Clinical outcomes of locking stand-alone cage versus anterior plate construct in two-level anterior cervical discectomy and fusion: a systematic review and meta-analysis
Two-level cervical degenerative disc disease (cDDD) can be effectively treated by anterior cervical discectomy and fusion (ACDF) similarly to single-level cDDD. Traditionally an anterior plate construct (APC) approach has been utilized, but ACDF without plate with a locking stand-alone cage (LSC) approach has emerged as an alternative option. The aim of this study was to compare the clinical outcome of LSC and APC in contiguous two-level ACDF used to treat cDDD the current literature.
Searches of seven electronic databases from inception to March 2018 were conducted following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Extracted data were analysed using meta-analysis of proportions.
The nine observational studies that satisfied all criteria described a pooled cohort of 687 contiguous two-level cDDD cases managed by ACDF, with 302 (44%) and 385 (56%) managed by LSC and APC approaches, respectively. When compared with APC, LSC was associated with significantly increased subsidence likelihood (OR 2.75; p < 0.001), greater disc height (MD 0.60 mm; p = 0.04) and reduced cervical lordosis (MD − 2.52°; p = 0.04) at last follow-up. Operative outcomes, fusion rates, functional scores and postoperative dysphagia rates were comparable.
Although significant radiological differences were most evident, the comparability between LSC and APC in contiguous two-level ACDF with respect to all other clinical outcomes does not implicate one approach as clearly superior to the other in two-level ACDF. Larger, randomized studies with longer follow-up are required to delineate outcomes further to validate the findings of this study.
KeywordsStand-alone Zero-profile Plate Anterior cervical discectomy and fusion Two-level
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interests.
- 4.Burkhardt JK, Mannion AF, Marbacher S, Kleinstuck FS, Jeszenszky D, Porchet F (2015) The influence of cervical plate fixation with either autologous bone or cage insertion on radiographic and patient-rated outcomes after two-level anterior cervical discectomy and fusion. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 24(1):113–119. https://doi.org/10.1007/s00586-014-3456-y CrossRefGoogle Scholar
- 7.Nambiar M, Phan K, Cunningham JE, Yang Y, Turner PL, Mobbs R (2017) Locking stand-alone cages versus anterior plate constructs in single-level fusion for degenerative cervical disease: a systematic review and meta-analysis. Eur Spine J 26(9):2258–2266. https://doi.org/10.1007/s00586-017-5015-9 CrossRefPubMedGoogle Scholar
- 9.Barbagallo GM, Romano D, Certo F, Milone P, Albanese V (2013) Zero-P: a new zero-profile cage-plate device for single and multilevel ACDF. A single institution series with 4 years maximum follow-up and review of the literature on zero-profile devices. Eur Spine J 22(Suppl 6):S868–S878. https://doi.org/10.1007/s00586-013-3005-0 CrossRefPubMedGoogle Scholar
- 12.Higgins J, Green S (2011) Cochrane handbook for systematic reviews of interventions. Wiley, New YorkGoogle Scholar
- 14.Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA 283(15):2008–2012CrossRefGoogle Scholar
- 16.Kim MK, Kim SM, Jeon KM, Kim TS (2012) Radiographic comparison of four anterior fusion methods in two level cervical disc diseases: autograft plate fixation versus cage plate fixation versus stand-alone cage fusion versus corpectomy and plate fixation. J Korean Neurosurg Soc 51(3):135–140. https://doi.org/10.3340/jkns.2012.51.3.135 CrossRefPubMedPubMedCentralGoogle Scholar
