Comparison of the long-term efficacy of ROI-C and conventional cage-plate in treatment of spinal cord injury without fracture or dislocation: a retrospective study.

BACKGROUND: The self-locking cage (ROI-C, LDR, Troyes, France) has been clinically applied in the treatment of cervical degenerative disc disease (CDDD). However, only a few long-term clinical and radiographic studies have been conducted on the treatment of spinal cord injury without fracture or dislocation (SCIWFD) so far. A comparison between ACDF with either ROI-C or CCP was performed to determine the better treatment for SCIWFD. METHODS: A total of 83 patients who underwent ACDF using either ROI-C or CCP were reviewed for radiological and clinical outcomes. The cohort comprised 60 males and 23 females, aged between 32 and 88 years old, with an average age of 58.23 years. All patients exhibited symptoms of nerve injury, including limb numbness, muscle weakness, hypoesthesia or urinary dysfunction. The preoperative ASIA classification of spinal nerve function: 7 cases of grade A, 23 cases of grade B, 34 cases of grade C and 19 cases of grade D were included in the study. RESULTS: A total of 48 patients underwent ACDF with ROI-C, while 35 patients received a conventional cage-plate. They were studied with a follow-up of 28.63 ± 17.41 months and 29.48 ± 15.43 months respectively. No significant difference was found in blood loss, JOA and ASIA between the two groups. No significant difference was found in cervical lordosis (CL) (P > 0.05). However, statistical difference was found in disc height of fused segment and T1 slope between the two groups (P < 0.05). No statistical difference was in the incidence of cage subsidence (P > 0.05). There was significant difference in the incidence of dysphagia. Both of two groups achieved bony fusion at final follow-up. CONCLUSION: Our study demonstrated that ROI-C has the same efficacy as CCP in improving the cervical stability in treatment of SCIWFD. The migration of cage didn't occur in ROI-C group at final follow-up, showing steadily fixed in cervical column. Moreover, the ROI-C does have the advantages of good therapeutic effect, mis-invasive, shorter operation time and fewer complications.

Clinical and radiographic outcomes after index anterior cervical discectomy and fusion with interbody spacer with integrated anchor fixation: a single-surgeon case study.

Background: The use of plate-cage systems in anterior cervical discectomy and fusion (ACDF) has been shown to produce fusion and good clinical outcomes though it has been associated with complications such as dysphagia at higher rates than stand-alone implant devices. This study aimed to assess the incidence of dysphagia and radiographic outcomes in adult patients who have undergone ACDF with interbody spacer with integrated anchor fixation (ISa). Methods: Patients who underwent index ACDF with a commercially available ISa by a fellowship-trained spine surgeon between January 2018 and December 2021 were retrospectively included. Patients with less than 90-days follow-up or those who underwent ACDF for trauma, infection, or tumor were excluded. Demographic data, perioperative data, radiographic data and perioperative complications were collected. Results: Forty-five patients were included for study. Eight patients (17.8%) experienced dysphagia immediately following surgery, which resolved by 6 months post-op, barring 1 patient. Preoperative global and segmental lordosis were 10.4°±9.3° and 6.9°±7.3° respectively. At three months postoperatively, global and segmental lordosis were 8.9°±7.9° (P=0.50) and 7.0°±5.9° (P=0.56) respectively. Fusion rate at six months was 78.3% (18/23) and 100% (18/18) at 1 year. Conclusions: ACDF with ISa is a viable alternative to traditional plate-cage systems. ISa shows lower rates of immediate, 3-month and 6-month dysphagia than traditional plate-cage systems described in the literature. More controlled studies on larger populations will help formulate a concrete conclusion on the advantages of ISa spacers.

Efficacy of an allograft cellular bone matrix as an alternative to autograft in anterior cervical discectomy and fusion: radiological results & safety.

