Use of Allogenic Mesenchymal Cellular Bone Matrix in Anterior and Posterior Cervical Spinal Fusion: A Case Series of 21 Patients

Srikanth Naga Divi,Mark M. Mikhael 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.3

Study Design: Retrospective case series. Purpose: To report our early experience using allogenic mesenchymal cellular bone matrix (CBM) products in cervical spine fusion. Overview of Literature: Multi-level cervical fusions have historically yielded lower fusion rates than single level fusions, especially in patients with high risk medical comorbidities. At this time, significant literature in cervical fusion outcomes with this cellular allograft technology is lacking. Methods: Twenty-one patients underwent either multilevel (3 or 4 level) anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion, or posterior cervical fusion. ViviGen (DePuy Synthes Spine, Raynham, MA, USA), an allogenic bone matrix product, was used in addition to standard instrumentation. Radiographic evaluation was performed at 2 weeks, 12 weeks, 24 weeks and 1 year postoperative. Visual analog scale (VAS) and neck disability index (NDI) scores along with return to work and leisure activity were recorded. Results: At 6 months postoperative, all patients had radiographic evidence of bone fusion regardless of age or medical comorbidities. All patients reported subjective improvement with a mean decrease in VAS from 8.3 to 1.5 and a mean decrease in NDI from 40.3% to 6.0% at 1 year. All patients also returned to work and/or regular leisure activity within 3 months. Conclusions: Twenty-one patients undergoing high-risk anterior and posterior cervical spine fusion, with the use of a commercially available mesenchymal CBM product, went on to radiographic fusion and all had improvement in subjective outcomes. While further effort and research is needed to validate its widespread use, this study shows favorable use of CBM in cervical fusion for high-risk cases.

Comparison of Bony Fusion Between the Hollow Cage Group and the Cage with Bone Substitutes Group in One-level Cervical Spinal Disorders

반유창,윤승환,김정민,박형천,박종운,현동근 대한척추신경외과학회 2010 Neurospine Vol.7 No.2

Objective: The aim of this study was to assess the clinical outcomes and bone fusion rates after insertion of hollow cages or cages with bone substitutes for treatment of disc protrusion in the cervical spine. Methods: We performed a retrospective review of 93 patients who had undergone cage‐assisted anterior cervical spine fusion. Patients were treated with hollow cages(N=52) or with cages with bone substitutes (N=41). Initial and follow up radiologic data were analyzed using Vavruch bone fusion criteria. Results: Clinical outcomes including preoperative and postoperative pain and functional scores were not significantly diffe- rent between the two patient groups. The over‐all fusion rates differed between the two groups: patients treated with hollow cages demonstrated an average fusion rate of 84.6%, while patients treated with cages with bone substitutes demonstrated an average fusion rate of 87.8%, but these differences were not significant 24 months after surgery. At 18 months after surgery, the fusion rates of patients treated with cages with bone substitutes were significantly different from those of patients treated with hollow cages. Among patients who received bone substitutes, patients who received DBM exhibited better fusion outcomes than patients treated with other bone materials after 18 months of follow‐up. Conclusion: Patients who are surgically treated with anterior cervical spine fusion for disc protrusion using cages with bone substitutes may achieve earlier fusion than patients treated with hollow cages, although both groups show similar final fusion rates.

The Effect of Subsidence on Segmental and Global Lordosis at Long-term Follow-up After Anterior Cervical Discectomy and Fusion

Akiro H. Duey,Christopher Gonzalez,Eric A. Geng,Pierce J. Ferriter Jr,Ashley M. Rosenberg,Ula N. Isleem,Bashar Zaidat,Paul M. Al-Attar,Jonathan S. Markowitz,Jun S. Kim,Samuel K. Cho 대한척추신경외과학회 2022 Neurospine Vol.19 No.4

Objective: Subsidence following anterior cervical discectomy and fusion (ACDF) may lead to disruptions of cervical alignment and lordosis. The purpose of this study was to evaluate the effect of subsidence on segmental, regional, and global lordosis. Methods: This was a retrospective cohort study performed between 2016–2021 at a single institution. All measurements were performed using lateral cervical radiographs at the immediate postoperative period and at final follow-up greater than 6 months after surgery. Associations between subsidence and segmental lordosis, total fused lordosis, C2–7 lordosis, and cervical sagittal vertical alignment change were determined using Pearson correlation and multivariate logistic regression analyses. Results: One hundred thirty-one patients and 244 levels were included in the study. There were 41 one-level fusions, 67 two-level fusions, and 23 three-level fusions. The median follow-up time was 366 days (interquartile range, 239–566 days). Segmental subsidence was significantly negatively associated with segmental lordosis change in the Pearson (r = -0.154, p = 0.016) and multivariate analyses (beta = -3.78; 95% confidence interval, -7.15 to -0.42; p = 0.028) but no associations between segmental or total fused subsidence and any other measures of cervical alignment were observed. Conclusion: We found that subsidence is associated with segmental lordosis loss 6 months following ACDF. Surgeons should minimize subsidence to prevent long-term clinical symptoms associated with poor cervical alignment.

