Comparison of Three Reconstructive Techniques in the Surgical Management of Patients With Four-Level Cervical Spondylotic Myelopathy.
METHODS
Retrospective clinical series.


OBJECTIVE
To compare perioperative parameters, clinical outcomes, radiographic parameters, and complication rates of three reconstructive techniques after the anterior decompression of four-level cervical spondylotic myelopathy (CSM).


BACKGROUND
At present, the decision to treat multilevel CSM, especially four-level CSM, remains controversial. No one compares multilevel anterior cervical discectomy and fusion (mACDF), segmental anterior cervical corpectomy and fusion (sACCF) to multilevel anterior cervical discectomy and fusion with cage alone (mACDF-CA) in four-level constructs.


METHODS
Between July 2006 and February 2014, 97 consecutive patients with four-level CSM were enrolled in this study and divided into sACCF (n = 39) group, mACDF (n = 31) group, and mACDF-CA (n = 27) group. The study compared perioperative parameters, complication rates, clinical and radiologic parameters of three reconstructive techniques after the anterior decompression of four-level CSM.


RESULTS
The mACDF-CA group had the least bleeding and cost of index surgery compared with the sACCF group having the most bleeding and cost. Although significant pain relief and functional activity improvement have been achieved in the three groups at the final follow-up, there was no significant difference in the Japanese Orthopedic Association, SF-36 and NDI scores among the three groups (P >0.05). The mACDF group maintained the best cervical lordosis at the final follow-up, compared with the sACCF group maintained the worst cervical lordosis. Solid fusion was achieved in 87.1% of subjects in sACCF group, 90.3% in mACDF, and in 88.9% in mACDF-CA. The mACDF-CA group had a higher rate of subsidence and lower rate of dysphagia than other two groups.


CONCLUSIONS
mACDF-CA can be considered an effective and safe alternative procedure in the treatment of the four-level CSM.


