Going Anterior With A Corpectomy is the Only Way to Solve the - - PowerPoint PPT Presentation

Gregory D. Schroeder, MD Assistant Professor, Orthopaedic Surgery The Rothman Institute at Thomas Jefferson University

Going Anterior With A Corpectomy is the Only Way to Solve the Problem

Goals of surgery

• Decompress cord
• Relieve kyphosis
• Decompress foramen
• Avoid complication
• Restore Cervical Alignment

Outcomes

• Fehlings. Spine. 2013.
• Mutlicentered observational study
• Multi-center Prospective observational study
• 264 patients (169 anterior, 95 posterior)
• JOA was less improved in anterior group, but patients in anterior

group had less severe symptoms to begin with

Outcomes

• Kato. JBJS. 2017.
• Propensity matched study of AOSpine prospective observational

study on cervical myelopathy

• No difference in outcomes between anterior and posterior
• mJOA score (15.1 versus 15.3, p = 0.53),
• Neck Disability Index (20.5 versus 24.1, p = 0.44),
• Short Form-36 (SF-36) Physical Component

Summary (PCS) score (41.9 versus 40.9, p = 0.30)

Outcomes

• Kato. JBJS. 2017.
• Propensity matched study of AOSpine prospective observational

study on cervical myelopathy

• No difference in total complication rate
• 16% versus 11%, p = 0.48
• dysphagia/dysphonia was reported only in the anterior

group

• surgical site infection and C5 radiculopathy were reported
• nly in the posterior group

Outcomes

• Nagoshi. JBJS. 2017
• AOSpine prospective mutlicentered observational study
• 470 patients underwent anterior or AP surgery for CSM
• Overall prevalence rate was 6.2%
• Odds ratio of 6.51 for AP surgery (p < 0.001)
• Odds ratio of 1.82 Multilevel procedure (p = 0.02)
• Other significant factors
• Comorbidities, Age, and baseline SF-36 PCS score

Outcomes

• Nagoshi. JBJS. 2017
• 79.3% presented with mild dysphagia;
• 13.8% with moderate symptoms
• 6.9% with severe
• total of 2/470 patients, or 0.4% total risk
• None needed tube feeding

Outcomes

• Sun. Clinical Neurology and Neurosurgery. 2015.
• Meta-analysis
• Statically significance final JOA score and shorter length of

stay of anterior approaches

• Lawrence. Spine 2013
• Meta-analysis
• No difference in neurologic outcome between approaches
• Infection rates were lower in anterior surgery
• Dysphagia/dysphonia was lower with posterior surgery

Outcomes

Outcomes

Doctor, my throat is sore

Outcomes

Doctor, my throat is sore I’m sorry, let me grab another drink

Outcomes

Doctor, is it normal that my wound looks like this

Outcomes

• Back to the OR

Outcomes

Doctor, is it normal that I can’t move my shoulders

When is Anterior Absolutely Needed

When is Anterior Absolutely Needed

• Microangiography
• Dynamic flex-ext
• Kyphosis
• Blood flow reduced
• Anterior sp art
• Radicular feeders
• Intramedullary
• Brieg. J Neurosurgery. 1966

When is Anterior Absolutely Needed

• Tension on neural elements
• Decrease caliber of

intramedullary vessels

• Reduction collateral circulation

– Radicular feeders

• Spinal cord injury
• Increased apoptosis

Epstein Spine 1990

When is Anterior Absolutely Needed

• Ames. JNS Spine. 2015

When is Anterior Absolutely Needed

• Attempt to translate principles of thoracolumbar

deformity surgery to the cervical spine.

• Unclear what the normal value for cervical lordosis

(CL) should be, what is a problematic SVA

When is Anterior Absolutely Needed

• Lee. JSDT 2012
• Described that the relationship

between T-1 Slope (TS) and CL is similar to the relationship between PI and LL

• Increase in TS necessitates an

increased CL to balance the head over the thoracic inlet

When is Anterior Absolutely Needed

• Ames. JNS Spine. 2015

“Expert Opinion”

When is Anterior Absolutely Needed

• Tang. Neurosurgery. 2012
• Retrospective review of 113 patients who underwent a

multilevel PCF for myelopathy

• C2-C7 SVA negatively correlated with SF-36 physical

component scores (r = -0.43, P < .001 and r = -0.36, P = .005, respectively).

• C2-C7 SVA positively correlated with NDI scores (r =

0.20, P = .036).

• For significant correlations between C2-C7 SVA and

NDI scores, regression models predicted a threshold C2-C7 SVA value of approximately 40 mm

When is Anterior Absolutely Needed

• Roguski. Spine. 2014
• A prospective, nonrandomized cohort of 49 patients

undergoing surgery for CSM.

• Postoperative C2–C7 SVA measurements were
• bserved to be negatively correlated with SF-36 PCS

scores ( ρ = −0.39, P = 0.008) and with mJOA scores ( ρ = −0.45, P = 0.002) at 1-year follow-up.

When is Anterior Absolutely Needed

• Hyun. Spine. 2016.
• Retrospective review of 38 patients who underwent a

multilevel posterior cervical decompression and fusion

• C2-C7 SVA positively correlated with neck disability

index (NDI) scores (r = 0.495).

• C2-C7 lordosis (P = 0.001) and T1S-CL (P = 0.002)

changes correlated with NDI score changes after surgery.

• Regression models predicted a threshold C2-C7 SVA

value of 50 mm, beyond which correlations were most significant for correlations between C2-C7 SVA and NDI scores

When is Anterior Absolutely Needed

• Hyun. Spine. 2017.
• Retrospective review of 31 patients who underwent a

multilevel posterior cervical decompression and fusion

• 2-C7 SVA positively correlated with neck disability

index (NDI) scores (r = 0.550).

• For significant correlations between C2-C7 SVA

and NDI scores, regression models predicted a threshold C2-C7 SVA value of 43.5 mm

• The T1S-CL also correlated positively with C2-C7 SVA

and NDI scores (r = 0.827 and r = 0.618, respectively).

• Results of the regression analysis indicated that a

C2-C7 SVA value of 43.5 mm corresponded to a T1S-CL value of 22.2°.

Corpectomy is Best

• Lau. JNS Spine. 2015
• 20 patients 2-level corpectomy vs 35 patients 3-

level ACDF

• No differences
• postoperative lordosis (7.2° vs 12.1°, p = 0.173),
• perative ASD (6.3% vs 3.6%, p = 0.682)
• Complications (20.0% vs 5.7%, p = 0.102)
• Similar improvement
• VAS neck pain scores (3.4 vs 3.2 for ACCF vs ACDF,

respectively; p = 0.860)

• Similar improvement Nurick scores (0.8 vs 0.7, p =

0.925

Corpectomy is Best

• Park. Spine. 2010
• 50 patients 1-level corpectomy vs 45 patients 2-

level ACDF

• No differences
• sagittal alignment
• cervical lordosis
• graft collapse
• adjacent-level ossification

Corpectomy is Best

• Uchida. JNS Spine. 2009
• 56 patients with myelopathy and 10 degrees or

more of kyphosis

Corpectomy is Best

• Park. Spine. 2016
• NIS database to look at reoperation rate

Conclusion

• Go from the front so you can get it right
• Restore the alignment
• Address the location where the compression is
• Less complications
• Or at least less severe complications

Thank You