Stand-Alone Cages for Anterior Cervical Fusion: Are There No Problems?

OBJECTIVE: There are complications in stand-alone cage assisted anterior cervical discectomy and fusion (ACDF), such as cage subsidence and kyphosis. Here we report our clinical result on ACDF, comparing with stand-alone cages and with cervical plate system for degenerative cervical spine diseases. METHODS: Patients with degenerative cervical disease who were diagnosed and treated in Konyang University Hospital between January 2004 and December 2014 were included in this study. Patients who had operation in single level ACDF were selected. Patients scored the degree of pain using visual analog scale before and after the surgery. Subsidence was defined as ≥3-mm decrease of the segmental height, and cervical kyphosis was defined as progression of ≥5° at 12 months after postoperative follow-up compared to that measured at the immediate postoperative period. RESULTS: A total of 81 patients were enrolled for this study. Forty-five patients were included in a cervical plate group and the others were in stand-alone cage group. There was no statistical difference in pain score between the 2 groups. Segmental subsidence was observed in 7 patients (15.6%) in plate-assisted cervical fusion group, and 13 patients (36.1%) in stand-alone cage group. Segmental kyphosis was observed in 4 patients (8.9%) in plate-assisted cervical fusion group, and 10 patients (27.8%) in stand-alone cage group. There was statistical difference between the 2 groups. CONCLUSION: There was no difference in pain between 2 groups. But stand-alone case group showed higher incidence rate than plate-assisted cervical fusion group in segmental subsidence and cervical kyphosis. When designing cervical fusion, more attention should be given selecting the surgical technique.

Kyphotic Neck and Correlation With Clinical Outcomes

STUDY DESIGN: A literature review regarding the correlation between a kyphotic neck and its clinical outcomes. OBJECTIVES: This review examines normal cervical alignment, methods for assessing alignment, a specific correlation between kyphotic neck and clinical outcomes, and indications and methods of surgical treatment. SUMMARY OF LITERATURE REVIEW: Cervical kyphotic deformity is problematic in terms of HRQOL due to nerve damage or loss of horizontal gaze. MATERIALS AND METHODS: Review of the literature. RESULTS: Cervical kyphosis can be caused by postlaminectomy, degenerative disc disease, and trauma, and the symptoms exhibit diverse clinical progression including compensatory mechanisms, adjacent segment disease, changes in quality of life, and cervical myelopathy. Given the serious complications of cervical surgery, we need a deep understanding of spine anatomy, preoperative planning, and correction methods. CONCLUSIONS: It is vital to investigate cervical sagittal alignment and to perform intensive treatment and corrective surgery to achieve better clinical outcomes.

Modificaciones del plano sagital cervical luego del tratamiento quirúrgico posterior en la escoliosis idiopática del adolescente Lenke 1 / Changes in the cervical alignment after posterior transpedicular instrumentation in Lenke type I adolescent idiopathic scoliosis

Introducción: Como la cifosis toracica y la lordosis cervical son directamente proporcionales, las modificaciones del plano sagital toracico impactarian sobre la columna cervical. Nuestro objetivo fue detectar cambios en el plano sagital cervical, a corto y mediano plazo, durante el tratamiento quirurgico segun una tecnica posterior. Materiales y Métodos: Estudio retrospectivo radiografico de tipo serie de casos, entre enero de 2005 y abril de 2009. Criterios de inclusion: escoliosis idiopatica del adolescente Lenke 1, tratamiento por via posterior con tornillos transpediculares. Seguimiento minimo 2 anos. Parametros analizados: nivel Cobb, nivel de instrumentacion proximal, densidad de implantes, lordosis cervical, cifosis toracica proximal, cifosis toracica principal, inclinacion sagital T1, balance sagital global, balance sagital cervical. Analisis estadistico mediante ANOVA de muestras repetitivas y Tukey, con el programa Graph-Pad-Prism. Resultados: 25 pacientes. Seguimiento promedio 4,3 anos. Cifosis toracica: media preoperatoria 26,8o, posoperatoria 20,6o. Efecto lordotizante despues del tratamiento quirurgico (p ≤0,001). La inclinacion sagital T1 y la cifosis proximal T2-T5 (p ≤0,038) mostraron un incremento hacia el ultimo control. El 72 % presentaba rectificacion o cifosis cervical antes de la cirugia. El 44 % experimento una mejoria hacia el ultimo control. Los niveles de artrodesis mas altos se correlacionaron con los casos que empeoraron su contorno sagital posoperatorio. Conclusiones: Nuestra tecnica de correccion genero un efecto lordotizante toracico. Esto se tradujo, a mediano plazo, en un incremento de la retropulsion del tronco y rectificacion o perdida de la lordosis a nivel cervical...

