Cage subsidence does not, but cervical lordosis improvement does affect the long-term results of anterior cervical fusion with stand-alone cage for degenerative cervical disc disease: a retrospective study

Abstract

Objective: Clinical outcomes of the stand-alone cage have been encouraging when used in anterior cervical discectomy and fusion (ACDF), but concerns remain regarding its complications, especially cage subsidence. This retrospective study was undertaken to investigate the long-term radiological and clinical outcomes of the stand-alone titanium cage and to evaluate the incidence of cage subsidence in relation to the clinical outcome in the surgical treatment of degenerative cervical disc disease.

Methods: A total of 57 consecutive patients (68 levels) who underwent ACDF using a titanium box cage for the treatment of cervical radiculopathy and/or myelopathy were reviewed for the radiological and clinical outcomes. They were followed for at least 5 years. Radiographs were obtained before and after surgery, 3 months postoperatively, and at the final follow-up to determine the presence of fusion and cage subsidence. The Cobb angle of C2-C7 and the vertebral bodies adjacent to the treated disc were measured to evaluate the cervical sagittal alignment and local lordosis. The disc height was measured as well. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) score for cervical myelopathy, before and after surgery, and at the final follow-up. The recovery rate of JOA score was also calculated. The Visual Analogue Scale (VAS) score of neck and radicular pain were evaluated as well. The fusion rate was 95.6% (65/68) 3 months after surgery.

Results: Successful bone fusion was achieved in all patients at the final follow-up. Cage subsidence occurred in 13 cages (19.1%) at 3-month follow-up; however, there was no relation between fusion and cage subsidence. Cervical and local lordosis improved after surgery, with the improvement preserved at the final follow-up. The preoperative disc height of both subsidence and non-subsidence patients was similar; however, postoperative posterior disc height (PDH) of subsidence group was significantly greater than of non-subsidence group. Significant improvement of the JOA score was noted immediately after surgery and at the final follow-up. There was no significant difference of the recovery rate of JOA score between subsidence and non-subsidence groups. The recovery rate of JOA score was significantly related to the improvement of the C2-C7 Cobb angle. The VAS score regarding neck and radicular pain was significantly improved after surgery and at the final follow-up. There was no significant difference of the neck and radicular pain between both subsidence and non-subsidence groups.

Conclusions: The results suggest that the clinical and radiological outcomes of the stand-alone titanium box cage for the surgical treatment of one- or two-level degenerative cervical disc disease are satisfactory. Cage subsidence does not exert significant impact upon the long-term clinical outcome although it is common for the stand-alone cages. The cervical lordosis may be more important for the long-term clinical outcome than cage subsidence.

Figures

Fig. 1

A 29-year-old female patient was treated with an ACDF at C5–C6. Preoperative plain radiograph showed slight lordosis of the cervical spine (a). MRI revealed a disc herniation at C5–C6 with spinal cord compression (b). Postoperative radiograph showed slight kyphotic alignment of cervical spine (c). The clinical outcome was satisfactory 5 years after surgery. The cage subsided but the segment was successfully fused. The cervical lordosis was preserved as shown by plain radiograph (d)

Fig. 2

A 66-year-old female patient with severe degeneration and good alignment of the cervical spine before surgery (a). MRI demostrated multi-level stenosis, with the level of C5–C6 and C6–C7 more severe (b). She underwent an ACDF at these two levels (c). Six years later, these two segments were fused with no cage subsidence (d). Both cervical alignment and clinical outcome was satisfactory

Fig. 3

Correlation between the improvement of C2–C7 Cobb angle and the recovery rate of JOA. The JOA recovery rate was significantly related to the improvement of the C2–C7 Cobb angle