Stulík J

Implant complications, fusion, loss of lordosis, and outcome after anterior cervical plating with dynamic or rigid plates: two-year results of a multi-centric, randomized, controlled study.

Study Design. Prospective, controlled, randomized, multicenter study. Objective. To analyze implant complications and speed. Summary of Background Data. Rigid plate designs, in which the screws are locked to the plate, are in common use and thought to provide more fixation than dynamic designs, in which the screws may glide when the graft is settling. The aim of the study is to analyze (1) implant complications, (2) speed of fusion, (3) loss of lordosis, and (4) clinical outcome in both types of plates. Methods. One hundred thirty-two patients were included and assigned by randomization to one of the groups in which they received a routine anterior cervical discectomy and autograft fusion with either a dynamic plate (ABC, study group) or a rigid plate (CSLP, control group). At discharge, after 3 and 6 months and finally after 2 years, implant complications, segmental mobility, absence of radiolucencies, absence of bone sclerosis, evidence of bridging trabecular bone, loss of lordosis, Visual Analog Scale (VAS) and Neck Disability Score were recorded. All radiographic measurements were performed by an independent radiologist. Results. There have been 4 patients with implant complications within the control group and no implant complications within the study group, P = 0.045. Mean segmental mobility before discharge for the study group was 1.7 mm, 1.4 mm after 3 months, 0.8 mm after 6 months, and 0.4 mm after 2 years. For the control group, these values were 1.0, 1.8, 1.6, and 0.5 mm. The difference at 6 months between both groups was significant (P = 0.024). Neither absence of radiolucencies, nor absence of sclerosis, nor evidence of bridging bone showed significant differences between the 2 groups through the postoperative follow-up (P > 0.05). The loss of segmental lordosis for the study group with respect to intraoperative radiograph was 1.3° at discharge and 4.3° after 2 years. For the controlgroup, these values were 0.9°, 0.7°. The difference at 2 years was significant (P = 0.003). Clinical postoperative outcome (VAS and ODI) was not different between the 2 groups through the postoperative follow-up (P > 0.05). Conclusion. Dynamic cervical plate designs provide less implant complications (no patient) compared with rigid plate designs (4 patients). Speed of fusion was faster in the presence of a dynamic plate. However, loss of segmental lordosis is significantly higher if dynamic plates are used, which did not result in differences regarding clinical outcome between dynamic and constrained plates after 2 years. Thus, dynamic plates should be considered to be the preferred treatment option because of the lower risk for implant failure-related revision surgery.

Total spondylectomy of C2: report of three cases and review of the literature.

Study Design A report on 3 patients undergoing total spondylectomy of the C2 vertebra for tumor and the technique for C1-3 reconstruction. Objective To illustrate the feasibility of complete resection of the C2 vertebra with preservation of the vertebral arteries and cervical nerve roots. Background Total spondylectomy provides improved progression free survival in many patients with locally aggressive spinal tumors. However, the perceived technical demands of effectively preserving both vertebral arteries, maintaining cervical nerve roots, and biomechanical reconstruction of the cranial-cervical junction often dissuades surgeons from carrying out total spondylectomy of the C2 vertebra. Methods A review of 3 patients undergoing total C2 spondylectomy for tumor (thyroid adenocarcinoma, chordoma, and solitary plasmocytoma) was done. The surgical procedure that was undertaken and the technique used are described. Results Postoperatively, all 3 patients had uneventful postoperative recovery with gradual improvement in their neurologic functions. Conclusion Preservation of bilateral vertebral arteries and all cervical nerve roots is feasible when carrying out intralesional total spondylectomy in patients with C2 vertebral body tumors and should be considered in patients thought to benefit from total C2 vertebra excision. In an attempt to augment construct stability and provide anterior column load sharing, we have used mesh cage and iliac crest graft between C1 and C3 held in place with a short cervical plate without complications.

Incidence of vascular complications arising from anterior spinal surgery in the thoraco-lumbar spine.

