Revision Anterior Cervical Discectomy Research Articles

What Is the Evidence Supporting Osteobiologic Use in Revision Anterior Cervical Discectomy and Fusion?

Systematic literature review. To analyze the literature and describe the evidence supporting osteobiologic use in revision anterior cervical discectomy and fusion (ACDF) surgery. A systematic search of PubMed/MEDLINE, EMBASE, Cochrane library, and ClinicalTrials.gov databases was conducted for literature reporting the use of osteobiologics in revision ACDF. We searched for studies reporting outcomes of using any osteobiologic use in revision ACDF surgeries (independently of the number of levels) in the above databases. There are currently no studies in the literature describing the outcome and comparative efficacy of diverse osteobiologic agents in the context of revision ACDF surgery. A majority of the current evidence is based only upon studies involving primary ACDF surgery. The current study highlights the paucity of literature evidence on the role of diverse osteobiologics in revision ACDF, and foregrounds the need for high-quality evidence on this subject.

Early Voice and Swallowing Disturbance Incidence and Risk Factors After Revision Anterior Cervical Discectomy and Fusion Using a Multidisciplinary Surgical Approach: A Retrospective Cohort Evaluation of a Prospective Database.

Dysphagia and vocal cord palsy (VCP) are common otolaryngological complications after revision anterior cervical discectomy and fusion (rACDF) procedures. Our objective was to determine the early incidence and risk factors of VCP and dysphagia after rACDF using a 2-team approach. Single-institution, retrospective analysis of a prospectively collected database of patients undergoing rACDF was enrolled from September 2010 to July 2021. Of 222 patients enrolled, 109 patients were included in the final analysis. All patients had prior ACDF surgery with planned revision using a single otolaryngologist and single neurosurgeon. MD Anderson Dysphagia Inventory and fiberoptic endoscopic evaluation of swallowing (FEES) were used to assess dysphagia. VCP was assessed using videolaryngostroboscopy. Seven patients (6.7%) developed new postoperative VCP after rACDF. Most cases of VCP resolved by 3 months postoperatively (mean time-to-resolution 79 ± 17.6 days). One patient maintained a permanent deficit. Forty-one patients (37.6%) reached minimum clinically important difference (MCID) in their MD Anderson Dysphagia Inventory composite scores at the 2-week follow-up (MCID decline of ≥6), indicating new clinically relevant swallowing disturbance. Forty-nine patients (45.0%) had functional FEES Performance Score decline. On univariate analysis, there was an association between new VCPs and the number of cervical levels treated at revision ( P = .020) with long-segment rACDF (≥4 levels) being an independent risk factor ( P = .010). On linear regression, there was an association between the number of levels treated previously and at revision for FEES Performance Score decline ( P = .045 and P = .002, respectively). However, on univariate analysis, sex, age, body mass index, operative time, alcohol use, smoking, and individual levels revised were not risk factors for reaching FEES Performance Score decline nor MCID at 2 weeks postoperatively. VCP is more likely to occur in long-segment rACDF but is often temporary. Clinically relevant and functional rates of dysphagia approach 37% and 45%, respectively, at 2 weeks postoperatively after rACDF.

Primary and Revision Anterior Cervical Discectomy and Fusion: A Study of Otolaryngologic Outcomes in a Large Cohort.

