Clinical Outcomes After Four-Level Anterior Cervical Discectomy and Fusion

Tyler M Kreitz, Douglas A Hollern, Eric M Padegimas, Gregory D Schroeder, Christopher K Kepler, Alexander R Vaccaro, Alan S Hilibrand, Tyler M Kreitz, Douglas A Hollern, Eric M Padegimas, Gregory D Schroeder, Christopher K Kepler, Alexander R Vaccaro, Alan S Hilibrand

Abstract

Study design: Retrospective cohort study.

Objectives: Anterior cervical discectomy and fusion (ACDF) demonstrates reliable improvement in neurologic symptoms associated with anterior compression of the cervical spine. There is a paucity of data on outcomes following 4-level ACDFs. The purpose of this study was to evaluate clinical outcomes for patients undergoing 4-level ACDF.

Methods: All 4-level ACDFs with at least 1-year clinical follow-up were identified. Clinical outcomes, including fusion rates, neurologic outcomes, and reoperation rates were determined.

Results: Retrospective review of our institutional database revealed 25 patients who underwent 4-level ACDF with at least 1-year clinical follow-up. Average age was 57.5 years (range 38.2-75.0 years); 14 (56%) were male, and average body mass index was 30.2 kg/m2 (range 19.9-43.4 kg/m2). Two (8%) required secondary cervical surgery at an average of 94.5 days postoperatively while the remaining 23 did not with an average follow-up of 19 months. Of 23 patients not requiring revision surgery, 16 (69%) patients fused by definition of less than 1 mm of spinous process motion per fused level in flexion and extension. Fifteen (65%) had at least one muscle group with one grade of weakness preoperatively. Nineteen of these patients (83%) had improved to full strength while no patients lost muscle strength.

Conclusions: Review of our institution's experience demonstrated a low rate of revision cervical surgery for any reason of 8% at mean 19 months follow-up, and neurological examinations consistently improved, despite a high rate of radiographic nonunion (31%).

Keywords: anterior cervical discectomy and fusion (ACDF); degenerative disc disease; multilevel; outcomes.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
A 52-year-old woman presents with 9 months of worsening right-sided radicular symptoms in the distribution of the fifth and seventh cervical nerves, deltoid and triceps weakness. The patient also complains of gait imbalance and demonstrates hyperreflexia consistent with myelopathy. (a) Preoperative lateral radiograph demonstrating spondylosis most pronounced at C4/5, C5/6, and C6/7. (b) A T2-weighted midsagittal magnetic resonance imaging (MRI) scan demonstrating C4-C5, C5-6, C6-7 central disc herniation with moderate to severe stenosis with evidence of cord compression at C6-7. (c) A T2-weighted parasagittal MRI demonstrating paracentral disc herniation at C3-C4 with moderate central stenosis. (d) A T2-weighted axial image of the C5/6 disc space demonstrated moderate right-sided foraminal stenosis. (e) A T2-weighted axial image of the C6/7 disc space demonstrated severe right-sided foraminal stenosis.
Figure 2.
Figure 2.
(a) A lateral radiograph taken 1-year postoperatively after anterior cervical discectomy and fusion between the C3/4, C4/5, C5/6, and C6/7 vertebrae. Interbody grafts demonstrate evidence of bridging bone, lack of periprosthetic lucency, or loosening consistent with fusion. (b) Lateral flexion and (c) lateral extension radiographs demonstrated motion less than 1 mm between spinous processes of fused levels consistent with fusion.

