|Year : 2019 | Volume
| Issue : 1 | Page : 28-32
Clinical presentation and outcome after anterior cervical discectomy and fusion for degenerative cervical disc disease
Ninad N Srikhande1, V A. Kiran Kumar1, NA Sai Kiran1, Amrita Ghosh2, Ranabir Pal3, Luis Rafael Moscote-Salazar4, V Anil Kumar5, Vishnu Vardhan Reddy1, Amit Agrawal1
1 Department of Neurosurgery, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
2 Department of Biochemistry, Calcutta Medical College, Kolkata, West Bengal, India
3 Department of Community Medicine, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
4 Department of Neurosurgery Critical Care, RED LATINO, Organización Latinoamericana De Trauma Y Cuidado, Neurointensivo, Bogota, Colombia
5 Department of Anesthesia, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
|Date of Web Publication||9-Apr-2019|
Dr. N A Sai Kiran
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Anterior cervical discectomy and fusion (ACDF) is a well-described surgical approach for symptomatic degenerative cervical disc disease which does not respond to conservative management. In the present study, we assessed clinical presentation and outcomes of ACDF.
Materials and Methods: The present study was conducted from October 1, 2015, to October 31, 2017, in the Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, among 100 consecutive adult patients who underwent single- or two-level ACDF for degenerative cervical disc disease.
Results: The mean age was 47.2 ± 12.8 years (range: 20–74 years). Majority of the patients were male (86/100). Presenting symptoms were neck pain (77%), limb weakness (73%), paresthesias (53%), radicular pain (49%), stiffness in limbs (16%), and bladder involvement (13%). Fusion was done with stand-alone titanium cage/bone graft or titanium cage/bone graft with anterior cervical plate. At the time of discharge, significant improvement in preoperative symptoms (neck pain [47/77-61%], radicular pain [31/49-63%], limb weakness [53/73-72.6%], paresthesias [44/53-83%], stiffness in limbs [13/16-81%], and bladder symptoms [8/13-61%]) was reported by majority of these patients. Majority of these patients also reported improvement in preoperative sensory deficits at the time of discharge. Postoperative complications were hoarseness of voice (22%), dysphagia (16%), deterioration of motor power (8%), and postoperative hematoma (7%).
Conclusions: A significant proportion of patients with degenerative cervical disc disease show remarkable recovery after ACDF.
Keywords: Anterior cervical discectomy, cervical radiculopathy, fusion
|How to cite this article:|
Srikhande NN, Kumar V A, Sai Kiran N A, Ghosh A, Pal R, Moscote-Salazar LR, Kumar V A, Reddy VV, Agrawal A. Clinical presentation and outcome after anterior cervical discectomy and fusion for degenerative cervical disc disease. J Craniovert Jun Spine 2019;10:28-32
|How to cite this URL:|
Srikhande NN, Kumar V A, Sai Kiran N A, Ghosh A, Pal R, Moscote-Salazar LR, Kumar V A, Reddy VV, Agrawal A. Clinical presentation and outcome after anterior cervical discectomy and fusion for degenerative cervical disc disease. J Craniovert Jun Spine [serial online] 2019 [cited 2019 Apr 23];10:28-32. Available from: http://www.jcvjs.com/text.asp?2019/10/1/28/255733
| Introduction|| |
Cervical pain associated with cervical degenerative disc disease can be incapacitating and can compromise the quality of life. It has been shown that on magnetic resonance imaging, many adults can have cervical degenerative disc disease without any associated clinical symptoms., Conservative management is the initial preferred management for symptomatic patients with degenerative cervical disc disease. Majority of the patients respond well to conservative management. Anterior cervical discectomy and fusion (ACDF) has been recommended for the subgroup of patients who do not respond to the conservative management.,,,, In well-selected group of patients (i.e., significant radicular pain, younger age, single-level soft disc, male gender, nonsmokers, matching radiological and clinical findings, and well-preserved neurological functions), ACDF has been shown to be associated with good outcome., In the present study, we assessed clinical presentation and outcomes following ACDF for cervical degenerative disc disease.
| Materials and Methods|| |
The present study was conducted from October 1, 2015, to October 31, 2017, in the Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, after approval from the Institutional Ethical Committee. Hundred consecutive adult patients who underwent anterior cervical discectomy for single- or two-level discectomy with fusion for degenerative cervical disc diseases operated during this period were included in the study. Patients with traumatic spine injuries who underwent corpectomy/>2-level discectomies were excluded from the study.
