Three-level Anterior Cervical Discectomy Research Articles

Two-Level Corpectomy and Fusion vs. Three-Level Anterior Cervical Discectomy and Fusion without Plating: Long-Term Clinical and Radiological Outcomes in a Multicentric Retrospective Analysis.

Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) represent effective alternatives in the management of multilevel cervical spondylotic myelopathy (CSM). A consensus on which of these techniques should be used is still missing. The databases of three centers were reviewed (January 2011-December 2018) for patients with three-level CSM, who underwent three-level ACDF without plating or two-level ACCF with expandable cage (VBRC) or mesh (VBRM). Demographic data, surgical strategy, complications, and implant failure were analyzed. The Neck Disability Index (NDI), the Visual Analog Scale (VAS), and the cervical lordosis were compared between the two techniques at 3 and 12 months. Logistic regression analyses investigated independent factors influencing clinical and radiological outcomes. Twenty-one and twenty-two patients were included in the ACDF and ACCF groups, respectively. The median follow-up was 18 months. ACDFs were associated with better clinical outcomes at 12 months (NDI: 8.3% vs. 19.3%, p < 0.001; VAS: 1.3 vs. 2.6, p = 0.004), but with an increased risk of loss of lordosis correction ≥ 1° (OR = 4.5; p = 0.05). A higher complication rate in the ACDF group (33.3% vs. 9.1%; p = 0.05) was recorded, but it negatively influenced only short-term clinical outcomes. ACCFs with VBRC were associated with a higher risk of major complications but ensured better 12-month lordosis correction (p = 0.002). No significant differences in intraoperative blood loss were noted. Three-level ACDF without plating was associated with better clinical outcomes than two-level ACCF despite worse losses in lordosis correction, which is ideal for fragile patients without retrovertebral compressions. In multilevel CSM, the relationship between the degree of lordosis correction and clinical outcome advantages still needs to be investigated.

Clinical and imaging outcomes of self-locking stand-alone cages and anterior cage-with-plate in three-level anterior cervical discectomy and fusion: a retrospective comparative study

BackgroundAnterior cervical discectomy and fusion has been considered standard management for cervical myelopathy and radiculopathy. However, the option of using self-locking stand-alone cages or cage-with-plate in three-level anterior cervical discectomy and fusion still remains controversial. The aim of this study was to evaluate the clinical and imaging outcomes of the two procedures in multilevel anterior cervical discectomy and fusion.MethodsSixty-seven patients who underwent three-level anterior cervical discectomy and fusion were enrolled in this study, of which 31 patients underwent surgery using self-locking stand-alone cages (group cage) and 36 patients using cage-with-plate (group plate). For the evaluation of clinical outcomes, modified Japanese Orthopedic Association scores, visual analogue scale for neck pain, neck disability index, Odom’s criteria and dysphagia status were measured. Imaging outcomes were evaluated by cervical sagittal angle, fusion segmental Cobb’s angle, fusion segmental height, range of motion, cage subsidence rate, fusion rate and adjacent segment degeneration. Statistical analyses were performed using the SPSS software (version 19.0).ResultsBoth groups showed improvement in modified Japanese Orthopedic Association scores, visual analogue scale for neck pain and neck disability index, after surgery, and there was no significant difference between the groups. The occurrence rate of dysphagia is significantly lower in the group cage compared with the group plate (p < 0.05). The postoperative cervical sagittal angle, fusion segmental Cobb’s angle, fusion segmental height and cage subsidence rate in the group plate were significantly superior to that in the group cage (p < 0.05). However, the rate of adjacent segment degeneration was significantly lower in the group cage compared with the group plate (p < 0.05). Both groups showed no significant difference in terms of fusion rate (p > 0.05).ConclusionsThe self-locking stand-alone cages are effective, reliable and safe in anterior cervical discectomy and fusion for the treatment of cervical myelopathy and radiculopathy. Self-locking stand-alone cages showed a significantly lower rate of dysphagia and adjacent segment degeneration, while anterior cervical cage-with-plate could provide stronger postoperative stability and maintain better cervical spine alignment.

Spine

The December 2022 Spine Roundup360 looks at: Deep venous thrombosis prophylaxis protocol on a Level 1 trauma centre patient database; Non-specific spondylodiscitis: a new perspective for surgical treatment; Disc degeneration could be recovered after chemonucleolysis; Three-level anterior cervical discectomy and fusion versus corpectomy- anterior cervical discectomy and fusion “hybrid” procedures: how does the alignment look?; Rivaroxaban or enoxaparin for venous thromboembolism prophylaxis; Surgical site infection: when do we have to remove the implants?; Determination of a neurologic safe zone for bicortical S1 pedicle placement; Do you need to operate on unstable spine fractures in the elderly: outcomes and mortality; Degeneration to deformity: when does the patient need both?