References

    1. Bono CM, Ghiselli G, Gilbert TJ, et al. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011;11:64–72. doi:10.1016/j.spinee.2010.10.023.
    1. Gebremariam L, Koes BW, Peul WC, Huisstede BM. Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review. Spine (Phila Pa 1976). 2012;37:E109–E118. doi:10.1097/BRS.0b013e318221b5af.
    1. Matz PG, Anderson PA, Kaiser MG, et al. Introduction and methodology: guidelines for the surgical management of cervical degenerative disease. J Neurosurg Spine. 2009;11:101–103. doi:10.3171/2009.1.SPINE08712.
    1. Nikolaidis I, Fouyas IP, Sandercock PA, Statham PF. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev. 2010;(1):CD001466. doi:10.1002/14651858.CD001466.pub3.
    1. Peolsson A, Peolsson M. Predictive factors for long-term outcome of anterior cervical decompression and fusion: a multivariate data analysis. Eur Spine J. 2008;17:406–414. doi:10.1007/s00586-007-0560-2.
    1. Rao RD, Gourab K, David KS. Operative treatment of cervical spondylotic myelopathy. J Bone Joint Surg Am. 2006;88:1619–1640. doi:10.2106/JBJS.F.00014.
    1. Persson LC, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. Eur Spine J. 1997;6:256–266.
    1. Sampath P, Bendebba M, Davis JD, Ducker T. Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review. Spine (Phila Pa 1976). 1999;24:591–597.
    1. Sampath P, Bendebba M, Davis JD, Ducker TB. Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review. Spine (Phila Pa 1976). 2000;25:670–676.
    1. Bohlman HH, Emery SE, Goodfellow DB, Jones PK. Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one hundred and twenty-two patients. J Bone Joint Surg Am. 1993;75:1298–1307.
    1. Lehmann CL, Buchowski JM, Stoker GE, Riew KD. Neurologic recovery after anterior cervical discectomy and fusion. Global Spine J. 2014;4:41–46. doi:10.1055/s-0033-1360723.
    1. Wang JC, McDonough PW, Kanim LE, Endow KK, Delamarter RB. Increased fusion rates with cervical plating for three-level anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 2001;26:643–646.
    1. Bolesta MJ, Rechtine GR, 2nd, Chrin AM. Three- and four-level anterior cervical discectomy and fusion with plate fixation: a prospective study. Spine (Phila Pa 1976). 2000;25:2040–2044.
    1. Fraser JF, Härtl R. Anterior approaches to fusion of the cervical spine: a metaanalysis of fusion rates. J Neurosurg Spine. 2007;6:298–303. doi:10.3171/spi.2007.6.4.2.
    1. Wang JC, McDonough PW, Endow KK, Delamarter RB. Increased fusion rates with cervical plating for two-level anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 2000;25:41–45.
    1. Vaccaro AR, Falatyn SP, Scuderi GJ, et al. Early failure of long segment anterior cervical plate fixation. J Spinal Disord. 1998;11:410–415.
    1. Kaiser MG, Haid RW, Jr, Subach BR, Barnes B, Rodts GE J. Anterior cervical plating enhances arthrodesis after discectomy and fusion with cortical allograft. Neurosurgery. 2002;50:229–236.
    1. Murrey D, Janssen M, Delamarter R, et al. Results of the prospective, randomized, controlled multicenter Food and Drug Administration investigational device exemption study of the ProDisc-C total disc replacement versus anterior discectomy and fusion for the treatment of 1-level symptomatic cervical disc disease. Spine J. 2009;9:275–286. doi:10.1016/j.spinee.2008.05.006.
    1. Samartzis D, Shen FH, Goldberg EJ, An HS. Is autograft the gold standard in achieving radiographic fusion in one-level anterior cervical discectomy and fusion with rigid anterior plate fixation? Spine (Phila Pa 1976). 2005;30:1756–1761.
    1. McAfee PC, Bohlman HH, Ducker TB, Zeidman SM, Goldstein JA. One-stage anterior cervical decompression and posterior stabilization. A study of one hundred patients with a minimum of two years of follow-up. J Bone Joint Surg Am. 1995;77:1791–1800.