- 17.Kim SY, Yoon SH, Kim D, Oh CH, Oh S (2017) A prospective study with cage-only or cage-with-plate fixation in anterior cervical discectomy and interbody fusion of one and two levels. J Korean Neurosurg Soc 60(6):691–700. https://doi.org/10.3340/jkns.2017.0211 CrossRefPubMedPubMedCentralGoogle Scholar
- 19.Oh JK, Kim TY, Lee HS, You NK, Choi GH, Yi S, Ha Y, Kim KN, Yoon DH, Shin HC (2013) Stand-alone cervical cages versus anterior cervical plate in 2-level cervical anterior interbody fusion patients: clinical outcomes and radiologic changes. J Spinal Disord Tech 26(8):415–420. https://doi.org/10.1097/BSD.0b013e31824c7d22 CrossRefPubMedGoogle Scholar
- 20.Perrini P, Cagnazzo F, Benedetto N, Morganti R, Gambacciani C (2017) Cage with anterior plating is advantageous over the stand-alone cage for segmental lordosis in the treatment of two-level cervical degenerative spondylopathy: a retrospective study. Clin Neurol Neurosurg 163:27–32. https://doi.org/10.1016/j.clineuro.2017.10.014 CrossRefPubMedGoogle Scholar
- 21.Yang Y, Ma L, Zeng J, Liu H, Hong Y, Wang B, Ding C, Deng Y, Song Y (2016) Comparison of anterior cervical discectomy and fusion with the zero-profile implant and cage-plate implant in treating two-level degenerative cervical spondylosis. Int J Clin Exp Med 9(11):21772–21779Google Scholar
- 24.Park MS, Kelly MP, Lee DH, Min WK, Rahman RK, Riew KD (2014) Sagittal alignment as a predictor of clinical adjacent segment pathology requiring surgery after anterior cervical arthrodesis. Spine J Off J N Am Spine Soc 14(7):1228–1234. https://doi.org/10.1016/j.spinee.2013.09.043 CrossRefGoogle Scholar
- 25.Di Martino A, Papalia R, Albo E, Cortesi L, Denaro L, Denaro V (2015) Cervical spine alignment in disc arthroplasty: should we change our perspective? Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 24(Suppl 7):810–825. https://doi.org/10.1007/s00586-015-4258-6 CrossRefGoogle Scholar
- 26.Janusz P, Tyrakowski M, Yu H, Siemionow K (2016) Reliability of cervical lordosis measurement techniques on long-cassette radiographs. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 25(11):3596–3601. https://doi.org/10.1007/s00586-015-4345-8 CrossRefGoogle Scholar
- 28.Grasso G, Giambartino F, Tomasello G, Iacopino G (2014) Anterior cervical discectomy and fusion with ROI-C peek cage: cervical alignment and patient outcomes. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 23(Suppl 6):650–657. https://doi.org/10.1007/s00586-014-3553-y CrossRefGoogle Scholar
- 29.Veeravagu A, Cole T, Jiang B, Ratliff JK (2014) Revision rates and complication incidence in single- and multilevel anterior cervical discectomy and fusion procedures: an administrative database study. Spine J Off J N Am Spine Soc 14(7):1125–1131. https://doi.org/10.1016/j.spinee.2013.07.474 CrossRefGoogle Scholar
- 30.Basques BA, Louie PK, Mormol J, Khan JM, Movassaghi K, Paul JC, Varthi A, Goldberg EJ, An HS (2018) Multi-versus single-level anterior cervical discectomy and fusion: comparing sagittal alignment, early adjacent segment degeneration, and clinical outcomes. Eur Spine J. https://doi.org/10.1007/s00586-018-5677-y CrossRefPubMedGoogle Scholar
- 31.Scholz M, Schleicher P, Pabst S, Kandziora F (2015) A zero-profile anchored spacer in multilevel cervical anterior interbody fusion: biomechanical comparison to established fixation techniques. Spine (Phila Pa 1976) 40(7):E375–E380. https://doi.org/10.1097/brs.0000000000000768 CrossRefGoogle Scholar
- 33.Bazaz R, Lee MJ, Yoo JU (2002) Incidence of dysphagia after anterior cervical spine surgery: a prospective study. Spine (Phila Pa 1976) 27(22):2453–2458. https://doi.org/10.1097/01.brs.0000031407.52778.4b CrossRefGoogle Scholar