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Back to Physician Literature CLINICAL OUTCOMES AFTER
CERVICAL SPINE FUSION
Cameron B. Huckell, MD The advent of sterile technique, modem anesthesia, and organized industrial society allowed great advances and widespread use of cervical arthrodesis for a variety of disorders.
In the second half of the 20th century, techniques were developed that refined the anterior cervical fusion. Anterior cervical spine fusion was made popular by Smith and Robinson,44 and Cloward14
in 1958. Twelve years later, Orozco-Delclos and Llovet-Tapies36
added internal fixation using screws and plates to add stability and prevent graft migration in trauma. This article defines expected outcome for cervical arthrodesis used to treat degenerative disease, trauma, deformity, and a variety of other disorders.
The goal of this article is challenging because methods for evaluating interventions change over time. With the advent of more rigorous techniques to evaluate the success of medical interventions, surgeons have
only recently begun applying more objective techniques to measure the results of cervical fusion. Most of outcome data have been obtained and evaluated using idiosyncratic methods specific to each author. Surgeons may
draw conclusions by comparing two retrospective reviews that have only superficial similarities. This method of reasoning is inherently flawed, and it may lead to unreliable conclusions. Surgeons have started to use
validated outcome surveys such as the SF-36 and Oswestry questionnaire to measure clinical success. Although these measurement methods are excellent at comparing a wide variety of interventions, they are often not
focused enough to answer a specific question about a problem. Many conditions are so rare that they can be evaluated only based on anecdotal reports. Multicenter trials may meet this challenge.
Measuring outcome
is affected by diagnosis, technique, patient selection, and methods of reporting and evaluation. Those disorders with a good natural history often have the best clinical results regardless of the treatment. Errors in
outcome measurement may be caused by errors in diagnosis and errors in measurement of clinical and radiographic data. Commercial, legal, and ethical issues can skew results. Any conclusions drawn must be critically
evaluated.
Most surgical advancements have been made by small stepwise improvements learned by surgeons that have been passed on to others through mentoring programs. The major factors that have led to a general
improvement in the quality of care of many cervical spinal conditions are experience; an understanding of anatomy, physiology, and basic science; and frequent exchange of information by informed experts. The goal of
objectively evaluating surgical success or failure is essential.
SURGICAL APPROACH
Surgeons debate advantages of the anterior or posterior approach. A logical approach is to deal with the pathology at
its offending site. Most spine surgeons can comfortably approach the spine via either method. The factors that determine the approach are the type of lesion, degree of instability, neurologic deficit, and need for
decompression. The anterior approach is less disruptive to the neck musculature than the posterior approach, but they are both safe with low morbidities. Anterior arthrodesis through an anterior approach can be
adequately performed from C2-T2 in most circumstances.39
Anterior decompression can be performed if indicated. There are natural tissue planes in the anterior approach that minimize the disruption and denervation of the muscles controlling neck movement compared with the posterior approach. There is a small risk, however, of voice change that is due to temporary recurrent laryngeal nerve dysfunction, but this usually resolves.
10, 40, 44 Swallowing difficulties occur with anterior exposure in the postoperative period, most resolve by 3 months.10, 40, 44
In the case of trauma, the disruption is frequently posterior, and repair often involves posterior intervention'; there are exceptions to this when there is an associated disc herniation and anterior decompression is required.
1, 15
If there is an anterior compressive lesion, it has been well shown that incomplete or complete neurologic injuries secondary to cervical trauma improve even after late anterior decompression, the complete cervical cord lesions recover an average of two cervical nerve root levels, and the incomplete lesions may recover significant motor function.
5,9
Controversy surrounds the use of an anterior or posterior approach in the treatment of multilevel cervical spinal stenosis, but present literature suggests that anterior cervical decompression and
fusion is the procedure of choice for multiple-level spondylitic radiculopathy over both laminectomy and laminoplasty.25
Often the surgeon's comfort determines the approach. 1f there is associated kyphosis with the cervical spinal stenosis, most surgeons agree that an anterior approach is indicated.51
Rare instances of severe pathology require a combined anterior and posterior approach (Fig. 1).30
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Figure 1. A quadriparetic 45-year-old man with cervical spinal stenosis and an associated kyphotic deformity. A, Sagittal midline T-2 weighted MRimage. B, Axial T-2 weighted image.
