Pseudarthrosis rate following anterior cervical discectomy with fusion using an allograft cellular bone matrix: a multi-institutional analysis

OBJECTIVE The use of osteobiologics, engineered materials designed to promote bone healing by enhancing bone growth, is becoming increasingly common for spinal fusion procedures, but the efficacy of some of these products is unclear. The authors performed a retrospective, multi-institutional study to investigate the clinical and radiographic characteristics of patients undergoing single-level anterior cervical discectomy with fusion performed using the osteobiologic agent Osteocel, an allograft mesenchymal stem cell matrix. METHODS The medical records across 3 medical centers and 12 spine surgeons were retrospectively queried for patients undergoing single-level anterior cervical discectomy and fusion (ACDF) with the use of Osteocel. Pseudarthrosis was determined based on CT or radiographic imaging of the cervical spine. Patients were determined to have radiographic pseudarthrosis if they met any of the following criteria: 1) lack of bridging bone on CT obtained > 300 days postoperatively, 2) evidence of instrumentation failure, or 3) motion across the index level as seen on flexion-extension cervical spine radiographs. Univariate and multivariate analyses were then performed to identify independent preoperative or perioperative predictors of pseudarthrosis in this population. RESULTS A total of 326 patients met the inclusion criteria; 43 (13.2%) patients met criteria for pseudarthrosis, of whom 15 (34.9%) underwent revision surgery. There were no significant differences between patients with and those without pseudarthrosis, respectively, for patient age (54.1 vs 53.8 years), sex (34.9% vs 47.4% male), race, prior cervical spine surgery (37.2% vs 33.6%), tobacco abuse (16.3% vs 14.5%), chronic kidney disease (2.3% vs 2.8%), and diabetes (18.6% vs 14.5%) (p > 0.05). Presence of osteopenia or osteoporosis (16.3% vs 3.5%) was associated with pseudarthrosis (p < 0.001). Implant type was also significantly associated with pseudarthrosis, with a 16.4% rate of pseudarthrosis for patients with polyetherethereketone (PEEK) implants versus 8.4% for patients with allograft implants (p = 0.04). Average lengths of follow-up were 27.6 and 23.8 months for patients with and those without pseudarthrosis, respectively. Multivariate analysis demonstrated osteopenia or osteoporosis (OR 4.97, 95% CI 1.51–16.4, p < 0.01) and usage of PEEK implant (OR 2.24, 95% CI 1.04–4.83, p = 0.04) as independent predictors of pseudarthrosis. CONCLUSIONS In patients who underwent single-level ACDF, rates of pseudarthrosis associated with the use of the osteobiologic agent Osteocel are higher than the literature-reported rates associated with the use of alternative osteobiologics. This is especially true when Osteocel is combined with a PEEK implant.

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Biomechanical Analysis of an Anterior Cervical Discectomy and Fusion Pseudarthrosis Model Revised With Machined Interfacet Allograft Spacers

Global Spine Journal ◽

10.1177/2192568219884265 ◽

2019 ◽

Vol 10 (8) ◽

pp. 973-981

Author(s):

Raymond J. Hah ◽

Ram Alluri ◽

Paul A. Anderson

Keyword(s):

