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Zhiming Tu, Yawei Li, Lei Li, Guohua Lv and Bing Wang

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Peng-Yuan Chang, Hsuan-Kan Chang, Jau-Ching Wu, Wen-Cheng Huang, Li-Yu Fay, Tsung-Hsi Tu, Ching-Lan Wu and Henrich Cheng

OBJECTIVE

Cervical disc arthroplasty (CDA) has been demonstrated to be as safe and effective as anterior cervical discectomy and fusion (ACDF) in the management of 1- and 2-level degenerative disc disease (DDD). However, there has been a lack of data to address the fundamental discrepancy between the two surgeries (CDA vs ACDF), and preservation versus elimination of motion, in the management of cervical myelopathy associated with congenital cervical stenosis (CCS). Although younger patients tend to benefit more from motion preservation, it is uncertain if CCS caused by multilevel DDD can be treated safely with CDA.

METHODS

Consecutive patients who underwent 3-level anterior cervical discectomy were retrospectively reviewed. Inclusion criteria were age less than 50 years, CCS (Pavlov ratio ≤ 0.82), symptomatic myelopathy correlated with DDD, and stenosis limited to 3 levels of the subaxial cervical (C3–7) spine. Exclusion criteria were ossification of the posterior longitudinal ligament, previous posterior decompression surgery (e.g., laminoplasty or laminectomy), osteoporosis, previous trauma, or other rheumatic diseases that might have caused the cervical myelopathy. All these patients who underwent 3-level discectomy were divided into 2 groups according to the strategies of management: preservation or elimination of motion (the hybrid-CDA group and the ACDF group). The hybrid-CDA group underwent 2-level CDA plus 1-level ACDF, whereas the ACDF group underwent 3-level ACDF. Clinical assessment was measured by the visual analog scales (VAS) for neck and arm pain, Japanese Orthopaedic Association (JOA) scores, and Nurick grades. Radiographic outcomes were measured using dynamic radiographs for evaluation of range of motion (ROM).

RESULTS

Thirty-seven patients, with a mean (± SD) age of 44.57 ± 5.10 years, were included in the final analysis. There was a male predominance in this series (78.4%, 29 male patients), and the mean follow-up duration was 2.37 ± 1.60 years. There were 20 patients in the hybrid-CDA group, and 17 in the ACDF group. Both groups demonstrated similar clinical improvement at 2 years' follow-up. These patients with 3-level stenosis experienced significant improvement after either type of surgery (hybrid-CDA and ACDF). There were no significant differences between the 2 groups at each of the follow-up visits postoperatively. The preoperative ROM over the operated subaxial levels was similar between both groups (21.9° vs 21.67°; p = 0.94). Postoperatively, the hybrid-CDA group had significantly greater ROM (10.65° vs 2.19°; p < 0.001) than the ACDF group. Complications, adverse events, and reoperations in both groups were similarly low.

CONCLUSIONS

Hybrid-CDA yielded similar clinical improvement to 3-level ACDF in patients with myelopathy caused by CCS. In this relatively young group of patients, hybrid-CDA demonstrated significantly more ROM than 3-level ACDF without adjacent-segment disease (ASD) at 2 years' follow-up. Therefore, hybrid-CDA appears to be an acceptable option in the management of CCS. The strategy of motion preservation yielded similar improvements of cervical myelopathy to motion elimination (i.e., ACDF) in patients with CCS, while the theoretical benefit of reducing ASD required further validation.

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Chih-Chang Chang, Li-Yu Fay, Jau-Ching Wu, Peng-Yuan Chang, Tsung-Hsi Tu, Henrich Cheng and Wen-Cheng Huang

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Chih-Chang Chang, Yu-Shu Yen, Tsung-Hsi Tu, Li-Yu Fay, Wen-Cheng Huang and Jau-Ching Wu

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Yu-Wen Cheng, Peng-Yuan Chang, Jau-Ching Wu, Chih-Chang Chang, Li-Yu Fay, Tsung-Hsi Tu, Wen-Cheng Huang and Henrich Cheng

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Hsuan-Kan Chang, Chih-Chang Chang, Tsung-Hsi Tu, Jau-Ching Wu, Wen-Cheng Huang, Li-Yu Fay, Peng-Yuan Chang, Ching-Lan Wu and Henrich Cheng

OBJECTIVE

Many reports have successfully demonstrated that cervical disc arthroplasty (CDA) can preserve range of motion after 1- or 2-level discectomy. However, few studies have addressed the extent of changes in segmental mobility after CDA or their clinical correlations.