Clinical and Radiological Comparison of Hybrid Surgery and Fusion Application with Peek Cage in Patients Undergoing Three-Level Anterior Cervical Discectomy.

In this study, we aimed to compare patients with degenerative cervical disc herniation (CDH) who had undergone three-level anterior cervical discectomy (ACD) and fusion with a peek cage supported by synthetic bone graft in all levels to the cases with CDH with hybrid surgery (HS) regarding their radiological findings and surgical results. The patients who had undergone three-level ACD were evaluated retrospectively. The cases who were followed up for 2years and longer were evaluated regarding gender, age, radiological findings, and patient satisfaction. A radiological assessment was made by calculating the Cobb angle on lateral cervical radiographs. Clinical assessment was performed by the Neck Disability Index (NDI). In the first group, 13 patients had undergone ACD and fusion with peek cage and bone graft, and in the hybrid group, there were 11 patients in whom fusion with peek cage and bone graft were made in two levels, and cervical disc arthroplasty was performed throughout the distance in-between. In the hybrid group, the 1-month and 24-month changes in cervical range of motion in hyperflexion were statistically significant (p < 0.05). In both groups, significant improvements of NDI were determined postoperatively (p < 0.05). When the groups were compared, the 1-month and 24-month improvements were statistically significantly increased in the hybrid surgery group compared to the group that underwent fusion surgery with a cage (p < 0.05). HS is a reliable and effective treatment method in the three-level cervical disk disease for preserving and improving cervical ROM, particularly in the flexion position.

P130. Comparative safety and efficacy of four surgical techniques in three level Anterior Cervical Discectomy and Fusion (ACDF)

<h3>BACKGROUND CONTEXT</h3> No consensus exists on the ideal surgical technique for multilevel ACDF, the gold standard treatment for cervical disc disease. Anterior plate (AP) fixation has been traditionally utilized for additional stability but associated complications have led to the increased use of stand-alone (SA) PEEK-anchored cages in recent years. There is a paucity of literature on use of these techniques in 3-level ACDF patients. In order to gain insight into the optimal surgical technique for 3-level ACDF, we conducted a retrospective comparative analysis of the safety and efficacy of the AP, SA and two other common surgical techniques. <h3>PURPOSE</h3> To compare the safety and efficacy of four surgical techniques in patients receiving three-level Anterior Cervical Discectomy and Fusion (ACDF). <h3>STUDY DESIGN/SETTING</h3> A retrospective chart review of patients who underwent primary 3-level ACDF by the two senior authors at two hospitals in Westchester County, NY. <h3>PATIENT SAMPLE</h3> A total of 50 patients who received primary 3-level ACDF by the senior authors between August 2015 and February 2020. <h3>OUTCOME MEASURES</h3> The outcomes investigated in this study include the following: Clinical Success (measured using Odom's criteria score), Safety (complication incidence), Operative (OP) Time, Blood Loss (BL) and Hospital Length of Stay (LOS). <h3>METHODS</h3> Surgical and clinical data for 50 patients who received primary 3-level ACDF by the senior authors between August 2015 and February 2020 was retrospectively analyzed. All patients received a combination of autograft and allograft. Four patient groups were compiled based on surgical technique performed; Anterior Plating with no cage at 3 levels (AP, 24%), Stand-Alone PEEK-anchored cages at 3 levels (SA, 30%), Stand-Alone PEEK-anchored cage at the first level and Anterior Plating with PEEK-anchored cages at the 2 subsequent levels (SAAP, 30%), and Anterior Plating with PEEK-anchored cages at three levels (APC, 16%). Patients were assessed at 5 time points: 1-4 weeks, 5-10 weeks, 3-5.5 months, 6-8 months and 9-12 months. At each time point, patients were evaluated for clinical success (using Odom's Criteria scoring) and safety (complication incidence). Other outcomes investigated include Operative (OP) Time, Blood Loss (BL) and Hospital Length of Stay (LOS). Data analysis was conducted in SPSS 20.0 (SPSS, Inc. Chicago, IL) and included one-way ANOVA, two-tailed t-test, and linear regression analyses. <h3>RESULTS</h3> Patients in the AP group had longer mean OP times (220 min) when compared to patients in the SA (170 min, p=0.04), SAAP (175 min, p=0.009), and APC (167 min, p=0.01) groups. The difference in mean OP time between the AP group and each of the other patient groups were statistically significant (p=0.008). A linear regression analysis showed no significant differences in the mean Odom's criteria score between the four groups (1) over time and (2) at each time point. There were four complications recorded, one per group. The complications were as follows (group in parenthesis): pulmonary embolism (AP), hematoma (SA), adjacent level disease (SAAP) and broken hardware (APC). There were no statistically significant differences between any of the patient groups regarding BL (p = 0.378) and LOS (p = 0.174). The following patient factors were controlled for in all analyses: advanced age (age greater than 65), gender, high BMI (BMI greater than 35), diabetes, osteoporosis, cardiac history (hypertension and/or myocardial infarction), sleep apnea and smoking status. None of these factors were found to have a statistically significant effect on the study outcomes. <h3>CONCLUSIONS</h3> Consistent with the literature, the OP times were longer for 3-level ACDF patients who underwent the AP technique compared to patients who underwent the SA technique. We demonstrated that patients in the AP group also had longer OP times than patients in the SAAP and APC groups. In addition, all four surgical techniques appeared to have analogous safety profiles and clinical success rates. Past studies in the literature examining the AP and SA techniques in 2-level ACDF patients have reported comparable clinical outcomes. Future studies should employ a larger sample size and investigate radiological outcomes such as fusion rate and loss of lordosis. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Use of zero-profile device for contiguous three-level anterior cervical discectomy and fusion: comparison with cage and plate construct.