Retrospective chart review. To determine risk factors for postoperative otolaryngologic complications among patients who undergo primary and revision anterior cervical discectomy and fusion (ACDF). Swallowing and voice dysfunction are frequent postoperative complaints after ACDF surgery with a published incidence varying between 1.2% and 60%. A thorough understanding of the incidence and risk factors for these complications is needed. Electronic medical records of adults who underwent ACDF with predicted difficult surgical site exposure performed by two-surgeon approach between 2008 and 2018 were reviewed. Patients were categorized by primary or revision ACDF status and by the number of levels addressed during the operation. Associations with postoperative otolaryngologic symptoms were assessed using simple and multivariable logistic regression. Participants included 718 adults with an average age of 55.8 years and 45% female sex. One hundred seventy-five patients (27%) underwent revision ACDF; ACDF status was unidentifiable for 74 patients. Seventy-nine cases (12%) involved one spinal level. New postoperative otolaryngologic symptoms among those who underwent primary and revision ACDF were 12.6% and 10.9% respectively. No evidence was found of an association between postoperative otolaryngologic symptoms and revision ACDF (OR, 0.84 [95% CI, 0.48-1.49]; P = 0.55), but evidence was found of an association with prior thyroidectomy (aOR, 3.8 [95% CI, 1.53-8.94], P = 0.0003). Significant evidence was found of increased odds for new postoperative dysphagia with increasing number of surgical levels (aOR, 1.5 [95% CI, 1.09-2.07]; P = 0.01). Prior thyroidectomy and number of spinal levels addressed during ACDF were identified as risk factors for postoperative otolaryngologic complications including dysphagia. Revision ACDF was not associated with increased odds of postoperative otolaryngologic symptoms or dysphagia.Level of Evidence: 4.

Impact of Depression on Patient Reported Outcomes Following Primary Versus Revision ACDF.

Retrospective cohort. To assess the relationship of depressive symptoms with patient reported outcome measures (PROMs) in patients undergoing either primary or revision anterior cervical discectomy and fusion (ACDF) procedures. Depression has been associated with poorer outcomes following ACDF. However, research examining the relationship between depression and PROMs in revision ACDF procedures is limited. A prospective database was retrospectively reviewed for primary or revision, single- or multilevel ACDF procedures from 2016 to 2019. Patients lacking preoperative Patient Health Questionnaire-9 (PHQ-9) surveys were excluded. Demographic and perioperative characteristics were recorded and analyzed using Fisher's exact test or t test. Patient-reported outcome measures were collected preoperatively and postoperatively. Postoperative improvement from baseline scores (ΔPROM) was calculated at all postoperative timepoints. Differences in mean PROM and ΔPROM between groups and changes from baseline PROM scores within groups were assessed using Student's t test. Linear regression analyzed the impact of preoperative PHQ-9 on ΔPROM. A total of 143 patients (121 primary and 22 revision) were included. Significant differences between groups were demonstrated at the preoperative timepoint for Neck Disability Index (NDI) (P = 0.022). ΔPROM values did not significantly differ between groups. Regression analysis revealed significant relationships between preoperative PHQ-9 and ΔPHQ-9 at all timepoints, ΔVAS neck at 6-weeks and 6-months, ΔVAS arm at 6-months, and ΔNDI at 6-weeks and 6-months for the primary group (all P < 0.05). Regression analysis revealed no significant associations for the revision group. Primary or revision ACDF procedures did not significantly differ in depressive symptoms through 1-year. Primary ACDF patients significantly improved in all PROMs through all timepoints, while revision patients had limited improvement in PROMs. Preoperative depression may have a stronger association on postoperative outcomes for primary procedures.Level of Evidence: 3.

Comparison of Cost and Perioperative Outcome Profiles for Primary and Revision Posterior Cervical Fusion Procedures.

Retrospective analysis. To compare perioperative outcomes and hospitalization costs between patients undergoing primary or revision posterior cervical discectomy and fusion (PCDF). While prior studies found differences in outcomes between primary and revision anterior cervical discectomy and fusion (ACDF), risk, and outcome profiles for posterior cervical revision procedures have not yet been elucidated. Institutional records were queried for cases involving isolated PCDF procedures to evaluate preoperative characteristics and outcomes for patients undergoing primary versus revision PCDF between 2008 and 2016. The primary outcome was perioperative complications, while perioperative and resource utilization measures such as hospitalization length, required stay in the intensive care unit (ICU), direct hospitalization costs, and 30-day emergency department (ED) admissions were explored as secondary outcomes. One thousand one hundred twenty four patients underwent PCDF, with 218 (19.4%) undergoing a revision procedure. Patients undergoing revision procedures were younger (53.0 vs. 60.5 yrs), but had higher Elixhauser scores compared with the non-revision cohort. Revision cases tended to involve fewer spinal segments (3.6 vs. 4.1 segments) and shorter surgical durations (179.3 vs. 206.3 min), without significant differences in estimated blood loss. There were no significant differences in the overall complication rates (P = 0.20), however, the primary cohort had greater rates of required ICU stays (P = 0.0005) and non-home discharges (P = 0.0003). The revision cohort did experience significantly increased odds of 30-day ED admission (P = 0.04) and had higher direct hospitalization (P = 0.03) and surgical (P < 0.0001) costs. Complication rates, including incidental durotomy, were similar between primary and revision PCDF cohorts. Although prior surgery status did not predict complication risk, comorbidity burden did. Nevertheless, patients undergoing revision procedures had decreased risk of required ICU stay but greater risk of 30-day ED admission and higher direct hospitalization and surgical costs.Level of Evidence: 3.

