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No correlation between radiological and clinical outcome 1 year following cervical arthrodesis

  • Original Article - Neurosurgery Training
  • Published:
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Abstract

Aim

To correlate clinical and radiological outcome following one- and two-level anterior cervical discectomy and fusion (ACDF) with stand-alone polyetheretherketone (PEEK) cages filled with demineralized bone matrix (DBM).

Methods

We performed a retrospective review of a consecutive patient cohort with degenerative disc disease that underwent ACDF with stand-alone PEEK cages filled with demineralized bone matrix (DBM) between 2010 and 2013 with a minimum follow-up of 12 months. Changes in the operated segments were measured and compared to radiographs directly after surgery. Clinical outcome was evaluated by a physical examination, pain by visual analog scale (VAS) for arm and neck. Health-related quality of life was measured using the EuroQOL questionnaire (EQ-5D).

Results

Of 282 consecutive cases, follow-up data were obtained from 194 (69%) cases. The median age at presentation was 54 years and 91 patients were male (46%). Ninety-eight and 96 patients had one- and two-level surgeries, respectively. Mean VAS pain was reduced from 5.2 ± 3.6 to 2.6 ± 2.4 (p < 0.001) and from 5.8 ± 3.3 to 2.1 ± 2.7 (p < 0.001) in the myelopathy and radiculopathy group, respectively. Fusion was achieved in 79 and 82% of segments in one- and two-level surgeries, respectively. Cervical alignment was better in 10 and 1%, similar in 68 and 76%, worse in 23 and 23% in one- and two-level surgeries, respectively. Subsidence was observed in 44 and 34% of segments in one- and two-level surgeries, respectively. Follow-up operations due to symptomatic adjacent disc disease or implant failure were needed in 13 (7%) and 15 (8%) of cases, respectively. Subsidence, adjacent disc disease, and cervical alignment all had no influence on the clinical outcome.

Conclusions

The clinical outcome after ACDF with PEEK cages filled with demineralized bone matrix is highly satisfactory. Radiological signs of non-fusion, subsidence, and cervical alignment have no influence on clinical outcome.

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Funding

The study was completely financed by the Department of Neurosurgery.

Author information

Authors and Affiliations

  1. Neurochirurgische Klinische und Poliklinik, Technische Universität München, Munich, Germany

    Ehab Shiban, Moritz Nies, Johann Kogler, Lorenz Kogler, Bernhard Meyer & Jens Lehmberg

  2. Serviço de Neurocirurgia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal

    Pedro Ribeiro da Cunha

Authors
  1. Ehab Shiban
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  2. Moritz Nies
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  3. Johann Kogler
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  4. Lorenz Kogler
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  5. Pedro Ribeiro da Cunha
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  6. Bernhard Meyer
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  7. Jens Lehmberg
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Corresponding author

Correspondence to Ehab Shiban.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The institutional review board and ethics committee approved of all study protocols (Project number: 5250/11). For this type of study, formal consent is not required.

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Comments

There is an ongoing debate on the importance of the radiological outcome for the clinical success in spine surgery and specifically in anterior cervical surgery. In our visually dominated world, not only radiologists but also spine surgeons and even patients focus on X-ray parameters.

ACDF is intended to achieve direct decompression, to reestablish cervical alignment, and to additionally allow indirect decompression of neural structures by reconstruction of the intervertebral height using cages. Most importantly, ACDF is a stabilizing procedure that is thought to eliminate further symptoms originating from this segment by achieving fusion.

This explains why US surgeons still use anterior plating with extra costs and potential complications practically for all their cases, although there is evidence that stand-alone cages do just as well especially in monosegmental disease. In contrast, intervertebral PMMA has been used in the past with great clinical success for decades in Germany regardless of hindering fusion and promoting pseudarthrosis.

Dr. Shiban’s study reminds us of the lack of correlation between the radiological outcome and the clinical result of surgery in a large cohort of mono- and bisegmental ACDF cases. Nevertheless, the debate will continue: Is plating beneficial? Is the cage material and/or cage surface relevant? Do we need to fill the cages? With autologous bone? With bone substitutes, etc.? The presented results, however, provide further evidence that stand-alone PEEK cages are an adequate solution.

We have to be aware, that poor outcome after spine surgery is multifactorial and especially psychosocial factors, but also adjacent degenerative changes cannot be adequately controlled. Duration of symptoms also seems to be an important parameter. In unsuccessful cases, spine surgeons tend to focus on cage subsidence, cervical malalignment and most importantly pseudarthrosis and promote revision surgery. This is the easy road to follow and may be the way to go, as patients clearly demand “correction of their suboptimal images.” It often won’t, however, solve our patients’ problems.

Claudius Thome

Tirol, Austria

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Shiban, E., Nies, M., Kogler, J. et al. No correlation between radiological and clinical outcome 1 year following cervical arthrodesis. Acta Neurochir 160, 845–853 (2018). https://doi.org/10.1007/s00701-018-3495-y

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  • DOI: https://doi.org/10.1007/s00701-018-3495-y

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