Long-Term Results after Multilevel Fusion of the Cervical Spine and the Cervicothoracic Junction: To Bridge or Not To Bridge?

Scholz, Christoph; Klingler, Jan-Helge; Masalha, Waseem; Hohenhaus, Marc; Volz, Florian; Vasilikos, Ioannis; Roelz, Roland; Scheiwe, Christian; Hubbe, Ulrich

doi:10.1016/j.wneu.2021.01.025

Cited by 4 publications

(22 citation statements)

References 19 publications

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“…The proposed advantages of crossing the CTJ include a decreased rate of adjacent segment disease and subsequent need for revision surgery 7–13. The average duration of follow-up in our study was ∼1.8 years.…”

Section: Discussionmentioning

confidence: 84%

“…In addition, our overall revision rate of 4.4% was considerably smaller than previously reported studies, which found rates between 10.1% and 27.8%. 8,11,13 This is likely due to our limited length of follow-up. Further, the study is subject to immortal time bias where longer follow-up may be required to detect the development of adjacent segment disease and its associated effects on patient-reported outcomes.…”

Section: Discussionmentioning

confidence: 98%

“…Crossing the CTJ in multilevel PCF may reduce the risk of adjacent segment disease and revision surgery, but it has also been shown to be associated with increases in patient morbidity due to prolonged surgical duration, increased surgical dissection, and increased blood loss. [7][8][9]11,13,27 While studies have debated whether improved surgical outcomes (sagittal alignment, revision rates, incidence of adjacent seg- ment disease) occur in patients with constructs crossing the CTJ in multilevel PCF, few studies have examined whether the effects of these surgical outcomes result in patientreported improvements in pain, function, or disability after surgery. Accordingly, the goal of this study was to determine if instrumenting across the CTJ in multilevel PCF had a significant impact on patient-reported outcomes following surgery.…”

Section: Discussionmentioning

confidence: 99%

“…The proposed advantages of crossing the CTJ include a decreased rate of adjacent segment disease and subsequent need for revision surgery. [7][8][9][10][11][12][13] The average duration of followup in our study was ∼1.8 years. During this time, there was a significant difference in revision surgery rates between groups, but the natural history of adjacent segment disease often occurs after the 2-year follow-up period.…”

Section: Discussionmentioning

confidence: 99%

“…Previous research has found that instrumenting across the CTJ reduces adjacent-segment disease while simultaneously resulting in higher fusion rates, lower reoperation/revision rates, and superior radiographic outcomes for C2-C7 sagittal vertical axis, cervical lordosis, and cervical lordosis minus T1 slope. [7][8][9][10][11][12][13][14] At baseline, the native disk at the CTJ experiences significant forces serving as the transition point between the rigid kyphotic thoracic spine and mobile lordotic cervical spine. 15 Multilevel PCF that does not cross the CTJ results in 2 adjacent lever arms joined together by the mobile C7-T1 transitional disk.…”

mentioning

confidence: 99%

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Instrumentation Across the Cervicothoracic Junction Does Not Improve Patient-reported Outcomes in Multilevel Posterior Cervical Decompression and Fusion

Toci

Karamian

Lambrechts

et al. 2022

Clinical Spine Surgery: A Spine Publication

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Objective: The objective of this study was to determine if instrumentation across the cervicothoracic junction (CTJ) in elective multilevel posterior cervical decompression and fusion (PCF) is associated with improved patient-reported outcome measures (PROMs).Summary of Background Data: Fusion across the CTJ may result in lower revision rates at the expense of prolonged operative duration. However, it is unclear whether constructs crossing the CTJ affect PROMs.Materials and Methods: Standard Query Language (SQL) identified patients with PROMs who underwent elective multilevel PCF ( ≥ 3 levels) at our institution. Patients were grouped based on anatomic construct: crossing the CTJ (crossed) versus not crossing the CTJ (noncrossed). Subgroup analysis compared constructs stopping at C7 or T1. Independent t tests and χ 2 tests were utilized for continuous and categorical data, respectively. Regression analysis controlled for baseline demographics. The α was set at 0.05.Results: Of the 160 patients included, the crossed group (92, 57.5%) had significantly more levels fused (5.27 vs. 3.71, P < 0.001), longer operative duration (196 vs. 161 min, P = 0.003), greater estimated blood loss (242 vs. 160 mL, P = 0.021), and a decreased revision rate (1.09% vs. 10.3%, P = 0.011). Neither crossing the CTJ (vs. noncrossed) nor constructs spanning C3-T1 (vs. C3-C7) were independent predictors of ΔPROMs (change in preoperative minus postoperative patient-reported outcomes) on regression analysis. However, C3-C7 constructs had a greater revision rate than C3-T1 constructs (15.6% vs. 1.96%, P = 0.030). Conclusion:Crossing the CTJ in patients undergoing elective multilevel PCF was not an independent predictor of improvement in PROMs at 1 year, but they experienced lower revision rates.

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Section: Discussionmentioning

confidence: 84%

Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

See 3 more Smart Citations

Instrumentation Across the Cervicothoracic Junction Does Not Improve Patient-reported Outcomes in Multilevel Posterior Cervical Decompression and Fusion

Toci

Karamian

Lambrechts

et al. 2022

Clinical Spine Surgery: A Spine Publication

View full text Add to dashboard Cite

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Effect of Cervicothoracic Junction LIV Selection on Posterior Cervical Fusion Mechanical Failure

Labrum,

Waddell,

Gupta

et al. 2023

Clinical Spine Surgery: A Spine Publication

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Study Design: Systematic review and Meta-analysis. Objective: Analyze and summarize literature evaluating the role of C7, T1, and T2 lowest instrumented vertebra (LIV) selection in posterior cervical fusion (PCF) and if this affects the progression of mechanical failure and revision surgery. Summary of Background Data: Literature evaluating mechanical failure and adjacent segment disease in the setting of PCF at or nearby the cervicothoracic junction (CTJ) remains limited with studies reporting conflicting results. Materials and Methods: Two reviewers conducted a detailed systematic review using EMBASE, PubMed, Web of Science, and Google Scholar on June 28, 2021, for primary research articles comparing revision and complication rates for posterior fusions ending in the lower cervical spine (C7) and upper thoracic spine (T1–T2). The initial systematic database yielded 391 studies, of which 10 met all inclusion criteria. Random effects meta-analyses compared revision and mechanical failure rates between patients with an LIV above the CTJ and patients with an LIV below the CTJ. Results: Data from 10 studies (total sample=2001, LIV above CTJ=1046, and LIV below CTJ=955) were meta-analyzed. No differences were found between the 2 cohorts for all-cause revision [odds ratio (OR)=0.75, 95% CI=0.42–1.34, P<0.0001] and construct-specific revision (OR=0.62, 95% CI=0.25–1.53, P<0.0001). The odds of total mechanical failure in the LIV below CTJ cohort compared with the LIV above CTJ cohort were significantly lower (OR=0.38, 95% CI=0.18–0.81, P<0.0001). Conclusion: The results show patients with PCFs ending below the CTJ have a lower risk of undergoing total mechanical failure compared with fusions ending above the CTJ. This is important information for both physicians and patients to consider when planning for operative treatment. Level of Evidence: Level I.

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Should we bridge the cervicothoracic junction in long cervical fusions? A meta-analysis and systematic review of the literature

Coban

Faloon

Changoor

et al. 2022

Journal of Neurosurgery: Spine

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OBJECTIVE Long posterior cervical decompression and fusion (PCF) is commonly performed to surgically treat patients with multilevel cervical pathology. In cases in which constructs may necessitate crossing the cervicothoracic junction (CTJ), recommendations for appropriate caudal fusion level vary in the literature. The aim of this study was to report the clinical and radiological outcomes of multilevel PCFs ending at C7 versus those crossing the CTJ. METHODS A systematic search of PubMed, CINAHL Plus, and Scopus was conducted to identify articles that evaluated clinical and radiological outcomes of long PCFs that ended at C7 (cervical group) or crossed the CTJ (thoracic group). Based on heterogeneity, random-effects models of a meta-analysis were used to estimate the pooled estimates and the 95% confidence intervals. RESULTS PCF outcome data of 1120 patients from 10 published studies were included. Compared with the cervical group, the thoracic group experienced greater mean blood loss (453.0 ml [95% CI 333.6–572.5 ml] vs 303.5 ml [95% CI 203.4–403.6 ml]), longer operative times (235.5 minutes [95% CI 187.7–283.3 minutes] vs 198.5 minutes [95% CI 157.9–239.0 minutes]), and a longer length of stay (6.7 days [95% CI 3.3–10.2 days] vs 6.2 days [95% CI 3.8–8.7 days]); however, these differences were not statistically significant. None of the included studies specifically investigated factors that led to the decision of whether to cross the CTJ. The cervical group had a mean fusion rate of 86% (95% CI 71%–94%) compared with the thoracic group with a rate of 90% (95% CI 81%–95%). Of patients in the cervical group, 17% (95% CI 10%–28%) required revision surgery compared with 7% (95% CI 4%–13%) of those in the thoracic group, but this difference was not statistically significant. The proportion of patients who experienced complications in the cervical group was found to be 28% (95% CI 12%–52%) versus 14% (95% CI 7%–26%) in the thoracic group; however, this difference was not statistically significant. There was no significant difference (no overlap of 95% CIs) in the incidence of adjacent-segment disease, pseudarthrosis, or wound-related complications between groups. CONCLUSIONS This meta-analysis suggests similar clinical and radiographic outcomes in multilevel PCF, regardless of inclusion of the CTJ. The lowest instrumented level did not significantly affect revision rates or complications. The ideal stopping point must be tailored to each patient on an individualized basis.

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Long-Term Results after Multilevel Fusion of the Cervical Spine and the Cervicothoracic Junction: To Bridge or Not To Bridge?

Cited by 4 publications

References 19 publications

Instrumentation Across the Cervicothoracic Junction Does Not Improve Patient-reported Outcomes in Multilevel Posterior Cervical Decompression and Fusion

Instrumentation Across the Cervicothoracic Junction Does Not Improve Patient-reported Outcomes in Multilevel Posterior Cervical Decompression and Fusion

Effect of Cervicothoracic Junction LIV Selection on Posterior Cervical Fusion Mechanical Failure

Should we bridge the cervicothoracic junction in long cervical fusions? A meta-analysis and systematic review of the literature

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