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Radiographic measurements of cervical alignment, fusion and subsidence after ACDF surgery and their impact on clinical outcome

  • Original Article - Spine degenerative
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Abstract

Background

Some recent studies indicate correlations between cervical alignment and clinical outcome after anterior cervical discectomy and fusion (ACDF) surgery. However, there still are no established criteria for the interpretation of alignment, fusion and subsidence in relation to clinical outcome.

Methods

A retrospective analysis of 208 radiographs of patients following ACDF with stand-alone PEEK cage implantation was performed. The measurements were obtained on plain radiographs in lateral and anteroposterior projections as well as flexion/extension radiographs. Cervical alignment was measured using the Gore, Laing and Cobb methods; fusion was evaluated by an assortment of radiographic hallmarks: the presence of bridging bone, the Cobb angle and the distances between the tips and bases of the spinous processes of the operated segments, respectively. For assessment of subsidence, we used the Mochida method in addition to ventral and dorsal segmental height reduction. Correlation analysis between the different radiological characteristics and clinical outcome at a minimum follow-up of 12 months was conducted.

Results

Two hundred and eight patients were evaluated for alignment, fusion and subsidence. Cervical alignment using the Gore and Cobb methods correlated among each other, but failed to exhibit significant correlation with clinical outcome. Interpretation of fusion rates varied greatly (43.9 to 89.4%) depending on the criteria used. Pearson coefficients between radiographic presence of pseudarthrosis and the measurements of the spinous process distances (0.595; p < 0.001), the Cobb angles (0.187; p = 0.007) and the presence of bridging bone (0.224; p < 0.001) each exhibited statistical significance. None of the methods employed significantly correlated with clinical outcome. Regarding subsidence, we found rates of 62%, 48% and 27% using the Mochida, ventral and dorsal segmental height reduction assessment methods, respectively. Pearson correlations between pairs of Mochida/ventral (r = 0.39; p = 0.66) and Mochida/dorsal (r = 0.007; p = 0.921) height reduction assessment methods were weak and no significant correlation between subsidence rates and clinical outcome was shown.

Conclusion

All measured parameters varied depending in the measurement method used. This was most pronounced for fusion. There was a moderate positive correlation between neck pain and subsidence as measured by the Mochida method.

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References

  1. Ames CP, Blondel B, Scheer JK, Schwab FJ, Le Huec JC, Massicotte EM, Patel AA, Traynelis VC, Kim HJ, Shaffrey CI, Smith JS, Lafage V (2013) Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. Spine 38:S149–S160. https://doi.org/10.1097/BRS.0b013e3182a7f449

    Article  PubMed  Google Scholar 

  2. Bartels RH, Donk RD, Feuth T (2006) Subsidence of stand-alone cervical carbon fiber cages. Neurosurgery 58:502–508; discussion 502-508. https://doi.org/10.1227/01.NEU.0000197258.30821.50

    Article  PubMed  Google Scholar 

  3. Buchowski JM, Liu G, Bunmaprasert T, Rose PS, Riew KD (2008) Anterior cervical fusion assessment: surgical exploration versus radiographic evaluation. Spine 33:1185–1191. https://doi.org/10.1097/BRS.0b013e318171927c

    Article  PubMed  Google Scholar 

  4. Cabraja M, Oezdemir S, Koeppen D, Kroppenstedt S (2012) Anterior cervical discectomy and fusion: comparison of titanium and polyetheretherketone cages. BMC Musculoskelet Disord 13:172. https://doi.org/10.1186/1471-2474-13-172

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Cannada LK, Scherping SC, Yoo JU, Jones PK, Emery SE (2003) Pseudoarthrosis of the cervical spine: a comparison of radiographic diagnostic measures. Spine 28:46–51. https://doi.org/10.1097/01.brs.0000038157.49250.59

    Article  PubMed  Google Scholar 

  6. Cauthen JC, Kinard RE, Vogler JB, Jackson DE, DePaz OB, Hunter OL, Wasserburger LB, Williams VM (1998) Outcome analysis of noninstrumented anterior cervical discectomy and interbody fusion in 348 patients. Spine 23:188–192

    Article  CAS  Google Scholar 

  7. Cloward RB (1958) The anterior approach for removal of ruptured cervical disks. J Neurosurg 15:602–617. https://doi.org/10.3171/jns.1958.15.6.0602

