Variation in Prevertebral Soft Tissue Swelling after Staged Combined Multilevel Anterior–Posterior Complex Cervical Spine Surgery: Anterior Then Posterior (AP) versus Posterior Then Anterior–Posterior (PAP) Surgery

Abstract

The influence of the sequence of surgery in the development of prevertebral soft tissue swelling (PSTS) in staged combined multilevel anterior–posterior complex spine surgery was examined. This study was conducted as a retrospective study of patients who underwent staged combined multilevel anterior–posterior complex cervical spine surgery from March 2014 to February 2021. Eighty-two patients were identified, of which fifty-seven were included in the final analysis after screening. PSTS was measured from routine serial monitoring lateral cervical radiographs prior to and after surgery for five consecutive days at each cervical level from C2 to C7 in patients who underwent anterior then posterior (AP) and posterior then anterior–posterior (PAP) surgery. The mean PSTS measurements significantly differed from the preoperative to postoperative monitoring days at all cervical levels (p = 0.0000) using repeated measures analysis of variance in both groups. PSTS was significantly greater in PAP than in AP at level C2 on postoperative day (POD) 1 (p = 0.0001). PSTS was more prominent at levels C2–4 during PODs 2–4 for both groups. In staged combined multilevel anterior–posterior complex spine surgery, PSTS is an inevitable complication. Therefore, surgeons should monitor PSTS after surgery when performing anterior–posterior complex cervical spine surgery, especially in the immediate postoperative period after PAP surgery.

Assessment of Biomechanical Advantages in Combined Anterior–Posterior Cervical Spine Surgery by Radiological Outcomes: Pedicle Screws over Lateral Mass Screws

“…For these purposes, combined anterior-posterior surgery is preferred. Whether to select lateral-mass-screw insertion or pedicle-screw insertion for the posterior-fixation method depends on patient-specific anatomical considerations and the surgeon's preference [5,36].…”

“…In this study, we selected patients who had undergone cervical decompression and fusion by the combined anterior-posterior approach as study objects. Our institution considered the combined approach for patients with certain indications based on previous studies [5,[20][21][22][23]. Those indications contained cervical myelopathy and radiculopathy with multilevel spondylosis, severe ossification of the posterior longitudinal ligament (OPLL), congenital stenosis, and multilevel fixed kyphotic deformity.…”

“…We prefer performing posterior-anterior-posterior (PAP) surgery over anterior-posterior (AP) surgery for various reasons: primarily, the advantage it offers in reducing prevertebral swelling. This preference is based on several studies and clinical observations that have demonstrated the efficacy of PAP surgery in reducing postoperative complications and improving patient outcomes [5].…”

“…The combined approach has shown minor complications and better clinical outcomes for multilevel cervical spondylotic myeloradiculopathy and degenerative kyphosis cases [1][2][3]. Techniques and protocols concerning multiple-stage operations for the combined approach have been developed, and it has been confirmed that certain techniques, such as posterior foraminotomy, can reduce complications such as C5 palsy or prevertebral swelling [4,5]. In the combined approach, deciding which way to proceed with posterior fixation is critical.…”

Posterior Preventive Foraminotomy before Laminectomy Combined with Pedicle Screw Fixation May Decrease the Incidence of C5 Palsy in Complex Cervical Spine Surgery in Patients with Severe Myeloradiculopathy

“…We intended to begin with a posterior rather than an anterior approach to allow for more uncomplicated posterior dissection and neurological decompression, as well as hemostasis and pedicle screw insertions. Then, ACDF using allospacers with foraminotomy and uncovertebrectomy was performed, followed by posterior rod assembly [ 21 , 22 ].…”