The aim of this study was to compare a traditional cervical cage with a zero-profile (ZP) fixation device in patients who underwent three-level anterior cervical decompression and fusion (ACDF) in terms of patient-reported outcomes (visual analog scale [VAS], Japanese Orthopaedic Association [JOA], and Neck Disability Index [NDI] scores), radiographic findings (sagittal alignment 2 years after surgery and likelihood of fusion), and complications. This study was a retrospective case series. Between January 2012 and December 2016, 58 patients with cervical spondylotic myelopathy (CSM) who required three-level ACDF procedures, as identified by spinal surgeons, were treated with three-level ACDF and an anterior cage-plate construct (ACPC) (n = 38) or a three-level stand-alone ZP device (n = 20). On the basis of patient choice, patients were divided into two groups (ACPC group and ZP group). All patients completed a minimum of 2 years of follow-up. Patient-reported outcome scores included VAS, JOA, and NDI scores. The radiographic findings included sagittal alignment and likelihood of fusion 2 years after surgery. Data related to patient-reported outcomes and sagittal alignment were collected preoperatively, postoperatively, and at the final follow-up. Intraoperative and postoperative complications were also documented and analyzed. The clinical outcomes, including VAS, JOA, and NDI scores, showed improvement in both groups, and no significant difference was observed between the two groups. Sagittal alignment and height of the fused segments were restored in all patients. However, the authors found no differences between the ZP and ACPC groups, and the groups exhibited similar fusion rates. The authors found no differences in complications, including dysphagia, adjacent-segment degeneration, and postoperative hematoma, between the groups. Use of ZP implants yielded satisfactory long-term clinical and radiological outcomes that were similar to those of the standard ACPC. Additionally, the rates of complications between the groups were not significantly different. Although the best surgical option for multilevel CSM remains controversial, the results of this work suggest that ACDF with the ZP device is feasible, safe, and effective, even for multilevel CSM.

The Relationship Between Cervical Sagittal Balance and Adjacent Segment Disease After Three-level Anterior Cervical Discectomy and Fusion.

Retrospective review of prospectively collected data. To determine the relationship between cervical sagittal balance and adjacent segment degeneration (ASD) development after 3-level anterior cervical discectomy and fusion (ACDF). ASD is a common complication after ACDF. Previous studies have shown that sagittal imbalance may be associated with ASD development after 1-level or 2-level ACDF. However, these findings may not be generalizable to 3-level procedures. We reviewed prospectively collected data of 46 patients who underwent 3-level ACDF at a tertiary institution. Lateral cervical radiographs taken preoperatively, postoperatively, and at last follow-up were reviewed for ASD. The mean follow-up duration was 5 years. Radiographic parameters measured were cervical sagittal alignment (CSA), segmental sagittal alignment, T1 slope (T1S), sagittal vertical axis, and T1S-cervical lordosis. ASD was present in 27 (58.7%) patients, but only 1 patient (2.2%) underwent reoperation at 4.8 years. The CSA, sagittal vertical axis, and T1S were similar preoperatively, but the T1S-cervical lordosis was higher in the ASD group (18.28 vs. 9.82, P =0.016). All 4 parameters were similar postoperatively and at last follow-up. The ASD group had a greater change in CSA over the follow-up period (-6.26 vs. -1.47, P =0.05), but they achieved similar sagittal alignment at last follow-up. There was no difference in clinical outcomes between the 2 groups. Unlike studies on 1-level and 2-level ACDF, this study found that cervical spinal alignment was not associated with ASD development after 3-level ACDF. ASD development also had no impact on clinical outcomes at 2 years. Level III-nonrandomized cohort study.

