Differences between arthroplasty and anterior cervical fusion in two-level cervical degenerative disc disease

Purpose

Although arthroplasty is an accepted option for two-level disease, there is a paucity of data regarding outcomes of two-level cervical arthroplasty. The current study was designed to determine differences between two-level cervical arthroplasty and anterior fusion.

Methods

Seventy-seven consecutive patients who underwent two-level anterior cervical operations for degenerative disc disease were divided into the arthroplasty (37 patients) and fusion (40 patients) groups. Clinical outcomes were measured by Visual Analogue Scale (VAS) of neck and arm pain, Japanese Orthopedic Association (JOA) scores, and Neck Disability Index (NDI). Every patient was evaluated by radiography and computed tomography for fusion or detection of heterotopic ossification.

Results

Thirty-seven patients (with 74 levels of Bryan discs) were compared with 40 patients who had two-level anterior fusion (mean follow-up of 39.6 ± 6.7 months). There was no difference in sex, but the mean age of the arthroplasty group was significantly younger (52.1 ± 9.1 vs. 63.0 ± 10.6 years, p < 0.001). The mean estimated blood loss was similar (p = 0.135), but the mean operation time was longer in the arthroplasty group (315.5 ± 82.0 versus 224.9 ± 61.8 min, p < 0.001). At 24 months post-operation, the arthroplasty group had increased their range of motion than pre-operation (23.5° versus 20.1°, p = 0.018). There were significant improvements in neck or arm VAS, JOA scores, and NDI in both groups. However, there were no differences in clinical outcomes or adverse events between the two groups.

Conclusions

Clinical outcomes of two-level arthroplasty and anterior cervical fusion are similar 39.6 months after surgery. Cervical arthroplasty preserves mobility at the index levels without increased adverse effects.     

Total disc replacement surgery for symptomatic degenerative lumbar disc disease: a systematic review of the literature

The objective of this study is to evaluate the effectiveness and safety of total disc replacement surgery compared with spinal fusion in patients with symptomatic lumbar disc degeneration. Low back pain (LBP), a major health problem in Western countries, can be caused by a variety of pathologies, one of which is degenerative disc disease (DDD). When conservative treatment fails, surgery might be considered. For a long time, lumbar fusion has been the “gold standard” of surgical treatment for DDD. Total disc replacement (TDR) has increased in popularity as an alternative for lumbar fusion. A comprehensive systematic literature search was performed up to October 2008. Two reviewers independently checked all retrieved titles and abstracts, and relevant full text articles for inclusion. Two reviewers independently assessed the risk of bias of included studies and extracted relevant data and outcomes. Three randomized controlled trials and 16 prospective cohort studies were identified. In all three trials, the total disc replacement was compared with lumbar fusion techniques. The Charité trial (designed as a non-inferiority trail) was considered to have a low risk of bias for the 2-year follow up, but a high risk of bias for the 5-year follow up. The Charité artificial disc was non-inferior to the BAK^® Interbody Fusion System on a composite outcome of “clinical success” (57.1 vs. 46.5%, for the 2-year follow up; 57.8 vs. 51.2% for the 5-year follow up). There were no statistically significant differences in mean pain and physical function scores. The Prodisc artificial disc (also designed as a non-inferiority trail) was found to be statistically significant more effective when compared with the lumbar circumferential fusion on the composite outcome of “clinical success” (53.4 vs. 40.8%), but the risk of bias of this study was high. Moreover, there were no statistically significant differences in mean pain and physical function scores. The Flexicore trial, with a high risk of bias, found no clinical relevant differences on pain and physical function when compared with circumferential spinal fusion at 2-year follow up. Because these are preliminary results, in addition to the high risk of bias, no conclusions can be drawn based on this study. In general, these results suggest that no clinical relevant differences between the total disc replacement and fusion techniques. The overall success rates in both treatment groups were small. Complications related to the surgical approach ranged from 2.1 to 18.7%, prosthesis related complications from 2.0 to 39.3%, treatment related complications from 1.9 to 62.0% and general complications from 1.0 to 14.0%. Reoperation at the index level was reported in 1.0 to 28.6% of the patients. In the three trials published, overall complication rates ranged from 7.3 to 29.1% in the TDR group and from 6.3 to 50.2% in the fusion group. The overall reoperation rate at index-level ranged from 3.7 to 11.4% in the TDR group and from 5.4 to 26.1% in the fusion group. In conclusion, there is low quality evidence that the Charité is non-inferior to the BAK cage at the 2-year follow up on the primary outcome measures. For the 5-year follow up, the same conclusion is supported only by very low quality evidence. For the ProDisc, there is very low quality evidence for contradictory results on the primary outcome measures when compared with anterior lumbar circumferential fusion. High quality randomized controlled trials with relevant control group and long-term follow-up is needed to evaluate the effectiveness and safety of TDR.     