DEFINITION OF CLINICAL AND RADIOGRAPHIC OUTCOME
There is no widely used standard outcome tool for measuring
clinical success in cervical spinal fusion. Presently the Cervical Spine Research Society is attempting to define a survey for such a use in determining the effectiveness of the anterior arthrodesis and
clinical success. Some authors are starting to use the SF-36, but this does not help evaluate arthrodesis status, and clinical success and arthrodesis status do not always correlate.10 The status of the
arthrodesis is also a source of great controversy because there is no wide agreement on the definition of arthrodesis in the literature, and this measure of outcome does not always relate to clinical
success. One might think that access to large government and insurance databases would clarify treatment issues, but they contain coding errors, and they are often unreliable for determining outcome.17
PHARMACOLOGIC AND ELECTRICAL FACTORS AFFECTING OUTCOME
Smoking is widely believed to accelerate degenerative disc disease by interfering with the nutrition of the disc,45 and it is known to
inhibit spinal arthrodesis.42 It has been proven that nicotine inhibits spinal fusion in an experimental rabbit model, and it is known that clinical pseudarthrosis rates for many types of cervical arthrodesis
are higher in smokers than nonsmokers, and animal studies have shown that nicotine inhibits the incorporation of cancellous bone graft.38 Many types of nonsteroidal anti-inflammatory drugs
(NSAIDs) inhibit and delay bone formation, and it has been shown that ketorolac increases pseudarthrosis rates by a factor of five in instrumented spinal fusion, indicating that it should not be used as
a postoperative analgesic.21 Undoubtedly, many agents used to control rheumatoid arthritis affect fusion rates.12 Methotrexate is known to inhibit growth of tissues undergoing rapid growth and
mitosis by inhibiting DNA synthesis; therefore, it also probably inhibits spinal fusion, and it should probably be discontinued in the perioperative period. The effect of alendronate (Fosamax) on spinal
fusion has not been examined in detail, but it is known to affect bone metabolism by reducing bone resorption.7 Electrical factors may play a role in spinal fusion, but no author has shown that it
affects clinical outcome in cervical spinal fusion.
BONE GRAFTING MATERIALS AND BONE GRAFT SUBSTITUTES
The best material presently available for use in cervical fusion is
autogenous cancellous bone, and it is usually taken from the iliac crest. Autograft iliac crest and fibulas have achieved consistently higher fusion rates than allograft in multiple-level cervical fusions.19, 50
The problem with this autogenous material is that it requires a second painful incision, and there is donor site morbidity. Some are starting to use processed bone substitutes in anterior cervical
fusion, but allograft combined with demineralized bone matrix has been found to be far inferior to the gold standard of autograft; the allograft is quite brittle and at risk to fracture and resorb.4 There are
new bone-grafting materials and bone morphogenetic proteins that are still in the development stages. No author has yet shown that these materials improve clinical outcome in cervical arthrodesis.
DESCRIPTION OF TECHNIQUES
Anterior
There are several widely used anterior techniques to obtain fusions, and clinical outcomes, radiographic fusion rates, and complication
rates are well described. A description of the technique and results follows.
Smith-Robinson
Smith and Robinson44 originally performed 22 disc arthrodeses in
14 patients ages 25 to 50. They performed the procedure for discogenic pain and radicular problems.40 They placed a slightly oversized bone graft from the iliac crest into a defect created by
removing an appropriate amount of end plate and bone in the body above and below, and it was tamped in place under compression. Their patient outcome was 11 good-excellent, 2 fair, and 1 poor
result, but they did not define their rating criteria. Solid fusion was a continuous bone bridge seen on the lateral radiograph. Eighteen out of 22 discs in the 14 patients were described as having achieved
solid fusion; the remainder had fibrous defects. There were two postoperative Homer's syndromes (one resolved) and two temporary recurrent laryngeal nerve palsies. Their report includes detailed
patient histories, the adjunctive cervical discography, and the details of the surgery (Fig. 2).40, 44
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Figure 2. Original figure from Smith-Robinson article. (From Smith GW, Robinson RA: The treatment of cervical spine disorders. J Bone Joint Surg 40:611, 1958; with permission.)