Revision Anterior Cervical Discectomy and Fusion and Revision Cervical Arthroplasty Are Associated with Similar Outcomes: Real-World Analysis from a National Quality Registry.

To utilize a national surgical quality registry to compare 30-day quality outcomes between repeat anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA). The National Surgical Quality Improvement Project (NSQIP) Participant User Files (PUF) for the years 2005-2018 were queried for patients undergoing repeat ACDF and CDA using current procedural terminology (CPT) and International Classification of Disease (ICD)-9th version codes. We compared demographic and baseline clinical characteristics, operative characteristics, 30-day readmissions, reoperations, and complications between the two groups. We also performed multivariable analyses to assess the impact of the type of repeat procedure on outcomes of interest. A total of 3,957 patients were identified, of which 182 underwent revision/removal of arthroplasty, while 3,775 underwent revision or removal of fusion. Up to 4.6% of patients (n=179) in the repeat ACDF group had a complication, compared to 0.5% (n=1) in the CDA group. The 30-day readmission rate was found to be similar between the two groups (repeat-ACDF, 3.8% (n=145), vs. repeat-CDA, 2.2% (n=4); p=0.23). Similarly, 30-day reoperation rate was also not found to be different between the two groups (repeat-ACDF, 3.9% (n=149) vs. repeat-CDA, 2.7% (n=5); p=0.39). On multivariable analysis, removal or revision ACDF was found to be only significantly associated with an increased risk of 30-day complications (OR, 8.00; 95% CI, 1.07-59.79; p=0.04). Repeat ACDF or repeat CDA can be performed safely and are associated with optimal 30-day outcomes, comparable to those of index procedures. However, patients undergoing revision ACDF may be slightly more likely to have complications than those undergoing revision CDA.

Postoperative Neurological Complications Following Revision Spine Surgery: A State Inpatient Database Analysis.

Postoperative neurological complications after spine surgery can result in increased mortality and morbidity. Despite the introduction of new spinal implants and surgical technology, reoperation rates have remained stable over recent years. Understanding the reasons for revision (refusion) surgery and the risk of neurological complications can assist in developing more effective screening protocols for repeat surgeries and early detection of potential neurological complications. This study was designed and conducted as a retrospective cohort study. The primary objective of this study was to evaluate whether revision spine surgery increased the risk of postoperative neurological deficits. A secondary objective of the study was to analyze whether deficits following repeat spine surgery increased morbidity and mortality. Data on revision spine procedures were extracted from the California State Inpatient Database for years 2008 to 2011. Patients who developed postoperative neurological deficits were then subdivided into causative procedure: revision anterior cervical discectomy and fusion, revision posterior cervical fusion, and revision thoracolumbar fusion. These data were then used to calculate the total incidence of postoperative neurological deficits following each type of procedure. The impact of neurological deficits on in-hospital morbidity following revision procedures was also calculated. Revision procedures accounted for 5.84% of all spine procedures in a total of 7645 patients. Among these patients, 67 patients (0.88%) developed a postoperative neurological deficit with an adjusted odds ratio of 1.56 (95% CI, 1.20-2.00, P < .05). When using individuals with no neurological deficit as the reference group, the odds of morbidity were 5.3 (95% CI, 3.15-9.00, P < .05) in those who sustained neurological deficit following revision procedure. This study exposes the increased risk of postoperative neurological complications in revision spine surgeries. In response, further studies are needed to evaluate the use of intraoperative neurophysiological monitoring to reduce this risk.