Congenital microgastria with limb defect combined with megaduodenum: case report and review of literature

Congenital microgastria is a rare developmental disorder with only 59 previously reported cases. Most of the patients undergoing reconstructive surgery are in early infancy, providing gastric augmentation to achieve optimal thrive. The Hunt-Lawrence pouch is the standard surgical treatment in infancy, but late surgery in early adulthood requires different approach. This case demonstrates that duodenojejunostomy is safe and effective in the treatment of congenital, functional duodenal obstruction in adulthood.     

颈椎前路椎间融合术与人工椎间盘置换术联合椎间融合术治疗连续双节段颈椎病的中长期疗效对比

目的 :比较前路颈椎椎间融合术(anterior cervical discectomy and fusion,ACDF)与颈前路人工椎间盘置换联合颈椎椎间融合(Hybrid手术)治疗连续双节段颈椎病的中长期疗效。方法:回顾性分析2007年1月~2012年3月在我科行ACDF及Hybrid手术治疗的连续双节段颈椎病患者,资料完整且随访时间60个月者共68例,其中ACDF 39例(ACDF组),Hybrid手术29例(Hybrid组),两组患者年龄、性别构成比、随访时间、手术节段等均无统计学差异。比较两组术前及末次随访时的JOA评分、颈椎功能障碍指数(NDI)、疼痛视觉模拟评分(VAS)、颈椎整体活动度、C2-C7颈椎曲度、相邻节段活动度、相邻节段退变情况等。结果:两组患者手术时间、出血量和术后引流量均无统计学差异;末次随访时的JOA、NDI及VAS评分均较同组术前有显著性改善(P0.05),两组间同时间点比较均无统计学差异(P0.05)。末次随访时根据Odom标准,Hybrid组的优良率为93.1%,ACDF组为92.3%,两组比较无统计学差异(P0.05);两组C2-C7曲度较术前均有所恢复,Hybrid组较ACDF组改善更好(P0.05);Hybrid组整体颈椎活动度及相邻节段活动度较术前无明显差异(P0.05),ACDF组颈椎活动度较术前明显降低(P0.05)、相邻节段活动度明显增加(P0.05);颈椎X线片评估相邻节段退变发生率无统计学差异(Hybrid组17.2%vs ACDF组20.5%,P0.05);末次随访时Hybrid组人工间盘置换节段异位骨化发生率为34.5%(10/29),其中Mobi-C假体发生率为41.2%(5/12),Pro Disc-C假体发生率为29.4%(5/17)。结论 :Hybrid手术治疗双节段颈椎病5年以上随访临床疗效及安全有效性与ACDF相当,但Hybrid手术可以更好地重建颈椎曲度,减少邻近节段代偿性活动的同时保持颈椎活动度。     

颈椎多肢畸形1例报道并文献复习

多肢畸形（supernumerary limb）是一种罕见的先天性疾病,主要发生在动物中,在人类中发生的报告很少。这种畸形的动物通常有一个或两个额外的肢体附着在身体的各个部位,可分为头肢（附着在头部）、胸肢（附着在胸部）、背肢（附着在脊柱）和臀肢（附着在骨盆）,其中背肢畸形（notomelia）是存在一个或两个附着在脊柱上的多余肢体,特别是在颈椎或胸椎水平。这些异常通常与遗传因素相关,具有遗传异质性,涉及各种可能的遗传机制,如致畸基因的表达和囊胚的不完全分裂。此外,环境和药物致畸剂在某些情况下也可引起肢体异常。我们收治1例发生在颈椎的多肢畸形患者,报道如下。     