Range Of Motion ◽

Study Design ◽

Axial Rotation ◽

Biomechanical Analysis ◽

Anterior Cervical Discectomy ◽

Lateral Bending ◽

Cervical Discectomy ◽

Single Level ◽

Flexion Extension ◽

Potential Applications

Study Design: Biomechanics study. Objectives: To evaluate the biomechanical advantage of interfacet allograft spacers in an unstable single-level and 2-level anterior cervical discectomy and fusion (ACDF) pseudoarthrosis model. Methods: Nine single-level and 8 two-level ACDF constructs were tested. Range of motion in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) at 1.5 N m were collected in 4 testing configurations: (1) intact spine, (2) ACDF with interbody graft and plate/screw, (3) ACDF with interbody graft and plate/loosened screws (loose condition), and (4) ACDF with interbody graft and plate/loosened screws supplemented with interfacet allograft spacers (rescue condition). Results: All fixation configurations resulted in statistically significant decreases in range of motion in all bending planes compared with the intact spine ( P < .05). One Level. Performing ACDF with interbody graft and plate on the intact spine reduced FE, LB, and AR 60.0%, 64.9%, and 72.9%, respectively. Loosening the ACDF screws decreased these reductions to 40.9%, 44.6%, and 52.1%. The addition of interfacet allograft spacers to the loose condition increased these reductions to 74.0%, 84.1%, and 82.1%. Two Level. Performing ACDF with interbody graft and plate on the intact spine reduced FE, LB, and AR 72.0%, 71.1%, and 71.2%, respectively. Loosening the ACDF screws decreased these reductions to 55.4%, 55.3%, and 51.3%. The addition of interfacet allograft spacers to the loose condition significantly increased these reductions to 82.6%, 91.2%, and 89.3% ( P < .05). Conclusions: Supplementation of a loose ACDF construct (pseudarthrosis model) with interfacet allograft spacers significantly increases stability and has potential applications in treating cervical pseudarthrosis.

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Polyetheretherketone Cage with Demineralized Bone Matrix Can Replace Iliac Crest Autografts for Anterior Cervical Discectomy and Fusion in Subaxial Cervical Spine Injuries

Journal of Korean Neurosurgical Society ◽

10.3340/jkns.2015.0203.014 ◽

2017 ◽

Vol 60 (2) ◽

pp. 211-219 ◽

Cited By ~ 8

Author(s):

Soo-Han Kim ◽

Jung-Kil Lee ◽

Jae-Won Jang ◽

Hyun-Woong Park ◽

Hyuk Hur

Keyword(s):

Cervical Spine ◽

Iliac Crest ◽

Demineralized Bone Matrix ◽

Bone Matrix ◽

Anterior Cervical Discectomy ◽

Cervical Spine Injuries ◽

Cervical Discectomy ◽

Subaxial Cervical Spine ◽

Spine Injuries ◽

Polyetheretherketone Cage

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Comparative study of anterior cervical discectomy and fusion by anterior cervical plate and stand-alone cervical cage

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20203540 ◽

2020 ◽

Vol 6 (5) ◽

pp. 888

Author(s):

Ansari Muqtadeer Abdul Aziz ◽

Venktesh Dattatray Sonkawade ◽

Ansari Ishtyaque Abdul Aziz ◽

Nair Pradeepkumar Sasidharan

Keyword(s):

Cervical Spine ◽

Intraoperative Complications ◽

Anterior Cervical Discectomy ◽

Research Centre ◽

Cervical Disc ◽

Cervical Discectomy ◽

Single Level ◽

Incision Size ◽

Cervical Plate ◽

Anterior Cervical Plate

Background: Anterior cervical discectomy (ACD) was used for management of degenerative cervical disc disorders (DCDD) in previous days. Further research and developments in management of DCDD led to evolution of standard and widely used operative technique as anterior cervical discectomy and fusion (ACDF) by either anterior cervical plate (ACDF-ACP) with bone grafting or stand-alone cage (ACDF-SAC). There is less data available in literature regarding when and where to use ACDF-ACP and ACDF-SAC.Methods: The study was conducted on 20 patients operated in Government Medical College and Hospital and Pacific Hospital and Research Centre, Aurangabad from June 2018 to March 2020. These patients divided into group A - 10 patients, operated by ACDF-SAC which are further divided as group Aa - 6 patients - operated for single level ACDF-SAC and group Ab - 4 patients - operated for two level ACDF-SAC, group B - 10 patients, operated by ACDF-ACP which are further divided as group Ba - 5 patients - operated for single level ACDF-ACP and group Bb - 5 patients - operated for two level ACDF-ACP. Patients evaluated preoperatively and postoperatively using X-ray cervical spine anteroposterior (AP) and lateral views, MRI cervical spine, visual analogue scale (VAS) for pain, Robinson’s criteria and Cobb’s angle.Results: In our study we found, ACDF-SAC has small incision size, less intraoperative time, easy to carry out for surgeons, less intraoperative complications and better clinical outcome as compared to ACDF-ACP. Whereas only radiological results were better in ACDF-ACP than ACDF-SAC.Conclusions: ACDF-SAC is superior to ACDF-ACP for appropriately selected patients and in well experienced hands.