Radiographic Fusion Rates Following a Stand-alone Interbody Cage Versus an Anterior Plate Construct for Adjacent Segment Disease After Anterior Cervical Discectomy and Fusion

Case-control. The aim of this study was to evaluate fusion rates and compare a stand-alone cage construct with an anterior-plate construct in the setting revision anterior cervical discectomy and fusion (ACDF) for adjacent segment disease. Anterior cervical discectomy and fusion are considered the criterion standard of surgical treatment for cervical myelopathy and radiculopathy. One common consequence is adjacent segment disease. Treatment of adjacent segment disease is complicated by the previous surgical implants, which may make application of an additional anterior cervical plate difficult. Stand-alone cage constructs obviate the need for removal or revision of prior implants in the setting of adjacent segment disease. All patients undergoing surgery for adjacent segment disease in a 2-year period were identified and separated into groups based on implant construct. A control group of patients undergoing primary, single-level ACDF were selected from during the same 2-year period. Demographic variables, fusion rate, and reoperation rate were compared between groups. Continuous variables were compared using Student t test, fusion, and revision rates were compared using Pearson χ test. Patients undergoing primary ACDF had lower age and American Society of Anesthesia score as well as shorter operative time. Fusion rate was higher for primary ACDF compared to all patients who underwent ACDF for adjacent segment disease (95% vs. 74%). When compared to primary ACDF, patients with a stand-alone cage construct had significantly lower fusion rate (69% vs. 95%) and higher reoperation rate (14% vs. 0%). There were no significant differences in anterior plate construct versus stand-alone cage construct in terms of fusion and reoperation. Symptomatic adjacent segment disease can be managed surgically with either revision anterior plating or a stand-alone cage constructs, although our results raise questions regarding a difference in fusion rates that requires further investigation. 3.

30-Day Postoperative Morbidity and Readmission Following Revision Anterior Cervical Discectomy and Fusion (ACDF).

This was a retrospective cohort study. To analyze risk factors associated with 30-day adverse outcomes and readmissions after revision anterior cervical discectomy and fusion (ACDF). No current literature has evaluated the risk factors associated with adverse outcomes after revision ACDF. The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using Current Procedural Terminology codes for ACDF (22551, 22554, and 63075) combined with Current Procedural Terminology codes 22830 (exploration of spinal fusion) or 22855 (removal of anterior instrumentation) to identify revision cases. Patients undergoing concurrent posterior cervical spine surgery and/or corpectomies were excluded from the analysis. A total of 1140 patients were retrieved for analysis. Out of a total of 1140 patients, 51 (4.5%) experienced at least 1 any adverse event, with 40 (3.5%) experiencing a severe adverse event, and 17 (1.5%) experiencing a minor adverse event. A 30-day readmission rate was 3.4% (N=39) after a revision ACDF. On multivariate analysis, any adverse events were significantly associated with male sex [odds ratio (OR), 1.98], 2-level versus 1-level fusion (OR, 2.05), and a length of stay (LOS)>1 day (OR, 7.70). Severe adverse events were independently associated with male sex (OR, 2.85), smoking (OR, 0.33), 2-level versus 1-level fusion (OR, 2.03), and LOS>1 day (OR, 7.28). LOS>1 day was the only significant factor associated with an minor adverse event (OR, 14.65) and readmission within 30 days (OR, 2.67). Using a national surgical database, the study is the first of its kind to report rates and risk factors associated with adverse outcomes after ACDFs. Providers should understand the need of preoperative risk stratification in these patients to reduce the risk of experiencing adverse outcomes. Level III-retrospective.

