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Anterior Cervical Discectomy

  • Author: Chih-Ta Lin, MD; Chief Editor: Cristian Gragnaniello, MD  more...
 
Updated: Sep 22, 2015
 

Background

Anterior cervical discectomy (ACD) was described in the mid-20th century as a treatment for lateral cervical disc syndrome.[1, 2] This procedure involved removing the symptomatic disc from an anterior approach without placement of a bone graft. Early studies demonstrated fusion rates that were similar to those of procedures using bone graft.[2, 3] Multiple larger studies have also shown the ACD procedure to be safe and effective.[4, 5]

With the advent of ACD, anterior cervical discectomy and fusion (ACDF) techniques were simultaneously and independently popularized by Cloward[6] and Smith and Robinson.[7] ACDF similarly involves removing the symptomatic cervical disc with an added step of placing bone graft to encourage bony fusion of the upper and lower vertebral body. This added step has been argued to further encourage cervical fusion to maximize stability and maintain disc space height to decrease the likelihood of foraminal stenosis.[8] However, placement of a bone graft also introduces potential complications of graft dislodgement and failure, as well as donor-site complications if autograft is used. Nonetheless, the ACDF technique has been found to have excellent long-term clinical outcomes.[9, 10]

The anterior cervical discectomy and fusion with instrumentation (ACDFI) technique involves the additional stabilization of the cervical spine with instrumentation. Early instrumentation involved wiring techniques. This was largely modified to cervical plate technology after their introduction and application in the 1980s.[11] Design has subsequently improved to now include constrained, nonconstrained, rotational, rigid, and dynamic plate subtypes[12] . Argued benefits of plate instrumentation include reduced graft dislodgements, increased fusion rates, and decreased foraminal stenosis. However, as with the introduction of bone graft, the additional placement of hardware introduces hardware-related complications.

Since their introductions, heated debates have compared ACD, ACDF, and ACDFI. Prospective randomized controlled trials have been performed that demonstrate similar clinical outcomes between the 3 groups, with a decreased rate of cervical fusion and increased incidence of kyphosis in the ACD group.[3, 13, 14, 15] Guidelines were also published in 2009.[16] Proponents and detractors for these different procedures can be found throughout the scientific and surgical community.

The purpose of this article is not to compare and contrast these different surgical techniques or plate technologies but to highlight the role of these 3 procedures for treatment of cervical spine disease.

Key considerations

As mentioned above, ACD, ACDF, and ACDFI are different but very similar techniques for the surgical treatment of cervical spine disease. This article discusses the differences between these techniques.

When referring to the ACDFI technique, various plate technologies exist. These can be roughly categorized as rigid versus dynamic versus rotational, nonconstrained versus constrained, and rotational plating systems. Recent biodegradable and single-screw-per-vertebral body systems have also been introduced. The nuances of these plating systems are not discussed in this article.

When referring to the bone graft techniques, namely ACDF and ACDFI, surgical choices of using autograft and allograft exist. The differences between these types of bone graft are not discussed.

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Indications

The indications for ACD, ACDF, and ACDFI include cervical spine trauma and resulting instability, radiculopathy, myelopathy, osteomyelitis, spondylosis, vertebral body tumors, opacified posterior longitudinal ligament, and postlaminectomy kyphosis.

(Left) MRI, Sagittal T2 sequence, demonstrating a (Left) MRI, Sagittal T2 sequence, demonstrating a central cervical disk herniation causing cervical myelopathy. (Center) MRI, Axial T2 sequence, demonstrating a normal cervical disk that does not cause compression of the spinal cord or the exiting nerve roots. (Right) MRI, T2 Sequence, Axial T2 sequence, demonstrating a central disk herniation causing compression and deformation of the spinal cord, causing symptoms of cervical myelopathy.
MRI, Axial T2 sequence, demonstrating a right-side MRI, Axial T2 sequence, demonstrating a right-sided cervical disk herniation causing cervical nerve root impingement and resulting radiculopathy.

Patient selection is important in complication prevention. Increased patient age, decreased bone density, and a positive smoking history can play a role in increasing complication rates. Additionally, an increase in the number of planned cervical levels to be decompressed can increase the complication risk.

Antibiotic infusions prior to skin incision should be used to decrease wound infection rates. Intraoperative fluoroscopic radiography should also be used to assess the cervical spine and facilitate proper hardware placement. An operative microscope that magnifies the operative field but also provides a strong light source is helpful. Intraoperative spinal cord monitoring has also been used as an effective measure for avoiding spinal cord and nerve root injury during surgical procedures.

