Two Level Anterior Cervical Discectomy and Fusion Gets it right Every Time! Frank X Pedlow Jr MD Spine Service Massachusetts General Hospital Boston MA
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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
ACDF • 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
Adjacent Segment Degeneration Rate of ASD following ACDF • – 2.9% per year during 1 st 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 outcomes
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 ACD F – 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%
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