Clinical and radiological outcomes of multilevel cervical laminoplasty versus three-level anterior cervical discectomy and fusion in patients with cervical spondylotic myelopathy.

Cervical spondylotic myelopathy (CSM) is one of the most common causes of spinal cord impairment in elderly patients. However, a consensus has yet to be reached on the ideal method of surgical intervention. In this study, we investigated serial changes of radiological findings after three-level anterior cervical discectomy and fusion (ACDF) and multilevel laminoplasty and attempted to identify the radiological parameters affecting long-term clinical outcomes in CSM. Of the 152 patients with multilevel CSM treated with three-level ACDF and multilevel laminoplasty, 42 had complete radiological parameters both before and 2 years after surgery (three-level ACDF, 22 patients; multilevel laminoplasty, 20 patients). Radiological parameters included spinal cord signal intensity (SI) changes on magnetic resonance imaging (MRI). Clinical outcomes including the Japanese Orthopaedic Association (JOA) score, neck disability index (NDI), Oswestry disability index (ODI), and 36-Item Short Form Health Survey score were measured. The ACDF group showed significant restoration of segmental lordosis postoperatively (preoperatively: 2.21°, 6 months: 8.37°, P=0.026), and segmental and cervical range of motion (ROM) was markedly reduced and well maintained until the final follow-up (preoperatively: 25.48°, 24 months: 4.35°, P<0.001; preoperatively: 41.71°, 24 months: 20.18°, P<0.001). The recovery rates of the JOA score were 42.85% and 57.40% in the ACDF and laminoplasty groups, respectively, although this difference was not statistically significant. Multivariate regression analysis demonstrated that signal change on MRI significantly affected the recovery rate (P=0.003). The visual analog scale (VAS) score and NDI decreased considerably only in the laminoplasty group, and device complications were confirmed only in the ACDF group (incidence rate =36.5%). Multilevel laminoplasty showed better radiological and similar clinical outcomes. ACDF had more surgical complications. Spinal cord SI change on preoperative MRI was the independent risk factor for poor clinical outcomes. We recommend laminoplasty instead of three-level ACDF to treat multilevel CSM.

Comparison of Clinical Outcomes and Sagittal Alignment After Different Levels of Anterior Cervical Discectomy and Fusion in Patients With Cervical Spondylotic Myelopathy: From One-level to Three-level.

A nonrandomized and prospective study. The aim of this study was to compare clinical outcomes and sagittal alignment after one-level, two-level, and three-level anterior cervical discectomy and fusion (ACDF) in patients with cervical spondylotic myelopathy (CSM). ACDF is a widely used surgical approach for CSM. It remains controversial regarding to whether corrected lordosis can be maintained over time after different levels ACDF. A total of 175 patients with cervical spondylotic myelopathy who underwent ACDF were enrolled in this retrospective study. The neurofunctional assessment was performed with the Japanese Orthopedic Association (JOA) score and the recovery rate of JOA score. Radiographic parameters included C2-C7 lordosis, fused segments lordosis, T1 slope, the cervical sagittal vertical axis (cSVA). Patients with more fusion levels had more operative time and blood loss and higher rate of complications. All patients showed a larger cervical lordosis than that preoperatively and the restored lordosis increased with more segments involved. The restored lordosis had little change during the whole follow-up in one-level and two-level group. CL decreased from 25.65 ± 9.31° on the third postoperative day to 20.25 ± 10.03° at the final follow-up in three-level group (P = 0.001). Only T1 slope in three-level increased significantly from preoperative 26.55 ± 9.36° to 29.06 ± 7.54° on the third postoperative day (P = 0.011) and decreased to 26.89 ± 7.22° (P = 0.043) at final follow-up. The JOA score all increased significantly at the last follow-up in each group, but the recovery rate of the JOA score in each group was similar (P = 0.096). ACDF with different levels had similar postoperative clinical outcomes. Three-level ACDF has an apparent advantage in restoring lordosis, a poor ability to maintain lordosis, and a higher incidence of complications compared to one-level or two-level ACDF.Level of Evidence: 3.

