Two Level Anterior Cervical Discectomy and Fusion Gets it right - - PowerPoint PPT Presentation

Two Level Anterior Cervical Discectomy and Fusion Gets it right Every Time!

Frank X Pedlow Jr MD Spine Service Massachusetts General Hospital Boston MA

No disclosures

CASE

• 20 year old housekeeper after MVA with cervical

radiculopathy and two level disease

• Treatment options:

– 2 level cervical disc arthroplasty – 2 level cervical discectomy / fusion – Posterior foraminotomy

Anterior cervical discectomy and fusion

• Accepted as an effective treatment for various

cervical spine abnormalities including disc herniation, spondylosis, fractures, tumors, infections

• More than 5 million performed between 1990-

1999

» Angevine et al, Spine 2003

• Advances made over the years in technique,

graft material, cervical plates and interbody devices - not always leading to better results

ACDF: benefits

• Direct removal of cervical pathology via anterior approach
• Restoration of disc height – indirect decompression of neural

elements / increase foraminal height

• Elimination of motion – decreases neural inflammation

ACDF : benefits

• Elimination of motion: prevent progression of / causes

regression of osteophytes

• Improves sagittal alignment

– Uchida J NS Spine 2009 – Gillis J NS Spine 2016

• More versatile

History

• Smith and Robinson JBJS Am 1958
• Cloward RB J Neurosurgery 1958

History

• Bohlman JBJS Am 1993
• 122 patients (62/1 level, 48/ 2 level, 11/3, 1/4)
• Avg f/u 5 yrs
• pseudoarthrosis in 24 of 195 operated segments ( 12%)
• 16 patients with non-unions had symptoms / only 4 bad enough to warrant further

surgery

• Excellent resolution of pain and neurologic deficits
• Brodke and Zdeblick 1992
• Modified technique including more aggressive endplate prep and Caspar distraction

in 51 patients

• 97% fusion rate in 1 and 94% in 2 level cases

History

• Anterior cervical plate

– Caspar NS 1989

» 60 cervical trauma cases

cervical plate literature:

• Promote fusion / decrease non-union rate
• Less graft collapse / kyphosis
• Maintain / restore lordotic alignment
• Maintains alignment even in presence of non-union
• No increase in complication rate

– Wang Spine 2000 – Bolesta Spine 2002 – Samartziz Spine J 2004

History

• Allogaft

–Safe and effective in one or two level ACDF with plate fixation –Fusion rates 91-97%

» Kaiser NS 2002 » Samartzis Spine J 2003 » Yeu Spine 2005 » Miller Spine 2011

How about cervical corpectomy?

• Role of corpectomy ( ACCF) vs 2 level discectomy and fusion

(ACDF) in 2 level disease.

– Similar outcomes – Less blood loss, operative time ACDF – Decreased complications ACDF – Better restoration / maintenance of alignment ACDF

» Wang Medicine 2016 » Oh Spine 2009 » Han PLOS ONE 2014

• 50 year history
• Long term follow-up
• Excellent results regarding pain relief and improved neurologic

function

– Butterman Spine 2017

• High fusion rate
• Relatively low but known complication rate

– Fountas Spine 2007

• Considered “Gold standard” for managing anterior cervical

degenerative disc disease

ACDF

Adjacent Segment Degeneration

• Rate of ASD following ACDF

– 2.9% per year during 1st 10 years post-op – Predicted rate of clinically significant ASD of 25.6 % over 10 years – Risk lower following multi-level fusion Hilibrand JBJS 1999

Biomechanical studies:

fused cervical segments cause increase in intradiscal pressure and segmental motion at adjacent segments

» Matsunaga Spine 1999 » Eck Spine 2002 » Schwab Spine 2006

• Previous studies had seemed to show that ACDF did not alter rate of ASD

» Gore Spine 1987 » Herkowitz Spine 1990

Adjacent Segment Degeneration

• Natural progression of cervical spondylosis or

secondary to altered biomechanics of fusion surgery?

CDR – theoretical advantage : maintain motion, reduce incidence of adjacent segment, improve long term

• utcomes

Clinical Trials: 2 level CDR vs ACDF

• 1. Prestige LP vs ACDF

– 84 month f/u – Claims statistical superiority to ACDF in overall success, lower serious adverse effects, lower reoperation rate

• 2. Mobi-C vs ACDF

– 5 year f/u – Better clinical outcomes: improvement in pain and functional outcomes – Decreases adjacent segment degeneration and repeat surgery

• 3. Possible issues
• Bias ? - Radcliff et al Curr Review Musculoskeletal Med 2017

– Publication bias – Threats to external validity : restrictive IDE study conditions – Confirmation bias / lack if blinding: an investigator or subjects preconception toward the hypothesis – Financial conflict of interest

• Can these results be reproduced outside the trials?

