Comparative evaluation of microdiscectomy only, autograft fusion, polymethylmethacrylate interposition, and threaded titanium cage fusion for treatment of single-level cervical disc disease: a prospective randomized study in 125 patients

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The need for interbody fusion or stabilization after anterior cervical microdiscectomy is still debated. The objectives of this prospective randomized study were 1) to examine whether combined interbody fusion and stabilization is more beneficial than microdiscectomy only (MDO) and 2) if fusion is found to be more beneficial than MDO, to determine which is the best method of fusion by comparing the results achieved using autologous bone graft (ABG), polymethylmethacrylate (PMMA) interposition, and threaded titanium cage (TTC).</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A total of 125 patients with a single-level cervical disc disease were included in this prospective study. All patients were randomized and assigned to one of the four following groups: Group 1 (33 patients), MDO; Group 2 (30 patients), microdiscectomy followed by ABG; Group 3 (26 patients), microdiscectomy followed by injection of PMMA; and Group 4 (36 patients), microdiscectomy followed by placement of a TTC. Clinical outcome according to Odom criteria was summarized as 1) excellent and good or 2) satisfactory and poor. One-year follow-up examination was performed in 123 patients. Patients in the TTC group experienced a significantly better outcome 6 months after surgery (92% excellent and good results) compared with those in the MDO and ABG groups (72.7 and 66.6% excellent and good results, respectively). Twelve months after surgery there was still a significant difference in outcomes between the TTC group (94.4% excellent and good results) and the MDO group (75.5% excellent and good results). Outcome in patients treated with PMMA was comparable with that in those treated with TCC after 6 (91.6%) and 12 months (87.5%), but no segmental fusion was achieved. Differences compared with MDO and ABG were, however, not significant, which may be related to the smaller number of patients in the PMMA group.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Interbody cage-assisted fusion yields a significantly better short- and intermediate-term outcome than MDO in terms of return to work, radicular pain, Odom criteria, and earlier fusion. In addition, the advantages of interbody cages over ABG fusion included better results in terms of return to work, Odom criteria, and earlier fusion after 6 months. These results suggest that interbody cage–assisted fusion is a promising therapeutic option in patients with single-level disc disease. Polymethylmethacrylate seems to be a good alternative to interbody cage fusion but is hindered by the absence of immediate fusion.</jats:p></jats:sec>

Bone graft substitutes in anterior cervical discectomy and fusion

“…Two prospective randomized trials found PMMA to have no detectable clinical advantage over discectomy only [9,103] or autograft [9]. Radiologically, Bärlocher et al found PMMA achieved no fusion in all 24 patients at 12 months [9].…”

“…Radiologically, Bärlocher et al found PMMA achieved no fusion in all 24 patients at 12 months [9]. Van den Bent et al found PMMA induced fewer osseous unions than discectomy only (P \ 0.005), experienced graft migration into adjacent vertebrae and was associated with sclerosis of surrounding bone [103].…”

Techniques for anterior cervical decompression for radiculopathy

“…Barlocher et al 3 reported on 125 patients with monoradiculopathy who underwent surgery. This study was primarily focused on examining methyl-methacrylate as an interbody device.…”

Cervical Radiculopathy: A Review

“…Cages can be titanium, polyetheretherketone, carbon fiber polymer, or structural allograft. All of these materials have been shown to be effective [23,48]; however, no clear advantage has been seen for one specific material. The same can be said for graft material [8], no specific advantage has been found to iliac crest autograft versus allograft bone [62].…”

“…Historically, the evacuated disc was then replaced by either bone graft material or nothing. [47][48][49][50][51][52] More recently, surgeons have favored restoring the normal height of the disc segment with structural grafts or cages. Some describe opening the foramen from the anterior approach, while performing only enough discectomy to reach the pathologic foramen [53][54][55].…”