to preoperative score, motor, JOA, VAS and NDI scores all statistically significant improved within the individual cohort. Compared to the first generation, the second generation has statistically significant improved VAS of 0.326+/−0.146 at 3 months and 0.648+/−0.163 at final follow-up and statistically significant improved NDI of 2.81+/−1.15 at final follow-up, p &lt; 0.05. Conclusions: Generation change of increasing percentage of endoscopic surgeries and expansion of endoscopic spinal indications over open surgeries in degenerative spinal conditions and disc herniations are possible as a surgeon gets more experience with endoscopic spine surgery producing good clinical outcomes.

Finite Element Analysis of the Effect of Dynamic Plating on Two-Level Anterior Cervical Discectomy Fusion Biomechanics

The limitations of anterior cervical discectomy and fusion (ACDF) are related to mechanical failure of the construct after recurring subsidence and migration. In the present study, we evaluated the effect of the maximum rotation of variable angle screws on the range of motion (ROM), cage migration, and subsidence. Five finite element models were developed from a C2-C7 cervical spine model. The first model was an intact C2-C7 spine model, and the second model was an altered C2-C7 model with C4-C6 cage insertion and a 2-level static plate. The other three models were altered C2-C7 models with the same C4-C6 cage insertion and a 2-level dynamic plate. The ROM of C4-C6 in the static plate model was reduced by ∼14° from the intact model but only reduced by ∼9° in the dynamic plate models. The maximum migration and subsidence at the cage-endplate interface in the dynamic plate models were lower than those in the static plate model for all moments. The von Mises stress of the C3-C4 and C6-C7 discs in the dynamic plate models was lower than that in the static plate model. Our results indicate that dynamic plating has promising potential (greater ROM and lower von Mises stress of discs) for stabilization in multilevel anterior cervical discectomy and fusion than static plating, although both dynamic and static plates showed lower ROM than the intact model. A lower screw rotational angle resulted in superior biomechanical performance (lower incidence of migration and subsidence) compared with a higher rotational angle in multilevel applications, regardless of loading.

Comparing Anterior Cervical Discectomy Fusion with Cervical Disc Arthroplasty in Cervical Spondylosis

The present article reviews updated research, patient selection, complications associated with types of cervical disc implants, and its use in patients with multilevel cervical spondylosis. Recent metanalysis comparing Cervical Disc Arthroplasty (CDA) and Anterior Cervical Discectomy and Fusion (ACDF) has demonstrated safety and equal or superior clinical outcomes based on SF-36 NDI and VAS scores. Recent studies show similar outcomes for using CDA in two-level cervical disc disease of those suffering radiculopathy and/or /myelopathy. Long-term studies are more available to show decreased rates of adjacent segment disease and reoperation rates following cervical disc replacement. Cervical arthroplasty continues to be a promising technique for which now there is growing level 1a evidence. Further long-term data is awaited to investigate two-level CDA and reoperation rates specifically due to adjacent level disease, subsidence, implant migration, and heterotropic ossification.

Does cervical facet degeneration impact surgical outcomes and sagittal balance in patients with radiculopathy?

PurposeIn our present study, we aimed to investigate (1) whether cervical facet degeneration (FD) affects the clinical functional scores of patients with cervical radiculopathy after single-segment anterior cervical discectomy fusion (ACDF) and (2) whether FD affects the sagittal parameters of the cervical spine.MethodsA total of 120 enrolled patients who underwent single-segment ACDF for radiculopathy with more than 2 years of follow-up were classified into two groups based on whether the preoperative mean FD was greater than or less than the mean FD grading score: mild FD group (mean score ≤ 2, n = 102) or severe FD group (mean score > 2, n = 48). Sagittal alignment changes and clinical functional scores were compared between the 2 groups. The relevant factors for FD were identified using multivariate logistic regression.ResultsAge, duration of symptoms, disc height and interfacet distance were independently associated with preoperative FD (age: P < 0.001; duration of symptoms: P = 0.020; disc height: P < 0.001; interfacet distance: P = 0.045). Compared with the mild FD group, the preoperative VAS (neck pain) score and NDI of the severe FD group were also higher, and the improvement of neck symptoms was better during the follow-up period. However, all clinical scores and radiographic parameters showed no significant differences during the 2-year follow-up. Additionally, no significant differences in the sagittal parameter changes were presented.ConclusionPatients with severe FD tended to experience more severe neck pain before surgery and greater improvement of neck symptoms at the follow-up visit. However, 2-year clinical efficacy and sagittal alignment after ACDF may not be markedly affected by preoperative FD severity. ACDF is considered to be a good choice for patients with radiculopathy, especially for patients with severe FD.