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Outcomes

Early studies demonstrated fusion rates that were similar to those of procedures using bone graft.[2, 3] Multiple larger studies have also shown the ACD procedure to be safe and effective.[4, 5]

The ACDF technique has been found to have excellent long-term clinical outcomes.[9, 10, 17]

Since their introductions, heated debates have compared ACD, ACDF, and ACDFI. Prospective randomized controlled trials have been performed that demonstrate similar clinical outcomes between the 3 groups, with a decreased rate of cervical fusion and increased incidence of kyphosis in the ACD group.[3, 13, 14, 15]

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Complications

Complications specific to ACD, ACDF, and ACDFI include hardware and graft failures, neurologic injury, and neck-related complications.[18]

Hardware complications involve failures related to instrumentation. Reported incidence rates are from 1%-20%.[19, 20, 21] Hardware complications can include screw backout (2%-10%),[19, 20] plate fracture (2%),[20] screw breakage (1%-7%),[19, 20] , and plate migration (1%-3%).[22, 23] Graft fusion failures have also been described with an incidence that ranges from 3%-9%.[19, 20, 21, 22, 23] Interestingly, plate length, increasing age, use of allograft, and a reoperative procedure have been linked to a higher incidence of plate failure.[19, 24]

Neurologic complications can also occur with cervical procedures. These include dural tears leading to cerebrospinal fluid leaks, spinal cord injuries, and nerve root injuries resulting in weakness (1%-5%)[19] .[25]

Complications related to neck surgery are also possible. Dysphagia due to esophageal retraction and intubation has been reported to range from 4%-16%.[19, 20, 23] Postoperative neck hematoma causing airway obstruction has been reported.[19, 20] Esophageal perforations can also occur, especially during the opening approach to the vertebral body.

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Contributor Information and Disclosures
Author

Chih-Ta Lin, MD Resident Physician, Division of Neurosurgery, Fletcher Allen Health Care, University of Vermont College of Medicine

Chih-Ta Lin, MD is a member of the following medical societies: American Association for Cancer Research, American Association of Neurological Surgeons, American College of Surgeons, Society for Neuro-Oncology, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Bruce I Tranmer, MD FRCS(C), FACS, Professor and Chairman, Division of Neurosurgery, Program Director, Neurosurgery Residency Program, Cordell E Gross, MD, Green and Gold Professor of Neurosurgery, University of Vermont College of Medicine, Fletcher Allen Health Care

Bruce I Tranmer, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, Canadian Medical Association, Society of Neurological Surgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Cristian Gragnaniello, MD Fellow in Spinal Neurosurgery, Department of Neurosurgery, Australian School of Advanced Medicine, Macquarie University, Australia

Cristian Gragnaniello, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

References
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  2. Murphy MG, Gado M. Anterior cervical discectomy without interbody bone graft. J Neurosurg. 1972 Jul. 37(1):71-4. [Medline].

  3. Martins AN. Anterior cervical discectomy with and without interbody bone graft. J Neurosurg. 1976 Mar. 44(3):290-5. [Medline].

  4. Bertalanffy H, Eggert HR. Complications of anterior cervical discectomy without fusion in 450 consecutive patients. Acta Neurochir (Wien). 1989. 99(1-2):41-50. [Medline].

  5. Hankinson HL, Wilson CB. Use of the operating microscope in anterior cervical discectomy without fusion. J Neurosurg. 1975 Oct. 43(4):452-6. [Medline].

  6. CLOWARD RB. The anterior approach for removal of ruptured cervical disks. J Neurosurg. 1958 Nov. 15(6):602-17. [Medline].

  7. SMITH GW, ROBINSON RA. The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am. 1958 Jun. 40-A(3):607-24. [Medline].

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  10. Xie JC, Hurlbert RJ. Discectomy versus discectomy with fusion versus discectomy with fusion and instrumentation: a prospective randomized study. Neurosurgery. 2007 Jul. 61(1):107-16; discussion 116-7. [Medline].

  11. Omeis I, DeMattia JA, Hillard VH, Murali R, Das K. History of instrumentation for stabilization of the subaxial cervical spine. Neurosurg Focus. 2004 Jan 15. 16(1):E10. [Medline].