Keystone
Simmons et al43 described the results of anterior cervical keystone fusion in 68 patients and 122 discs. The patients were treated for
discogenic pain and radicular problems with a chronic history of pain. They performed a detailed review of patients and defined their outcome (excellent-no complaint, no handicap; good-only
intermittent symptoms not affecting work; fair-improvement but physical activities limited; poor-unimproved or worse). They reported 55 excellent or good, 10 fair, and 3 poor results. There was 100%
fusion rate (not defined), and only one graft extrusion. They also report a low incidence of bone graft site pain and two patients with swallowing difficulties. There were no infections, involvement of the
recurrent laryngeal nerve, or esophageal perforations. The major advantage of this technique is that graft extrusion rates are low and fusion rates are high, but the procedure does not lend itself to
allowing complete resection of large compressive osteophytes without including additional motion segments in the fusion (Fig. 3).43
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Figure 3. Technique for decompression using the Keystone technique.
Cloward Technique
In 1958, Cloward14
described his detailed procedure involving the use of a 10- to 12-mm bone dowel for the treatment of symptomatic degenerative disease if necessary with resection of compressing
osteophytes. He developed a special technique using autogenous bone dowels and used special reamers to achieve decompression, but it was difficult to achieve excellent distraction (Fig. 4). High
fusion rates were achieved, but there was some development of mild segmental kyphosis.
Figure 4. Cloward technique is unable to distract the disc interspace by virtue of its geometry.
Anterior Plate-Fusion
Orozco-Deldos and Llovet-Tapies36 first made a technical report of augmenting an anterior fusion with an H-plate device for use in spinal fractures. There are presently no randomized prospective
studies that answer the question about what effect the plate has on
fusion rates. The advantages and disadvan tages of plating are not known in comparison to uninstrumented fusion. Many treating
surgeons believe that plating is not indicatedfor degenerative disease when a standard single-level fusion is required. Indications for anterior plating can include trauma with instability.1, 36 One large
clinical series with 42 consecutive patients reported a 100% fusion rate with the use of a titanium H-plate design.27 The diagnoses in this patient group were mixed. Average outcome was 18 months,
and there were no clinical outcome evaluations apart from reports of postoperative complications. Some authors recommend plates if the decompression is extensive and for multiple level pathology. In the
author's opinion, long anterior plates and 14-mm. unicortical locking screws for fusion in greater than three-level degenerative pathology are at high risk to pull out or loosen at the inferior margin; the author
tries to avoid this technique. There is still controversy about the necessity of achieving one or two cortical purchase on the anterior vertebral body screws. Bone graft resorption influences the success
of rigid plating because the plate prevents collapse and could perhaps increase the pseudarthrosis rate or drive the screws into the end plate or disc space (Fig. 5). Some new plate designs
address this problem by incorporating a sliding mechanism, but there are no long-term published data regarding this topic, and it is theoretically possible that there will be development of segmental
kyphosis when fusion occurs.
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Figure 5. C5-6 fracture subluxation in a 78-year-old osteoporotic woman. A, Lateral radiograph shows subluxation at C5-6. B, Sagittal MRimage shows cord
impingement. C, Right parasagittal image showing compression reaches C6-7 disc space. D, Treated with interbody autograft and plate. E, Lateral radiograph
taken 1 year postoperatively shows possible delayed union at C5-6 but no implant migration with some graft resorption.