Background: The predominant surgical procedure employed for patients with symptomatic cervical radiculopathy is anterior cervical discectomy and fusion (ACDF). ACDF typically involves the use of an interbody cage augmented with iliac crest bone graft (ICBG) or local autograft to enhance fusion rate. Substantial complications can arise from autograft use, including donor site morbidity, difficulties with ambulation, and diminished quality of life. This study aims to evaluate the effectiveness and safety of an allograft cellular bone matrix (ACBM) as an osteopromotive bone, in ACDF procedures. Methods: This retrospective, single-center, consecutive case series included 73 patients who underwent an ACDF procedure. The surgical procedure involved the placement of an interbody cage supplemented with anterior plate fixation and an ACBM within the interbody spacer. Patient charts were reviewed to gather demographic information, radiographic findings, as well as perioperative and post-operative complications. Radiographic fusion was assessed at 6 and 12 months by a blinded, musculoskeletal-trained radiologist and a board-certified spinal surgeon reviewer. Any discrepancies were settled by a third, senior reviewer. Complete fusion was defined as: evidence of bridging bone across the disc space on CT, angular motion <3 degrees, and translational motion <2 mm on lateral radiographs. Complications were analyzed at 6, 12, and 15+ months post-operatively to assess clinical outcomes and device performance. Results: A total of 73 patients (50 males, 23 females) with an average age of 54.6 (range, 31-77) years underwent an ACDF procedure between C3-T1 with an ACBM. The breakdown of levels operated on was 26%, 32%, 34%, and 8% for one, two, three, and four level procedures, respectively. There were three patients who received spinal injections for pain within the first year post-operatively. There were two patients who required secondary surgery within the first 12 months where supplemental posterior hardware was needed. Notably, there were no instances of cage subsidence, cage migration, cage/graft removal, or reoperation. There were no cases of chronic dysphasia. At 6 months, 45% of patients with available imaging demonstrated complete fusion, while 97.4% of patients with available imaging demonstrated complete fusion at 12 months. Conclusions: At the 12-month follow-up, our study demonstrates a high fusion rate in a real-world population of up to 4 operative levels. There were no bone graft related complications or incidences of cage migration/subsidence. It is noteworthy that the study involved a significant number of multilevel cases (74% of cases). Despite this, our results align with historical fusion rates and provide support for the utilization of ACBMs as a fusion adjunct in ACDF procedures up to 4 levels.

What is the True Cost of Motion Preservation? A Time-driven Activity-Based Cost Analysis of Anterior Cervical Discectomy and Fusion Versus Disc Replacement.

INTRODUCTION: Total disc replacement (TDR) has become a viable alternative to anterior cervical discectomy and fusion (ACDF) for select patients. Although most comparative studies have assessed outcomes, cost differences remain largely uninvestigated. This information is critical as we move towards value-based reimbursement. To address this knowledge gap, we used time-driven activity-based costing (TDABC) to compare total intraoperative costs between the two procedures. METHODS: Total cost was divided into direct (personnel and supply cost) and indirect costs (administrative and overhead costs). Individual costs were determined through direct observation, electronic medical records, and through querying multiple departments (including business operations, sterile processing, plant operations, and pharmacy). Timestamps for all involved personnel and material resources were documented, in conjunction with process mapping of the intraoperative period. Total intraoperative costs were estimated for all ACDFs (n=810) and TDRs (n=54) from 2017 to 2022. Regression analyses were performed to identify factors associated with total cost. RESULTS: A total of 810 and 54 patients underwent one- and two-level ACDFs and TDRs, respectively. The average total intraoperative cost for an ACDF was $6,776 +/- $2,808, compared to $12,026 +/- $4,235 for TDR. Supply cost accounted for the majority of total cost for both procedures ($4,173 +/- $2,225 for ACDF and $9,532 +/- $4,010 for TDR). On multivariable linear regression analysis, TDR was associated with roughly $3,885 of additional cost compared to ACDF (p<0.001), as well as $4,072 in additional supply cost (p<0.001), most of which was driven by the higher cost of implants (p<0.001). CONCLUSION: TDABC is a highly useful methodology for estimating differences in true costs between procedures and determining cost drivers. TDRs were associated with an additional $3,885 of total intraoperative cost as compared to ACDFs, the majority of which was driven by the cost of implants.

Positive Cutibacterium acnes Intervertebral Discs Are Not Associated with Subsidence Following Anterior Cervical Discectomy and Fusion at 3 or 6 Months.

Background/Objectives:Cutibacterium acnes (C. acnes), formerly known as Propionibacterium acnes (P. acnes), is an anaerobic, low-virulent bacterium that has been associated with postoperative infections of the shoulder, knee, and cervical spine. Recent studies have highlighted an association between C. acnes and the development of degenerative disc disease (DDD). The aim of this study is to ascertain whether C. acnes increases the risk of subsidence following anterior cervical discectomy and fusion (ACDF). Methods: After IRB approval, consecutive patients undergoing elective ACDF for DDD from 2017 to 2018 were enrolled in this prospective cohort study. Intervertebral disc samples were taken at each affected level and cultured. A total of 66 patients with radiographic follow-ups were included in the final analysis. The extent of subsidence and cervical lordosis was determined immediately postoperatively and at the 3- and 6-month follow-ups. Results: No significant difference in subsidence was observed at 3 months (p = 0.07) or 6 months (p = 0.11) between culture-positive and -negative cohorts. Additionally, there was no significant difference detected in the change in cervical lordosis observed at 3 months (p = 0.16) or 6 months (p = 0.27) between culture-positive and -negative cohorts. For the most inferiorly fused segment, there was a significant difference in subsidence observed at 3 months (1.5 mm, 95% CI: 0.2-2.7 mm, p = 0.02) but not at 6 months (p = 0.17). Conclusions: Intervertebral discs with a positive C. acnes culture were not associated with greater levels of subsidence at 3 or 6 months following ACDF for DDD. Further research is necessary to endorse these results and to gauge the clinical significance of C. acnes infection.

Obesity is an independent risk factor for postoperative pulmonary embolism after anterior cervical discectomy and fusion.