P112. 30-day postoperative morbidity and readmissions following revision anterior cervical discectomy and fusion (ACDF)

BACKGROUND CONTEXT Despite a 48% national increase in the incidence of revision anterior cervical fusions from 2007 to 2010, as well as higher inpatient costs and longer hospital length of stay as compared to primary ACDFs, current literature remains limited to with regard to how revision ACDF patients fare in the acute 30-day postoperative period. PURPOSE Utilizing a national surgical database, the current study was designed to understand the incidence and risk factors for adverse outcomes and re-admissions following a revision ACDF. Furthermore, as a secondary objective, the study evaluated the causes of re-admissions and re-operations in these patients. STUDY DESIGN/SETTING Retrospective cohort study performed using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database. PATIENT SAMPLE The 2012-2016 ACS-NSQIP database files were queried using Current Procedural Terminology codes for ACDF (22551, 22554 and 63075) combined with Current Procedural Terminology codes 22830 (exploration of spinal fusion) or 22855 (removal of anterior instrumentation) to identify revision cases. Patients undergoing concurrent posterior cervical fusion and/or decompression (laminectomies/laminotomies) were excluded from the study. In addition, patients undergoing posterior segmental/non-segmental instrumentation and/or corpectomies were also excluded. OUTCOME MEASURES Thirty-day outcomes were categorized into severe adverse events (SAEs) and minor adverse events (MAEs). SAEs included the following – deep surgical site infection (SSI), organ/space SSI, wound disruption/dehiscence, unplanned intubation, postoperative ventilator use >48 hours, pulmonary embolism, deep venous thrombosis, myocardial infarction, cardiac arrest, stroke, acute renal failure, sepsis, septic shock, re-operation and death. MAEs included the occurrence of urinary tract infections, bleeding requiring transfusions, pneumonia, progressive renal insufficiency and superficial SSI. An additional variable defined as “any adverse event” or “AAE” recorded the presence of at least one SAE or MAE. METHODS Multi-variate logistic regression analyses were used to identify significant risk factors associated with experiencing adverse 30-day outcomes following revision ACDFs. Descriptive analyses were used to report the causes of readmissions and re-operations in these patients. RESULTS Out of a total of 1,140 patients, 51 (4.5%) experienced at least one adverse event (AAE), with 40 (3.5%) experiencing a severe adverse event (SAE) and 17 (1.5%) experiencing a minor adverse event (MAE). On multivariate analysis, AAEs were significantly associated with male gender (OR 1.98; p=0.023), 2-level vs 1-level fusion (OR 2.05; p=0.019) and a LOS>1 day (OR 7.70; p 1 day (OR 7.28; p 1 day was the only significant factor associated with a MAE (OR 14.65; p CONCLUSIONS In conclusion, 4.5 % of patients experience an adverse event following a revision ACDF with up to 3.4% experiencing a re-admission. The study is the also the first of its kind to analyze the risk factors for experiencing an adverse event following a revision ACDF. Providers should utilize these data to enhance the dissemination of knowledge regarding postoperative outcomes following a revision ACDF among hospital staff and/or patients to improve shared decision-making, reduce fragmentation of services and increase the quality of care to improve outcomes and curb costs in these high-risk patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Assessment of the Reliability of the Fiberoptic Endoscopic Evaluation of Swallowing as an Outcome Measure in Patients Undergoing Revision Anterior Cervical Discectomy and Fusion