  12. Shao H, Chen J, Ru B, Yan F, Zhang J, Xu S, et al. Zero-profile implant versus conventional cage-plate implant in anterior cervical discectomy and fusion for the treatment of degenerative cervical spondylosis: a meta-analysis. J Orthop Surg Res. 2015 Sep 17. 10 (1):148. [Medline].

  13. Rosenørn J, Hansen EB, Rosenørn MA. Anterior cervical discectomy with and without fusion. A prospective study. J Neurosurg. 1983 Aug. 59(2):252-5. [Medline].

  14. Savolainen S, Rinne J, Hernesniemi J. A prospective randomized study of anterior single-level cervical disc operations with long-term follow-up: surgical fusion is unnecessary. Neurosurgery. 1998 Jul. 43(1):51-5. [Medline].

  15. Xie JC, Hurlbert RJ. Discectomy versus discectomy with fusion versus discectomy with fusion and instrumentation: a prospective randomized study. Neurosurgery. 2007 Jul. 61(1):107-16; discussion 116-7. [Medline].

  16. Matz PG, Ryken TC, Groff MW, Vresilovic EJ, Anderson PA, Heary RF, et al. Techniques for anterior cervical decompression for radiculopathy. J Neurosurg Spine. 2009 Aug. 11(2):183-97. [Medline].

  17. Selvanathan SK, Beagrie C, Thomson S, Corns R, Deniz K, Derham C, et al. Anterior cervical discectomy and fusion versus posterior cervical foraminotomy in the treatment of brachialgia: the Leeds spinal unit experience (2008-2013). Acta Neurochir (Wien). 2015 Sep. 157 (9):1595-600. [Medline].

  18. Shriver MF, Lewis DJ, Kshettry VR, Rosenbaum BP, Benzel EC, Mroz TE. Pseudoarthrosis rates in anterior cervical discectomy and fusion: a meta-analysis. Spine J. 2015 Sep 1. 15 (9):2016-27. [Medline].

  19. Bose B. Anterior cervical fusion using Caspar plating: analysis of results and review of the literature. Surg Neurol. 1998 Jan. 49(1):25-31. [Medline].

  20. Zaveri GR, Ford M. Cervical spondylosis: the role of anterior instrumentation after decompression and fusion. J Spinal Disord. 2001 Feb. 14(1):10-6. [Medline].

  21. Caspar W, Geisler FH, Pitzen T, Johnson TA. Anterior cervical plate stabilization in one- and two-level degenerative disease: overtreatment or benefit?. J Spinal Disord. 1998 Feb. 11(1):1-11. [Medline].

  22. Epstein NE. Reoperation rates for acute graft extrusion and pseudarthrosis after one-level anterior corpectomy and fusion with and without plate instrumentation: etiology and corrective management. Surg Neurol. 2001 Aug. 56(2):73-80; discussion 80-1. [Medline].

  23. Mayr MT, Subach BR, Comey CH, Rodts GE, Haid RW Jr. Cervical spinal stenosis: outcome after anterior corpectomy, allograft reconstruction, and instrumentation. J Neurosurg. 2002 Jan. 96(1 Suppl):10-6. [Medline].

  24. Paramore CG, Dickman CA, Sonntag VK. Radiographic and clinical follow-up review of Caspar plates in 49 patients. J Neurosurg. 1996 Jun. 84(6):957-61. [Medline].

  25. Shapiro SA, Snyder W. Spinal instrumentation with a low complication rate. Surg Neurol. 1997 Dec. 48(6):566-74. [Medline].

  26. Deletis V. Intraoperative neurophysiology of the corticospinal tract of the spinal cord. Suppl Clin Neurophysiol. 2006. 59:107-12. [Medline].

 
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(Left) MRI, Sagittal T2 sequence, demonstrating a central cervical disk herniation causing cervical myelopathy. (Center) MRI, Axial T2 sequence, demonstrating a normal cervical disk that does not cause compression of the spinal cord or the exiting nerve roots. (Right) MRI, T2 Sequence, Axial T2 sequence, demonstrating a central disk herniation causing compression and deformation of the spinal cord, causing symptoms of cervical myelopathy.
MRI, Axial T2 sequence, demonstrating a right-sided cervical disk herniation causing cervical nerve root impingement and resulting radiculopathy.
Upright lateral plain film following an anterior cervical diskectomy and fusion, demonstrating the bone graft between the vertebral bodies and the abutting cervical plate.
 
 
 
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