BACKGROUND: Over the past decade, the prevalence of obesity has risen in the United States, in parallel with the demand for anterior cervical discectomy with fusion (ACDF). Prior studies have evaluated the role of obesity classes in cervical spine surgery in smaller patient populations. We aimed to evaluate any potential correlation to a national population sample by utilizing a large multicenter database. PURPOSE: The purpose of this study was to analyze obesity level's influence on perioperative complication rates in patients undergoing ACDF. STUDY DESIGN/SETTING: A retrospective cohort, large multicenter database study. PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify patients who had undergone an elective ACDF procedure between 2011 and 2020 using Current Procedural Terminology (CPT) code 22551. OUTCOME MEASURES: Medical and surgical complications within thirty days of operation. METHODS: Patients were categorized into four BMI groups: nonobese (BMI 18.5-29.9 kg/m2), obese class I (BMI 30-34.9 kg/m2), obese class II (BMI 35-39.9 kg/m2), and obese class III (BMI ≥40 kg/m2). A univariate analysis conducted for demographic variables and preoperative comorbidities identified age, sex, race, smoking status, hypertension requiring medication, diabetes, history of congestive heart failure, history of bleeding disorder, and chronic obstructive pulmonary disease as risk factors. Chi-square test was used to compare incidence of complications among groups. A multivariable logistic regression analysis was subsequently performed to adjust for these preoperative risk factors and compare obesity classes I-III to nonobese patients. RESULTS: About 64,718 patients were identified of whom 33,365 were nonobese, 17,190 were obese class I, 8,608 were obese class II, and 5,555 were obese class III. Obese classes I-III patients had a higher incidence of surgical site infections (0. 33%, 0.36%, 0.41%, vs. 0.24%, p=.039) and pulmonary embolism (PE) (0.25%, 0.31, 0.29 vs. 0.15%, p=.003). Obese classes I-III had a lower incidence of blood transfusion (0.23%, 0.17%, 0.27% vs. 0.4%, p<.001) obese class I, obese class II, and obese class III independently increased the risk for PE (OR: 1.716, 95% CI (1.129-2.599); OR: 2.213, 95% CI (1.349-3.559); OR: 2.207, 95% CI (1.190--3.892), respectively). CONCLUSIONS: Risk for postoperative PEs after an ACDF was significantly higher for obese classes I-III compared to nonobese patients. These findings may further support the use of additional prophylaxis measures and precaution in the perioperative setting.

Symptomatic Subsidence of a Box-Shaped Titanium Cage After Anterior Cervical Discectomy and Fusion: Two Case Reports and Review of the Literature.

This study reports two cases of rare symptomatic subsidence of titanium cages after anterior cervical discectomy and fusion (ACDF). First, an 82-year-old man underwent ACDF at C5/6 and C6/7 using two 6 mm height box-type titanium cages. On the 34th postoperative day, motor weakness occurred in the right upper limb, and CT showed that the cage at C5/6 had subsided 6 mm into the C6 vertebral body. On postoperative day 55, both cages were removed, and C6 corpectomy was performed. The C5-7 space was refixed with a mesh cage and plate. He was discharged home from the rehabilitation hospital three months later. Second, a 41-year-old man underwent ACDF at C5/6 and C6/7 using two 5 mm height box-type titanium cages. He fell violently on the 33rd postoperative day, causing pain from the neck to the left hand, weakness, and skillful movement disorder in the left hand, and CT showed that the cages at C5/6 and C6/7 had subsided by 7 mm and 6 mm, respectively. On the 65th postoperative day, both cages were removed by reoperation, and C6 and 7 corpectomy was performed. The space between C5 and T1 was refixed with a mesh cage and plate. He was discharged home two months later. Possible causes of titanium cage subsidence include osteoporosis, trauma, vertebral cortex damage by an operative procedure, and cage height of 6 mm or more. While ACDF is safe and effective for cervical spondylosis, special caution is needed in older osteoporotic patients.

Does the Angulation of the Screws in the Zero-P Implant Affect the Clinical and Radiological Outcomes of Patients?