Yoga and disc degenerative disease in cervical and lumbar spine: an MR imaging-based case control study

The objective of the current study was to find out whether yoga practice was beneficial to the spine by comparing degenerative disc disease in the spines of long-time yoga practitioners and non-yoga practicing controls, using an objective measurement tool, magnetic resonance imaging. This matched case–control study comprised 18 yoga instructors with teaching experience of more than 10 years and 18 non-yoga practicing asymptomatic individuals randomly selected from a health checkup database. A validated grading scale was used to grade the condition of cervical and lumbar discs seen in magnetic resonance imaging of the spine, and the resulting data analyzed statistically. The mean number of years of yoga practice for the yoga group was 12.9 ± 7.5. The overall (cervical + lumbar) disc scores of the yoga group were significantly lower (indicating less degenerative disc disease) than those of the control group (P < 0.001). The scores for the cervical vertebral discs of the yoga group were also significantly lower than those of the control group (P < 0.001), while the lower scores for the yoga group in the lumbar group approached, but did not reach, statistical significance (P = 0.055). The scores for individual discs of yoga practitioners showed significantly less degenerative disease at three disc levels, C3/C4, L2/L3 and L3/L4 (P < 0.05). Magnetic resonance imaging showed that the group of long-term practitioners of yoga studied had significantly less degenerative disc disease than a matched control group.     

Bryan人工间盘置换与前路减压融合治疗颈椎退行性疾病的中期随访研究

 目的 评价人工椎间盘置换术治疗颈椎退行性疾病的中期疗效,并探讨其是否可以减少邻近节段退变的发生。方法 前瞻性对比分析接受颈椎人工间盘置换术(置换组,45例)与颈椎前路减压融合术(融合组,48例)治疗的颈椎退行性疾病患者的随访6年临床疗效和影像学资料。临床疗效评价指标为日本骨科协会评分(Japanese Orthopaedic Association Scores,JOA)、颈椎功能残障指数量表(neck disability index,NDI)和Odom评分。影像学评价指标为矢状位曲度、活动度、邻近节段退变。结果28例置换组患者和35例融合组患者完成随访。两组患者末次随访的JOA评分和NDI均较术前有明显改善,组间比较差异无统计学意义。92.9%的置换组患者和97.1%的融合组患者Odom评分获得很好或较好的结果。两组患者颈椎矢状位曲度末次随访较术前均得到保持。颈椎整体活动度置换组末次随访与术前无明显差异,而融合组则是明显降低。置换组置换节段活动度术前为9.5°±3.7°,术后3个月为7.0°±3.0°,末次随访为6.6°±4.1°,末次随访较术后3个月无明显改变。邻近节段退变评估采用侧位X线片和MRI T2加权像,置换组上、下邻近节段退变均明显少于融合组。结论 Bryan人工椎间盘置换术6年的随访结果基本满意,能更好地保留颈椎生理活动及生物力学环境,从而降低邻近节段退变的发生率。     

Combined anterior interbody fusion and posterior pedicle screw fixation in patients with degenerative lumbar disc disease

We reviewed 47 consecutive patients with degenerative lumbar disc disease. All patients were treated by anterior interbody fusion using an autogenous iliac bone graft in combination with posterior pedicle fixation but without a posterior fusion. There were 32 men and 15 women with a mean age of 44 (range 23–56) years. One third (n=15) of the patients had previous surgery. We saw complications in six patients including two with vascular injury. The mean follow-up was 2.2 years. Seventy-two per cent of the cases had a satisfactory clinical outcome, and the overall fusion rate was 97%.

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Résumé Nous avons examiné 47 malades consécutifs présentant une Maladie du Disque Lombaire Dégénératif. Tous les malades ont été traités par fusion corporéale antérieure utilisant une greffe iliaque autogène combinée avec une fixation pédiculaire postérieure mais sans une fusion postérieure. Il y avait 32 hommes et 15 femmes, avec un âge moyen de 44 ans (23–56 ans). Un tiers (n=15) des malades avaient déjà été opéré. Il y a eu des complications chez six malades, en incluant deux malades avec blessure vasculaire. Le suivi moyen était de 2,2 années. 72% des cas avaient un résultat clinique satisfaisant, et le taux de la fusion total était de 97%.