    Article  CAS  PubMed  Google Scholar 

  8. Cobb JR (1948) Outline for the study of scoliosis. The American Academy of Orthopedic Surgeons Instructional Course Lectures 5

  9. Davis RJ, Kim KD, Hisey MS, Hoffman GA, Bae HW, Gaede SE, Rashbaum RF, Nunley PD, Peterson DL, Stokes JK (2013) Cervical total disc replacement with the Mobi-C cervical artificial disc compared with anterior discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease: a prospective, randomized, controlled multicenter clinical trial: clinical article. J Neurosurg Spine 19:532–545. https://doi.org/10.3171/2013.6.SPINE12527

    Article  PubMed  Google Scholar 

  10. 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 24(Suppl 7):810–825. https://doi.org/10.1007/s00586-015-4258-6

    Article  PubMed  Google Scholar 

  11. Elias F (1958) Roentgen findings in the asymptomatic cervical spine. N Y State J Med 58:3300–3303

    CAS  PubMed  Google Scholar 

  12. Faldini C, Miscione MT, Acri F, Leonetti D, Nanni M, Chehrassan M, Giannini S (2012) Single level cervical fusion by an anterior approach using autologous bone graft influences the adjacent levels degenerative changes: clinical and radiographic results at 10-year minimum follow-up. Eur Spine J 21:90–93. https://doi.org/10.1007/s00586-012-2215-1

    Article  PubMed Central  Google Scholar 

  13. Feng SW, Chang MC, Chou PH, Lin HH, Wang ST, Liu CL (2018) Implantation of an empty polyetheretherketone cage in anterior cervical discectomy and fusion: a prospective randomised controlled study with 2 years follow-up. Eur Spine J 27:1358–1364. https://doi.org/10.1007/s00586-017-5450-7

    Article  PubMed  Google Scholar 

  14. Fujiwara H, Oda T, Makino T, Moriguchi Y, Yonenobu K, Kaito T (2018) Impact of cervical sagittal alignment on axial neck pain and health-related quality of life after cervical laminoplasty in patients with cervical spondylotic myelopathy or ossification of the posterior longitudinal ligament: a prospective comparative study. Clin Spine Surg 31:E245–e251. https://doi.org/10.1097/bsd.0000000000000619

    Article  PubMed  Google Scholar 

  15. Gercek E, Arlet V, Delisle J, Marchesi D (2003) Subsidence of stand-alone cervical cages in anterior interbody fusion: warning. Eur Spine J 12:513–516. https://doi.org/10.1007/s00586-003-0539-6

    Article  PubMed  PubMed Central  Google Scholar 

  16. Gore DR (2001) Roentgenographic findings in the cervical spine in asymptomatic persons: a ten-year follow-up. Spine 26:2463–2466. https://doi.org/10.1097/00007632-200111150-00013

    Article  CAS  PubMed  Google Scholar 

  17. Gore DR, Sepic SB, Gardner GM, Murray MP (1987) Neck pain: a long-term follow-up of 205 patients. Spine 12:1–5. https://doi.org/10.1097/00007632-198701000-00001

    Article  CAS  PubMed  Google Scholar 

  18. Grob D, Frauenfelder H, Mannion AF (2007) The association between cervical spine curvature and neck pain. Eur Spine J 16:669–678. https://doi.org/10.1007/s00586-006-0254-1

    Article  CAS  PubMed  Google Scholar 

  19. Harrison DE, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ, Holland B (2000) Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. Spine 25:2072–2078

    Article  CAS  Google Scholar 

  20. Hipp JA, Reitman CA, Wharton N (2005) Defining pseudoarthrosis in the cervical spine with differing motion thresholds. Spine 30:209–210

    Article  Google Scholar 

  21. Hisey MS, Bae HW, Davis R, Gaede S, Hoffman G, Kim K, Nunley PD, Peterson D, Rashbaum R, Stokes J (2014) Multi-center, prospective, randomized, controlled investigational device exemption clinical trial comparing Mobi-C Cervical Artificial Disc to anterior discectomy and fusion in the treatment of symptomatic degenerative disc disease in the cervical spine. Int J Spine Surg 8. https://doi.org/10.14444/1007