OBJECTIVE: When implanting the Zero-P device, the screws of Zero-P form a bone wedge with a 40 ± 5° cranial and caudal angle (CCA). However, no study has been performed in the optimal CCA of the Zero-P implant. To investigate whether the cranial/caudal angles (CCA) of the screws affect the clinical and radiological outcomes in patients undergoing ACDF with the Zero-P implant. METHODS: From January 2016 to December 2023, we retrospectively analyzed 186 patients who underwent 1-level ACDF with the Zero-P device. The patients were divided into four groups: group A (cranial angle ≤40°, caudal angle ≤40°); group B (cranial angle ≤40°, caudal angle >40°); group C (cranial angle >40°, caudal angle ≤40°); and group D (cranial angle >40°, caudal angle >40°). The clinical outcomes, including Japanese Orthopaedic Association (JOA), neck disability index (NDI), and visual analogue scale (VAS) scores, the radiological parameters, including cervical lordosis (CL), cervical lordosis of operated segments (OPCL), intervertebral space height (ISH) and fusion rate (FR), and the complications, were evaluated and compared. Parametric tests, non-parametric tests, and chi-square tests were conducted to analyze the data. RESULTS: The OPCL of group A was significantly less than that of the other groups at the final follow-up (p < 0.05). The ISH of group D was significantly less than that of group A at the final follow-up (p < 0.05). The subsidence rate of group A was significantly less than that of group D at the final follow-up (p < 0.05). At the final follow-up, the upper adjacent-level degeneration (ASD) of group D was significantly less severe than that of groups A and B (p < 0.05). The clinical outcomes do not differ among groups (p > 0.05). CONCLUSION: A larger CCA of the screws (cranial angle >40°, caudal angle >40°) was better for maintaining OPCL and reducing the incidence of ASD. A smaller CCA of the screws (cranial angle ≤40°, caudal angle ≤40°) was better for maintaining ISH and reducing the rate of subsidence.

Outcomes of non-contiguous two-level anterior cervical discectomy and fusion in patients with degenerative cervical myelopathy: a retrospective study.

BACKGROUND: Non-contiguous two-level Anterior Cervical Discectomy and Fusion (ACDF) may be a viable option for patients with degenerative cervical myelopathy and imaging-evident spine and radicular compression at two non-contiguous cervical levels. The risk of hastening degeneration and triggering Adjacent Segment Disease at the spine levels located between the fused levels is a putative adverse event, which was assessed in a few studies. The aim of this study is to investigate the clinical outcomes of patients undergoing non-contiguous two levels ACDF and to assess biomechanical modifications at non-fused segments. METHOD: We retrospectively reviewed all patients with noncontiguous two-level spine and radicular compression, who underwent simultaneous noncontiguous two-level ACDF at our center. We analyzed clinical and radiological outcomes and investigated the rate of adjacent segment disease. Radiographic parameters were calculated on pre- and postoperative images. RESULTS: Thirty-two patients underwent simultaneous noncontiguous two-level ACDF for cervical myelo-radiculopathy between 2015 and 2021 and were followed up for a mean period of 43.3 months. For all patients, the mJOA score significantly improved from 14.57 ± 2.3 to 16.5 ± 2.1 (p<0.01) and the NDI score significantly decreased from 21.45 ± 4.3 to 12.8 ± 2.3 (p<0.01) postoperatively. Cervical lordosis increased after surgery (from 9.65° ±9.47 to 15.12° ± 6.09); intermediate disc height decreased (5.68 mm ± 0.57 to 5.27 mm ±0.98); the ROMs of intermediate (from 12.45 ± 2.33 to 14.77 ± 1.98), cranial (from 14.63 ± 1.59 to 15.71 ± 1.02), and caudal (from 11.58 ± 2.32 to 13.33 ± 2.67) segments slightly increased. During follow-up assessment, in one patient the myelopathy worsened due to spine compression at the intermediate level. CONCLUSIONS: Simultaneous and non-contiguous two-level ACDF is a safe and effective procedure. The occurrence of postoperative adjacent and intermediate segment disease is rare.

Does hydrogen peroxide help mitigate the incidence of Cutibacterium acnes in cervical spine surgeries?

Background: Surgical site infection (SSI) is a common yet serious complication of cervical spine surgery. While initially thought to be clinically insignificant, Cutibacterium acnes (C. acnes) is an important cause of infection. The purpose of this study was to investigate the ability of a hydrogen peroxide (H2O2) application during standard presurgical skin preparation to reduce the burden of C. acnes in patients undergoing cervical spine surgery. Methods: This was a retrospective review of prospectively collected data. Subjects were randomly assigned to either standard surgical preparation plus H2O2 (experimental) or without H2O2 (control). Prescrub, postscrub, and dermal cultures were obtained to assess the C. acnes burden after cultures on an aerobic and anaerobic growth medium were held for 21 days. Multivariate analysis was conducted to determine factors associated with presence of C. acnes. Outcome measures included the results of intraoperative cultures and the development of a SSI within 90 days postoperatively. Results: Patients (n=86) undergoing elective 2- or 3-level fusion via anterior approach were included. Prior to application of the antiseptic solution, 65% (28/43) of the experimental cohort and 77% (33/43) of the control cohort had positive C. acnes cultures (p=.34). Following application of antiseptic solution, there were no differences in positive C. acnes culture rates between the experimental and control cohorts in the epidermal (30% vs. 28%, p=1.00) or dermal (40% vs. 42%, p=1.00) cultures. No differences in the rates of C. acnes eradication from preantiseptic to postantiseptic application occurred for epidermal (p=1.00) or dermal (p=1.00) skin layers. None of the factors were associated with positive C. acnes epidermal cultures on multivariable logistic regression analysis (p>.05). Conclusions: While there is potential for H2O2 to reduce the positive culture rate of C. acnes in cervical spine patients, no difference was seen when compared to standard surgical skin preparation.