Impact of Interspace Distraction on Fusion and Clinical Outcomes in Anterior Cervical Discectomy and Fusion: A Longitudinal Cohort Study

Lawless Michael H.,Yoon Elise J.,Jasinski Jacob M.,Gabrail Joseph,Jordan Noah,Kado Karl,Tong Doris,Soo Teck M.,Carr Daniel A. 대한척추외과학회 2022 Asian Spine Journal Vol.16 No.3

Study Design: Longitudinal cohort study.Purpose: To determine the effect of change in interspace height on fusion and postoperative neck pain.Overview of Literature: The optimal height of a cervical interbody device (cage) in anterior cervical discectomy and fusion (ACDF) is not well defined. In addition, the effect of interspace distraction on fusion and postoperative neck pain remains unclear.Methods: We retrospectively reviewed the charts of consecutive patients who underwent one- or two-level ACDF using polyetheretherketone cages by multiple surgeons from January 2015 to June 2016. We excluded patients younger than 18 years old, patients who had prior surgery at the same level (s), those with two-stage procedures, and those with less than 3 months of followup. Fusion was determined using the “Song” criteria. Ordinal regression was used to determine predictors of fusion. Patient-reported outcomes (PRO) were analyzed.Results: We identified 323 consecutive patients. Twenty-two patients met the exclusion criteria. A total of 435 operative levels were included in the 301 remaining patients. Interspace fusion did not significantly vary by increasing interspace height with fusion rates between 76.2% and 82.8% at a mean follow-up of 17.9±12.6 months. The effect of an increase in interspace height and neck pain PRO was available for 163 patients who underwent one-level ACDF at a mean follow-up period of 16.2±13.1 months. We found no significant difference in fusion rate or neck pain score with increasing interspace height from 1 to 8 mm. Ordinal regression demonstrated no significant predictors of fusion.Conclusions: Interspace distraction from 1 to 8 mm did not result in significantly different pseudarthrosis rates or postoperative neck pain.

Comparisons of Two-level Discectomy and Fusion with Cage Alone versus Single-level Corpectomy and Fusion with Plate in the Treatment of Cervical Degenerative Disc Disease

하복용,심홍보,여인욱,박은석,권순찬,박준범 대한척추신경외과학회 2012 Neurospine Vol.9 No.3

Objective: To compare the radiologic parameters and clinical outcomes of two-level anterior cervical discectomy and fusion(ACDF) with cage alone versus single-level anterior cervical corpectomy and fusion (ACCF) with plate in the treatment of two-level contiguous cervical degenerative disc disease. Methods: Of all 38 consecutive patients who were included in this study, 22 patients underwent on a two-level contiguous ACDF with cage alone (ACDF-CA group), 16 patients underwent a single-level ACCF with plate (ACCF-P group). We compared following parameters between these two groups; perioperative parameters (hospital stays, blood loss and operation duration), clinical parameters (Japanese Orthopedic Association scores and Odom’s criteria) and radiologic parameters segmental height ratio (SHR), segmental lordotic angle (SLA), global lordotic angle (GLA) and fusion rate). Results: The amount of operative blood loss in the ACCF-P group was higher than in the ACDF-CA group with statistical significance (p<0.05). Clinical outcomes and fusion rates were similar between groups. The postoperative SHRs in both groups were higher than that of preoperative period with statistical significance; however, these values significantly decreased at the last follow up period. The SLA increased during the immediate postoperative period, and then mild decreased. The values of GLA in both groups did show variable differences according to each time frame. Conclusion: The results of ACDF-CA were comparable with ACCF-P with regard to clinical and radiologic outcomes in contiguous two-level cervical fusion. A two-level ACDF-CA as a treatment modality for two-level contiguous cervical disc disease may be a worthwhile method as an alternative to single-level ACCF-P.