    Article  Google Scholar 

  22. Jackson BL, Harrison DD, Robertson GA, Barker WF (1993) Chiropractic biophysics lateral cervical film analysis reliability. J Manip Physiol Ther 16:384–391

    CAS  Google Scholar 

  23. Kaiser MG, Mummaneni PV, Matz PG, Anderson PA, Groff MW, Heary RF, Holly LT, Ryken TC, Choudhri TF, Vresilovic EJ, Resnick DK, Joint Section on Disorders of the S, Peripheral Nerves of the American Association of Neurological S, Congress of Neurological S (2009) Radiographic assessment of cervical subaxial fusion. J Neurosurg Spine 11:221–227. https://doi.org/10.3171/2009.3.SPINE08719

    Article  PubMed  Google Scholar 

  24. Kaptain GJ, Simmons NE, Replogle RE, Pobereskin L (2000) Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy. J Neurosurg 93:199–204

    Article  CAS  Google Scholar 

  25. Katsuura A, Hukuda S, Imanaka T, Miyamoto K, Kanemoto M (1996) Anterior cervical plate used in degenerative disease can maintain cervical lordosis. J Spinal Disord 9:470–476

    Article  CAS  Google Scholar 

  26. Kim JH, Kim JH, Kim JH, Kwon TH, Park YK, Moon HJ (2015) The relationship between neck pain and cervical alignment in young female nursing staff. J Korean Neurosurg Soc 58:231–235. https://doi.org/10.3340/jkns.2015.58.3.231

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Kim W-B, Hyun S-J, Choi H, Kim K-J, Jahng T-A, Kim H-J (2016) Long-term follow-up results of anterior cervical inter-body fusion with stand-alone cages. J Korean Neurosurg Soc 59:385–391. https://doi.org/10.3340/jkns.2016.59.4.385

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Laing RJ, Ng I, Seeley HM, Hutchinson PJ (2001) Prospective study of clinical and radiological outcome after anterior cervical discectomy. Br J Neurosurg 15:319–323

    Article  CAS  Google Scholar 

  29. Lemcke J, Menz H, Al-Zain F, Meier U (2007) Outcome after cervical anterior fusion--a clinical study of 368 patients. Z Orthop Unfall 145:744–752. https://doi.org/10.1055/s-2007-965800

    Article  CAS  PubMed  Google Scholar 

  30. Lofgren H, Johannsson V, Olsson T, Ryd L, Levander B (2000) Rigid fusion after cloward operation for cervical disc disease using autograft, allograft, or xenograft: a randomized study with radiostereometric and clinical follow-up assessment. Spine 25:1908–1916

    Article  CAS  Google Scholar 

  31. Mochida J, Nishimura K, Nomura T, Toh E, Chiba M (1996) The importance of preserving disc structure in surgical approaches to lumbar disc herniation. Spine 21:1556–1563 discussion 1563-1554

    Article  CAS  Google Scholar 

  32. Moon HJ, Kim JH, Kim JH, Kwon TH, Chung HS, Park YK (2011) The effects of anterior cervical discectomy and fusion with stand-alone cages at two contiguous levels on cervical alignment and outcomes. Acta Neurochir 153:559–565. https://doi.org/10.1007/s00701-010-0879-z

    Article  PubMed  Google Scholar 

  33. Pechlivanis I, Thuring T, Brenke C, Seiz M, Thome C, Barth M, Harders A, Schmieder K (2011) Non-fusion rates in anterior cervical discectomy and implantation of empty polyetheretherketone cages. Spine 36:15–20. https://doi.org/10.1097/BRS.0b013e3181cbf870

    Article  PubMed  Google Scholar 

  34. Scheer JK, Tang JA, Smith JS, Acosta FL Jr, Protopsaltis TS, Blondel B, Bess S, Shaffrey CI, Deviren V, Lafage V, Schwab F, Ames CP, Group tISS (2013) Cervical spine alignment, sagittal deformity, and clinical implications. J Neurosurg Spine 19:141–159. https://doi.org/10.3171/2013.4.SPINE12838

    Article  PubMed  Google Scholar 

  35. Shad A, Leach JC, Teddy PJ, Cadoux-Hudson TA (2005) Use of the Solis cage and local autologous bone graft for anterior cervical discectomy and fusion: early technical experience. J Neurosurg Spine 2:116–122. https://doi.org/10.3171/spi.2005.2.2.0116