Data were entered into the Microsoft Excel sheet, and interpretation was done using statistical software SPSS Statistics Version 24.0 (IBM, Armonk, New York, USA). The data were expressed using descriptive statistics such as mean and standard deviation for continuous variables and frequency and percentage for categorical variables. Chi-square test was used to find the significance of categorical data. P < 0.05 was considered statistically significant.
| Results|| |
Clinical and radiographic details are summarized in [Table 1]. The mean age was 47 years (range: 20–74 years). Majority of the patients were in the age group of 41–60 years (54%). Presenting symptoms were neck pain (77%), limb weakness (73%), paresthesias (53%), radicular pain (49%), stiffness in limbs (16%), and bladder involvement (13%). History of smoking was recorded in 35 patients and alcohol consumption in 30 patients. Most common level for degenerative cervical disc disease was C3–4 (31%). Single-level ACDF was done in 95 patients and two-level ACDF in 5 patients [Table 1]. Fusion was done with stand-alone titanium cage/bone graft or titanium cage/bone graft with anterior cervical plate. At the time of discharge, significant improvement in preoperative symptoms (neck pain [47/77-61%], radicular pain [31/49-63%], limb weakness [53/73-72.6%], paresthesias [44/53-83%], stiffness in limbs [13/16-81%], and bladder symptoms [8/13-61%]) was reported by majority of these patients. Improvement in the preoperative symptoms and new postoperative symptoms is summarized in [Table 2]. Majority of the patients also reported improvement in their preoperative sensory deficits [Table 3]. Postoperative complications were hoarseness of voice (22%), dysphagia (16%), deterioration of motor power (8%), and postoperative hematoma (7%).
|Table 1: Age, gender distribution, and level of cervical degenerative disease|
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|Table 2: Evaluation of symptoms pre- and postoperatively following anterior cervical discectomy and fusion|
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|Table 3: Evaluation of sensory deficits in the upper and lower limbs pre- and postoperatively following anterior cervical discectomy and fusion|
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| Discussion|| |
Cervical disc degeneration and subsequent herniation can lead to spinal cord or nerve root compression with resultant myelopathy and/or radiculopathy. Cervical degenerative disc disease is most commonly reported in middle-age group (35–55 years)., Majority of the patients in this study were in the age group of 41–60 years. Increasing age has been shown to be associated increased risk of 30-day postoperative complications and also is an independent risk factor for increased morbidity and increased stay in hospital.,,, Males are more prone to develop cervical degenerative disc disease.,,,,,,, Higher incidence of spondylosis changes in population with increasing age and in males was reported by Sasaki et al. Higher incidence of cervical degenerative disc disease in males was also reported by Hukuda and Kojima Indian studies have also reported that age and gender are important risk factors for having cervical spondylosis. In our study, majority of the patients were male (86%) and in the age group of 41–60 years (54%). The most frequently levels for cervical disc herniation to occur are C4/5, C5/6, and C6/7. However, in our study, majority of the patients (31/100%–31%) had degenerative disc disease at C3–4 level.
Smoking is an important risk factor for cervical disc degeneration and can also affect the postoperative outcome.,,,,, Grisdela et al. found that patients who were smokers had cervical disc degeneration (with or without myelopathy) more frequently and at younger age than those who did not smoke. Smoking increases the rate of perioperative complications such as infection, adjacent segment disease, and dysphagia.,,,, Smoking adversely affects bony fusion and increases the chances of pseudoarthrosis.,,,,, Thus, it is mandatory to know the smoking habit of the patient with cervical disc degeneration before surgery. Measures such as nicotine replacement therapy and use of bone morphogenetic proteins during surgery can be considered to improve the outcome after surgery. Alcohol use is associated with increased risk of degenerative cervical disc disease and its consequences. Alcohol intake can be dangerous in patients with cervical degenerative disc disease with canal stenosis as cervical spine may not be properly supported after alcohol intake due to the muscle relaxant action of alcohol.