     

Simultaneous anterior and posterior dislocation of hips:a case report and review of literature

The presence of anterior hip dislocation along with contralateral posterior hip dislocation in the absence of other major traumas is a distinctly rare injury pattern.We report such a case,along with a ...     

Hypertrophy of the anterior arch of the atlas associated with congenital nonunion of the posterior arch: a retrospective case-control study

Background contextNonunion of the posterior arch of the atlas is an uncommon but normal developmental variant. It is usually asymptomatic in the patient but may be associated with greater incidence of fracture because of increased stress on the anterior arch.PurposeWe sought to determine whether anterior arch hypertrophy is present in cases of congenital nonunion of the posterior arch of the atlas.Study design/settingA retrospective analysis of 1 year (February 2005–January 2006) of computed tomography cervical spine studies requested by the University of California San Diego Medical Center Trauma Department was undertaken.Patient sampleAll patients matching the search criteria (see Study design) were included.Outcome measuresArea density product, defined as the midline cross-sectional area of the anterior arch on sagittal reformat multiplied by the average areal radiodensity in Hounsfield units (HU) as measured by two raters, was calculated for cases and controls.MethodsCases of posterior arch nonunion were identified and matched to controls. The significance of differences in area density product between cases and controls were established by the Student t test. Interrater correlation was calculated.ResultsPosterior arch nonunion was identified in 26 individuals (3.1% of 839 studies reviewed). Compared with age- and sex-matched controls, a 21% increase in area density product of the midline anterior arch was observed in posterior arch nonunion cases (773 HU-cm² in cases vs. 637 HU-cm² in controls; p<.001). This increase was attributable to a 21% increase in cross-sectional area (1.05 cm² in cases vs. 0.87 cm² in controls; p<.002). In contrast, there was no significant difference with regard to increased average radiodensity.ConclusionsIt has long been subjectively recognized but not objectively quantified, until the present study, that the anterior arch of the atlas is hypertrophied in cases of posterior arch nonunion. Anterior arch hypertrophy may represent an adaptive response to chronically elevated mechanical stress and loss of hoop strength in cases of posterior nonunion.     

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

Objective

Clinical outcomes of the stand-alone cage have been encouraging when used in anterior cervical discectomy and fusion (ACDF), but concerns remain regarding its complications, especially cage subsidence. This retrospective study was undertaken to investigate the long-term radiological and clinical outcomes of the stand-alone titanium cage and to evaluate the incidence of cage subsidence in relation to the clinical outcome in the surgical treatment of degenerative cervical disc disease.

Methods

A total of 57 consecutive patients (68 levels) who underwent ACDF using a titanium box cage for the treatment of cervical radiculopathy and/or myelopathy were reviewed for the radiological and clinical outcomes. They were followed for at least 5 years. Radiographs were obtained before and after surgery, 3 months postoperatively, and at the final follow-up to determine the presence of fusion and cage subsidence. The Cobb angle of C2–C7 and the vertebral bodies adjacent to the treated disc were measured to evaluate the cervical sagittal alignment and local lordosis. The disc height was measured as well. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) score for cervical myelopathy, before and after surgery, and at the final follow-up. The recovery rate of JOA score was also calculated. The Visual Analogue Scale (VAS) score of neck and radicular pain were evaluated as well. The fusion rate was 95.6% (65/68) 3 months after surgery.

Results

Successful bone fusion was achieved in all patients at the final follow-up. Cage subsidence occurred in 13 cages (19.1%) at 3-month follow-up; however, there was no relation between fusion and cage subsidence. Cervical and local lordosis improved after surgery, with the improvement preserved at the final follow-up. The preoperative disc height of both subsidence and non-subsidence patients was similar; however, postoperative posterior disc height (PDH) of subsidence group was significantly greater than of non-subsidence group. Significant improvement of the JOA score was noted immediately after surgery and at the final follow-up. There was no significant difference of the recovery rate of JOA score between subsidence and non-subsidence groups. The recovery rate of JOA score was significantly related to the improvement of the C2–C7 Cobb angle. The VAS score regarding neck and radicular pain was significantly improved after surgery and at the final follow-up. There was no significant difference of the neck and radicular pain between both subsidence and non-subsidence groups.