The Formation of Extragraft Bone Bridging after Anterior Cervical Discectomy and Fusion : A Finite Element Analysis

Kwon, Shin Won,Kim, Chi Heon,Chung, Chun Kee,Park, Tae Hyun,Woo, Su Heon,Lee, Sung-Jae,Yang, Seung Heon The Korean Neurosurgical Society 2017 Journal of Korean neurosurgical society Vol.60 No.6

Objective : In addition to bone bridging inside a cage or graft (intragraft bone bridging, InGBB), extragraft bone bridging (ExGBB) is commonly observed after anterior cervical discectomy and fusion (ACDF) with a stand-alone cage. However, solid bony fusion without the formation of ExGBB might be a desirable condition. We hypothesized that an insufficient contact area for InGBB might be a causative factor for ExGBB. The objective was to determine the minimal area of InGBB by finite element analysis. Methods : A validated 3-dimensional, nonlinear ligamentous cervical segment (C3-7) finite element model was used. This study simulated a single-level ACDF at C5-6 with a cylindroid interbody graft. The variables were the properties of the incorporated interbody graft (cancellous bone [Young's modulus of 100 or 300 MPa] to cortical bone [10000 MPa]) and the contact area between the vertebra and interbody graft (Graft-area, from 10 to $200mm^2$). Interspinous motion between the flexion and extension models of less than 2 mm was considered solid fusion. Results : The minimal Graft-areas for solid fusion were $190mm^2$, $140mm^2$, and $100mm^2$ with graft properties of 100, 300, and 10000 MPa, respectively. The minimal Graft-areas were generally unobtainable with only the formation of InGBB after the use of a commercial stand-alone cage. Conclusion : ExGBB may be formed to compensate for insufficient InGBB. Although various factors may be involved, solid fusion with less formation of ExGBB may be achieved with refinements in biomaterials, such as the use of osteoinductive cage materials; changes in cage design, such as increasing the area of polyetheretherketone or the inside cage area for bone grafts; or surgical techniques, such as the use of plate/screw systems.

The Effect of Bi-Cortical Screw Fixation for Subsidence and Cervical Alignment in Patients Undergoing Single-Level Anterior Cervical Discectomy and Fusion

Han Woong,Moon Byoung Gwan,김덕령,Kim Jae Hoon,Kang Hee In,김주승 대한말초신경학회 2019 The Nerve Vol.5 No.2

Objective Anterior cervical discectomy and fusion (ACDF) is a treatment for cervical degenerative disease. However, there are few in vivo or long-term data sets including complete graft consolidation. This study aimed to verify the validity of bi-cortical screw fixation in patients undergoing ACDF. Methods We enrolled 133 patients who underwent ACDF between February 2002 and March 2017. Patients were divided into the mono-cortical fixation group (group A) and bi-cortical fixation group (group B). Consecutive cervical radiography was performed. The end point of data collection was completion of fusion. We evaluated graft subsidence, the global cervical angle (C2-C7 Cobb’s angle), and segmental angle (SA; index level Cobb’s angle). Results There were no significant differences or surgical level between groups A and B (graft type p=0.292, surgical level p=0.065). However, types of plate were statistically different (plate type p-value=0.011), and the difference in subsidence between groups A and B was significant (group A, 3.946±2.43mm; group B, 2.369±1.96mm, p<0.001). In the logistic regression, bi-cortical screw fixation was found to be the most important factor contributing to subsidence reduction (β-coefficient, 1.002; odds ratio=2.725; p=0.012). There was a significant difference in the SA when fusion was achieved (group A, 2.14±5.05°; group B, 4.84±4.83°; p=0.002). The change in the SA (ΔSA) was significantly different between group A and group B (group A, ΔSA -4.42±4.04°; group B, ΔSA -1.15±3.64°; p=0.001). Conclusion Bi-cortical screw fixation in ACDF led to reduced graft subsidence and a less kyphotic SA change.

Analysis of Surgical Results According to the Number of Fused Levels in Anterior Cervical Discectomy and Fusion: A Retrospective Study

Bum-Suk Yu,Yudoyono Farid,이성,Yoon Ha,김긍년,윤도흠,신동아 대한말초신경학회 2017 The Nerve Vol.3 No.2

Objective To analyze the surgical outcomes of patients who underwent 1-level, 2-level, and 3-level anterior cervical discectomy and fusion (ACDF). Methods We retrospectively assessed 182 patients with symptomatic cervical degenerative disease who underwent ACDF with allograft and a plate at our institution between January 2012 and March 2014. After only including patients with a >24 month follow-up, 142 fulfilled our inclusion criteria (71 underwent 1-level, 46 underwent 2-level, and 25 underwent 3-level ACDF). The assessment tools included the Short Form-36 (SF-36), Neck Disability Index (NDI), and visual analog scale (VAS). The fusion status was measured by radiography at 24 months postoperatively. Statistical analyses were performed with SPSS version 20.0. Results The fusion rate was 84% in the 3-level group, 98.6% in the 1-level group, and 97.8% in the 2-level (p=0.017). There was a significant difference between 2-level vs. 3-level ACDF (p=0.049). Complications occurred in 4 (16%) patients of the 3-level group, 2 (2.8%) patients of the 1-level group, and 1 (2.2%) patient of the 2-level group (p=0.030). The subsidence rate was significantly higher in the 3-level group than in the other 2 groups (52%, p=0.047). Significant differences were observed between groups in terms of the NDI and SF-36 at the last follow-up (p=0.040 and p=0.046, respectively). Conclusion The surgical outcome of the 3-level ACDF group was worse than that of the 1-level or 2-level ACDF groups, which was indicated by the lower fusion rate, higher complication rate, and higher subsidence rate.