Discussion of Anterior Techniques
Pain relief is highly predictable in the majority of patients in many series.36, 40, 44 Smith and Robinson44 and Simmons et al43 did not
generally recommend osteophyte resection or discuss this point in detail; in contradistinction, Cloward14 believed it was important. Many authors reported that osteophytes would slowly remodel.43
Certain patients with profound stenosis or severe anterior compression and kyphosis, however, require thorough decompression and possible correction of deformity.5, 9, 49 The
surgeon should alter his or her technique for each patient; grafting and stabilization should fit the needs of the decompression. Patients with severe neurologic involvement and major compression
may need complex or combined approaches for anterior decompression and posterior stabilization.30
The modified Smith-Robinson and keystone techniques are widely
used. Many surgeons do not resect the end plate, whereas others insist on resection.10, 49 It is probably important to resect structures that are causing severe compression if there is neurologic
dysfunction as a result of the compression.49 There is also a dynamic component to any compression because of the mechanics of the motion segment, and it is known that pseudarthrosis
negatively affects clinical outcome.10
Theoretically the graft should be oversized several millimeters if the foramen is narrowed because of disc collapse to restore the native
disc height. Logically the graft should distract the motion segment several millimeters and indirectly decompress the neural foramen,2 but graft resorption and collapse may lessen this effect as healing
occurs; perhaps the addition of an anterior plate would prevent this complication, but it could at the same time theoretically increase the pseudarthrosis rate. When it comes to choosing the technique
for treatment of acute soft cervical disc herniations, Herkowitz et al.26 have shown that anterior fusion has a better outcome than posterior foraminotomy. Pseudarthrosis after anterior
decompression and fusion can be successfully treated by posterior nerve root decompression, arthrodesis, and stabilization18 or by repeat anterior grafting after resecting the pseudarthrosis.51
Lateral mass plating has also been highly successful for obtaining fusion, although no article addresses this method specifically for pseudarthrosis (Fig. 6).35 In the author's opinion, it is preferable to
use a noninstrumented technique for stable single-level anterior cervical degenerative disorders because fusion and clinical success rates are so high. The use of internal fixation is helpful if there is
obvious instability, and it probably avoids the necessity of postoperative bracing. Internal fixation can be a source of morbidity, however, such as instrumentation malposition. or loosening.27
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Figure 6. Anterior C5-6 pseuclarthrosis was successfully treated with posterior lateral mass plates.
Graft dislodgment tends to occur inferiorly because of higher loads at the distal margin. The goal of prevention of graft dislodgment without a plate can be achieved by careful graft carpentry or the use
of the keystone technique, which locks the graft into place. The use of an anterior buttress plate for long segment fusions at the distal end of the cervical bone graft can avoid anterior displacement of the
graft and aid fusion by allowing graft resorption and collapse to occur. The end surfaces of the graft maintain contact with the body above and below and fuse, albeit slightly shortened and perhaps in
slight segmental kyphosis.
Surgeons should be cautioned not to use an anterior polymethylmethacrylate spacer in patients with degenerative disease because this is not a fusion, and there is risk for loosening
and failure of fixation.31 The metastatic tumor patient with a short life expectancy may benefit from an anterior column reconstruction that uses methylmethacrylate because this gives the advantage of
immediate stability and if there is perioperative radiation, no bone healing is necessary.16
Role of Immobilization and Orthoses
The surgeon can achieve protection of an uninstrumented graft by various external orthoses, including the halo-vest; complications of this apparatus occur, however, and rigid fixation is only partly achieved.20
Many recommend a semirigid neck orthosis to accompany an uninstrumented anterior fusion, but there is little agreement on which type of brace to use or whether it is necessary.
For complex or multiple-level arthrodeses, some use an additional halo-vest and even a halo cast.
Posterior
Posterior fusions are used frequently for pathology at the
occipitocervical junction; for C1-2 disorders; in trauma when there are unstable fractures or fracture-dislocations; and with degenerative disease causing instability or neurologic problems, such as
radiculopathy or myelopathy. There are rare indications for fusion in patients with degenerative conditions that cause intractable pain.' A discussion of laminoplasty is specifically excluded because it is
beyond the scope of this discussion, but laminoplasty certainly plays an important role in the treatment of ossification of the posterior longitudinal ligament and congenital cervical stenosis.