Conclusions

The results suggest that the clinical and radiological outcomes of the stand-alone titanium box cage for the surgical treatment of one- or two-level degenerative cervical disc disease are satisfactory. Cage subsidence does not exert significant impact upon the long-term clinical outcome although it is common for the stand-alone cages. The cervical lordosis may be more important for the long-term clinical outcome than cage subsidence     

Clinical and radiographic results after treatment of cervical degenerative disc disease with the bryan disc prosthesis: a prospective study with 2-year follow-up

The purpose of this study was to prospectively evaluate the clinical and radiographic results obtained with the Bryan disc prosthesis (Medtronic Sofamor Danek, Memphis, TN) in 20 consecutive patients with single-level or two-level cervical degenerative disc disease. All patients were followed up for at least two years. The mean Neck Disability Index and the visual analogue scale for neck and arm pain scores were significantly reduced for all postoperative periods compared with the mean preoperative values. SF-36 outcome measures, including the physical and mental component scores, significantly improved after surgery and remained unchanged or improved at two years postoperatively. According to Odom's scale, 18 patients (90%) had good to excellent outcomes. The range of movement of the cervical spine, of the functional spinal unit, the treated segment and the adjacent segment temporarily decreased at the early assessment, but all recovered to preoperative levels over a 6-24 months time period. There was no heterotopic ossification at the implanted levels, no adjacent level degeneration and no prosthesis subsidence or excursion. Cervical disc replacement using the Bryan disc prosthesis appeared to be safe and demonstrated encouraging clinical and radiological outcomes. However, further studies are required to assess the long-term efficacy of this prosthesis and its protective influence on adjacent levels.     

全麻下手法复位严重颈椎骨折脱位联合前后路手术1例报道并文献回顾

患者,男,34岁,以“高空坠落致四肢瘫痪6 h余”为主诉于2020年7月23日晚入院。6 h前从高6 m处高压线触电后坠落致四肢感觉活动障碍,无意识障碍。至当地医院予以对症处理后,由救护车转运至我院就诊。体格检查:神志模糊,精神差,双侧瞳孔等大等圆,直径2.5 mm,对光反射迟钝,颈部颈托外固定。     

Alcaptonuria with lumbar disc prolapse: case study and review of the literature.

BACKGROUND CONTEXT: Patients with alcaptonuria frequently complain of pain in the large joints and the spinal column, this condition is being assumed to be normal. It is very rare for patients with ochronosis to undergo lumbar surgery since the disk protrusion is not characteristic for them and overlaps with the general complaints due to the spondiloarthritic and stenotic changes. PURPOSE: To prove the possibility of a lumbar disc herniation in a patient with alcaptonuria as a real entity that causes lumbar and radiculalgic complaints. STUDY DESIGN: A case of a 33-year old patient with alcaptonuria and lumbar disc herniation is presented. METHODS: The case is presented together with its clinical course, the diagnostic techniques, the surgical findings, histological results and the treatment outcome. RESULTS: After the surgical treatment the patient's complaints were alleviated and almost no complaints were registered, during the next follow-up. CONCLUSIONS: The most common symptoms seen in alcaptonuria are complaints of pain in large joints and back pain. They are usually associated with the main disease. The case we present demonstrates that even there is a small likelihood for a prolapsed lumbar disk, it should be sought in such patients as the surgical treatment is able to yields a positive results.     

