|Year : 2012 | Volume
| Issue : 1 | Page : 31-35
Treatment of cervical radiculopathy by anterior cervical discectomy and cage fusion
Osman A Mohamed1, Samir A Al Shoura1, Fathy H Salama1, Mohamed El-Menawy1, Mostafa A Al-Samee2
1 Department of Orthopedic Surgery, Al-Azhar University, Damietta, Egypt
2 Department of Neuro Surgery, Al-Azhar University, Damietta, Egypt
|Date of Web Publication||20-Jun-2012|
Osman A Mohamed
Department of Orthopedic Surgery, Al-Azhar University, Damietta
Source of Support: None, Conflict of Interest: None
Introduction: Since the pioneering days of the anterior cervical approach introduced by Cloward et al. in the early 1950s, anterior cervical discectomy and fusion (ACDF) has been the standard procedure for most discogenic and degenerative cervical spinal lesions. Although traditional interbody fusion using iliac bone can maintain the patency of the neuroforamen and ensure solid fusion, selection of patients, and of surgical procedure for ACDF is a continuous challenge. Aim: The aim of this study was to assess the results of cervical discectomy and fusion with cervical cages in treatment of cervical radiculopathy clinically and radiologically. Materials and Methods: Eighteen patients suffering from cervical radiculopathy were operated upon using this technique. They were 15 males and 3 females. Clinical and radiological assessment, visual analog scale (VAS) for neck and arm and modified Oswestery neck disability index (NDI) were done preoperatively and at 4 weeks, 3, 6, and 12 months postoperatively. Polyetheretherketone (Peek) cages filled with iliac bone graft were used after cervical discectomy. The levels operated upon were C 5-6 in 16 patients and C4-5 in 2 patients. Results: Marked clinical improvement as regard arm and neck pain, and NDI was observed. The pre and post operative mean and standard deviations (SD) of the various scores were as follows. VAS for pain in arm reduced from mean of 8 (SD 1.76) to mean 0.4 (SD 0.4), VAS for neck pain reduced from mean of 3.5 (SD 1.58) to mean of 0.8 (SD 0.47), and NDI from mean of 20.2 (SD 0.89) to 2.1(SD 1.05). Fusion occurred in all patients. Subjectively 79% of the patients reported marked improvement in neck pain, and 95% reported marked reduction in arm pain. Conclusion: Anterior cervical discectomy and cage fusion resulted in high fusion rate with minimal preservation of lordosis.
Keywords: Anterior cervical discectomy, cage fusion, cervical radiculopathy
|How to cite this article:|
Mohamed OA, Al Shoura SA, Salama FH, El-Menawy M, Al-Samee MA. Treatment of cervical radiculopathy by anterior cervical discectomy and cage fusion. Med J DY Patil Univ 2012;5:31-5
|How to cite this URL:|
Mohamed OA, Al Shoura SA, Salama FH, El-Menawy M, Al-Samee MA. Treatment of cervical radiculopathy by anterior cervical discectomy and cage fusion. Med J DY Patil Univ [serial online] 2012 [cited 2020 Jul 5];5:31-5. Available from: http://www.mjdrdypu.org/text.asp?2012/5/1/31/97509
| Introduction|| |
During the past several decades, ACDF has been shown to be an effective treatment for upper-extremity radicular pain, axial neck pain, and myelopathic symptoms related to degenerative disease of the cervical spine. Success rates of the procedure have been reported as high as 90 to 95%. ,
Anterior cervical discectomy (ACD) has been established as a safe and effective procedure for the treatment of degenerative disk disease. This approach allows direct visualization of the disk space and the anterior aspect of the spinal cord. Interbody fusion following ACD for treatment of cervical radiculopathy is thought to have several advantages compared with discectomy alone. ,,
Cervical cages involve a process known as "local autograft" to provide for bony fusion. During the implantation process, bone is gathered from drill reamings and placed within the cage. ,, They are hollow implants that restore physiological disk height, allowing bone growth within and around them, thus stimulating bone fusion. They have been developed to prevent disk collapse. ,,,
The present study was designed to evaluate the rate of arthrodesis and successful clinical outcome when anterior cervical interbody fusion was performed using Peek interbody fusion cage in degenerative disease.
| Materials and Methods|| |
This study was done from 2005 to 2007, 18 patients were operated upon (15 males and 3 females), with their age ranging from 47 to 67 years old with the mean age 57 years old. They were operated upon by ACD and interbody fusion with Peek cage. The duration of follow up ranged from 16 to 24 months with the mean 18 months.
The selected patients were those with severe pain and decreased motor power less than grade 4, decreased disk height, osteophyte formation with failure of conservative treatment.
Patients with cervical myelopathy, osteoporosis, cervical instability, and psychosomatic disorders were excluded. Patients with neuropathies and peripheral compression were also excluded.
Preoperative protocol included proper history and clinical examination. Plain X-rays and MRI were done for all patients. The patients were also screened for respiratory and cardiovascular disorders, besides diabetes and other chronic diseases.