METHODS

Data from consecutive patients who underwent 1-level CDA were retrospectively reviewed. Indications for surgery were medically intractable degenerative disc disease and spondylosis. Clinical outcomes, including visual analog scale (VAS)–measured neck and arm pain, Neck Disability Index (NDI), and Japanese Orthopaedic Association (JOA) scores, were analyzed. Radiographic outcomes, including C2–7 Cobb angle, the difference between pre- and postoperative C2–7 Cobb angle (ΔC2–7 Cobb angle), sagittal vertical axis (SVA), the difference between pre- and postoperative SVA (ΔSVA), segmental range of motion (ROM), and the difference between pre- and postoperative ROM (ΔROM), were assessed for their association with clinical outcomes. All patients underwent CT scanning, by which the presence and severity of heterotopic ossification (HO) were determined during the follow-up.

RESULTS

A total of 50 patients (mean age 45.6 ± 9.33 years) underwent a 1-level CDA (Prestige LP disc) and were followed up for a mean duration of 27.7 ± 8.76 months. All clinical outcomes, including VAS, NDI, and JOA scores, improved significantly after surgery. Preoperative and postoperative ROM values were similar (mean 9.5° vs 9.0°, p > 0.05) at each indexed level. The mean changes in segmental mobility (ΔROM) were −0.5° ± 6.13°. Patients with increased segmental mobility after surgery (ΔROM > 0°) had a lower incidence of HO and HO that was less severe (p = 0.048) than those whose ΔROM was < 0°. Segmental mobility (ROM) was significantly lower in patients with higher HO grade (p = 0.012), but it did not affect the clinical outcomes. The preoperative and postoperative C2–7 Cobb angles and SVA remained similar. The postoperative C2–7 Cobb angles, SVA, ΔC2–7 Cobb angles, and ΔSVA were not correlated to clinical outcomes after CDA.

CONCLUSIONS

Segmental mobility (as reflected by the mean ROM) and overall cervical alignment (i.e., mean SVA and C2–7 Cobb angle) had no significant impact on clinical outcomes after 1-level CDA. Patients with increased segmental mobility (ΔROM > 0°) had significantly less HO and similarly improved clinical outcomes than those with decreased segmental mobility (ΔROM < 0°).

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Tsung-Hsi Tu, Jau-Ching Wu, Henrich Cheng and Praveen V. Mummaneni

For patients with multilevel cervical stenosis at nonadjacent segments, one of the traditional approaches has included a multilevel fusion of the abnormal segments as well as the intervening normal segment. In this video we demonstrate an alternative treatment plan with tailored use of a combination of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) with an intervening skipped level.

The authors present the case of a 72-year-old woman with myeloradiculopathy and a large disc herniation with facet joint degeneration at C3–4 and bulging disc at C5–6. After nonoperative treatment failed, she underwent a single-level ACDF at C3–4 and single-level arthroplasty at C5–6, which successfully relieved her symptoms. No intervention was performed at the normal intervening C4–5 segment. By using ACDF combined with arthroplasty, the authors have avoided a 3-level fusion for this patient and maintained the range of motion of 2 disc levels.

The video can be found here: https://youtu.be/OrxcPUBvqLk.

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Tsung-Hsi Tu, Chih-Chang Chang, Jau-Ching Wu, Li-Yu Fay, Wen-Cheng Huang and Henrich Cheng

The most commonly accepted indications for cervical disc arthroplasty (CDA) are 1- and 2-level cervical disc herniation or spondylosis causing radiculopathy or myelopathy that is refractory to medical management. Unlike anterior cervical discectomy and fusion (ACDF), which eliminates motion, CDA aims to restore the physiological range of motion of the indexed joint. Thus, the effect of indirect decompression gained by the insertion of a sufficiently large interbody graft and incorporation into arthrodesis after ACDF cannot be duplicated for CDA. For patients undergoing CDA, during extreme flexion/extension or rotation, the exiting nerve roots might be impinged by inadequately decompressed foraminal osteophytes. Therefore, the authors advocate generous decompression, including resection of the posterior longitudinal ligament (PLL) and bilateral uncovertebral joints (UVJs), even in the asymptomatic side. This video demonstrates full dural expansion and enlarged neuroforamen after removal of the PLL and UVJs. Venous hemorrhage encountered during foraminotomy can always be controlled by cottonoid packing or hemostatic agents. Also, the endplates of the surrounding vertebral bodies were meticulously prepared for parallel insertion of the ProDisc-C Nova (DePuy Synthes Spine) artificial disc. Please note that the ProDisc-C Nova is currently not available on the US market.

The video can be found here: https://youtu.be/XUo34j6WFYs.