Surgical management of congenital cervical spondylolytic spondylolisthesis: illustrative case.

BACKGROUND: Congenital cervical spondylolytic spondylolisthesis is a rare and complex disorder of the cervical spine. Surgical treatment is reserved for those symptomatic patients who do not improve with conservative management. OBSERVATIONS: A 34-year-old man presented with bilateral C7 radiculopathy for the past 6 months. Magnetic resonance imaging of the cervical spine revealed grade II C6-7 spondylolisthesis. Computed tomography showed the presence of spondyloarthritis, bilateral pedicle dysplasia, bilateral isthmic defect, and spinous process schisis. Dynamic radiographs showed no signs of vertebral instability. Dynamic magnetic resonance imaging showed kinking of the spinal cord over the fulcrum of C6-7 kyphosis during flexion, with no signs of myelopathy. The patient underwent C6-7 anterior fusion surgery. His symptoms improved postoperatively, with a 2-month computed tomography scan showing initial bony bridging. LESSONS: The absence of evident instability on radiography does not always correspond to the absence of actual functional compression of neurological structures. Spinal misalignment, muscle dysfunction, and kyphotic deformity with kinking of the spinal cord and stretching of the nerve roots may also contribute to the development of symptoms. In this setting, dynamic magnetic resonance imaging can be extremely useful. Single-level anterior fusion surgery without posterior fixation can achieve solid fusion and improve the clinical conditions of patients. https://thejns.org/doi/10.3171/CASE24174.

The Clinical Efficacy of Anterior Cervical Discectomy and Fusion Under Three-Dimensional Microscopy.

A plethora of studies has substantiated the remarkable clinical efficacy of anterior cervical discectomy and fusion (ACDF) in the treatment of cervical spondylotic myelopathy.1,2 This procedure effectively removes the posterior osteophytes and protruding nucleus pulposus, achieving direct decompression of the spinal cord and effectively alleviating compression symptoms. Concurrently, by distracting the intervertebral space, ACDF contributes to the restoration of the physiological curvature of the cervical spine. However, several pressing issues remain to be addressed during the surgical process. The depth of the surgical field and the lighting conditions often limit the clear identification of the spinal cord and surrounding delicate structures, compounded by the limited operating space and potential interference between the primary surgeon and assistants, all of which may increase surgical risks.3,4 To surmount these challenges, the application of three-dimensional (3D) microscopy in anterior cervical surgery has been proven to be an effective solution. In Video 1, we demonstrate the complete 2-stage ACDF operation under 3D microscopy, where both the primary surgeon and the assistant observe the surgical area through monitors and external screens, ensuring a comfortable posture and good coordination. In our retrospective review, we analyzed 16 ACDF cases aided by 3D microscopy(including both cervical spondylotic myelopathy with disc herniation and cases with spinal instability). Based on the results of the normality test, we use mean (SD) to describe the data. The mean (SD) decompression time was 37.06 (13.30) minutes, with overall surgical duration of 114.56 (18.11) minutes and blood loss of 68.13 (21.36) mL, with no surgically related complications. At the 6-month follow-up, there was a significant improvement in the Japanese Orthopaedic Association score, neck disability index score, visual analog scale score, and C2-7 Cobb angle compared with preoperative values (Japanese Orthopaedic Association from 11.06 [1.00] to 15.38 [1.09], neck disability index from 30.75 [3.49] to 14.81 [2.93], visual analog scale from 5.19 [1.60] to 1.88 [0.96], and C2-7 Cobb angle from 11.97 [4.63] to 15.49 [4.06], respectively; P < 0.05). 3D microscopy-assisted ACDF demonstrated clear advantages in terms of decompression operation time, intraoperative blood loss, exposure and resection of the posterior longitudinal ligament, and complication rate, achieving satisfactory short-term therapeutic outcomes in the treatment of cervical spondylotic myelopathy. Assisted by 3D microscopy, ACDF surgery offers a high-definition visual field that enhances precision, thereby reducing procedural risks and improving clinical outcomes. This technology alleviates the physical strain on surgeons, fosters collaborative teamwork, and facilitates educational exchanges. With a relatively short learning curve, 3D microscopy significantly enhances the safety and efficiency of ACDF procedures.

Revisiting the Posterior Approach for Cervical Radiculopathy Utilizing Endoscopic Techniques: A Favorable Short-Term Outcome and Cost Comparison With Anterior Cervical Discectomy and Fusion.