All the selected patients had neck and arm pain with sensory deficit. Only one patient had gross motor symptoms. They were evaluated according to visual analog scale (VAS) which is a ten point scale and Oswestry neck disability index (NDI).
Postoperative radiological follow up was done to see the position of the cage, its migration or subsidence to superior or inferior end plates of the adjacent vertebral body.
X-ray was also done to see the degree of fusion. Standard radiographs were assessed for lucencies in the immediate vicinity of the implant. Fusion was assumed when there was less than 2° of motion on lateral flexion − extension views and if less than 50% of the anteroposterior distance of the interface between the endplates and the implants was radiolucent.
The level of surgery was C5-6 in 16 patients, and C4-5 in 2 patients. The patient was placed supine on the operating table with a sandbag between the shoulders blades to ensure extension of the neck. The patient's head was turned away from the planned incision to provide good access to the neck. A left transverse skin incision from the middle line to the posterior border of the sternomastoid muscle was made. The platysma was split vertically using the tip of the fingers. Anterior border of sternomastoid muscle was identified, then the fascia anterior to it was incised and the sternomastoid muscle retracted laterally and the sternohyoid, sternothyroid with the underlying oesophagus, and trachea medially. The carotid artery was palpated, and a plane between it and the midline structures was developed, cutting the pretracheal fascia and retracting the sheath and the sternomastoid laterally. The cervical vertebrae were visible now, covered by longus coli muscle and the prevertebral fascia. Using cautery, the longus coli muscle was split longitudinally over the midline of the vertebral bodies then dissected subperiosteally with the anterior longitudinal ligament. Level to be operated was localized with a needle and lateral radiograph. The disk was incised with a blade, and decompression was done through removal of all disk material and both endplates. Spurs were exised by a high speed burr. The cage was filled with cancellous iliac bone graft with special instrument that allows percutaneous harvesting. Then the distractor was used, the cage put in the disk space, and then distractor was removed to check for stability. The platysma and skin were closed over a suction drain. Postoperatively hard collar was used.
| Results|| |
Fusion occurred in all patients clinically and radiologically. There was marked improvment in VAS scores for neck and arm pain and also in NDI, as shown in [Table 1]. There was also improvement of sensory symptoms in all the cases. Pre-operative X-ray/MRI and post-operative X-ray appearances are shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4] and [Figure 5].
|Figure 1: Plain X-ray A P View taken pre-operatively showing C5 - C6 disk degeneration and compression|
Click here to view
|Figure 2: Plain X-Ray lateral view taken pre-operatively showing C5 - C6 disk degeneration and compression|
Click here to view
|Figure 3: MRI taken pre-operatively showing C5 - C6 disk degeneration and compression|
Click here to view
|Figure 4: Post operative A P view showing PEEK cage in C5 - C6 disk space|
Click here to view
|Figure 5: Post operative lateral view showing PEEK cage in C5 - C6 disk space|
Click here to view
Loss of lordosis occurred in 15 patients, while in 1 patient there was displacement of the cage after 1 month anteriorly, which was managed by replacing with bigger sized one.
| Discussion|| |
In this study, the fusion rates at 6 and 12 month follow-ups among patients who underwent ACDF with PEEK cages and autogenous bone grafts were significantly excellent. Rather, our result echoed the results of a study by Cho et al.,  who found that the fusion rate was better, and that fusion occurred sooner in patients who underwent ACD with PEEK fusion. ACD is a standard neurosurgical treatment for myelopathy and radiculopathy. ,,,
Smith and Robinson's original discectomy method preserved the end plate and posterior longitudinal ligament (PLL). In recent years, several surgeons have modified this surgical technique to achieve more extensive decompression and to enhance the rate of fusion. ,
In our study, we applied a specially designed 1-mm disk punch, a high-speed drill to remove the disk, PLL, and uncinate osteophyte. The posterior border of the vertebral body was tunneled for adequate cord decompression, and a foraminotomy was performed for nerve root decompression. ,,
In 1988, Bagby described the principle of distraction compression, the basic principle of stand-alone intervertebral cage fusion. 
PEEK cages have two titanium spikes on the upper and lower frames, which dig into the vertebral bodies to aid cage fixation.
The PEEK cages also have retention teeth on the surfaces of the upper and lower frames to reduce cage dislodgement and to offer a fixation mechanism, similar to the function of a plate and screw. These features might contribute to fixation and promote early fusion. ,
Techniques to achieve more extensive decompression and to enhance the rate of fusion have been described. ,,
PEEK is a semicrystalline polyaromatic linear polymer that provides a good combination of strength, stiffness, toughness, and environmental resistance. The elastic modulus of the PEEK cage is close to that of bone, which helps to decrease stress shielding and increase bony fusion. The PEEK cage has a deleterious influence on cell attachment and growth and exhibits a stimulatory effect on the protein content of osteoblasts. 
Some surgeons believe that anterior fusion after discectomy is not necessary.  In a randomized study of one level anterior cervical surgery, Savolainen reported that outcomes were similar for patients who underwent simple discectomy and those who underwent discectomy and fusion, they also found a higher incidece of kyphosis. 