Finite element analysis of the effect of plate placement angle on cervical spine stability in anterior cervical fusion surgery

Using the method of finite element analysis, to compare the biomechanical properties between the plate deviating from the long axis of the cervical spine and the standard placement of the plate in the anterior cervical fusion surgery. A healthy female volunteer was selected and CT scan (C1-T1) was performed. Using Mimics 19.0, Geomagic Studio 2015, Solidworks 2018, Ansys Workbench 17.2 to establish a lower cervical spine (C3-C7) model and to verify the reliability of the model. Subsequently, anterior cervical plates of different angles and lengths were placed to establish an anterior cervical discectomy fusion (ACDF) model. Applying 73.6 N axial pressure and 1 NM pure moment on C3 to make the model produce flexion, extension, lateral bending and rotation activities, observed the model stress cloud diagram and recorded the maximum stress value of the instrument and the intervertebral mobility. The lower cervical spine (C3-C7) finite element model was established and verified against the published literature on the range of motion (ROM) of cervical spine. Effect of steel plate offset axis on stress distribution, maximum stress value and intervertebral ROM of internal fixation apparatus was minimal, and the mechanical effect of steel plate offset was less in double section steel plate than in single section steel plate. Little effect on the mechanical stability of the cervical spine was anticipated when the anterior cervical plate was not perfectly aligned with the long axis of the cervical spine. If the tilt of the plate in clinical surgery is less than 20°, there is no need to readjust the position of the plate.

Assessment of spino cranial angle of cervical spine sagittal balance system after multi-level anterior cervical discectomy and fusion

BackgroundTo analyze the impact of spino cranial angle (SCA) on alteration of cervical alignment after multi-level anterior cervical discectomy fusion (ACDF) and explore the relationship between SCA and health-related quality of life (HRQOL) scores.Material and methodsIn total, 49 patients following multi-level ACDF for multi-level cervical spondylotic myelopathy (MCSM) with more than 2 years follow-up period were enrolled. Radiographic data including SCA were measured. Receiver operating characteristics (ROC) curve analysis was applied to confirm the optimal cut-off values of SCA for predicting sagittal balance. Patients were divided into two groups on the basis of the cut-off value of preoperative SCA. Correlation coefficients were analyzed between SCA and HRQOL scores.ResultsOptimal cut-off values for predicting sagittal balance was SCA of 88.6°. Patients with higher SCA, no matter preoperatively, postoperatively and at follow-up, got lower T1-Slope (T1s), C2–C7 lordosis angle (CA) and higher △SCA (pre vs post: p = 0.036, pre vs F/U: p = 0.022). Simultaneously, pre-SCA, post-SCA, and F/U-SCA in the high SCA group were positively correlated with the pre-NDI, post-NDI, and F/U-NDI scores respectively (pre: p < 0.001, post: p = 0.015, F/U: p = 0.003). However, no correlation was performed in the low SCA group.ConclusionAn excessive SCA can be considered to cause poorer clinical outcomes at preoperative and better correction after surgery. The SCA could be used as a new reference value to determine sagittal balance parameters of the cervical spine and to assess the quality of life.

Perioperative Hidden Blood Loss in Elderly Cervical Spondylosis Patients With Anterior Cervical Discectomy Fusion and Influencing Factors.

Introduction:To analyze the perioperative hidden blood loss (HBL) and its influencing factors in elderly cervical spondylosis patients treated with anterior cervical discectomy fusion (ACDF).Materials and Methods:From January 2017 to December 2018, 128 elderly cervical spondylosis patients (age > 65 y) treated with ACDF were selected. The patients’ height, weight, duration of symptoms, previous medical history and other basic information were routinely recorded. The hemoglobin (Hb), hematocrit (Hct) and blood coagulation function preoperative and the next day postoperative were recorded. The operation time, surgical bleeding, ASA classification, fixation method, total drainage and the time for extraction of drainage tube were recorded. The total blood loss (TBL) was calculated according to the Gross’s formula, and HBL was calculated based on TBL, total drainage and surgical bleeding. The statistical analysis of HBL was performed, and then influential factors were further analyzed by multivariate linear regression analysis and t test.Results:The mean surgical bleeding was 102.70 ± 46.78 mL and HBL was 487.98 ± 255.96 mL. HBL accounted for 67.61 ± 5.20% of TBL. According to the multiple linear regression analysis, the gender (P = 0.047), operation time (P = 0.000), fixation method (P = 0.014) and international normalized ratio (INR) (P = 0.003) influenced the amount of HBL. Body mass index (BMI) (P = 0.624), hypertension (P = 0.977), diabetes (P = 0.528), blood type (P = 0.577), ASA classification (P = 0.711), duration of symptoms (P = 0.661), preoperative cobb angle (P = 0.152), number of surgical level (P = 0.709), intramedullary hyperintensity (P = 0.967), drainage time (P = 0.294), postoperative drainage volume (P = 0.599), prothrombin time (PT) (P = 0.674), activated partial thromboplastin time (APTT) (P = 0.544) and thrombin time (TT) (P = 0.680) had no correlation with the amount of HBL.Conclusions:There was obvious HBL during the perioperative period of ACDF in elderly cervical spondylosis patients. The male patients, longer operation time, fusion with titanium plate and cage and high INR were independent risk factors for HBL.

Frequency, recognition, and management of postoperative hematomas following anterior cervical spine surgery: A review.