Postoperative complications ranging from 4.4% to as high as 20% are reported following ACDF.,,,,, Postoperative complications following ACDF reported include injury to esophagus/trachea/vascular/neural structures, wound hematoma, wound infection, bone graft extrusion, instrumentation failure, pseudoarthrosis, etc.,,,,, Various immediate postoperative complications observed in this study were hoarseness of voice, dysphagia, local infection, wound hematoma, transient motor power deterioration, and radicular pain. Tsuzuki et al. reported that C5 radiculopathy may occur after both anterior and posterior approaches to the cervical spine. Infection rates following ACDF were low (may be due to rich vascular supply); however, literature suggest that poor surgical technique and inadequate wound care can increase the risk of wound infection.,,,, The most dreaded complication associated with anterior cervical spine surgery is wound hematoma (incidence ranges from 0.2% to 1.9%) which can result in potentially fatal airway compromise.,,,, In the present study, we used drain for at least initial 24 h following surgery to avoid this potentially fatal complication. Majority of the patients report a significant improvement in preoperative symptoms such as neck pain, radicular pain, and motor/sensory deficits following ACDF.,,,, However, few patients may report new symptoms (such as neck/radicular pain and paresthesias, which were not present preoperatively) after ACDF, as also noted in the present study.,,,, Majority of these postoperative symptoms respond well to conservative treatment.,,,,
| Conclusions|| |
A significant proportion of patients with degenerative cervical disc disease show remarkable recovery after ACDF.
The present work is a part of the dissertation and was submitted to the Dr. NTR University of Health Sciences, Vijayawada.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
de Bruin F, Ter Horst S, van den Berg R, de Hooge M, van Gaalen F, Fagerli KM, et al
. Signal intensity loss of the intervertebral discs in the cervical spine of young patients on fluid sensitive sequences. Skeletal Radiol 2016;45:375-81.
Teraguchi M, Yoshimura N, Hashizume H, Muraki S, Yamada H, Minamide A, et al.
Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: The wakayama spine study. Osteoarthritis Cartilage 2014;22:104-10.
Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain 1994;117:325-35.
Jacobs W, Willems PC, van Limbeek J, Bartels R, Pavlov P, Anderson PG, et al.
Single or double-level anterior interbody fusion techniques for cervical degenerative disc disease. Cochrane Database Syst Rev 2011. doi: 10.1002/14651858.CD004958.
Cepoiu-Martin M, Faris P, Lorenzetti D, Prefontaine E, Noseworthy T, Sutherland L, et al.
Artificial cervical disc arthroplasty: A systematic review. Spine (Phila Pa 1976) 2011;36:E1623-33.
Cloward RB. The anterior approach for removal of ruptured cervical disks. J Neurosurg 1958;15:602-17.
Robinson RA. Fusions of the cervical spine. J Bone Joint Surg Am 1959;41-A:1-6.
Smith GW, Robinson RA. The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am 1958;40-A:607-24.
Anderson PA, Subach BR, Riew KD. Predictors of outcome after anterior cervical discectomy and fusion: A multivariate analysis. Spine (Phila Pa 1976) 2009;34:161-6.
Peolsson A, Peolsson M. Predictive factors for long-term outcome of anterior cervical decompression and fusion: A multivariate data analysis. Eur Spine J 2008;17:406-14.
Czervionke LF, Fenton DS. Imaging painful spine disorders. 1st ed. Philadelphia: Elsevier Health Sciences; 2011.
Somani S, Di Capua J, Kim JH, Kim J, Levon DM, Lee NJ, et al
. ASA as a risk factor following anterior cervical discectomy and fusion (ACDF). Spine J 2016;16:S360-1.
Di Capua J, Somani S, Kim JS, Phan K, Lee NJ, Kothari P, et al.
Elderly age as a risk factor for 30-day postoperative outcomes following elective anterior cervical discectomy and fusion. Global Spine J 2017;7:425-31.
Buerba RA, Giles E, Webb ML, Fu MC, Gvozdyev B, Grauer JN, et al.
Increased risk of complications after anterior cervical discectomy and fusion in the elderly: An analysis of 6253 patients in the american college of surgeons national surgical quality improvement program database. Spine (Phila Pa 1976) 2014;39:2062-9.