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A prospective clinical and radiographic 12-month outcome study of patients undergoing single-level anterior cervical discectomy and fusion for symptomatic cervical degenerative disc disease utilizing a novel viable allogeneic, cancellous, bone matrix (trinity evolution™) with a comparison to historical controls

European Spine Journal ◽

10.1007/s00586-016-4414-7 ◽

2016 ◽

Vol 25 (7) ◽

pp. 2233-2238 ◽

Cited By ~ 19

Author(s):

Jed Vanichkachorn ◽

Timothy Peppers ◽

Dennis Bullard ◽

Scott K. Stanley ◽

Raymond J. Linovitz ◽

...

Keyword(s):

Cancellous Bone ◽

Degenerative Disc Disease ◽

Bone Matrix ◽

Anterior Cervical Discectomy ◽

Outcome Study ◽

Disc Disease ◽

Cervical Discectomy ◽

Degenerative Disc ◽

Single Level ◽

Historical Controls

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Stabilization of Anterior Cervical Spine with Bioabsorbable Polymer in One- and Two-level Fusions

Neurosurgery ◽

10.1227/01.neu.0000108942.07872.2a ◽

2004 ◽

Vol 54 (3) ◽

pp. 631-635 ◽

Cited By ~ 28

Author(s):

Min S. Park ◽

Henry E. Aryan ◽

Burak M. Ozgur ◽

Rahul Jandial ◽

William R. Taylor

Keyword(s):

Cervical Spine ◽

Internal Fixation ◽

San Diego ◽

Medical Center ◽

Anterior Cervical Discectomy ◽

Controlled Study ◽

Bioabsorbable Polymer ◽

Cervical Discectomy ◽

Single Level ◽

Additional Surgery

Abstract OBJECTIVE We present our experience using a bioabsorbable polymer in the surgical management of one- and two-level degenerative disc disease of the cervical spine with anterior cervical discectomy and fusion. Twenty-six patients were treated at the University of California, San Diego Medical Center or the Veterans Affairs Medical Center in San Diego, CA. All cases were performed under the direction of a single neurosurgeon (WRT). METHODS A retrospective review of patients' charts and imaging was performed to determine outcomes after anterior cervical spine operations. Specifically, we looked at the need for additional surgery, local reaction to the bioabsorbable polymer, fusion rate, and complications. Procedures involved the C3–C4, C4–C5, C5–C6, and/or C6–C7 levels, and fibular allograft was used in all but one case. The anterior cervical discectomy and fusion procedures with internal fixation were performed in 26 patients between March 2000 and November 2001. The patients were followed for up to 2 years after surgery (average, 14 mo). RESULTS Radiographic fusion was achieved in 25 (96.2%) of 26 patients. Only one instance of treatment failure was encountered that required additional surgery and the placement of a titanium plate. There were no clinical signs or symptoms of reaction to the bioabsorbable material. CONCLUSION The rates of fusion after single-level anterior cervical discectomy and fusion with internal fixation using bioabsorbable polymer and screws in this study match those using metallic implants, as previously reported in the literature, and are superior to those achieved with noninstrumented fusions. Preliminary results suggest that this newly available technology for anterior fusion is as effective in single-level disease as traditional titanium plating systems. The bioabsorbable material seems to be tolerated well by patients. A larger, randomized, controlled study is necessary to bring the results to statistical significance.

