title: Vertebral body fracture after anterior cervical discectomy and fusion with zero-profile anchored cages in adjacent levels: a cautionary tale.
abstract: Zero-profile (also called self-locking, anchored or stand-alone cages) have been recently proposed as an interesting alternative for anterior cervical discectomy and fusion (ACDF), as they are supposed to reduce the rates of post-operative cage extrusion without necessarily incurring in the additional surgical time and increased rates of dysphagia associated with plating. Nevertheless, the exact indications of zero-profile anchored cages have not yet been established in the literature.
  
  
  
  To report the first case of a vertebral body fracture between the blades of zero-profile anchored cages after ACDFs in adjacent levels and to review the available literature on hardware-related complications after multi-level ACDFs with zero-profile anchored cages.
  
  
  
  Case report and systematic literature review.
  
  
  
  The authors report the first case of a vertebral body fracture between the blades of zero-profile anchored cages after ACDFs in adjacent levels. The patient presented with refractory mechanical neck pain at the 1-month post-operative follow-up, ultimately requiring a posterior instrumented fusion. A comprehensive systematic literature review on the available data regarding the safety, complications as well as radiological and clinical outcomes of zero-profile anchored cages is also performed.
  
  
  
  In the reported case, the use of zero-profile anchored cages in adjacent levels on the cervical spine led to a fracture of the vertebral body between the cages at the 1-month follow-up, with anterior avulsion of the part of the vertebral body where the blades from the two cages converged. According to the systematic literature review which included 409 patients from 10 different clinical series (with a total cumulative follow-up of approximately 535 patients-year), there were only two reported hardware-related complications after ACDF with zero-profile anchored cages, none of them involving fracture at the level of convergence of blades or screws.
  
  
  
  Although hardware-related complications after the use of zero-profile anchored cages seem to be rare events, future biomechanical and clinical studies are warranted in order to evaluate the safety of employing such devices for the treatment of multilevel degenerative disc disease in the cervical spine.
authors.affiliation: Department of Neurosurgery, Brain and Spine Center/InvisionHealth, 400 International Drive, Buffalo, NY, 14221, USA. tmattei@invisionhealth.com.
authors.forename: Tobias A
authors.initials: TA
authors.lastname: Mattei
authors.affiliation: Neurosurgery Unit, Hospital São José-Santa Casa de Porto Alegre, Porto Alegre, Brazil.
authors.forename: Alisson R
authors.initials: AR
authors.lastname: Teles
authors.affiliation: Department of Neurosurgery, The University of Illinois at Peoria, Peoria, IL, USA.
authors.forename: Dzung H
authors.initials: DH
authors.lastname: Dinh
mesh_terms: D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery; D003680:Deglutition Disorders; D017586:Diskectomy / Q000009:adverse effects; D006801:Humans; D013123:Spinal Fusion / Q000009:adverse effects; D000083442:Vertebral Body
keywords: Anchored cages; Anterior cervical discectomy and fusion; Anterior cervical plating; Self-locking cages; Zero-profile cages