    Article  PubMed  Google Scholar 

  36. Shiban E, Gapon K, Wostrack M, Meyer B, Lehmberg J (2016) Clinical and radiological outcome after anterior cervical discectomy and fusion with stand-alone empty polyetheretherketone (PEEK) cages. Acta Neurochir 158:349–355. https://doi.org/10.1007/s00701-015-2630-2

    Article  PubMed  Google Scholar 

  37. Shiban E, Meyer B, Lehmberg J (2016) Influence of demineralized bone matrix on clinical and radiological outcome in anterior cervical discectomy and fusion. Spine J 16:S354–S355. https://doi.org/10.1016/j.spinee.2016.07.467

    Article  Google Scholar 

  38. Skolasky RL, Maggard AM, Hilibrand AS, Northrup BE, Ullrich CG, Albert TJ, Coe JD, Riley LH 3rd. (2006) Agreement between surgeons and an independent panel with respect to surgical site fusion after single-level anterior cervical spine surgery: a prospective, multicenter study. Spine 31:E503–E506. https://doi.org/10.1097/01.brs.0000224503.31608.f9

    Article  PubMed  Google Scholar 

  39. Smith GW, Robinson RA (1958) The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am 40-a:607–624

    Article  CAS  Google Scholar 

  40. Sudhakar N, Laing RJC, Redfern RM (2003) Assessment of fusion after anterior cervical discectomy. Br J Neurosurg 17:54–59. https://doi.org/10.3109/02688690309177972

    Article  CAS  PubMed  Google Scholar 

  41. Tuli SK, Chen P, Eichler ME, Woodard EJ (2004) Reliability of radiologic assessment of fusion: cervical fibular allograft model. Spine 29:856–860

    Article  Google Scholar 

  42. Upadhyaya CD, Wu JC, Trost G, Haid RW, Traynelis VC, Tay B, Coric D, Mummaneni PV (2012) Analysis of the three United States Food and Drug Administration investigational device exemption cervical arthroplasty trials. J Neurosurg Spine 16:216–228. https://doi.org/10.3171/2011.6.SPINE10623

    Article  PubMed  Google Scholar 

  43. Villavicencio AT, Babuska JM, Ashton A, Busch E, Roeca C, Nelson EL, Mason A, Burneikiene S (2011) Prospective, randomized, double-blind clinical study evaluating the correlation of clinical outcomes and cervical sagittal alignment. Neurosurgery 68:1309–1316; discussion 1316. https://doi.org/10.1227/NEU.0b013e31820b51f3

    Article  PubMed  Google Scholar 

  44. Wu WJ, Jiang LS, Liang Y, Dai LY (2012) Cage subsidence does not, but cervical lordosis improvement does affect the long-term results of anterior cervical fusion with stand-alone cage for degenerative cervical disc disease: a retrospective study. Eur Spine J 21:1374–1382. https://doi.org/10.1007/s00586-011-2131-9

    Article  PubMed  Google Scholar 

  45. Zajonz D, Franke AC, von der Hoh N, Voelker A, Moche M, Gulow J, Heyde CE (2014) Is the radiographic subsidence of stand-alone cages associated with adverse clinical outcomes after cervical spine fusion? An observational cohort study with 2-year follow-up outcome scoring. Patient Saf Surg 8:43. https://doi.org/10.1186/s13037-014-0043-4

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

The study was completely financed by the Department of Neurosurgery.

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Author notes

  1. Thomas Obermueller and Arthur Wagner contributed equally to this work.

Authors and Affiliations

  1. Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany

    Thomas Obermueller, Arthur Wagner, Lorenz Kogler, Ann-Kathrin Joerger, Nicole Lange, Bernhard Meyer & Ehab Shiban

  2. Department of Neurosurgery, Städtisches Klinikum München Bogenhausen, Munich, Germany

    Jens Lehmberg

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  1. Thomas Obermueller
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  2. Arthur Wagner
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Correspondence to Arthur Wagner.

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Obermueller, T., Wagner, A., Kogler, L. et al. Radiographic measurements of cervical alignment, fusion and subsidence after ACDF surgery and their impact on clinical outcome. Acta Neurochir 162, 89–99 (2020). https://doi.org/10.1007/s00701-019-04139-1

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