Study Design Modern biomaterials and instrumentation have popularised surgery of the thoraco-lumbar spine through an anterior route. The advantage of anterior surgery is that it allows for a direct decompression of the compromised spinal canal. However, the potential for devastating long-term sequelae as a result of complications is high. Purpose The aim of this study was to give a general overview and identify the incidence of vascular complications. Overview of Literature There is limited literature describing the overall incidence and complications of anterior spinal surgery. Methods A retrospective review of a prospective database of 1,262 consecutive patients with anterior surgery over a twelve-year period. Results In our study, 1.58% (n=20) of patients suffered complications. Injury to a major vessel was encountered in 14 (1.11%) cases, of which nine involved an injury to the common iliac vein. In six cases, the original procedure was abandoned due to a life-threatening vascular injury (n=3) and unfavourable anatomy (n=3). Conclusions The incidence of vascular and other complications in our study was relatively low. Nevertheless, the potential for devastating long-term sequelae as a result of complications remains high. A thorough knowledge and awareness of normal and abnormal anatomy should be gained before attempting such a procedure, and a vascular surgical assistance especially should be readily accessible. We believe use of access surgeons is mandatory in cases with difficult or aberrant anatomy.

Four-year results of a prospective single-arm study on 200 semi-constrained total cervical disc prostheses: clinical and radiographic outcome.

OBJECTIVE Recent studies have described encouraging outcomes after cervical total disc replacement (cTDR), but there are also critical debates regarding the long-term effects of heterotopic ossification (HO) and the prevalence of adjacent-level degeneration. The aim in this paper was to provide 4-year clinical and radiographic outcome results on the activ C disc prosthesis. METHODS A total of 200 subjects underwent single-level activ C (Aesculap AG) implantation between C-3 and C-7 for the treatment of symptomatic degenerative disc disease. Clinical and radiographic assessments were performed preoperatively, intraoperatively, at discharge, and again at 6 weeks, 6 months, 1 year, 2 years, and 4 years. Radiographic evaluations were done by an independent core laboratory using a specific software for quantitative motion analysis. RESULTS Neck Disability Index (NDI) and visual analog scale (VAS) score for neck and arm pain decreased significantly from baseline to the 4-year follow-up. The mean improvement for NDI was 20, for VAS severity and frequency of neck pain 26.4 and 28, and for VAS severity and frequency of arm pain 30.7 and 35.1, respectively. The neurological situation improved for the majority of patients (86.4%); 76.1% of cases were asymptomatic. Subsequent surgical interventions were reported in 7% of the cases, including device removals in 3%. In 2.5% a subsidence greater than 3 mm was recorded; 1 of these cases also had a migration greater than 3 mm. No device displacement, expulsion, disassembly, loose or fractured device, osteolysis, or facet joint degeneration at the index level was observed. Segmental lordotic alignment changed from -2.4° preoperatively to -6.2° at 4 years, and postoperative height was maintained during the follow-up. Advanced HO (Grade III and IV) was present in 27.1% of the cases; 82.4% showed segmental mobility. A progression of radiographic adjacent-segment degeneration occurred in 28.2%, but only 4.5% required surgical treatment. CONCLUSIONS The activ C is a safe and effective device for cervical disc replacement confirming the encouraging results after cTDR. Clinical trial registration no.: NCT02492724 ( clinicaltrials.gov ).

Treatment of Cervical Facet Subluxations, Dislocations and Fracture-Dislocations

Cervical facet dislocations are potentially devastating injuries which account for 75 % of subaxial spine injuries. Classification, timing of surgery and types of fixation vary between surgeons and there is still no gold standard. There remains open debate regarding the role of MRI in the diagnostics and selection of the optimal treatment strategy, anterior, posterior or combined approach. In the presence or suspicion of disc herniation behind the displaced vertebral body, anterior approach is indicated. Posterior approach alone is recommended in cases where successful closed awake reduction was achieved or the presence of disc herniation was ruled out by MRI. Because most of these injuries lead to significant damage of both the anterior and posterior column, combined approach is commonly performed, especially in poly-traumatized, alcoholics or other non-compliant patients or in those with additional injury of the superior end-plate of the inferior vertebra.

The Rheumatoid Cervical Spine

Rheumatoid arthritis (RA) is a progressive, debilitating disease with serious physical, psychological and economic consequences [24, 36]. RA afflicts about 1% of world population, more than 2.9 million Europeans and over two million patients in the United States. The clinical course of RA fluctuates and prognosis is unpredictable [13, 14]. Seventy percent of patients with recent onset of RA show evidence of radiographic changes within 3 years [35]. Fifty percent of RA patients are work-disabled within 10 years of disease onset [1, 30, 37].