Background: As thoracic kyphosis and cervical lordosis are proportionally related, every change in the thoracic sagittal plane will impact on the cervical alignment. Our objective was to detect changes in the sagittal cervical plane at short- and medium term follow-up during surgical treatment, according to the posterior technique. Methods: Retrospective, radiographic case series study performed between January 2005 and April 2009. Inclusion criteria: Lenke type 1 adolescent idiopathic scoliosis, and posterior screw fixation surgery. Radiographic parameters: Cobb angle, uppermost instrumented vertebra, implant density, cervical lordosis, proximal thoracic kyphosis, main thoracic kyphosis, T1 sagittal tilt, global sagittal balance and cervical sagittal balance. Statistical analysis: ANOVA of repetitive samples and Tukey, using the Graph-Pad-Prism. Results: 25 patients. Mean follow-up 4.3 years. Thoracic kyphosis (T5-T12): average, preoperative 26.8º and 20.6º postoperative. Lordosing effect after surgical treatment (p ≤0.001). T1 sagittal tilt and T2-T5 proximal thoracic kyphosis (p ≤0.038) tended to increase at last control. Seventy two per cent of our sample showed rectification or even cervical kyphosis before surgery. Only 44 % had certain better alignment at the last follow-up. Higher UIV correlated with a worse cervical plane alignment after surgery. Conclusions: Our derotational concavity technique with poliaxial pedicle screws and titanium 5.5 rod demonstrated a lordosing effect in the thoracic sagittal plane. This was translated into a trunk retropulsion and rectification or lost of lordosis in the sagittal cervical plane in the medium-term follow-up...

Derrumbamiento de la columna cervical asociado a neurofibromatosis / Collapse of the cervical spine associated with neurofibromatosis

Objetivo: Presentar un caso de derrumbamiento cervical en una paciente con neurofibromatosis y su resolución quirúrgica. Descripción: Estudio retrospectivo sobre una paciente de 29 años con antecedente de exéresis de neurofibroma cutáneo, en región cervical posterior a los 20 años. Consultó por cuadriparesia moderada a severa a predominio izquierdo, post traumatismo cervical por caída de su propia altura, cervicalgia, parestesias y signos de liberación piramidal. La Rx de columna cervical evidenció derrumbamiento vertebral con ángulo de cifosis de 35° y cambios distróficos. La TAC confirmó estrechamiento del canal medular a nivel C4-5. La IRM evidenció compresión medular con mielomalacia a nivel C4-5. Discusión: Se realizó tracción cervical bajo anestesia general y colocación de halo vest. Luego cirugía a dos tiempos. Primero abordaje anterior, corporectomía C4, C5 y C6, reemplazo corporal y fijación con placa y tornillos a los cuerpos de C3 y C7. En un segundo tiempo, se completó el tratamiento con abordaje posterior y fijación occipito-C7 con barras y ganchos sublaminares. La paciente evolucionó con notable mejoría neurológica. Los controles por imágenes mostraron buena descompresión medular, corrección de la cifosis y su consiguiente elongación cervical. Conclusión: El derrumbamiento cervical asociado a neurofibromatosis es una complicación extremadamente infrecuente. La hipermovilidad, dada por la importante elasticidad ligamentaria asociada a la neurofibromatosis, permitió la realineación del raquis cervical, facilitando el tratamiento quirúrgico por vía anterior.Una vez lograda la alineación quirúrgica, se completó el tratamiento con la fijación posterior.