BACKGROUND: Cervical radiculopathy is a spine ailment frequently requiring surgical decompression via anterior cervical discectomy and fusion (ACDF) or posterior foraminotomy/discectomy. While endoscopic posterior foraminotomy/discectomy is gaining popularity, its financial impact remains understudied despite equivalent randomized long-term outcomes to ACDF. In a cohort of patients undergoing ACDF vs endoscopic posterior cervical foraminotomy/discectomy, we sought to compare the total cost of the surgical episode while confirming an equivalent safety profile and perioperative outcomes. METHODS: A single-center retrospective cohort study of patients with unilateral cervical radiculopathy undergoing ACDF or endoscopic cervical foraminotomy between 2018 and 2023 was undertaken. Primary outcomes included the total cost of care for the initial surgical episode (not charges or reimbursement). Perioperative variables and neurological recovery were recorded. Multivariable analysis tested age, body mass index, race, gender, insurance type, operative time, and length of stay. RESULTS: A total of 38 ACDF and 17 endoscopic foraminotomy/discectomy operations were performed. All patients underwent single-level surgery except for 2 two-level endoscopic decompressions. No differences were found in baseline characteristics and symptom length except for younger age (46.8 ± 9.4 vs 57.6 ± 10.3, P = 0.002) and more smokers (18.4% vs 11.8%, P = 0.043) in the ACDF group. Actual hospital costs for the episode of surgical care were markedly higher in the ACDF cohort (mean ±95% CI; $27,782 ± $2011 vs $10,103 ± $720, P < 0.001) driven by the ACDF approach (ß = $17,723, P < 0.001) on multivariable analysis. On sensitivity analysis, ACDF was never cost-efficient compared with endoscopic foraminotomy, and endoscopic failure rates of 64% were required for break-even cost. ACDF was associated with significantly longer operative time (167.7 ± 22.0 vs 142.7 ± 27.4 minutes, P < 0.001) and length of stay (1.1 ± 0.5 vs 0.1 ± 0.2 days, P < 0.001). No significant difference was found regarding 90-day neurological improvement, readmission, reoperation, or complications. CONCLUSION: Compared with patients treated with a single-level ACDF for unilateral cervical radiculopathy, endoscopic posterior cervical foraminotomy/discectomy can achieve a similar safety profile, pain relief, and neurological recovery at considerably less cost. These findings may help patients and surgeons revisit offering the posterior cervical foraminotomy/discectomy utilizing endoscopic techniques. CLINICAL RELEVANCE: Endoscopic posterior cervical foraminotomy/discectomy offers comparable safety, pain relief, and neurological recovery to traditional methods but at a significantly lower cost.

The Effect of Patient Resilience on Postoperative Scores After One- and Two-Level Anterior Cervical Discectomy and Fusion.

OBJECTIVE: To investigate the association between resilience and outcomes of pain and neck-related disability after single- and double-level anterior cervical discectomy and fusion (ACDF). METHODS: Patients who underwent single- or double-level ACDF were sent a survey between 6 months and 2 years after surgery. The survey included the Brief Resilience Scale (BRS), visual analogue scale (VAS) for pain, Neck Disability Index (NDI), and Pain Self-Efficacy Questionnaire (PSEQ-2). Patients completed the VAS and NDI twice, once describing preoperative pain and disability and once describing current pain and disability. Respondents were classified as high resilience (HR), medium resilience (MR), or low resilience (LR). Demographics, PSEQ-2 scores, pre- and postoperative VAS and NDI scores, and change in VAS (ΔVAS) and NDI (ΔNDI) scores were compared between groups. RESULTS: Thirty-three patients comprised the HR group, 273 patients comprised the MR group, and 47 patients comprised the LR group. All groups demonstrated postoperative improvement in VAS and NDI scores that exceeded previously established MCID values. The HR group demonstrated greater improvement in pain compared with the LR group (ΔVAS: -5.8 for HR vs. -4.4 for LR, P = 0.05). Compared with the MR group, the LR group demonstrated greater postoperative pain (VAS: 3.2 for LR vs. 2.5 for MR, P = 0.02) and disability (NDI: 11.9 for LR vs. 8.6 for MR, P = 0.02). CONCLUSIONS: Patients demonstrated improvement in pain and neck-related disability after single- and double-level ACDF, regardless of resilience score. Patients with greater resilience may be expected to demonstrate more improvement in pain after ACDF.

Monocentric Retrospective Analysis of Clinical Outcomes, Complications, and Adjacent Segment Disease in 507 Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Myelopathy.

BACKGROUND: Degenerative cervical myelopathy (DCM) is a leading cause of nontraumatic spinal cord injury. Surgery aims to arrest neurological decline and improve conditions, but controversies surround risks and benefits in elderly patients, outcomes in mild myelopathy, and the risk of adjacent segment disease (ASD). METHODS: Retrospective data of patients who underwent anterior cervical discectomy and fusion for DCM in our hospital were collected. Patients were stratified by preoperative modified Japanese Orthopaedic Association (mJOA) (mild, moderate, severe) and age (under 70, over 70). Clinical outcomes, complications, and ASD rate were analyzed. We evaluated the relationship between mJOA recovery rate and the risk of complications and various preoperative parameters. RESULTS: Five hundred seven consecutive patients were included in the study, with a mean follow-up of 43.52 months (12-71). Improvement in all outcome variables was observed in mild, moderate, and severe myelopathy categories, with elderly patients showing a lower improvement. Except for age, no other variable correlated with mJOA recovery rate. We observed 45 complications (11.1% of patients), with 14 in the U70 group and 31 in the O70 group (P value < 0.001). Age, Charlson comorbidity index, and ASA score were found to be predictors of complications. Fourteen patients (2.8% of total), mean age 54.2, developed radiological and clinical ASD. Most had cranial-level ASD with Pfirmann grade ≥ 2 before index surgery. CONCLUSIONS: Most myelopathic patients improve after anterior cervical discectomy and fusion. Elderly patients show a lower improvement and higher complication rates than their younger counterparts. ASD rates are low, and younger patients with preexisting cranial level alterations are more susceptible.

