title: Is cervical disc arthroplasty good for congenital cervical stenosis?
abstract: OBJECTIVE Cervical disc arthroplasty (CDA) has been demonstrated to be as safe and effective as anterior cervical discectomy and fusion (ACDF) in the management of 1- and 2-level degenerative disc disease (DDD). However, there has been a lack of data to address the fundamental discrepancy between the two surgeries (CDA vs ACDF), and preservation versus elimination of motion, in the management of cervical myelopathy associated with congenital cervical stenosis (CCS). Although younger patients tend to benefit more from motion preservation, it is uncertain if CCS caused by multilevel DDD can be treated safely with CDA. METHODS Consecutive patients who underwent 3-level anterior cervical discectomy were retrospectively reviewed. Inclusion criteria were age less than 50 years, CCS (Pavlov ratio ≤ 0.82), symptomatic myelopathy correlated with DDD, and stenosis limited to 3 levels of the subaxial cervical (C3-7) spine. Exclusion criteria were ossification of the posterior longitudinal ligament, previous posterior decompression surgery (e.g., laminoplasty or laminectomy), osteoporosis, previous trauma, or other rheumatic diseases that might have caused the cervical myelopathy. All these patients who underwent 3-level discectomy were divided into 2 groups according to the strategies of management: preservation or elimination of motion (the hybrid-CDA group and the ACDF group). The hybrid-CDA group underwent 2-level CDA plus 1-level ACDF, whereas the ACDF group underwent 3-level ACDF. Clinical assessment was measured by the visual analog scales (VAS) for neck and arm pain, Japanese Orthopaedic Association (JOA) scores, and Nurick grades. Radiographic outcomes were measured using dynamic radiographs for evaluation of range of motion (ROM). RESULTS Thirty-seven patients, with a mean (± SD) age of 44.57 ± 5.10 years, were included in the final analysis. There was a male predominance in this series (78.4%, 29 male patients), and the mean follow-up duration was 2.37 ± 1.60 years. There were 20 patients in the hybrid-CDA group, and 17 in the ACDF group. Both groups demonstrated similar clinical improvement at 2 years' follow-up. These patients with 3-level stenosis experienced significant improvement after either type of surgery (hybrid-CDA and ACDF). There were no significant differences between the 2 groups at each of the follow-up visits postoperatively. The preoperative ROM over the operated subaxial levels was similar between both groups (21.9° vs 21.67°; p = 0.94). Postoperatively, the hybrid-CDA group had significantly greater ROM (10.65° vs 2.19°; p < 0.001) than the ACDF group. Complications, adverse events, and reoperations in both groups were similarly low. CONCLUSIONS Hybrid-CDA yielded similar clinical improvement to 3-level ACDF in patients with myelopathy caused by CCS. In this relatively young group of patients, hybrid-CDA demonstrated significantly more ROM than 3-level ACDF without adjacent-segment disease (ASD) at 2 years' follow-up. Therefore, hybrid-CDA appears to be an acceptable option in the management of CCS. The strategy of motion preservation yielded similar improvements of cervical myelopathy to motion elimination (i.e., ACDF) in patients with CCS, while the theoretical benefit of reducing ASD required further validation.
authors.affiliation: Department of Neurosurgery, Neurological Institute, and.|School of Medicine, and.
authors.forename: Peng-Yuan
authors.initials: PY
authors.lastname: Chang
authors.affiliation: Department of Neurosurgery, Neurological Institute, and.|School of Medicine, and.
authors.forename: Hsuan-Kan
authors.initials: HK
authors.lastname: Chang
authors.affiliation: Department of Neurosurgery, Neurological Institute, and.|School of Medicine, and.
authors.forename: Jau-Ching
authors.initials: JC
authors.lastname: Wu
authors.affiliation: Department of Neurosurgery, Neurological Institute, and.|School of Medicine, and.
authors.forename: Wen-Cheng
authors.initials: WC
authors.lastname: Huang
authors.affiliation: Department of Neurosurgery, Neurological Institute, and.|School of Medicine, and.|Institute of Pharmacology, National Yang-Ming University; and.
authors.forename: Li-Yu
authors.initials: LY
authors.lastname: Fay
authors.affiliation: Department of Neurosurgery, Neurological Institute, and.|School of Medicine, and.|Molecular Medicine Program, International Graduate Program, Academia Sinica, Taipei, Taiwan.
authors.forename: Tsung-Hsi
authors.initials: TH
authors.lastname: Tu
authors.affiliation: Department of Radiology, Taipei Veterans General Hospital.|School of Medicine, and.
authors.forename: Ching-Lan
authors.initials: CL
authors.lastname: Wu
authors.affiliation: Department of Neurosurgery, Neurological Institute, and.|Department of Radiology, Taipei Veterans General Hospital.|School of Medicine, and.
authors.forename: Henrich
authors.initials: H
authors.lastname: Cheng
mesh_terms: D000328:Adult; D001178:Arthroplasty; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D017586:Diskectomy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007403:Intervertebral Disc / Q000000981:diagnostic imaging / Q000601:surgery*; D055959:Intervertebral Disc Degeneration / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019547:Neck Pain / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D010147:Pain Measurement; D012189:Retrospective Studies; D013118:Spinal Cord Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D013123:Spinal Fusion; D013130:Spinal Stenosis / Q000151:congenital* / Q000601:surgery*; D016896:Treatment Outcome
keywords: ACDF = anterior cervical discectomy and fusion; ASD = adjacent-segment disease; CCS = congenital cervical stenosis; CDA = cervical disc arthroplasty; CSM = cervical spondylotic myelopathy; DDD = degenerative disc disease; IDE = Investigational Device Exemption; JOA = Japanese Orthopaedic Association; Pavlov ratio; ROM = range of motion; SC = spinal canal; SCI = spinal cord injury; Torg ratio; VAS = visual analog scale; VB = vertebral body; anterior cervical discectomy and fusion; cervical disc arthroplasty; cervical hybrid arthroplasty; cervical myelopathy; cervical spondylotic myelopathy; congenital cervical stenosis