METHODS
4.
Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing, The People's Republic of China.|Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, The People's Republic of China.
Zhonghai
Z
Li
Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing, The People's Republic of China.
Huadong
H
Wang
Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing, The People's Republic of China.
Jiaguang
J
Tang
Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing, The People's Republic of China.
Dongfeng
D
Ren
Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing, The People's Republic of China.
Li
L
Li
Department of Orthopaedics, First Affiliated Hospital of PLA General Hospital, Beijing, The People's Republic of China.
Shuxun
S
Hou
Department of Orthopedics, Tenth People's Hospital of TongJi University, Shanghai, The People's Republic of China.
Hailong
H
Zhang
Department of Orthopedics, Tenth People's Hospital of TongJi University, Shanghai, The People's Republic of China.
Tiesheng
T
Hou
D000328:Adult; D002574:Cervical Vertebrae / Q000601:surgery*; D019299:Decompression, Surgical / Q000379:methods; D017586:Diskectomy / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000379:methods; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000379:methods; D013128:Spinal Osteophytosis / Q000601:surgery; D055009:Spondylosis / Q000601:surgery*; D016896:Treatment Outcome
Chacko AG, Joseph M, Turel MK, et al. Multilevel oblique corpectomy for cervical spondylotic myelopathy preserves segmental motion. Eur Spine J 2012; 21:1360–1367.
Liu Y, Hou Y, Yang L, et al. Comparison of 3 reconstructive techniques in the surgical management of multilevel cervical spondylotic myelopathy. Spine (Phila Pa 1976) 2012; 37:E1450–E1458.
Song KJ, Lee KB, Song JH. Efficacy of multilevel anterior cervical discectomy and fusion versus corpectomy and fusion for multilevel cervical spondylotic myelopathy: a minimum 5-year follow-up study. Eur Spine J 2012; 21:1551–1557.
Liu Y, Qi M, Chen H, et al. Comparative analysis of complications of different reconstructive techniques following anterior decompression for multilevel cervical spondylotic myelopathy. EurSpine J 2012; 21:2428–2435.
Li F, Li Z, Huang X, et al. Comparison of two reconstructive techniques in the surgical management of four-level cervical spondylotic myelopathy. Biomed Res Int 2015; 2015:513906.
Li Z, Huang J, Zhang Z, et al. A Comparison of Multilevel Anterior Cervical Discectomy and Corpectomy in Patients with 4-level Cervical Spondylotic Myelopathy: A Minimum 2-year Follow-up Study. Clin Spine Surg 2016; [Epub ahead of print] PMID: 25353205 DOI: 10.1097/BSD.0000000000000212.
Li Z, Guo Z, Hou S, et al. Segmental anterior cervical corpectomy and fusion with preservation of middle vertebrae in the surgical management of 4-level cervical spondylotic myelopathy. Eur Spine J 2014; 23:1472–1479.
Dalbayrak S, Yilmaz M, Naderi S. Skip corpectomy in the treatment of multilevel cervical spondylotic myelopathy and ossified posterior longitudinal ligament. J Neurosurg Spine 2010; 12:33–38.
Wei-bing X, Wun-Jer S, Gang L, et al. Reconstructive techniques study after anterior decompression of multilevel cervical spondylotic myelopathy. J Spinal Disord Tech 2009; 22:511–515.
Odate S, Shikata J, Kimura H, et al. Hybrid Decompression and Fixation Technique Versus Plated 3-Vertebra Corpectomy for 4-Segment Cervical Myelopathy: Analysis of 81 Cases With a Minimum 2-Year Follow-Up. Clin Spine Surg 2016; 29:226–233. PMID: 23168392 DOI: 10.1097/BSD.0b013e31827ada3.
Ashkenazi E, Smorgick Y, Rand N, et al. Anterior decompression combined with corpectomies and discectomies in the management of multilevel cervical myelopathy: a hybrid decompression and fixation technique. J Neurosurg Spine 2005; 3:205–209.
Oh MC, Zhang HY, Park JY, et al. Two-level anterior cervical discectomy versus one-level corpectomy in cervical spondylotic myelopathy. Spine (Phila Pa 1976) 2009; 34:692–696.
Yalamanchili PK, Vives MJ, Chaudhary SB. Cervical spondylotic myelopathy: factors in choosing the surgical approach. Adv Orthop 2012; 2012:783762.
Hirabayashi K, Bohlman HH. Multilevel cervical spondylosis. Laminoplasty versus anterior decompression. Spine (Phila Pa 1976) 1995; 20:1732–1734.
Hee HT, Majd ME, Holt RT, et al. Complications of multilevel cervical corpectomies and reconstruction with titanium cages and anterior plating. J Spinal Disord Tech 2003; 16:1–8.
Nakase H, Park YS, Kimura H, et al. Complications and long-term follow-up results in titanium mesh cage reconstruction after cervical corpectomy. J Spinal Disord Tech 2006; 19:353–357.
Wang JC, Hart RA, Emery SE, et al. Graft migration or displacement after multilevel cervical corpectomy and strut grafting. Spine (Phila Pa 1976) 2003; 28:1016–1021.
Vaccaro AR, Falatyn SP, Scuderi GJ, et al. Early failure of long segment anterior cervical plate fixation. J Spinal Disord 1998; 11:410–415.
Daubs MD. Early failures following cervical corpectomy reconstruction with titanium mesh cages and anterior plating. Spine (Phila Pa 1976) 2005; 30:1402–1406.
Shunzhi Y, Zhonghai L, Fengning L, et al. Surgical management of 4-level cervical spondylotic myelopathy. Orthopedics 2013; 36:e613–e620. PMID: 23672914 DOI: 10.3928/01477447-20130426-24.
Fujibayashi S, Shikata J, Kamiya N, et al. Missing anterior cervical plate and screws: a case report. Spine (Phila Pa 1976) 2000; 25:2258–2261.
Fountas KN, Kapsalaki EZ, Nikolakakos LG, et al. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976) 2007; 32:2310–2317.
Jung A, Schramm J. How to reduce recurrent laryngeal nerve palsy in anterior cervical spine surgery: a prospective observational study. Neurosurgery 2010; 67:10–15.
Jung A, Schramm J, Lehnerdt K, et al. Recurrent laryngeal nerve palsy during anterior cervical spine surgery: a prospective study. J Neurosurg Spine 2005; 2:123–127.
Cagli S, Isik HS, Zileli M. Cervical screw missing secondary to delayed esophageal fistula: case report. Turk Neurosurg 2009; 19:437–440.