Dysphagia is one of the most common complications of anterior cervical spine surgery, and there is a need to establish that the means of testing for it are reliable and valid. The objective of this study was to measure observer variability of the fiberoptic endoscopic evaluation of swallowing (FEES) test, specifically when used for evaluation of dysphagia in patients undergoing revisionary anterior cervical decompression and fusion (ACDF). Images from patients undergoing revision ACDF at a single institution were collected from May 1, 2010, through July 1, 2014. Two senior certified speech pathologists independently evaluated the swallowing function of patients preoperatively and at 2 weeks postoperatively. Their numeric evaluations of the Rosenbeck Penetration-Aspiration Scale and the Swallowing Performance Scale during the FEES were then compared for interrater reliability. Positive agreement between raters was 94% for the preoperative Penetration-Aspiration Scale (prevalence-adjusted bias-adjusted κ, 0.77). The postoperative Penetration-Aspiration Scale showed reliability coefficients for κ, Kendall's W, and intraclass correlation coefficient (ICC) of 0.34 (fair agreement), 0.70 (extremely strong agreement), and 0.35 (poor agreement), respectively. The preoperative Swallowing Performance Scale showed strong agreement, with a Kendall's W coefficient of 0.68, and fair reliability, with an ICC of 0.40. The postoperative Swallowing Performance Scale indicated extremely strong agreement between raters, with a Kendall's W of 0.82, and good agreement, with an ICC of 0.53. The FEES test appears to be a reliable assessor of dysphagia in patients undergoing ACDF and may be a useful measure for exploring outcomes in this population.

Proton Pump Inhibitor Use Affects Pseudarthrosis Rates and Influences Patient-Reported Outcomes

Study Design:Retrospective cohort reviewObjectives:Cervical pseudarthrosis is a frequent cause of need for revision anterior cervical discectomy and fusion (ACDF) and may lead to worse patient-reported outcomes. The effect of proton pump inhibitors on cervical fusion rates are unknown. The purpose of this study was to determine if patients taking PPIs have higher rates of nonunion after ACDF.Methods:A retrospective cohort review was performed to compare patients who were taking PPIs preoperatively with those not taking PPIs prior to ACDF. Patients younger than 18 years of age, those with less than 1-year follow-up, and those undergoing surgery for trauma, tumor, infection, or revision were excluded. The rates of clinically diagnosed pseudarthrosis and radiographic pseudarthrosis were compared between PPI groups. Patient outcomes, pseudarthrosis rates, and revision rates were compared between PPI groups using either multiple linear or logistic regression analysis, controlling for demographic and operative variables.Results:Out of 264 patients, 58 patients were in the PPI group and 206 were in the non-PPI group. A total of 23 (8.71%) patients were clinically diagnosed with pseudarthrosis with a significant difference between PPI and non-PPI groups (P = .009). Using multiple linear regression, PPI use was not found to significantly affect any patient-reported outcome measure. However, based on logistic regression, PPI use was found to increase the odds of clinically diagnosed pseudarthrosis (odds ratio 3.552, P = .014). Additionally, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores (P = .022).Conclusions:PPI use was found to be a significant predictor of clinically diagnosed pseudarthrosis following ACDF surgery. Furthermore, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores.

Communication about incisional hernia through an iliac crest bone harvest site after reoperative cervical anterior fusion

Abstract We report the case of an incisional hernia through the wound made for iliac bone harvest for re-operative cervical fusion surgery. A 50-year old woman underwent revision anterior cervical discectomy and fusion (ACDF) using a poly ether ether ketone cage and titanium alloy locking plate for adjacent segment disease after prior ACDF. As an autograft, iliac cancellous bone was again harvested from the left iliac crest, using the prior surgical scar. Although only cancellous bone from the medial side of the iliac bone was collected, leaving the iliac crest intact, she complained of a protrusion from the left lower abdomen, of which diagnosis was an incisional hernia through the iliac bone harvest site. Formation of an incisional hernia at the iliac bone harvest site is a possible complication after spine surgery. Care must be taken for oblique abdominal muscle repair around the iliac bone harvest site, particularly in re-operative cases.

Differences in Short-Term Outcomes Between Primary and Revision Anterior Cervical Discectomy and Fusion.