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Radiographic and clinical outcomes following single-level anterior cervical discectomy and allograft fusion without plate placement or cervical collar

Journal of Neurosurgery Spine ◽

10.3171/spi/2008/8/5/420 ◽

2008 ◽

Vol 8 (5) ◽

pp. 420-428 ◽

Cited By ~ 80

Author(s):

Jay Jagannathan ◽

Christopher I. Shaffrey ◽

Rod J. Oskouian ◽

Aaron S. Dumont ◽

Christian Herrold ◽

...

Keyword(s):

Clinical Outcomes ◽

Anterior Cervical Discectomy ◽

Radiographic Evidence ◽

Disc Space ◽

Cervical Discectomy ◽

Single Level ◽

Flexion Extension ◽

The Mean ◽

Graft Migration

Object Although the clinical outcomes following anterior cervical discectomy and fusion (ACDF) surgery are generally good, 2 major complications are graft migration and nonunion. These complications have led some to advocate rigid internal fixation and/or cervical immobilization postoperatively. This paper examines a single-surgeon experience with single-level ACDF without use of plates or hard collars in patients with degenerative spondylosis in whom allograft was used as the fusion material. Methods The authors conducted a retrospective review of a prospective database of (Cloward-type) ACDF operations performed by the senior author (J.A.J.) between July 1996 and June 2005. Radiographic follow-up included static and flexion/extension radiographs obtained to assess fusion, focal and segmental kyphosis, and change in disc space height. At most recent follow-up, the patients' condition was evaluated by an independent physician examiner. The Odom criteria and Neck Disability Index (NDI) were used to assess outcome. Results One hundred seventy patients underwent single-level ACDF for degenerative pathology during the study period. Their most common presenting symptoms were pain, weakness, and radiculopathy; 88% of patients noted ≥ 2 neurological complaints. The mean hospital stay was 1.76 days (range 0–36 days), and 3 patients (2%) had major immediate postoperative complications requiring reoperation. The mean duration of follow-up was 22 months (range 12–124 months). Radiographic evidence of fusion was present in 160 patients (94%). Seven patients (4%) showed radiographic evidence of pseudarthrosis, and graft migration was seen in 3 patients (2%). All patients had increases in focal kyphosis at the operated level on postoperative radiographs (mean −7.4°), although segmental alignment was preserved in 133 patients (78%). Mean change in disc space height was 36.5% (range 28–53%). At most recent clinical follow-up, 122 patients (72%) had no complaints referable to cervical disease and were able to carry out their activities of daily living without impairment. The mean postoperative NDI score was 3.2 (median 3, range 0–31). Conclusions Single-level ACDF without intraoperative plate placement or the use of a postoperative collar is an effective treatment for cervical spondylosis. Although there is evidence of focal kyphosis and loss of disc space height, radiographic evidence of fusion is comparable to that attained with plate fixation, and the rate of clinical improvement is high.

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Neck angioedema after anterior cervical discectomy and fusion with coexistent epiglottic cyst

Surgical Neurology International ◽

10.25259/sni_808_2020 ◽

2020 ◽

Vol 11 ◽

pp. 459

Author(s):

Miltiadis Georgiopoulos ◽

Dimitrios Papadakos ◽

Pantelis Kraniotis ◽

Spyridon Lygeros ◽

Vasilios Margaritis ◽

...