颈椎前路Hybrid手术不同组合方式治疗连续三节段颈椎病的疗效对比

目的 :比较不同组合方式颈椎前路Hybrid手术[颈前路椎间盘切除减压融合术(anterior cervical discectomy and fusion,ACDF)+人工颈椎间盘置换术(cervical disc arthroplasty,CDA)]治疗连续三节段颈椎病的临床疗效。方法:回顾性分析2012年6月～2018年12月因连续三节段颈椎病于我科行手术治疗的病例,根据手术方式的不同分为FFF组(连续三节段ACDF患者)、1A2F组(单节段CDA+双节段ACDF患者)和2A1F组(双节段CDA+单节段ACDF患者)。根据纳入排除标准,共98例患者纳入研究,其中FFF组22例,年龄58.95±9.28岁,随访时间为29.23±14.79个月;1A2F组47例,年龄51.70±8.23岁,随访时间为36.09±16.72个月;2A1F组29例,年龄48.72±7.76岁,随访时间为36.58±14.81个月。对比分析三组患者术前与术后3d、3个月、6个月、12个月及末次随访时颈部及上肢疼痛视觉模拟评分(visual analog scale,VAS)、日本骨科协会(Japanese Orthopedic Association,JOA)脊髓功能评分及颈椎残障功能指数(neck disability index,NDI)评分。同时于术前与术后3d、3个月、6个月、12个月及末次随访时在颈椎侧位及过伸过屈位X线片上测量颈椎C2-C7曲度、手术节段曲度、颈椎C2-C7活动度、手术节段活动度、上位邻近节段活动度,末次随访时结合颈椎CT评估ACDF节段融合情况。结果:三组患者术后各时间点颈痛VAS评分、上肢痛VAS评分和JOA评分均较术前显著改善(P0.05),三组之间无显著性差异(P0.05)。术后3个月时FFF组NDI评分为17.86±2.55分,显著高于1A2F组的15.13±3.76分和2A1F组的15.55±4.07分(P0.05),余时间点三组之间无显著性差异(P0.05)。三组患者术后3d时颈椎C2-C7曲度和手术节段曲度均较术前显著改善(P0.05)。末次随访时,FFF组颈椎C2-C7曲度和手术节段曲度均较术前显著降低(P0.05),1A2F组和2A1F组与术前相比无显著性差异(P0.05),三组之间无显著性差异(P0.05)。术后6个月、12个月及末次随访时,FFF组颈椎C2-C7活动度及手术节段活动度均显著低于1A2F组和2A1F组(P0.05)。术后12个月时,2A1F组颈椎C2-C7活动度高于1A2F组(P0.05)。术后12个月及末次随访时,2A1F组手术节段活动度高于1A2F组(P0.05)。末次随访时,FFF组、1A2F组和2A1F组上位邻近节段活动度分别为11.97°±2.27°、9.80°±2.99°和8.45°±2.26°,三组之间及两两比较均有显著性差异(P0.05)。末次随访时FFF组、1A2F组和2A1F组融合率分别为81.82%(18/22)、91.49%(43/47)和96.55%(28/29),差异无统计学意义(P0.05)。结论:相较于单纯三节段ACDF,颈椎前路Hybrid手术能够获得与其一致的临床疗效,但在早期颈椎功能康复、颈椎整体活动度及对邻近节段影响方面更具优势,且双节段CDA+单节段ACDF组合方式比单节段CDA+双节段ACDF更优。     

Treatment of degenerative cervical disc disease with uncoforaminotomy--intermediate clinical outcome

BACKGROUND: Anterior cervical uncoforaminotomy (uncoforaminotomy) is an operative method intended to preserve the functional motion segment of the cervical spine while removing the underlying pathology. Controversy exists concerning the patients best suited for this treatment modality. Furthermore, no long-term outcome analyses have been published. METHODS: Between November 2002 and June 2004, 96 patients underwent single-level uncoforaminotomy in our neurosurgical department for the treatment of cervical radiculopathy. The patients were divided into three groups: A, soft disc; B, hard disc; C, hard and soft disc. Follow-up was performed 2 years after surgery. Clinical outcome was classified according to Odom et al. and to the cervical Oswestry and 11-point box scales for arm and neck pain. RESULTS: Ninety patients (92%) underwent intermediate follow-up examinations at an average of 33 months after surgery. Forty-nine patients were in group A, 24 in group B, and 17 in group C. At discharge, 98% of those in group A, 96% in group B, and 94% in group C showed excellent or good results. In two patients revision surgery was performed within 4 weeks due to recurrent disc herniation. In one patient revision was carried out due to a subcutaneous hematoma. In group B one case of vertebral artery injury occurred. Additionally in one patient of this group revision surgery was performed due to inadequate decompression of the neural foramen. At follow-up 94% of the patients in group A, 89% in group B, and 87% in group C had excellent or good results. The scores on the cervical Oswestry scale and the 11-point-box scale showed no significant differences among the groups. CONCLUSION: Uncoforaminotomy, especially in patients with soft-disc pathologies, is a good operative method for the treatment of radicular pain.