Posterior Grafting Techniques
Occipitocervical Fusion. Indications for occipitocervical fusion are rare. Rheumatoid arthritis, trauma, and tumors are the most
common reasons for requiring occipitocervical fusion. Usually, there is severe disruption of the occipitocervical junction or invagination of the odontoid into the foramen magnum. There are also a small
number of patients with developmental abnormalities and osteogenesis imperfecta that develop pathology at this level. Several techniques are described, including bone grafting with halo
immobilization, posterior bone grafting with wiring, instrumented fusions with either rods and wires or plates, and combinations of these techniques. Bone grafting with wiring achieves good fusion
rates, but it does not always maintain reduction achieved by traction or positioning because of the semirigid fixation.31 Severely affected rheumatoid patients with poor bone quality have achieved good
clinical results with Ransford loop fixation.37 In rheumatoid patients, plate fixation of the occipitocervical junction has achieved fusion rates greater than 94% and higher rates of neurologic improvement
than wire and methacrylate fusions using the Brattstrom. technique presumably because of improved ability to reduce the subluxation of the occiptocervical junction (Fig. 7).11, 22
Figure 7. A, Sagittal T2-weighted MR image of a 48-year-old woman showing a
displaced odontoid nonunion causing brain stem compression. B, Patient was treated with reduction and occipitocervical fusion with plates. (T2-weighted MR image). C, Postoperative lateral radiograph.
C1-2 Posterior Arthrodesis. C1-2 instability or certain C2 fractures, including some odontoid fractures, can lead to the necessity of C1-2
arthrodesis. If there is sufficient instability to affect neurologic function or cause intractable pain, arthrodesis is indicated. The classic techniques of fusion include the methods described by
Gallie and Brooks. The Gallie technique is the least rigid, and it has a pseudarthrosis rate as high as 50% in rheumatoid patients.41 Although the Brooks technique does not avoid wire passage under
the C2 lamina, it achieves high fusion rates .13 A technique using a C1-2 transarticular screw for stabilization achieves the most rigid construct of this motion segment; concomitant wiring is
recornmended to supplement the fusion (Fig. 8). Clinically, arthrodesis rates are greater than 95%.23 If there is no lamina of C1 or it has fractured and it is not attached to the anterior ring of C1,
this technique may be indicated.23 The drawback of this technically demanding technique is that it requires near perfect radiographic control and the vertebral artery has a highly variable course through
this region, and it can be injured.29 Preoperative imaging should document the anatomic location of the vertebral artery in C2. If the artery is injured or anatomy does not allow use of this procedure,
cabling or wiring can be combined with the use of a halo-vest.
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Figure 8. A 35 year old male smoker with c1-2 pseudarthrosis after odontoid fracture treated with Gallie fusion. A. Three-dimensional CT reconstruction showing the
pseudarthrosis. B. Lateral radiograph showing failure of the C1 ring to unite to C2. C. Lateral radiograph showing placement of C1-2 transarticlar screws. D. Open mouth AP view of C1-2 transarticular screws.
Posterior Fusion Techniques
In the author's opinion, patient selection and fine details of
technique and grafting play a greater role in determining clinical success and fusion rates than the choice of posterior fusion technique. Most retrospective literature does not allow reliable
conclusions to be drawn when comparisons are made between techniques. In general, posterior fusions are used for instability secondary to trauma, especially when the posterior ligamentous
tonsion band is disrupted, and it is biornechanically advantageous to perform a posterior reconstruction to attain stability.
Instability and pain are often the indications for surgery, and their
definition is imprecise. The best definition of stability is the ability of the motion segment to withstand normal physiologic loading. Healing constantly alters this equation; in the case of a biologic
system, predicting outcome of injury or arthrodesis is probably as complex as long-term weather prediction. One wants to reduce the measurement of success and outcome to simple terms that do not
reflect real-life complexity.
Most surgeons use simple wiring or cabling techniques when using the posterior approach to help maintain rigidity of the motion
segment during arthrodesis. Cables are known to loosen if there is bone resorption that decreases the distance around which the cables must pass. Uninstrumented posterior cervical fusions are not
commonly used. The simplest techniques make use of the spinous processes as a site of segmental attachment to the spine, and they are useful when the lamina is intact. The Rogers wiring technique
employs wire that is passed through the middle of the spinous processes dorsal to the ventral laminar cortices of two adjacent vertebrae; the wire is tightened to itself completing a circular tension
band posteriorly. The bone graft may be incorporated into the construct. Most surgeons create this hole with a burr or towel clip then tighten an appropriate gauge of wire by twisting it. Some have
changed to the use of a cable that is more pliable and that may be crimped at specific tension.