Arnold PM, Rice LR, Anderson KK, McMahon JK, Connelly LM, Norvell DC, et al.
Factors affecting hospital length of stay following anterior cervical discectomy and fusion. Evid Based Spine Care J 2011;2:11-8.
Gruskay JF, Buerba R, Basques B, Bohl D, Webb M, Grauer JN. Factors Predicting Complications and Length of Stay Following Elective Cervical Discectomy and Fusion. New Orleans, LA: North American Spine Society; 2013.
Basques BA, Hijji FY, Khechen B, Haws BE, Mayo BC, Massel DH, et al
. Sex differences for anterior cervical fusion: Complications and length of stay. Spine (Phila Pa 1976) 2018;43:1025-30.
Sasaki T, Kadoya S, Iizuka H. Roentgenological study of the sagittal diameter of the cervical spinal canal in normal adult Japanese. Neurol Med Chir (Tokyo) 1998;38:83-8.
Hukuda S, Kojima Y. Sex discrepancy in the canal/body ratio of the cervical spine implicating the prevalence of cervical myelopathy in men. Spine (Phila Pa 1976) 2002;27:250-3.
Singh S, Kumar D, Kumar S. Risk factors in cervical spondylosis. J Clin Orthop Trauma 2014;5:221-6.
Gupta SK, Roy RC, Srivastava A. Sagittal diameter of the cervical canal in normal Indian adults. Clin Radiol 1982;33:681-5.
Lee HM, Kim NH, Kim HJ, Chung IH. Mid-sagittal canal diameter and vertebral body/canal ratio of the cervical spine in Koreans. Yonsei Med J 1994;35:446-52.
Liguoro D, Vandermeersch B, Guérin J. Dimensions of cervical vertebral bodies according to age and sex. Surg Radiol Anat 1994;16:149-55.
Wiegand R, Kettner NW, Brahee D, Marquina N. Cervical spine geometry correlated to cervical degenerative disease in a symptomatic group. J Manipulative Physiol Ther 2003;26:341-6.
Berman D, Oren JH, Bendo J, Spivak J. The effect of smoking on spinal fusion. Int J Spine Surg 2017;11:29.
Chung HY, Machado P, van der Heijde D, D'Agostino MA, Dougados M. Smokers in early axial spondyloarthritis have earlier disease onset, more disease activity, inflammation and damage, and poorer function and health-related quality of life: Results from the DESIR cohort. Ann Rheum Dis 2012;71:809-16.
Schroeder GD, Kepler CK, Hilibrand AS. The effect of smoking on patients having spinal surgery. Curr Orthop Pract 2016;27:140-5.
Jha P, Ramasundarahettige C, Landsman V, Rostron B, Thun M, Anderson RN, et al.
-century hazards of smoking and benefits of cessation in the United States. N Engl J Med 2013;368:341-50.
Jr., Buser Z, D'Oro A, Paholpak P, Liu JC, Wang JC, et al.
Trends analysis of surgical procedures for cervical degenerative disc disease and myelopathy in patients with tobacco use disorder. Eur Spine J 2017;26:2386-92.
Flynn TB. Neurologic complications of anterior cervical interbody fusion. Spine (Phila Pa 1976) 1982;7:536-9.
Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF, Johnston KW, Grigorian AA, et al.
Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976) 2007;32:2310-7.
Jones SJ, Buonamassa S, Crockard HA. Two cases of quadriparesis following anterior cervical discectomy, with normal perioperative somatosensory evoked potentials. J Neurol Neurosurg Psychiatry 2003;74:273-6.
Kelleher MO, Tan G, Sarjeant R, Fehlings MG. Predictive value of intraoperative neurophysiological monitoring during cervical spine surgery: A prospective analysis of 1055 consecutive patients. J Neurosurg Spine 2008;8:215-21.
Khan MH, Smith PN, Balzer JR, Crammond D, Welch WC, Gerszten P, et al.
Intraoperative somatosensory evoked potential monitoring during cervical spine corpectomy surgery: Experience with 508 cases. Spine (Phila Pa 1976) 2006;31:E105-13.
Lee JY, Hilibrand AS, Lim MR, Zavatsky J, Zeiller S, Schwartz DM, et al.