Titanium-Coated Polyetheretherketone Cages Vs Full Titanium Cages for Stand-Alone 1- or 2-Level Anterior Cervical Discectomy and Fusion: A Comparative Study.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) for the surgical treatment of cervical degenerative disease often includes an intervertebral cage, which restores disc height and lordosis while promoting fusion . Cage materials include titanium (TTN) or polyetheretherketone (PEEK). Controversy in material selection stems from higher fusion rates with TNN, despite a higher subsidence rate, while PEEK cages demonstrate superior preservation of interspace height. Combining the advantages of both materials, TTN-coated PEEK (TCPEEK) cages were developed, featuring a PEEK core with similar stiffness to the bone, enveloped with a TTN coat, improving osteointegration. However, the potential superiority of TCPEEK over TTN cages has not been investigated. This study aimed to compare clinical and radiographic outcomes following single- or double-level ACDF using either TTN or TCPEEK cages. METHODS: This retrospective single-center study included patients undergoing single- or double-level ACDF between 2017 and 2019. Clinical outcomes included the Neck Disability Index and revision surgery incidence. Radiographic parameters included cervical and segmental lordosis, C2 to C7 sagittal vertical axis, fusion, subsidence, and adjacent segment degeneration at a minimum 12-month follow-up. RESULTS: A total of 45 patients (16 TTN; 29 TCPEEK) and 58 cervical levels (21 TTN; 37 TCPEEK) were included. Both cages significantly improved Neck Disability Index scores (TTN -10.0; TCPEEK -14.1) without significant differences. Two single-level TCPEEK patients required revision surgery due to non-union. In the radiological assessments, no significant difference was found for subsidence rates (TTN 52.4%; TCPEEK 56.8%), adjacent segment degeneration, cervical and segmental lordosis, and changes in C2 to C7 sagittal vertical axis. Though not statistically significant, fusion rates trended slightly higher with TTN (90.5%) vs TCPEEK cages (86.5%). CONCLUSION: TTN and TCPEEK cages achieve satisfactory clinical and radiological outcomes in single- or double-level ACDF. This finding suggests that the choice between them can be based on other factors, such as surgeon preference or availability, rather than specific material properties. CLINICAL RELEVANCE: This study found that the selection of ACDF cage material did not affect clinical outcomes.

Advanced chronic kidney disease increases complications in anterior cervical discectomies with fusions: An analysis of 75,508 patients.

Background: Although anterior cervical discectomy and fusion (ACDF) procedures for cervical spine disease have been increasing amid a growing population of patients with kidney dysfunction, there is a scarcity of literature focusing on kidney dysfunction as a risk-factor for post-operative ACDF complications. The purpose is to evaluate the differential impact of kidney dysfunction on perioperative outcomes including surgical and medical complications, extended length of hospital stay (LOS), and death within 30 days following ACDF. Patient Sample: This was a retrospective cohort study of prospectively collected data using the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who had undergone an elective ACDF procedure between 2011-2021 using Current Procedural Terminology code 22551. Patients were categorized into five cohorts based on eGFR according to the "Kidney Disease: Improving Global Outcomes" Classification: values of: ≥ 90(reference cohort), 60-89 (G2), 30-59 (G3), 15-29 (G4), and <15 (G5). One-way ANOVA for continuous variables and chi-square tests for categorical variables were used to identify differences in perioperative variables between the five groups. Multivariable logistic regression analysis assessed the effect of kidney dysfunction on post-operative surgical outcomes. Significance was defined as p<.05. Results: About 75,508 ACDF patients were included, of who 57,480 were G1, 15,186 were G2, 2,192 were G3, 312 were G4, and 338 were G5. G4 and G5 independently increased the risk of medical complications (OR: 1.893, 95% CI [1.296-2.705]; OR: 2.241, 95% CI [1.222-3.964]) and blood transfusion. Only G5 independently increased the risk for extended LOS (OR: 2.410, 95% CI [1.281-4.371], p=.005). Conclusion: High grade CKD is an independent risk factor for medical complications, extended hospital LOS, and blood transfusions following ACDF, underscoring the importance of risk stratification to optimize perioperative management and reduce the burden of complications and healthcare costs. Conversely, low grade CKD does not increase the risk of complications in ACDF.