No author has formally addressed the relative clinical success rates
of the various cables or wires in the use of a Rogers wiring technique. The triple wiring technique is a valuable way of incorporating two slabs of corticocancellous autogenous iliac crest
bone into the construct, and high clinical success and fusion rates were achieved using this simple and straightforward technique.36, 42 The triple-wiring technique requires an intact lamina because it is
the main attachment site to the spine; it is inappropriate for fusions that accompany same-level larninectomy. The Dewar technique makes use of a Steinmann fine-threaded percutaneous pin through
the two spinous processes to help reconstruct a posterior tension band effect (Fig. 9).
Figure 9. A 35-year-old female nurse presented with a posterior facet fracture
requiring posterior C5 decompression. A, Sagittal CT view showing bone fragment compressing nerve root. B, and C, Postoperative AP/lateral radiographs showing posterior decompression (hemifacetectomy) and fusion
using posterior tension band technique (Dewar).
The passage of sublaminar wires should be condemned in the
subaxial cervical spine because there is a risk of iatrogenic neurologic deterioration after passage of the wire through the spinal canal.28 In a normal spinal canal at the occipitocervical junction,
however, there is more space available for the cord, and sublaminar wire passage is generally safe.
Posterior Fusion with Laminectomy
Some patients require both laminectomy and fusion via a posterior
approach. Historically, facet wiring is a well-described technique for use in the patient with a laminectomy; however, there are no large series reporting fusion or clinical success rates.39
It is not as widely used as the more recently popular posterior plating techniques using lateral mass screws. Implants specifically designed for this use have not yet been approved for this purpose by the Food and
Drug Administration. Most surgeons have found this technique simple with low rates of complication secondary to instrumentation, especially between C3 and C6. The technique is especially useful if
the patient needs or has had a laminectomy. The lateral mass is the site of fixation for the segmental screw-plate instrumentation. Screw insertion at varying angles may reduce risk to the vertebral
artery or the exiting nerve root.3 It is harder to insert a lateral mass screw into C2 or C7 for anatomic reasons. Pedicle screws may improve fixation if anatomy permits, but there are no long-term
clinical studies supporting the use of pedicle screws in C2 or C7.24 There are no long-term outcome studies evaluating the use of lateral mass plates for the treatment of cervical disorders, but there are
rare fixation-related complications known to occur in difficult cervical reconstructions, including neurologic injury, instrumentation malposition, and breakage or loosening (Fig. 10).24
 |
Figure 10. Postlaminectomy kyphosis in a 50-year-old achondroplast woman treated with lateral mass plates. A, Lateral postoperative radiograph. B, Lateral
radiograph obtained 5 days postoperatively after patient had fallen out of bed.
Long-Term Outcome Studies of Cervical Fusion in Special Subgroups of Patients
Rheumatoid Arthritis Patients. The severely affected rheumatoid
patient has poor bone quality and is technically challenging. A large thorough clinical study of rheumatoid patients made sound recommendations: To minimize the potential risk of irreversible
paralysis, operative stabilization of the rheumatoid cervical spine is recommended, in the presence or absence of a neurologic deficit, for patients who have atlanto axial subluxation and a posterior
atlanto-odontoid interval of 14 mm or less, patients who have atlanto axial subluxation and at least 5 mm of basilar invagination, and patients who have subaxial subluxation and a sagittal diameter of
the spinal canal of 14 mm. or less.6
Adolescent Patients. The implications of cervical fusion in adolescents are that there may be late development of stiffness and
osteoarthritis in remaining motion segments. An average 17-year follow-up showed that worsening of pain and development of neurologic problems were rare.34
SUMMARY
Well-selected patients treated by appropriate surgery can lead to highly successful treatment for a variety of cervical pathologies. The trend of applying more rigorous epiden-dologic evaluations of
outcome data will enhance understanding of the effect of surgical interventions and lead to an improvement in the quality of patient care in this field.
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Address reprint requests to
Cameron B. Huckell, MD
Department of Orthopaedics
State University of New York at Buffalo
235 North Street Buffalo, NY 14201
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