Retrospective cohort study. To compare short-term morbidity for primary and revision anterior cervical discectomy and fusion (ACDF). Revision ACDF procedures are relatively common, yet their risks are poorly characterized in the literature. There is a need to assess the relative risk of revision ACDF procedures compared with primary surgery. The prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent primary and revision ACDF from 2005 to 2014. The occurrence of 30-day postoperative complications, readmission, operative time, and postoperative length of stay were compared between primary and revision procedures using multivariate regression to control for patient and operative characteristics. A total of 20,383 ACDF procedures were identified, 1219 (6.0%) of which were revision cases. On multivariate analysis, revision procedures were associated with significantly increased risk of any adverse event (relative risk [RR] 2.3, P < 0.001), any severe adverse event (RR 2.2, P < 0.001), thromboembolic events (RR 3.3, P = 0.001), surgical site infections (RR 3.2, P < 0.001), return to the operating room (RR 1.9, P = 0.001), any minor adverse event (RR 2.5, P < 0.001), and blood transfusion (RR 8.3, P < 0.001). Revision procedures had significantly increased risk of readmission within 30 days (RR = 1.6, P = 0.001). Minor, but statistically significant increases in average operative time and postoperative length of stay were identified for revisions procedures (7 min and half a day, respectively [P < 0.001 for both]). Revision procedures were associated with significantly increased risk of multiple adverse outcomes, including thromboembolic events, surgical site infections, return to the operating room, blood transfusion, and readmission within 30 days. These results are important for patient counseling and risk stratification. 3.

Subsequent Cervical Disc Herniation following Single-Level ACDF

Introduction Subsequent herniated cervical disc (HCD) and revision anterior cervical discectomy and fusion (ACDF) is not an uncommon disease and procedure. And we, as a spinal surgeon, have some difficulties in decision-making, because of the airway, esophagus, and vocal cord problems. Adjacent segment disease is well known as the pathologic process, in which the changes in the other segment may occur at the cranial or caudal segment. In this study, we discuss about the subsequent HCD which requires surgical treatment following single-level ACDF. Materials and Methods From 2006 to 2012, 27 Korean patients, who were operated for subsequent HCD following previous ACDF, were enrolled. The subsequent HCD was detected not only in adjacent segments just around fused spine but also in the skipped segments. A total of 23 patients were approached anteriorly (22 revision ACDF and 1 anterior foraminotomy) and 4 patients were approached posteriorly for posterior keyhole surgery. All 23 patients with anterior approach were evaluated for vocal cord palsy before anterior revision surgery. We retrospectively reviewed and analyzed the pre- and postoperative data. Results The subsequent HCD significantly occurred on the caudal segment in patients with C3–4 and C4–5 fused patients and on the cranial segment in C6–7 and C7–T1 fused patients ( p = 0.045). In C5–6 fused patients, the subsequent HCD occurred similarly, both caudally and cranially (5 cranially, 6 caudally). The use of plate in primary ACDF has no significant effect on either the caudal or the cranial segment ( p = 0.168). The direction of approach in primary ACDF (right vs. left) was mainly on contralateral side to the patient's symptom ( p = 0.007), whereas there was no laterality of approach in the revision ACDF according to the symptom and previous ACDF ( p = 0.767). Vocal cord palsy developed only in one patient with anterior keyhole surgery, who had been approached right in primary ACDF and left in revision surgery and there was right-sided vocal cord damage. Conclusion Revision ACDF was the major surgical method for subsequent HCD. There was no relationship between the laterality of the approach according to the previous operation and development of vocal cord palsy. The vocal cord palsy was detected in a significantly lower incidence (4.3%, 1/23) compared with the results of other studies. The subsequent HCD had a tendency of developing in the caudal segments in C3–4, 4–5 fused patients and in cranial segment in C6–7, C7–T1 fused patients. In C5–6 fused patients, the subsequent HCD occurred both caudally and cranially.

Patient Satisfaction After Revision Anterior Cervical Discectomy and Fusion (ACDF) for Adjacent Segment Disease: Relationship to Clinical Outcomes, Patient Characteristics and Cost-Effectiveness

Adjacent segment disease (ASD) has been found to occur in up to 26% of patients at 10 years following index anterior cervical discectomy and fusion (ACDF) surgery. Revision ACDF surgery is effective and durable in treating ASD, however information is scarce regarding patient reported satisfaction following the operation. Gathering patient satisfaction data can be valuable for clinicians and directly relevant to treatment effectiveness.