Exploration on sagittal alignment and clinical outcomes after consecutive three-level hybrid surgery and anterior cervical discectomy and fusion: a minimum of a 5-year follow-up

PurposeTo compare sagittal alignment and clinical outcomes between three-level hybrid surgery (HS) and anterior cervical discectomy and fusion (ACDF) on cervical spondylotic myelopathy (CSM) over a 5-year follow-up.MethodThe study included 32 patients with ACDF, 36 patients with 1 prosthesis and 2 cages (HS1 group), and 25 cases with 2 prostheses and 1 cage (HS2 group). Alignment parameters included C2–C7 cervical lordosis (CL), C2–C7 sagittal vertical axis (SVA), T1 slope (T1S), and T1S minus CL (T1SCL). Radiographic parameters were range of motion (ROM), upper and lower adjacent ROM (UROM and LROM), and operated-segment lordosis (OPCL), as well as adjacent segment degeneration (ASD). Clinical outcomes included the neck disability index (NDI) and Japanese Orthopedic Association (JOA) score.ResultsThree groups were well-matched in demographics. All groups gained comparable improvement on NDI and JOA (P < 0.01). All groups gained CL improvement at the final visit (P < 0.05). There were no statistical differences on SVA and T1SCL among the groups and among preoperation, 1 week later, and final follow-up (P > 0.05) while T1S improved at 1 week later and final follow-up with HS2. The final change of all alignment parameters among the three groups was of no differences. ROM decreased and OPCL increased in all groups at the final follow-up (P < 0.05). UROM and LROM increased with ACDF but kept stable with HS1 and HS2. There was no inter-group difference on the incidence of ASD (P > 0.05).ConclusionCervical alignment was comparably improved. HS and ACDF provided identified mid-term efficacy, and it was not necessary to have to use prosthesis on three-level CSM.

Sagittal Alignment Outcomes in Lordotic Cervical Spine: Does Three-Level Anterior Cervical Discectomy and Fusion Outperform Laminoplasty?

A prospective cohort study. To compare the radiological outcomes between three-level anterior cervical discectomy and fusion (ACDF) and plate-only open-door laminoplasty (LAMP) in patients with lordotic cervical spine. Both three-level ACDF and LAMP are important surgical methods for multilevel cervical spondylotic myelopathy, but the cervical sagittal alignment outcomes and the lordosis preserving abilities between the two specific approaches have not been carefully compared. Sixty patients, all of whom had lordotic cervical spines and underwent three-level ACDF (n = 22) or LAMP (n = 38) for the treatment of multilevel cervical spondylotic myelopathy, were prospectively studied. Upright neutral cervical lateral radiographs were assessed preoperatively, at 3 days after surgery, and at the last follow-up (1.5 years). The primary radiological outcomes are C2-7 Cobb angle, and the secondary outcomes include C2-7 sagittal vertical axis , disc height, Harrison angle, and Ishihara index. The relationship between preoperative parameters and follow-up outcomes were assessed. Preoperative cervical sagittal alignment parameters were similar between the two groups. Patients in the ACDF group obtained larger C2-7 Cobb angles than those the LAMP group early after surgery. However, the lordosis in the ACDF group decreased significantly during follow-up, leading to similar outcomes between the two groups. The lordosis-preserving ability of ACDF is significantly poorer than that of LAMP. Secondary radiological parameters also showed similar trends. In both groups, the preoperated Ishihara index was significantly related to follow-up C2-7 Cobb angles. For patients with Ishihara index less than 20, ACDF is more likely to produce a larger C2-7 Cobb angled at the time of follow-up. In patients with lordotic cervical spine, the sagittal alignment outcomes of the two approaches were similar, and the lordosis-preserving ability was poorer in ACDF. Further research should focus on the factors related to the lordosis-preserving ability of multilevel ACDF. 3.

Is stand alone PEEK cage the gold standard in multilevel anterior cervical discectomy and fusion (ACDF)? Results of a minimum 1-year follow up

IntroductionThis study was designed to evaluate the clinical and radiologic results of stand-alone synthetic polyetheretherketone (PEEK) cages for two- or three-level anterior cervical discectomy and fusion (ACDF), with a focus on subsidence. Materials and methodsWe retrospectively reviewed a total of 68 patients who underwent two- or three-level ACDF with a stand-alone PEEK cage between April 2005 and August 2016. Radiologic parameters were assessed on lateral radiographs, and fusion was assessed on computed tomography scans. For the evaluation of clinical outcomes, visual analogue scale, neck disability index, and modified Japanese Orthopedic Association scores were measured. ResultsAmong the total of 68 patients with a total of 144 segments, ACDF at two and three levels was performed in 60 and 8 patients, respectively, with a mean follow-up duration of 27.6 months. The overall fusion rate was 81.3% (117 of 144 segments), and subsidence occurred in 63 segments (43.8%) at the last follow-up. There was no statistically significant difference between the subsidence group and the nonsubsidence group in terms of fusion rate, radiologic outcomes, and clinical outcomes (p > .05). ConclusionSubsidence might be an inevitable course and only a radiologic phenomenon with no effect on the clinical and radiologic outcomes of the use of stand-alone cages.