Systematic Review and Meta-Analysis

Of randomized controlled trials and prospective studies

• Insufficient evidence to draw strong

conclusions secondary to relatively low- quality and varied nature of the evidence

• Wu Medicine 2017
• Zou Eur Spine J 2017
• Kepler Evidence-Based Spine-Care J 2012

Systematic Review and Meta-Analysis

Adjacent Segment Degeneration

• No statistically significant difference in ASD between CDA and

ACDF

– Botelho Neurosurg Focus 2010 – Dong Spine J 2017

• Radiographic evidence of ASD after CDR

– Yi Surgical Neurology 2009

• 72 patients: 9 (12.5%) with ASD
• Mean onset 16.3 months
• 4 ( 44%) of these had HO

Complications

• Implant migration

– 196 patients over 9 year period – 5 patients ( 3%) prosthetic dislocation

– Ozbek World NS 2016

Complications

• Heterotopic ossification

– 2 systematic reviews and meta analysis

• Rate: 38% 1-2 yrs, 52.6% 2-5 yrs, 53.6% 5-10 yrs
• Kong Medicine 2017
• Rate: 44.6% 12 months, 58.2% 24 months
• Chen Eur Spine J 2012
• wear particle debris

– Inflammatory response / early failure

• Gornet Spine 2017
• Cavanaugh Spine 2009

Goffin Spine 2003

• Metallosis

– Leading to lession secondary to lymphocytic reaction

• Guyer Spine 2011

Complications

• Post-operative kyphosis
• Johnson Neurosug Focus 2004
• Pickett Neurosurg Focus 2004
• Fracture
• Datta J Spinal Disord Tech 2007
• Shim J Spinal Disord Tech 2007
• Dysphagia

– Increased or decreased rate?

• McAfee J Spinal Disord Tech 2010
• Anderson Spine 2008

Late Complications

After 4 years

• 5 patients returning with return of neck and arm pain between 48-

72 months post-op

• Bone loss, collapse, retropuslion
• Cause unknown – possible wear debris induced osteolysis

Cervical Foraminotomy

• “Excellent alternative for cervical radiculopathy secondary to

foraminal stenosis or lateral disc herniation”

» Skovrlj Spine J 2014

Cervical Foraminotomy

• Potential problems

– Higher rate of reoperation that ACDF

– Lubelski Spine J 2015 – Bydon J Neurosurg Spine 2014 – Sayari Global Spine J 2017

– May predispose to development of post-op kyphosis

– Jagannathan J Neurosurg Spine 2009

– Higher incidence of nerve root palsy

– Choi World Neurosurgery 2013

MVA

• Traumatic injury vs degenerative herniation
• 2 level injury
• Potential for associated injuries
• Whiplash injury and risk for persistent problems
• MVA associated neck pain and disability

Conclusions

• Although evidence may be trending in favor of CDR, no clear strong

evidence for its use to be the new standard in treatment of 2 level cervical disc disease

» Similar outcomes and reported improvement in neck and arm pain to ACDF » No strong evidence that it decreases rate of ASD » Limited clinical indications » Increasing reporting of late complications » Risk of HO, recurrent neural compression

• The best candidate, as the one described in this case, are young, with

minimal disc space collapse and spondylotic changes

» But these patients may be most exposed to unknown long term wear characteristics and late complications disc » Revision surgery can be complex

• Bone loss, subsidence, retropulsion

Conclusions

• Posterior formaminotmy +/- discectomy not

recommended for reasons given

• 2 level ACDF

– 50 year history – Long term follow-up studied – Excellent results regarding pain relief and improved neurologic function – High fusion rate – Relatively low but known complication rate – Additional surgery generally less complicated than revision CDR procedures

Two level ACDF

Thank you

Complications

• Spine 2007
• Retrospective review 1015 patients

– Dysphagia 9.5% – Hematoma 5.6% – Re-operation 2.4 % – RLN palsy 3.1% – Dural tear 0.5% – Esophageal perforation 0.3% – Horners sydrome 0.1% – Infection 0.1%