국소 자가골을 이용한 경추 전방 유합술의 유용성

심대무(Dae Moo Shim),김태균(Tae Kyun Kim),오성균(Sung Kyun Oh),김상열(Sang Yul Kim),이승빈(Seung Bin Lee) 대한정형외과학회 2014 대한정형외과학회지 Vol.49 No.2

목적: 국소 자가골과 자가 장골을 충전한 polyetheretherketone (PEEK) 케이지 삽입술 및 경추 전방 유합술 후 결과를 비교하여 국 소 자가골 이용의 유용성을 알아 보고자 하였다. 대상 및 방법: 2002년 1월에서 2009년 3월까지 전방 추간판 제거술 및 PEEK 케이지와 전방 금속판을 이용한 전방 유합술을 시행 받은 환자들을 무작위로 두 그룹으로 나누어 국소 자가골을 케이지에 충전한 15예와 자가 장골만을 충전한 16예, 총 31예를 대상으 로 후향적 연구를 실시하였다. 결과: Visual analogue scale 점수는 경부 동통/방사통이 국소 자가골을 이용한 경우 술 전 5.8/7.7에서 술 후 1.6/2.3으로 호전되었 으나 통계적 차이를 보이지 않았고(p>0.05), neck disability index도 국소 자가골군에서 평균 6.25점, 자가 장골군에서 평균 5.75점 으로 더 우수한 결과를 보였으나 두 군간의 통계적 차이는 보이지 않았다(p>0.05). 방사선학적 유합 시기는 국소 골이 평균 14.0주 에, 자가 장골이 평균 12.62주로 평균 1.38주 자가장골이 더 짧은 유합 시기를 보였으나 통계적 차이는 보이지 않았다(p=0.76). 결론: 국소 자가골을 충전한 PEEK 케이지를 이용한 경추 전방 유합술은 자가 장골을 이용한 경우와 방사선학적 골유합과 임상결과 에 있어서도 유사한 결과를 얻을 수 있다. Purpose: The purpose of this study is to evaluate the usefulness of locally harvested bone in anterior cervical interbody fusion. Materials and Methods: A retrospective review was conducted, including 31 patients who underwent anterior cervical interbody fusion using a polyetheretherketone (PEEK) cage and anterior plate fixation. We randomly divided the patients into two groups, local bone group and iliac bone group. In 15 patients of the local bone group, the cage was filled with locally harvested bone, and in another 16 patients of the iliac bone group, the cage was filled with autogenous iliac bone. Results: Improvements in mean visual analogue scale (VAS) scores, from 5.8 and 7.7 to 1.6 and 2.3 for neck pain and arm pain, respectively, were observed in cases using locally harvested bone, while the improvements were from 5.7 and 7.2 to 1.4 and 2.2, respectively, in those using autogenous iliac bone grafts. However, no significant differences in mean VAS and neck disability index were observed between the two groups at the last follow up (p>0.05). Radiologic union was achieved at 14.0±2.50 weeks in the local bone group, and at 12.62±1.58 weeks in the iliac bone group. However, no significant difference was observed between the two groups (p=0.076). Conclusion: Utilization of locally harvested bone for packing in a PEEK cage for anterior cervical interbody fusion is considered a useful method because it gives satisfactory clinical results for retention of bone union and lordosis angles.

Adjacent Segment Pathology after Anterior Cervical Fusion

정재윤,박종범,서형연,김성규 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.3

Anterior cervical fusion has become a standard of care for numerous pathologic conditions of the cervical spine. However, subsequent development of clinically significant disc disease at levels adjacent to fused discs is a serious long-term complication of this procedure. As more patients live longer after surgery, it is foreseeable that adjacent segment pathology (ASP) will develop in increasing numbers of patients. Also, ASP has been studied more intensively with the recent popularity of motion preservation technologies like total disc arthroplasty. The true nature and scope of ASP remains poorly understood. The etiology of ASP is most likely multifactorial. Various factors including altered biomechanical stresses, surgical disruption of soft tissue and the natural history of cervical disc disease contribute to the development of ASP. General factors associated with disc degeneration including gender, age, smoking and sports may play a role in the development of ASP. Postoperative sagittal alignment and type of surgery are also considered potential causes of ASP. Therefore, a spine surgeon must be particularly careful to avoid unnecessary disruption of the musculoligamentous structures, reduced risk of direct injury to the disc during dissection and maintain a safe margin between the plate edge and adjacent vertebrae during anterior cervical fusion.