title: 4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results.
abstract: In the future, there will be an increased number of cervical revision surgeries, including 4- and more-levels. But, there is a paucity of literature concerning the geometrical and clinical outcome in these challenging reconstructions. To contribute to current knowledge, we want to share our experience with 4- and 5-level anterior cervical fusions in 26 cases in sight of a critical review of literature. At index procedure, almost 50% of our patients had previous cervical surgeries performed. Besides failed prior surgeries, indications included degenerative multilevel instability and spondylotic myelopathy with cervical kyphosis. An average of 4.1 levels was instrumented and fused using constrained (26.9%) and non-constrained (73.1%) screw-plate systems. At all, four patients had 3-level corpectomies, and three had additional posterior stabilization and fusion. Mean age of patients at index procedure was 54 years with a mean follow-up intervall of 30.9 months. Preoperative lordosis C2-7 was 6.5 degrees in average, which measured a mean of 15.6 degrees at last follow-up. Postoperative lordosis at fusion block was 14.4 degrees in average, and 13.6 degrees at last follow-up. In 34.6% of patients some kind of postoperative change in construct geometry was observed, but without any catastrophic construct failure. There were two delayed unions, but finally union rate was 100% without any need for the Halo device. Eleven patients (42.3%) showed an excellent outcome, twelve good (46.2%), one fair (3.8%), and two poor (7.7%). The study demonstrated that anterior-only instrumentations following segmental decompressions or use of the hybrid technique with discontinuous corpectomies can avoid the need for posterior supplemental surgery in 4- and 5-level surgeries. However, also the review of literature shows that decreased construct rigidity following more than 2-level corpectomies can demand 360 degrees instrumentation and fusion. Concerning construct rigidity and radiolographic course, constrained plates did better than non-constrained ones. The discussion of our results are accompanied by a detailed review of literature, shedding light on the biomechanical challenges in multilevel cervical procedures and suggests conclusions.
authors.affiliation: German Scoliosis Center, Bad Wildungen, Hessen, Germany. hempfing@yahoo.de
authors.forename: Heiko
authors.initials: H
authors.lastname: Koller
authors.forename: Axel
authors.initials: A
authors.lastname: Hempfing
authors.forename: Luis
authors.initials: L
authors.lastname: Ferraris
authors.forename: Oliver
authors.initials: O
authors.lastname: Maier
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Hitzl
authors.forename: Peter
authors.initials: P
authors.lastname: Metz-Stavenhagen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D019299:Decompression, Surgical / Q000295:instrumentation / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000209:etiology; D011859:Radiography; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013117:Spinal Cord Compression / Q000209:etiology / Q000473:pathology / Q000601:surgery; D013122:Spinal Diseases / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D013123:Spinal Fusion / Q000295:instrumentation / Q000379:methods* / Q000706:statistics & numerical data; D013128:Spinal Osteophytosis / Q000209:etiology / Q000473:pathology / Q000601:surgery; D016896:Treatment Outcome