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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

  • Victor M. Lu
  • Ralph J. Mobbs
  • Bernard Fang
  • Kevin Phan
Review Article

Abstract

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.

Keywords

Stand-alone Zero-profile Plate Anterior cervical discectomy and fusion Two-level 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interests.

Supplementary material

586_2018_5811_MOESM1_ESM.pptx (152 kb)
Supplementary material 1 (PPTX 152 kb)
586_2018_5811_MOESM2_ESM.docx (141 kb)
Supplementary material 2 (DOCX 141 kb)

References

  1. 1.
    Cunningham MR, Hershman S, Bendo J (2010) Systematic review of cohort studies comparing surgical treatments for cervical spondylotic myelopathy. Spine (Phila Pa 1976) 35(5):537–543.  https://doi.org/10.1097/brs.0b013e3181b204cc CrossRefGoogle Scholar
  2. 2.
    Fraser JF, Hartl R (2007) Anterior approaches to fusion of the cervical spine: a metaanalysis of fusion rates. J Neurosurg Spine 6(4):298–303.  https://doi.org/10.3171/spi.2007.6.4.2 CrossRefPubMedGoogle Scholar
  3. 3.
    Rao RD, Gourab K, David KS (2006) Operative treatment of cervical spondylotic myelopathy. J Bone Jt Surg 88(7):1619–1640.  https://doi.org/10.2106/jbjs.f.00014 CrossRefGoogle Scholar
  4. 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
  5. 5.
    Yun DJ, Lee SJ, Park SJ, Oh HS, Lee YJ, Oh HM, Lee SH (2017) Use of a zero-profile device for contiguous 2-level anterior cervical diskectomy and fusion: comparison with cage with plate construct. World Neurosurg 97:189–198.  https://doi.org/10.1016/j.wneu.2016.09.065 CrossRefPubMedGoogle Scholar
  6. 6.
    Song KJ, Taghavi CE, Lee KB, Song JH, Eun JP (2009) The efficacy of plate construct augmentation versus cage alone in anterior cervical fusion. Spine (Phila Pa 1976) 34(26):2886–2892.  https://doi.org/10.1097/brs.0b013e3181b64f2c CrossRefGoogle Scholar
  7. 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
  8. 8.
    Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF, Johnston KW, Grigorian AA, Lee GP, Robinson JS Jr (2007) Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976) 32(21):2310–2317.  https://doi.org/10.1097/brs.0b013e318154c57e CrossRefGoogle Scholar
  9. 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
  10. 10.
    Moher D, Liberati A, Tetzlaff J, Althman D (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PloS Med 6(7):e1000097.  https://doi.org/10.1371/journal.pmed.1000097 CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5(1):13.  https://doi.org/10.1186/1471-2288-5-13 CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Higgins J, Green S (2011) Cochrane handbook for systematic reviews of interventions. Wiley, New YorkGoogle Scholar
  13. 13.
    Wan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14:135.  https://doi.org/10.1186/1471-2288-14-135 CrossRefPubMedPubMedCentralGoogle Scholar
  14. 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
  15. 15.
    Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ Br Med J 327(7414):557–560CrossRefGoogle Scholar
  16. 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. 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
  18. 18.
    Kwon WK, Kim PS, Ahn SY, Song JY, Kim JH, Park YK, Kwon TH, Moon HJ (2017) Analysis of associating factors with C2-7 sagittal vertical axis after two-level anterior cervical fusion. Spine 42(5):318–325.  https://doi.org/10.1097/BRS.0000000000001776 CrossRefPubMedGoogle Scholar
  19. 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. 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. 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
  22. 22.
    Yu J, Ha Y, Shin JJ, Oh JK, Lee CK, Kim KN, Yoon DH (2017) Influence of plate fixation on cervical height and alignment after one- or two-level anterior cervical discectomy and fusion. Br J Neurosurg 32:1–8.  https://doi.org/10.1080/02688697.2017.1394980 CrossRefGoogle Scholar
  23. 23.
    Daffner SD, Wang JC (2009) Anterior cervical fusion: the role of anterior plating. Instr Course Lect 58:689–698PubMedGoogle Scholar
  24. 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. 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. 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
  27. 27.
    Song KS, Piyaskulkaew C, Chuntarapas T, Buchowski JM, Kim HJ, Park MS, Kang H, Riew KD (2014) Dynamic radiographic criteria for detecting pseudarthrosis following anterior cervical arthrodesis. J Bone Jt Surg Am 96(7):557–563.  https://doi.org/10.2106/jbjs.M.00167 CrossRefGoogle Scholar
  28. 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. 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. 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. 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
  32. 32.
    Galbusera F, Bellini CM, Costa F, Assietti R, Fornari M (2008) Anterior cervical fusion: a biomechanical comparison of 4 techniques. Laboratory investigation. J Neurosurg Spine 9(5):444–449.  https://doi.org/10.3171/spi.2008.9.11.444 CrossRefPubMedGoogle Scholar
  33. 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
  34. 34.
    Kim Y-S, Park J-Y, Moon BJ, Kim S-D, Lee J-K (2018) Is stand alone PEEK cage the gold standard in multilevel anterior cervical discectomy and fusion (ACDF)? Results of a minimum 1-year follow up. J Clin Neurosci 47:341–346.  https://doi.org/10.1016/j.jocn.2017.10.022 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Victor M. Lu
    • 1
  • Ralph J. Mobbs
    • 1
    • 2
  • Bernard Fang
    • 3
  • Kevin Phan
    • 1
    • 2
  1. 1.Prince of Wales Clinical SchoolUniversity of New South WalesSydneyAustralia
  2. 2.NeuroSpine Surgery Research Group (NSURG)Prince of Wales Private HospitalSydneyAustralia
  3. 3.Faculty of Medicine, Sydney Medical SchoolUniversity of SydneySydneyAustralia

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