Pitzen TR, Chrobok J, Stulik J, et al. Implant complications, fusion, loss of lordosis, and outcome after anterior cervical plating with dynamic or rigid plates: two-year results of a multi-centric, randomized, controlled study. Spine (Phila Pa 1976) 2009; 34:641–646.
Huang SL, Yan HW, Wang KZ. Use of Fidji cervical cage in the treatment of cervical spinal cord injury without radiographic abnormality. Biomed Res Int 2013; 2013:810172.
Lin Q, Zhou X, Wang X, et al. A comparison of anterior cervical discectomy and corpectomy in patients with multilevel cervical spondylotic myelopathy. Euro Spine J 2012; 21:474–481.
Shunzhi Y, Zhonghai L, Fengning L, et al. Surgical management of 4-level cervical spondylotic myelopathy. Orthopedics 2013; 36:e613–e620.
Chang SW, Kakarla UK, Maughan PH, et al. Four-level anterior cervical discectomy and fusion with plate fixation: radiographic and clinical results. Neurosurgery 2010; 66:639–646.
King JT Jr, Roberts MS. Validity and reliability of the Short Form-36 in cervical spondylotic myelopathy. J Neurosurg 2002; 97:180–185.
Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther 1991; 14:409–415.
Yonenobu K, Abumi K, Nagata K, et al. Interobserver and intraobserver reliability of the japanese orthopaedic association scoring system for evaluation of cervical compression myelopathy. Spine (Phila Pa 1976) 2001; 26:1890–1894.
Odom GL, Finney W, Woodhall B. Cervical disk lesions. J Am Med Assoc 1958; 166:23–28.
Bazaz R, Lee MJ, Yoo JU. Incidence of dysphagia after anterior cervical spine surgery: a prospective study. Spine (Phila Pa 1976) 2002; 27:2453–2458.
Gercek E, Arlet V, Delisle J, et al. Subsidence of stand-alone cervical cages in anterior interbody fusion: warning. Eur Spine J 2003; 12:513–516.
Koller H, Hempfing A, Ferraris L, et al. 4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results. Euro Spine J 2007; 16:2055–2071.
Sayana MK, Jamil H, Poynton A. Cervical laminoplasty for multilevel cervical myelopathy. Adv Orthop 2011; 2011:241729.
Manzano GR, Casella G, Wang MY, et al. A prospective, randomized trial comparing expansile cervical laminoplasty and cervical laminectomy and fusion for multilevel cervical myelopathy. Neurosurgery 2012; 70:264–277.
Bapat MR, Chaudhary K, Sharma A, et al. Surgical approach to cervical spondylotic myelopathy on the basis of radiological patterns of compression: prospective analysis of 129 cases. Eur Spine J 2008; 17:1651–1663.
Thorell W, Cooper J, Hellbusch L, et al. The long-term clinical outcome of patients undergoing anterior cervical discectomy with and without intervertebral bone graft placement. Neurosurgery 1998; 43:268–273.
Murphy MA, Trimble MB, Piedmonte MR, et al. Changes in the cervical foraminal area after anterior discectomy with and without a graft. Neurosurgery 1994; 34:93–96.
Emery SE, Bolesta MJ, Banks MA, et al. Robinson anterior cervical fusion comparison of the standard and modified techniques. Spine (Phila Pa 1976) 1994; 19:660–663.
Hilibrand AS, Fye MA, Emery SE, et al. Increased rate of arthrodesis with strut grafting after multilevel anterior cervical decompression. Spine (Phila Pa 1976) 2002; 27:146–151.
Fujibayashi S, Neo M, Nakamura T. Stand-alone interbody cage versus anterior cervical plate for treatment of cervical disc herniation: sequential changes in cage subsidence. J Clin Neurosci 2008; 15:1017–1022.
Anakwenze OA, Auerbach JD, Milby AH, et al. Sagittal cervical alignment after cervical disc arthroplasty and anterior cervical discectomy and fusion: results of a prospective, randomized, controlled trial. Spine (Phila Pa 1976) 2009; 34:2001–2007.
Smith JS, Shaffrey CI, Lafage V, et al. Spontaneous improvement of cervical alignment after correction of global sagittal balance following pedicle subtraction osteotomy. J Neurosurg Spine 2012; 17:300–307.
Villavicencio AT, Babuska JM, Ashton A, et al. Prospective, randomized, double-blind clinical study evaluating the correlation of clinical outcomes and cervical sagittal alignment. Neurosurgery 2011; 68:1309–1316.
Ferch RD, Shad A, Cadoux-Hudson TA, et al. Anterior correction of cervical kyphotic deformity: effects on myelopathy, neck pain, and sagittal alignment. J Neurosurg 2004; 100:13–19.
Flynn TB. Neurologic complications of anterior cervical interbody fusion. Spine (Phila Pa 1976) 1982; 7:536–539.
Frempong-Boadu A, Houten JK, Osborn B, et al. Swallowing and speech dysfunction in patients undergoing anterior cervical discectomy and fusion: a prospective, objective preoperative and postoperative assessment. J Spinal Disord Tech 2002; 15:362–368.
Kriskovich MD, Apfelbaum RI, Haller JR. Vocal fold paralysis after anterior cervical spine surgery: incidence, mechanism, and prevention of injury. Laryngoscope 2000; 110:1467–1473.
Lee MJ, Bazaz R, Furey CG, et al. Influence of anterior cervical plate design on dysphagia: a 2-year prospective longitudinal follow-up study. J Spinal Disord Tech 2005; 18:406–409.
Min Y, Kim WS, Kang SS, et al. Incidence of Dysphagia and Serial Videofluoroscopic Swallow Study Findings After Anterior Cervical Discectomy and Fusion: A Prospective Study. Clin Spine Surg 2016; 29:E177–E181. PMID: 24326242 DOI: 10.1097/BSD.0000000000000060.
Park HW, Lee JK, Moon SJ, et al. The efficacy of the synthetic interbody cage and Grafton for anterior cervical fusion. Spine (Phila Pa 1976) 2009; 34:E591–E595.
Wu WJ, Jiang LS, Liang Y, et al. Cage subsidence does not, but cervical lordosis improvement does affect the long-term results of anterior cervical fusion with stand-alone cage for degenerative cervical disc disease: a retrospective study. Europ Spine J 2012; 21:1374–1382.
Hacker RJ, Cauthen JC, Gilbert TJ, et al. A prospective randomized multicenter clinical evaluation of an anterior cervical fusion cage. Spine (Phila Pa 1976) 2000; 25:2646–2654.
Schmieder K, Wolzik-Grossmann M, Pechlivanis I, et al. Subsidence of the wing titanium cage after anterior cervical interbody fusion: 2-year follow-up study. J Neurosurg Spine 2006; 4:447–453.