Minimally invasive posterior cervical foraminotomy versus anterior cervical fusion and arthroplasty: Systematic review and updated meta-analysis.

Introduction: This study is a systematic review and meta-analysis that investigates the efficacy of different surgical methods for treating cervical disc herniation or cervical foraminal stenosis. Research question: The research aimed to compare the efficacy of Minimally Invasive Posterior Cervical Foraminotomy (MI-PCF) with anterior approaches, namely Anterior Cervical Discectomy and Fusion (ACDF) and Cervical Disc Arthroplasty (CDA). Material and methods: The study included a comprehensive review of eight articles that compared ACDF and MI-PCF, and four articles that compared CDA to MI-PCF. Results: The results indicated no significant difference in surgical duration, hospital stay, complication rates, and reoperation rates between MI-PCF and ACDF. However, when comparing CDA with MI-PCF, it was found that CDA had a higher complication rate, while MI-PCF had a higher reoperation rate. Discussion and conclusion: Despite these findings, the study recommends MI-PCF as the preferred surgical method for cervical radiculopathy, owing to the advancements in minimally invasive techniques. However, these findings are preliminary, and further research with longer follow-up periods and larger sample sizes is necessary to confirm these findings and to further explore the potential advantages and disadvantages of these surgical methods.

Safety of anterior cervical corpectomy and fusion (ACCF) for the treatment of subaxial cervical spine injuries, a single center comparative matched analysis.

INTRODUCTION: Anterior Cervical Discectomy and Fusion (ACDF) and Anterior Cervical Corpectomy and Fusion (ACCF) are both common surgical procedures in the management of pathologies of the subaxial cervical spine. While recent reviews have demonstrated ACCF to provide better decompression results compared to ACDF, the procedure has been associated with increased surgical risks. Nonetheless, the use of ACCF in a traumatic context has been poorly described. The aim of this study was to assess the safety of ACCF as compared to the more commonly performed ACDF. METHODS: All patients undergoing ACCF or ACDF for subaxial cervical spine injuries spanning over 2 disc-spaces and 3 vertebral-levels, between 2006 and 2018, at the study center, were eligible for inclusion. Patients were matched based on age and preoperative ASIA score. RESULTS: After matching, 60 patients were included in the matched analysis, where 30 underwent ACDF and ACCF, respectively. Vertebral body injury was significantly more common in the ACCF group (p = 0.002), while traumatic disc rupture was more frequent in the ACDF group (p = 0.032). There were no statistically significant differences in the rates of surgical complications, including implant failure, wound infection, dysphagia, CSF leakage between the groups (p ≥ 0.05). The rates of revision surgeries (p > 0.999), mortality (p = 0.222), and long-term ASIA scores (p = 0.081) were also similar. CONCLUSION: Results of both unmatched and matched analyses indicate that ACCF has comparable outcomes and no additional risks compared to ACDF. It is thus a safe approach and should be considered for patients with extensive anterior column injury.

(Cost-)effectiveness of personalised multimodal physiotherapy compared to surgery in patients with cervical radiculopathy: A systematic review.

RATIONALE: Cervical radiculopathy is initially typically managed conservatively. Surgery is indicated when conservative management fails or with severe/progressive neurological signs. Personalised multimodal physiotherapy could be a promising conservative strategy. However, aggregated evidence on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with/without post-operative physiotherapy is lacking. AIM/OBJECTIVES: To systematically summarise the literature on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with or without post-operative physiotherapy in patients with cervical radiculopathy. METHODS: PubMed, Embase, CINAHL, PsycINFO and Web of Science were searched from inception to 1st of March 2023. Primary outcomes were effectiveness regarding costs, arm pain intensity and disability. Neck pain intensity, perceived recovery, quality of life, neurological symptoms, range-of-motion, return-to-work, medication use, (re)surgeries and adverse events were considered secondary outcomes. Randomised clinical trials comparing personalised multimodal physiotherapy versus surgical approaches with/without post-operative physiotherapy were included. Two independent reviewers performed study selection, data-extraction, and risk of bias assessment using the Cochrane RoB 2 and Consolidated Health Economic Evaluation Reporting Standards statement. Certainty of the evidence was determined using Grading of Recommendations, Assessment, Development and Evaluations. RESULTS: From 2109 records, eight papers from two original trials, with 117 participants in total were included. Low certainty evidence showed there were no significant differences on arm pain intensity and disability, except for the subscale 'heavy work' related disability (12 months) and disability at 5-8 years. Cost-effectiveness was not assessed. There was low certainty evidence that physiotherapy improved significantly less on neck pain intensity, sensory loss and perceived recovery compared to surgery with/without physiotherapy. Low certainty evidence showed there were no significant differences on numbness, range of motion, medication use, and quality of life. No adverse events were reported. CONCLUSION: Considering the clinical importance of accurate management recommendations and the current low level of certainty, high-quality cost-effectiveness studies are needed.