Wilson and Campbell reported good or excellent outcomes after anterior cervical decompression alone in 85% of their series. 
Martins reported good outcome after anterior cervical decompression and fusion but 10% of the patients who underwent simple discectomy developed kyphosis. 
Lowery and McDonough have reported a hardware failure rate of 35% in a series of 133 patients and a pseudoarthrosis rate of 31% in index procedures, despite the fact that the hardware appeared intact. 
Savolainen reported a slightly better 6-months fusion rate in patients who underwent plate assisted fusion compared with those in whom plates were not used. 
The present study had a number of limitations. It was a case series with a limited sample size of 18 cases, with no control group. The efficacy of the procedure can only be well established if it can be compared with an equivalent control group managed with conservative treatment. The follow-up evaluation was not done by an independant investigator but by the operating surgeons which might have introduced some observer bias. With better resources, more rigorous studies can be undertaken in the future.
| Conclusion|| |
Anterior cervical decompression and Peek cage fusion is a good option in treatment of cervical radiculopathy, it gives a good chance of fusion rate. Selection of the patients and preoperative preparation is very important. Patients with myelopathy, osteoporosis, cervical instability, and patients received corticosteroids should be excluded. Lordosis is not maintained; thus, additional anterior plate fixation gives better results.
| References|| |
|1.||Robinson RA. Fusions of the cervical spine. J Bone Joint Surg Am 1959;41:1-6. |
|2.||Smith GW, Robinson RA. The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am 1958;40:607-24. |
|3.||Robinson R, Smith G. Anterior lateral disc removal and interbody fusion for cervical disc syndrome. Bull Johns Hopkins Hosp 1955;69:223-4. |
|4.||Cloward RB. The anterior approach for removal of ruptured cervical disks. J Neurosurg 1958;15:602-17. |
|5.||Wigfield CC, Nelson RJ. Nonautologous interbody fusion materials in cervical spine surgery: How strong is the evidence to justify their use? Spine (Phila Pa 1976) 2001;26:687-94. |
|6.||Malloy KM, Hilibrand AS. Autograft versus allograft in degenerative cervical disease. Clin Orthop Relat Res 2002;394:27-38. |
|7.||Zdeblick TA, Ducker TB. The use of freeze-dried allograft bone for anterior cervical fusions. Spine (Phila Pa 1976) 1991;16:726-9. |
|8.||Zdeblick TA, Phillips FM. Interbody cage devices. Spine (Phila Pa 1976) 2003;28:S2-7. |
|9.||Savolainen S, Rinne J, Hernesniemi J. Aprospective randomized study of anterior single level cervical disc operations with long- term follow up:surgical fusion is unnecessary. Neurosurgery 1998;43:51-5. |
|10.||Moreland DB, Asch HL, Clabeaux DE, Castiglia GJ, Czajka GA, Lewis PJ, et al. Anterior cervical discectomy and fusion with implantable titanium cage: Initial impressions, patient outcomes and comparison to fusion with allograft. Spine J 2004;4:184-91. discussion 191. |
|11.||Schmieder K, Wolzik-Grossmann M, Pechlivanis I, Engelhardt M, Scholz M, Harders A. Subsidence of the wing titanium cage after anterior cervical interbody fusion: 2-year followup study. J Neurosurg Spine 2006;4:447-53. |
|12.||Cho DY, Lee WY, Sheu PC. Treatment of multilevel cervical fusion with cages. Surg Neurol 2004;62:378-85. discussion 385-6. |
|13.||Wilson DH, Campbell DD. Anterior cervical discectomy without bone graft. Report of 71 cases. J Neurosurg 1977;47:551-5. |
|14.||Martins AN. Anterior cervical discectomy with and without interbody bone graft. J Neurosurg 1976;44:290-5. |
|15.||Baba H, Furusawa N, Tanaka Y, Wada M, Imura S, Tomita K. Anterior decompression and fusion for cervical myeloradiculopathy secondary to ossification of the posterior ligament. Int Orthop 1994;18:204-9. |
|16.||Baba H, Furusawa N, Imura S, Kawahara N, Tsuchiya H, Tomita K. Late radiographic findings after anterior cervical fusion for spondylotic myeloradiculopathy. Spine (Phila Pa 1976) 1993;18:2167-73. |
|17.||Pan YH, Cheng CY, Chen SY, Lin J F, Chiou T L, Chen WF, et al. Complications of multilevel anterior cervical fusion. Tzu Chi Med J 2004;16:79-84. |
|18.||Matge G. Cervical cage fusion with 5 different implants: 250 cases. Acta Neurochir (Wien) 2002;144:539-49. discussion 550. |
|19.||Bagby GW. Arthrodesis by the distraction-compression method using a stainless steel implant. Orthopedics 1988;11:931-4. |
|20.||Lowery GL, McDonough RF. The significance of hardware failure in anterior cervical plate fixation. Patients with 2-7 years follow up. Spine (Phila Pa 1976) 1998;15:181-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]