Cervical Spondylotic Myelopathy Secondary to Dropped Head Syndrome: Report of a Case and Review of the Literature.

The dropped head syndrome (DHS) is a disabling condition caused by severe weakness of the neck extensor muscles causing progressive reducible kyphosis of the cervical spine and the inability to hold the head up. Weakness can occur in isolation or in association with a generalized neuromuscular disorder. Isolated cases are owed to the late onset of noninflammatory myopathy designated as INEM, where persistent chin to chest deformity may gradually cause or aggravate preexisting degenerative changes of the cervical spine and ultimately result in myelopathy. In review of the literature, we could find only 5 cases, with no unique guidelines to address the management of these two concomitant pathologies. Herein, a 69-year-old man who had developed cervical myelopathy 2 years after being affected by isolated dropped head syndrome is presented. Chin to chest deformity and cervical myelopathy were managed through three-level anterior cervical discectomy and fusion (ACDF) combined with decompressive cervical laminectomy and stabilization with C2 to C7 pedicle screw-rod construct. At 4-month follow-up, despite recovery in patient's neurological status, flexion deformity reappeared with recurrence of dropped head due to C7 pedicle screws pull-out. However, this was successfully managed with extension of the construct to the upper thoracic levels.

Clinical and radiological outcome after anterior cervical discectomy and fusion with stand-alone empty polyetheretherketone (PEEK) cages

To evaluate long-term results after one-, two-, and three-level anterior cervical discectomy and fusion (ACDF) with stand-alone empty polyetheretherketone (PEEK) cages. We performed a retrospective review of a consecutive patient cohort that underwent ACDF with stand-alone empty PEEK cages between 2007 and 2010 with a minimum follow-up of 12 months. Radiographic follow-up included static and flexion/extension radiographs. Changes in the operated segments were measured and compared to radiographs directly after surgery. Clinical outcome was evaluated by a physical examination, pain visual analog scale (VAS), and health-related quality of life (HRQL) using the EuroQOL questionnaire (EQ-5D). Analysis of associations between fusion, subsidence, cervical alignment, and clinical outcome parameters were performed. Of 407 consecutive cases, 318 met all inclusion criteria. Follow-up data were obtained from 265 (83 %) cases. The mean age at presentation was 55 years and 139 patients were male (52 %). In the sample, 127, 125, and 13 patients had one-, two-, and three-level surgeries, respectively; 132 (49 %) presented with spondylotic cervical myelopathy and 133 (50 %) with cervical radiculopathy. Fusion was achieved in 85, 95, and 94 % of segments in one-, two-, and three-level surgeries, respectively. Non-fusion was associated with higher VAS pain levels. Radiographic adjacent segment disease (ASD) was observed in 20, 29, and 15 % in one-, two-, and three-level surgeries, respectively. ASD was associated with lower HRQL. Subsidence was observed in 25, 27, and 15 % of segments in one-, two-, and three-level surgeries, respectively. However, this had no influence on clinical outcome. Follow-up operations for symptomatic adjacent disc disease and implant failure at index level were needed in 16 (6 %) and four (1.5 %) cases, respectively. Younger age was associated with better clinical outcome. Multilevel surgery favored better myelopathy outcomes and fusion reduced overall pain. ASD worsened EuroQOL-Index values. Worsening of the cervical alignment induced arm pain. One- and two-level ACDF with stand-alone empty PEEK cages achieved very high fusion rates and a low rate of follow-up operations. The rate of good clinical outcome is highly satisfactory. Younger age was the single most influential factor associated with better clinical outcome.

Polyetheretherketone cages alone with allograft for three-level anterior cervical fusion.

A total of 25 consecutive patients suffering from degenerative cervical disc disease who underwent three-level anterior cervical discectomy and fusion (ACDF) including polyetheretherketone (PEEK) cages packed with allograft were followed up for at least two years. The fusion rate reached 72% (18/25), and asymptomatic pseudarthrosis was seen in 6 patients but without mobility on flexion-extension radiographs, and revision surgery was not needed. Cage subsidence occurred at one level (C67), but it was not progressive, and reoperation was not necessary. A significant increase (P < 0.001) in fused segment angle (FSA) and fused segment height (FSH) was observed postoperatively. Similarly, a significant clinical improvement (P < 0.001) was demonstrated postoperatively in terms of Japanese Orthopedic Association (JOA) score and visual analog scales (VASs) score. PEEK cages alone with allograft proved to be a safe and effective surgical option in the treatment of three-level degenerative cervical disc disease. Although the fusion rate was not high, this technique may offer improvement of symptomatology and maintenance of cervical spine's sagittal profile.