Background: We reviewed the frequency, recognition, and management of postoperative hematomas (HT) (i.e. retropharyngeal [RFH], wound [WH], and/or spinal epidural hematomas [SEH]) following anterior cervical discectomy/fusion (ACDF), anterior corpectomy fusion (ACF), and/or anterior cervical spine surgery (ACSS).Methods: Postoperative cervical hematomas following ACDF, ACF, and ACSS ranged from 0.4% to 1.2% in a series of 11 studies involving a total of 44, 030 patients. These included; 4 single case reports, 2 small case series (6 and 30 cases), 4 larger series (758–2375 for a total of 6729 patients), an a large NSQUIP (National Surgical Quality Improvement Program ) Database involving 37,261 ACDF patients.Results: Risk factors contributing to postoperative cervical hematomas included; DISH (diffuse idiopathic skeletal hyperostosis), ossification of the posterior longitudinal ligament (OPLL), therpeutic heparin levels, longer operative times, multilevel surgery, ASA Scores of +/= 3, (American Society of Anesthesiologists), prone surgery, operative times > 4 hours, smoking, higher/lower body mass index (BMI), anemia, age >65, > medical comorbidities, and male gender. Notably, the use of drains did not prevent HT, and did not increase the infection, or reoperation rates.Conclusion: In our review of 11 studies focused on anterior cervical surgery, the incidence of postoperative hematomas ranged from 0.4 to 1.2%. Early recognition of these postoperative hemorrhages, and appropriate management (surgical/non-surgical) are critical to optimize recovery, and limit morbidity, and mortality.

Anterior Cervical Discectomy fusion: Cervical PEEK Cage vs Dynamic Cervical Implant

Background: There are wide treatment modalities for degenerative disc diseases of cervical spines. However, surgery is indicated when conservative treatment fails, and each procedure had its limitation. Aim of the work: to compare the outcome between cervical peek cage and dynamic cervical implant for anterior cervical discectomy fusion (ACDF) for patients with degenerated cervical disc disease. Patients and methods: Fifty patients with degenerative disk disease (DDD) were treated by cervical poly- etherether-ketone (PEEK) cage (25 patients) and another 25 with dynamic cervical implant (DCI). All patients assessed pre- and post-operatively by clinical and radiological examinations, with pain assessment by visual analogue scale and calculation of the range of motion. Any neurological deficits were documented in both pre-and post-operative periods. Results: Both groups were comparable regarding patient characteristics, preoperative pain and preoperative range of motion. The mean percentage of pain reduction was significantly higher among PEEK when compared to DCI group (81.93±7.07 vs 66.23±11.48 respectively). In DCI group, preoperative mean range of motion at the operated level was 7.56, changed to 6.64 postoperatively, which is statistically significant. Similarly, in PEEK cage group, preoperative mean range of motion at operated level was 7.60 Changed to 7.52 which is statistically non-significant. Complications were mild and treated conservatively. Conclusion: PEEK cage is associated with better alleviation of pain either at the neck or arm pain. On the other side, DCI is associated with slightly better range of motion. However, global range of motion is comparable between both groups.

S3444 Balloon Dilation of an Upper Esophageal Stricture as a Complication of Anterior Cervical Discectomy Fusion Surgery (ACDF) Using an Ultrathin Scope and Seldinger Wire Technique

INTRODUCTION: Dysphagia after anterior cervical discectomy and fusion (ACDF) surgery is a frequent and well-known complication however the pathophysiology of dysphagia is unclear and there is sparse data on the best methods for evaluation and treatment. CASE DESCRIPTION/METHODS: A 64 year-old female was seen in the Gastroenterology clinic for complaints of dysphagia primarily to solids and pills and an unintentional weight loss of nearly 20 pounds after a C3-C4 ACDF was performed earlier in the year. At the index endoscopy, a standard-sized endoscope could not pass through the upper esophagus and the procedure required completion with an ultrathin (UT) endoscope. A barium swallow following the case revealed a focal stricture 4 × 7mm in diameter just below the ACDF site. To attempt dilation during a subsequent endoscopy, a wire was placed through the UT scope and the scope was removed. A through-the-scope (TTS) balloon was pre-loaded into a standard endoscope and the wire was then placed through the balloon. The scope was advanced using a Seldinger wire technique and the balloon was dilated in the upper esophagus being careful to avoid a large osteophyte at C-7 found on prior MRI. The patient required three sessions with wire exchange and dilation up to a max of 15mm resulting in the ability to pass a standard endoscope through the upper esophagus. Since the last endoscopy, the patient has had improvement in her dysphagia with significant weight gain within 2 months post-procedure. DISCUSSION: Up to 15% of ACDF patients can still present with dysphagia one year post-op however the exact causes are largely unknown and therapeutic strategies have not been described. Management of complex strictures in the setting of recent cervical spine surgery can be challenging however lessons learned from our case include the importance of careful imaging review to avoid potential complications (such as dilating against an osteophyte), use of the UT scope to navigate the stricture and employment of the Seldinger technique to accommodate focal balloon dilation which can be successfully employed for upper esophageal strictures.