Characterization of neurophysiologic alerts during anterior cervical spine surgery. Spine (Phila Pa 1976) 2006;31:1916-22.
Bohlman HH, Emery SE, Goodfellow DB, Jones PK. Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one hundred and twenty-two patients. J Bone Joint Surg Am 1993;75:1298-307.
Brigham CD, Tsahakis PJ. Anterior cervical foraminotomy and fusion. Surgical technique and results. Spine (Phila Pa 1976) 1995;20:766-70.
Heidecke V, Rainov NG, Marx T, Burkert W. Outcome in cloward anterior fusion for degenerative cervical spinal disease. Acta Neurochir (Wien) 2000;142:283-91.
Pointillart V, Cernier A, Vital JM, Senegas J. Anterior discectomy without interbody fusion for cervical disc herniation. Eur Spine J 1995;4:45-51.
Nandoe Tewarie RD, Bartels RH, Peul WC. Long-term outcome after anterior cervical discectomy without fusion. Eur Spine J 2007;16:1411-6.
Baron EM, Soliman AM, Gaughan JP, Simpson L, Young WF. Dysphagia, hoarseness, and unilateral true vocal fold motion impairment following anterior cervical diskectomy and fusion. Ann Otol Rhinol Laryngol 2003;112:921-6.
Apfelbaum RI, Kriskovich MD, Haller JR. On the incidence, cause, and prevention of recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine (Phila Pa 1976) 2000;25:2906-12.
Kraus DR, Stauffer ES. Spinal cord injury as a complication of elective anterior cervical fusion. Clin Orthop Relat Res 1975;112:130-41.
Tsuzuki N, Abe R, Saiki K, Okai K. Paralysis of the arm after posterior decompression of the cervical spinal cord. II. Analyses of clinical findings. Eur Spine J 1993;2:197-202.
Christiano LD, Goldstein IM. Late prevertebral abscess after anterior cervical fusion. Spine (Phila Pa 1976) 2011;36:E798-802.
Kulkarni AG, Hee HT. Adjacent level discitis after anterior cervical discectomy and fusion (ACDF): A case report. Eur Spine J 2006;15 Suppl 5:559-63.
Levi AD, Dickman CA, Sonntag VK. Management of postoperative infections after spinal instrumentation. J Neurosurg 1997;86:975-80.
Pompili A, Canitano S, Caroli F, Caterino M, Crecco M, Raus L, et al
. Asymptomatic esophageal perforation caused by late screw migration after anterior cervical plating: Report of a case and review of relevant literature. Spine (Phila Pa 1976) 2002;27:E499-502.
Darouiche RO. Spinal epidural abscess. N Engl J Med 2006;355:2012-20.
Marotta N, Landi A, Tarantino R, Mancarella C, Ruggeri A, Delfini R, et al.
Five-year outcome of stand-alone fusion using carbon cages in cervical disc arthrosis. Eur Spine J 2011;20 Suppl 1:S8-12.
Bertalanffy H, Eggert HR. Complications of anterior cervical discectomy without fusion in 450 consecutive patients. Acta Neurochir (Wien) 1989;99:41-50.
Emery SE, Bohlman HH, Bolesta MJ, Jones PK. Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-up. J Bone Joint Surg Am 1998;80:941-51.
Tew JM Jr., Mayfield FH. Complications of surgery of the anterior cervical spine. Clin Neurosurg 1976;23:424-34.
Palumbo MA, Aidlen JP, Daniels AH, Thakur NA, Caiati J. Airway compromise due to wound hematoma following anterior cervical spine surgery. Open Orthop J 2012;6:108-13.
Hacker RJ, Cauthen JC, Gilbert TJ, Griffith SL. A prospective randomized multicenter clinical evaluation of an anterior cervical fusion cage. Spine (Phila Pa 1976) 2000;25:2646-54.
Jagannathan J, Shaffrey CI, Oskouian RJ, Dumont AS, Herrold C, Sansur CA, et al.
Radiographic and clinical outcomes following single-level anterior cervical discectomy and allograft fusion without plate placement or cervical collar. J Neurosurg Spine 2008;8:420-8.
[Table 1], [Table 2], [Table 3]