Three-level anterior cervical discectomy and fusion with self-locking stand-alone polyetheretherketone cages

Anterior cervical plating is regarded as standard practice after multilevel anterior cervical discectomy and fusion. However, plate implantation in the anterior cervical spine poses a substantial risk of hardware-related complications. We retrospectively analyzed the efficacy and outcomes of 15 consecutive patients treated with a 3-level anterior cervical fusion using self-locking stand-alone polyetheretherketone (PEEK) cages. Patients were evaluated preoperatively and postoperatively using the Japanese Orthopedic Association (JOA) scale scores and radiographs. Clinical results were assessed using Odom’s criteria. The mean JOA score (± standard deviation) improved significantly from 7.3 ± 1.5 points to 14.1 ± 1.3 points ( p < 0.05) at the final follow-up. The outcomes were excellent for four patients (26.7%), good for nine patients (60%) and fair for two patients (13.3%). None of the patients experienced a poor clinical outcome. Thirteen patients achieved a solid fusion, after an average time of 5.7 months. The radiographic fusion rate of this procedure was 93.3%. Of 45 cages inserted in total, only four (8.89%) cages, in three patients, were found to have subsided. The degree of spinal curvature before surgery differed significantly from that immediately after surgery, and from that at the final follow-up examination ( p < 0.05). Self-locking stand-alone PEEK cages packed with excised local osteophytes and calcium sulfate are safe and effective. This procedure can effectively restore cervical lordosis, obviate the complications related to graft harvest and screw-plate fixation, and lead to satisfactory outcomes.

Outcomes of three anterior decompression and fusion techniques in the treatment of three-level cervical spondylosis

The purpose of this article is to compare the outcomes of three different anterior approaches for three-level cervical spondylosis. The records of 120 patients who underwent anterior approaches because of three-level cervical spondylosis between 2006 and 2008 were reviewed. Based on the type of surgery, the patients were divided into three groups: Group 1 was three-level anterior cervical discectomy and fusion (ACDF); Group 2 anterior cervical hybrid decompression and fusion (ACHDF, combination of ACDF and ACCF); and Group 3 two-level anterior cervical corpectomy and fusion (ACCF). The clinical outcomes including blood loss, operation time, complications, Japanese Orthopedic Association (JOA) scores, C2-C7 angle, segmental angle, and fusion rate were compared. There were no significant differences in JOA improvement and fusion rate among three groups. However, in terms of segmental angle and C2-C7 angle improvement, Group 2 was superior to Group 3 and inferior to Group 1 (all P < 0.01). Group 2 was less in operation time than Group 3 (P < 0.01) and more than Group 1 (P < 0.01). Group 3 had more blood loss than Group 1 and Group 2 (all P < 0.01) and had higher complication rate than Group 1 (P < 0.05). No significant differences in blood loss and complication rate were observed between Group 1 and Group 2 (P > 0.05). ACDF was superior in most outcomes to ACCF and ACHDF. If the compressive pathology could be resolved by discectomy, ACDF should be the treatment of choice. ACHDF was an ideal alternative procedure to ACDF if retro-vertebral pathology existed. ACCF was the last choice considered.

Comparison of three-level anterior cervical discectomy and fusion using iliac crest bone graft and plate vs interbody cages with allograft and plate