Keyword(s):

Cervical Spine ◽

Airway Obstruction ◽

Spine Surgery ◽

Cervical Myelopathy ◽

Anterior Cervical Discectomy ◽

Case Description ◽

Neck Swelling ◽

Cervical Discectomy ◽

Cervical Spine Surgery ◽

Degenerative Cervical Myelopathy

Background: We present a case and reviewed the literature regarding airway obstruction and angioedema after an anterior cervical discectomy and fusion (ACDF). Case Description: A 60-year-old female with degenerative cervical myelopathy and a previously undiagnosed epiglottic cyst underwent a C5–C6 ACDF; notably, the anesthesiologist found an epiglottic cyst when the patient was first intubated. Two hours postoperatively, the patient acutely developed severe neck swelling with airway obstruction due to angioedema. She was immediately treated with hydrocortisone and required a tracheostomy. The edema decreased markedly in the next 12 h and by the 3rd postoperative day it resolved. Three months later, she had no residual medical sequelae. Conclusion: Patients with epiglottic cysts who need cervical spine surgery should either first have the cyst treated or should be closely monitored postoperatively.

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A single-center retrospective analysis of 3- or 4-level anterior cervical discectomy and fusion: surgical outcomes in 66 patients

Journal of Neurosurgery Spine ◽

10.3171/2020.6.spine20171 ◽

2021 ◽

Vol 34 (1) ◽

pp. 45-51

Author(s):

Jesse J. McClure ◽

Bhargav D. Desai ◽

Leah M. Shabo ◽

Thomas J. Buell ◽

Chun-Po Yen ◽

...

Keyword(s):

Cervical Spine ◽

Surgical Outcomes ◽

Anterior Cervical Discectomy ◽

Lateral Flexion ◽

Disc Disease ◽

Exclusion Criteria ◽

Cervical Discectomy ◽

Initial Symptoms ◽

Flexion Extension ◽

Spine Pathology

OBJECTIVEAnterior cervical discectomy and fusion (ACDF) is a safe and effective intervention to treat cervical spine pathology. Although these were originally performed as single-level procedures, multilevel ACDF has been performed for patients with extensive degenerative disc disease. To date, there is a paucity of data regarding outcomes related to ACDFs of 3 or more levels. The purpose of this study was to compare surgical outcomes of 3- and 4-level ACDF procedures.METHODSThe authors performed a retrospective chart review of patients who underwent 3- and 4-level ACDF at the University of Virginia Health System between January 2010 and December 2017. In patients meeting the inclusion/exclusion criteria, demographics, fusion rates, time to fusion, and reoperation rates were evaluated. Fusion was determined by < 1 mm of change in interspinous distance between individual fused vertebrae on lateral flexion/extension radiographs and lack of radiolucency between the grafts and vertebral bodies. Any procedure requiring a surgical revision was considered a failure.RESULTSSixty-six patients (47 with 3-level and 19 with 4-level ACDFs) met the inclusion/exclusion criteria of having at least one lateral flexion/extension radiograph series ≥ 12 months after surgery. Seventy percent of 3-level patients and 68% of 4-level patients had ≥ 24 months of follow-up. Ninety-four percent of 3-level patients and 100% of 4-level patients achieved radiographic fusion for at least 1 surgical level. Eighty-eight percent and 82% of 3- and 4-level patients achieved fusion at C3–4; 85% and 89% of 3- and 4-level patients achieved fusion at C4–5; 68% and 89% of 3- and 4-level patients achieved fusion at C5–6; 44% and 42% of 3- and 4-level patients achieved fusion at C6–7; and no patients achieved fusion at C7–T1. Time to fusion was not significantly different between levels. Revision was required in 6.4% of patients with 3-level and in 16% of patients with 4-level ACDF. The mean time to revision was 46.2 and 45.4 months for 3- and 4-level ACDF, respectively. The most common reason for revision was worsening of initial symptoms.CONCLUSIONSThe authors’ experience with long-segment anterior cervical fusions shows their fusion rates exceeding most of the reported fusion rates for similar procedures in the literature, with rates similar to those reported for short-segment ACDFs. Three-level and 4-level ACDF procedures are viable options for cervical spine pathology, and the authors’ analysis demonstrates an equivalent rate of fusion and time to fusion between 3- and 4-level surgeries.

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