Purpose: To report a case of cervical overthrow in a patient with neurofibromatosis and its surgical resolution.Description: Retrospective review of a 29-year-old female, with a history of cutaneous neurofibroma exeresis in the posterior cervical region. Moderate to severe quadriparesis was the main clinical manifestation, associated with cervicalgia, paresthesias and signs of pyramidal release. X-rays showed a severe vertebral overthrow with a 35° kyphosis angle and dystrophic changes. CT showed a narrowing of the spinal canal at C4-5. MRI confirmed spinal cord compression with myelomalacia at C4-5 levelDiscussion: Cervical traction under general anesthesia and halo vest placement. Afterwards, a two steps surgery was performed. First, anterior approach, C4, C5 and C6 corpectomy, vertebral body replacement and C3 to C7 fixation with plate and screws. Second, a posterior approach and occipito-C7 fixation with rods and sub-laminar hooks.The patient developed remarkable neurological improvement. The postoperative imaging studies showed good spinal cord decompression, kyphosis correction and its corresponding cervical elongation.Conclusion: Cervical spine overthrow associated to neurofibromatosis is an extremely infrequent complication. The hypermobility, due to the important ligament elasticity associated to Von Recklinghausen disease, allowed the realignment of the cervical spine, improving the conditions for an anterior surgical approach. Once achieved the surgical alignment, the treatment was completed with posterior fixation.

Specific Sagittal Curve Patterns of Cervical Spine in Adolescent Idiopathic Scoliosis (AIS)

STUDY DESIGN: A retrospective study. OBJECTIVES: To evaluate the sagittal alignment of cervical spine in AIS. SUMMARY OF LITERATURE REVIEW: Little has been known about the sagittal curve patterns of cervical spine in AIS patients. MATERIALS AND METHODS: One-hundred-thirty-three AIS patients were checked by scanographs and followed up for more than 2 years were divided into cervical kyphosis (> or =+5degrees), lordosis (< or =-5degrees) and straight (-4degrees~+4degrees) groups according to the sagittal curves of cervical spine (C2~C7). Each group was evaluated for thoracic kyphosis, lumbar lordosis, sagittal balance and Cobb's angle on coronal plane. Of the patients, 49 were treated by braces, 84 were surgically corrected (rod derotation in 52, direct vertebral rotation (DVR) in 32). RESULTS: At the initial radiographs, cervical kyphosis was found in 97, lordosis in 23 and straight in 13 patients. In the kyphosis group, cervical kyphosis showed typical patterns of angular kyphosis. Thoracic and upper T-kyphosis (T1~T5) were lower than those in the cervical lordosis group (p=0.000, 0.001, respectively.) Other factors showed no significant differences between the groups. Patients treated by conservative management or by rod derotation had no significant differences in cervical kyphosis during the follow-up periods, though the thoracic hypokyphosis was surgically corrected. On the contrary, patients who were treated by DVR restored cervical lordosis (14/32=43.8%) from initial state showed significant differences in both conservative and rod derotation groups (p=0.008, 0.002, respectively). CONCLUSIONS: Cervical kyphosis in AIS was a compensatory curve correlated with both thoracic hypokyphosis and rotational deformity. Rotational corrections should be considered during the surgical treatment.

Anterior Fusion with Corpectomy and Autogenous Iliac Graft for Cervical Kyphosis in Neurofibromatosis: A case report / 대한척추외과학회지

Scoliosis is the most common deformity of the spine in neurofibromatosis patient, but kyphosis of the cervical spine has rarely been reported. Most authors have reported anterior corpectomy and multilevel interbody grafting and plate osteosynthesis, combined with posterior arthrodesis, as the treatment of cervical kyphosis in neurofibromatosis. A case is presented of a 17-yearold boy with neurofibromatosis Who had 52 degrees of dystrophic kyphosis (as measured on radiographs between C3 and C7) of the cervical spine. He was treated successfully by anterior multilevel interbody grafting using an autogenous iliac bone graft. Anterior corpectomy and arthrodesis appears to provide another surgical option with a moderate degree of cervical kyphosis.