Anterior cervical plate fixation is believed to stabilize the operative motion segments, decreasing graft migration and preventing graft collapse that could lead to loss of cervical lordosis, malunion or nonunion and neurologic compromise. Although reports have noted high fusion rates in plated multilevel anterior cervical discectomy and fusion (ACDF) that range from 47% to 100% and are dependent on the number of levels fused, the efficacy of the combination of a titanium cage with allograft in comparison with autograft in such patients has not been investigated. We retrospectively analyzed 36 cases of three-level ACDF with anterior semi rigid plating. All cases were performed between August 2000 and June 2005. There were 19 males and 17 females with an average age of 51.6 (range from 35 to 69). Operated levels were C4-C7 in 30 patients, C3-C6 in 5 and C5-T1 in one patient. Nineteen patients (52%) had autologous iliac crest tricortical grafts, 17 (47%) had PEEK cages placed filled with allografts. The technique was the same in all cases: a standard left anteromedial approach to the cervical spine. The intervertebral discs were removed. All patients had burring of the end plates, 2 mm distraction and countersinking of the grafts by 2 mm from the anterior vertebral border. The autologous bone graft was tricortical and was harvested from the iliac crest using a low speed oscillating saw. The allograft used was fresh frozen, vacuum sealed cancellous chips and putty. An anterior cervical titanium plate was selected with variable angle locked screws. Clinical and radiographic data at 1 and 2 years postoperatively were obtained. Clinical outcome was assessed on 1 and 2 year follow-up and rated according to the Odom criteria. Fusion was achieved in 18 (94%) of the iliac crest group and 12 (71%) of the PEEK cage-allograft group. 1 patient in the iliac crest group and 5 in the cage-allograft group developed nonunions. Clinical outcome at 2 years was excellent in 5, good in 12 and fair in 2 patients of the iliac crest group. On the cage-allograft group it was excellent in 3, good in 13 and fair in 1. The 5 nonunions had good clinical outcome and 1 fair. We concluded that although autograft is the gold standard for 3 level ACDF, the use of allograft has the same functional status irrespective of the higher number of pseudarthrosis. The decision to use an autograft or a cage and an allograft for ACDF is therefore based mainly on personal preferences.

Three-level anterior cervical discectomy: radiographic and clinical results analysis.

Objective Retrospective study of radiographic and clinical results for cervical spondylo-sis patients treated with three-level anterior cervical discectomy. Methods From October 2002 to January 2007, 23 cervical spondylosis patients (including 15 males, 8 females, with the mean age of 51.4 years) un-derwent three-level anterigr cervical discectomy, iliae crest autograft fusion and titanium plate fixation. Pa-tients wore collar braces for a period of 6 to 8 weeks post surgery. Radiographic and clinic follow-up data were collected respectively. Study parameters include the JOA score and its improvement rate, results were graded from excellent to poor using the Odom criteria and post operative assessment of neck symptoms. The sagittal segmental alignment of fusion levels were measured using the Cobb method before and after surgery. Adjacent level degeneration and graft fusion rate were observed upon final follow up. Results All patients were followed up for 11-48 months, with the average of 19.8 months. The JOA score in 20 patients was 11.1±1.0 preoperatively, and 14.6±1.0 three months postoperatively. The mean JOA score improvement rate was 62%. Three patients with radiculopathy: one patient presenting with deltoid muscle weakness improved from grade 2 before surgery to grade 4 after surgery, symptoms of the other two patients were alleviated. Sur-gical results graded according to Odom criteria: 15 excellent, 4 good, 4 fair. Remnant neck symptoms inci-dence was 17.4%(4/23). Graft fusion rate was 100%. Radiograph analysis indicated preoperative mean seg-mental lordosis 3.7°, mean segmental lordosis 10.8° upon one week follow up, and segmental lordosis was 10.4° upon final follow up. No detectable adjacent level disease incidence was noted. No neurological and instrumentation-related complications occurred. Conclusion Three-level anterior cervical discectomy, iliac crest autograft fusion, and titanium plate fixation, present high fusion rates with positive clinic outcomes in the treatment of multilevel cervical spondylosis. Key words: Cervical spondylosis; Diskectomy; Spinal fusion

Three-Level Anterior Cervical Discectomy and Fusion with Plate Fixation: Radiographic Results of 127 Patients

Study Design. A retrospective radiographic review of all patients treated by a single surgeon with a three-level anterior cervical discectomy and fusion with plate fixation. Objectives. To compare fusion success rates and pseudoarthrosis results with published data for three-level anterior cervical constructs including; anterior cervical discectomy and fusion with plating (ACDFP) and anterior cervical corpectomy with and without plating (ACCP, ACC). Methods. In this study, authors have reviewed a series of 1416 patients done by a single surgeon between May 2001 and February 2008. Of these, 127 patients met standard criteria including a minimum of six months follow up, no previous cervical surgeries, and flexion/extension lateral radiographs. Pseudoarthrosis was defined as abnormal movement between the spinous processes, lucency at the graft vertebral body interface or absence of trabecular bone spanning the complete fused space. Fusion was identified by the absence of abnormal motion of the fused segments on flexion/extension lateral radiographs and the presence of continuous trabecular bone formation at the graft/endplate junction. Results. Of the 127 patients, 124 had successful fusions and 3 had pseudoarthrosis. Three hundred seventy-six out of three-hundred eighty-one (98.7%) levels fused while only five (1.3%) levels developed pseudoarthrosis. Conclusions. This study presents the largest reported series of patients undergoing a three-level ACDFP by a single surgeon with close follow up, and suggests that three-level ACDFP utilizing a standardized modified Smith-Robinson technique has an acceptably high level of fusion in comparison to other modalities.