    1. Hilibrand AS, Fye MA, Emery SE, Palumbo MA, Bohlman HH. Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am. 2001;83-A:668–673.
    1. Hilibrand AS, Fye MA, Emery SE, Palumbo MA, Bohlman HH. Increased rate of arthrodesis with strut grafting after multilevel anterior cervical decompression. Spine (Phila Pa 1976). 2002;27:146–151.
    1. Gruskay J, Kepler CK, Smith J, Radcliff K, Vaccaro A. Is surgical case order associated with increased infection rate after spine surgery? Spine (Phila Pa 1976). 2012;37:1170–1174.
    1. Kwon BK, Fisher CG, Boyd MC, et al. A prospective randomized controlled trial of anterior compared with posterior stabilization for unilateral facet injuries of the cervical spine. J Neurosurg Spine. 2007;7:1–12. doi:10.3171/SPI-07/07/001.
    1. Mehta AI, Babu R, Sharma R, et al. Thickness of subcutaneous fat as a risk factor for infection in cervical spine fusion surgery. J Bone Joint Surg Am. 2013;95:323–328. doi:10.2106/JBJS.L.00225.
    1. Chang SW, Kakarla UK, Maughan PH, et al. Four-level anterior cervical discectomy and fusion with plate fixation: radiographic and clinical results. Neurosurgery. 2010;66:639–646. doi:10.1227/01.NEU.0000367449.60796.94.
    1. De la Garza-Ramos R, Xu R, Ramhmdani S, et al. Long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion. J Neurosurg Spine. 2016;24:885–891. doi:10.3171/2015.10.SPINE15795.
    1. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383.
    1. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–619.
    1. Cuthbert SC, Goodheart GJ., Jr On the reliability and validity of manual muscle testing: a literature review. Chiropr Osteopat. 2007;15:4 doi:10.1186/1746-1340-15-4.
    1. Rhee JM, Chapman JR, Norvell DC, Smith J, Sherry NA, Riew KD. Radiological determination of postoperative cervical fusion: a systematic review. Spine (Phila Pa 1976). 2015;40:974–991. doi:10.1097/BRS.0000000000000940.
    1. Aronson N, Filtzer DL, Bagan M. Anterior cervical fusion by the smith-robinson approach. J Neurosurg. 1968;4:396–404.
    1. Wang SJ, Ma B, Huang YF, Pan FM, Zhao WD, Wu DS. Four-level anterior cervical discectomy and fusion for cervical spondylotic myelopathy. J Orthop Surg (Hong Kong). 2016;24:338–343. doi:10.1177/1602400313.
    1. An HS, Simpson JM, Glover JM, Stephany J. Comparison between allograft plus demineralized bone matrix versus autograft in anterior cervical fusion. A prospective multicenter study. Spine (Phila Pa 1976). 1995;20:2211–2216.
    1. Lau D, Chou D, Ziewacz JE, Mummaneni PV. The effects of smoking on perioperative outcomes and pseudarthrosis following anterior cervical corpectomy: clinical article. J Neurosurg Spine. 2014;21:547–558. doi:10.3171/2014.6.SPINE13762.
    1. Martin GJ, Jr, Haid RW, Jr, MacMillan M, Rodts GE, Jr, Berkman R. Anterior cervical discectomy with freeze-dried fibula allograft. Overview of 317 cases and literature review. Spine (Phila Pa 1976). 1999;24:852–858.
    1. Wang JC, McDonough PW, Endow K, Kanim LE, Delamarter RB. The effect of cervical plating on single-level anterior cervical discectomy and fusion. J Spinal Disord. 1999;12:467–471.
    1. Luszczyk M, Smith JS, Fischgrund JS, et al. Does smoking have an impact on fusion rate in single-level anterior cervical discectomy and fusion with allograft and rigid plate fixation? Clinical article. J Neurosurg Spine. 2013;19:527–531. doi:10.3171/2013.7.SPINE13208.
    1. Gao Y, Liu M, Li T, Huang F, Tang T, Xiang Z. A meta-analysis comparing the results of cervical disc arthroplasty with anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical disc disease. J Bone Joint Surg Am. 2013;95:555–561. doi:10.2106/JBJS.K.00599.

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever