Anterior correction of cervical kyphotic deformity: effects on myelopathy, neck pain, and sagittal alignment

Ferch, Richard; Shad, Amjad; Cadoux-Hudson, Tom; Teddy, Peter J.

doi:10.3171/spi.2004.100.1.0013

Cited by 99 publications

(138 citation statements)

References 35 publications

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“…Postoperative kyphosis at a fused cervical motion segment has been reported frequently, especially in uninstrumented anterior fusion [28], with an incidence as high as 27.3% [13]. Sagittal malalignment after ACDF may relate to the cervical instability, postoperative axial pain, and the deterioration of neurological deficit, and may influence the functional recovery [7,12]. The local loss of cervical lordosis may also alter dynamic kinematics of the cervical spine and increase biomechanical stress on the anterior vertebral elements in neighboring segments, thus promoting the progression of degenerative changes in the adjacent segments and deteriorating the long-term clinical outcome [2,18].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2011

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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. ResultsSuccessful 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. ConclusionsThe 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 longterm clinical outcome than cage subsidence

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Section: Discussionmentioning

confidence: 99%

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

et al. 2011

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“…It permits decompression of anterior pathology as well as kyphosis correction with strut grafting [26]. There were some studies of anterior correction of cervical kyphosis via a single anterior approach, after which no postoperative neurological deficit occured [13,26,27]. With the anterior procedure, it is easy to apply a distraction force between vertebral bodies, which provides segmental widening of the disc space to create cervical lordosis.…”

Section: Discussionmentioning

confidence: 99%

“…Thereby, the neural foramen is enlarged during kyphosis correction with the anterior procedure, which must be one reason for the reported lack of postoperative neurological deficits. As to correction angles of kyphotic deformity in the cervical spine treated by anterior procedures, Ferch et al [27] reported the preoperative kyphosis was 10°and correction was 11°on average. Herman et al [13] reported that their kyphosis correction was 21°on average.…”

Section: Discussionmentioning

confidence: 99%

A late neurological complication following posterior correction surgery of severe cervical kyphosis

et al. 2010

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Though a possible cause of late neurological deficits after posterior cervical reconstruction surgery was reported to be an iatrogenic foraminal stenosis caused not by implant malposition but probably by posterior shift of the lateral mass induced by tightening screws and plates, its clinical features and pathomechanisms remain unclear. The aim of this retrospective clinical review was to investigate the clinical features of these neurological complications and to analyze the pathomechanisms by reviewing pre-and post-operative imaging studies. Among 227 patients who underwent cervical stabilization using cervical pedicle screws (CPSs), six patients who underwent correction of cervical kyphosis showed postoperative late neurological complications without any malposition of CPS (ND group). The clinical courses of the patients with deficits were reviewed from the medical records. Radiographic assessment of the sagittal alignment was conducted using lateral radiographs. The diameter of the neural foramen was measured on preoperative CT images. These results were compared with the other 14 patients who underwent correction of cervical kyphosis without late postoperative neurological complications (non-ND group). The six patients in the ND group showed no deficits in the immediate postoperative periods, but unilateral muscle weakness of the deltoid and biceps brachii occurred at 2.8 days postoperatively on average. Preoperative sagittal alignment of fusion area showed significant kyphosis in the ND group. The average of kyphosis correction in the ND was 17.6°per fused segment (range 9.7°-35.0°), and 4.5°( range 1.3°-10.0°) in the non-ND group. A statistically significant difference was observed in the degree of preoperative kyphosis and the correction angles at C4-5 between the two groups. The diameter of the C4-5 foramen on the side of deficits was significantly smaller than that of the opposite side in the ND group. Late postoperative neurological complications after correction of cervical kyphosis were highly associated with a large amount of kyphosis correction, which may lead foraminal stenosis and enhance posterior drift of the spinal cord. These factors may lead to both compression and traction of the nerves, which eventually cause late neurological deficits. To avoid such complications, excessive kyphosis correction should not be performed during posterior surgery to avoid significant posterior shift of the spinal cord and prophylactic foraminotomies are recommended if narrow neuroforamina were evident on preoperative CT images. Regardless of revision decompression or observation, the majority of this late neurological complication showed complete recovery over time.

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“…However, at last follow-up, we did not observe any statistically significant positive correlation between clinical outcome and TCL C2-7. As concerns the influence of lordosis on neurologic recovery, Ferch et al [32] reported on 28 patients with progressive myelopathy and kyphotic deformity, which underwent instrumented ACDF. Improvement in myelopathy scores was significantly associated with a local postoperative lordotic angle of about 4°.…”

Section: Influence Of Cervical Lordosismentioning

confidence: 99%

“…The literature offers some hints that reconstruction of cervical lordosis might be favourable concerning clinical outcome and neurologic recovery [32,70,72,113]. However, the question of any influence of a distinct amount of lordotic realignement following the reconstruction of the multilevel decompressed cervical spine demands further investigation [12].…”

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confidence: 99%

4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results

et al. 2007

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In the future, there will be an increased number of cervical revision surgeries, including 4-and more-levels. But, there is a paucity of literature concerning the geometrical and clinical outcome in these challenging reconstructions. To contribute to current knowledge, we want to share our experience with 4-and 5-level anterior cervical fusions in 26 cases in sight of a critical review of literature. At index procedure, almost 50% of our patients had previous cervical surgeries performed. Besides failed prior surgeries, indications included degenerative multilevel instability and spondylotic myelopathy with cervical kyphosis. An average of 4.1 levels was instrumented and fused using constrained (26.9%) and non-constrained (73.1%) screw-plate systems. At all, four patients had 3-level corpectomies, and three had additional posterior stabilization and fusion. Mean age of patients at index procedure was 54 years with a mean follow-up intervall of 30.9 months. Preoperative lordosis C2-7 was 6.5°in average, which measured a mean of 15.6°at last follow-up. Postoperative lordosis at fusion block was 14.4°in average, and 13.6°at last follow-up. In 34.6% of patients some kind of postoperative change in construct geometry was observed, but without any catastrophic construct failure. There were two delayed unions, but finally union rate was 100% without any need for the Halo device. Eleven patients (42.3%) showed an excellent outcome, twelve good (46.2%), one fair (3.8%), and two poor (7.7%). The study demonstrated that anterior-only instrumentations following segmental decompressions or use of the hybrid technique with discontinuous corpectomies can avoid the need for posterior supplemental surgery in 4-and 5-level surgeries. However, also the review of literature shows that decreased construct rigidity following more than 2-level corpectomies can demand 360°instrumentation and fusion. Concerning construct rigidity and radiolographic course, constrained plates did better than non-constrained ones. The discussion of our results are accompanied by a detailed review of literature, shedding light on the biomechanical challenges in multilevel cervical procedures and suggests conclusions.

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Anterior correction of cervical kyphotic deformity: effects on myelopathy, neck pain, and sagittal alignment

Cited by 99 publications

References 35 publications

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

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

A late neurological complication following posterior correction surgery of severe cervical kyphosis

4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results

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