Early development and progression of heterotopic ossification in cervical total disc replacement

Clinical article

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Object

The purpose of cervical total disc replacement (TDR) is to decrease the incidence of adjacent segment disease through motion preservation. Heterotopic ossification (HO) is a well-known complication after hip and knee arthroplasties. There are few reports regarding HO in patients undergoing cervical TDR, however; and the occurrence of HO and its effects on cervical motion have rarely been reported. Moreover, temporal progression of HO has not been fully addressed. One goal of this study involved determining the incidence of HO following cervical TDR, as identified from plain radiographs, and demonstrating the progression of HO during the follow-up period. A second goal consisted of determining whether segmental motion could be preserved and identifying the relationship between HO and clinical outcomes.

Methods

The authors conducted a retrospective clinical and radiological study of 28 consecutive patients who underwent cervical TDR with Mobi-C prostheses (LDR Medical) between September 2006 and October 2008. Radiological outcomes were evaluated using lateral dynamic radiographs obtained preoperatively and at 1, 3, 6, 12, and 24 months postoperatively. The occurrence of HO was interpreted on lateral radiographs using the McAfee classification. Cervical range of motion (ROM) was also measured. The visual analog scale (VAS) and Neck Disability Index (NDI) were used to evaluate clinical outcome.

Results

The mean follow-up period was 21.6 ± 7.0 months, and the mean occurrence of HO was at 8.0 ± 6.6 months postoperatively. At the last follow-up, 18 (64.3%) of 28 patients had HO: Grade I, 6 patients; Grade II, 8 patients; Grade III, 3 patients; and Grade IV, 1 patient. Heterotopic ossification progression was proportional to the duration of follow-up; HO was present in 3 (10.7%) of 28 patients at 1 month; 7 (25.0%) of 28 patients at 3 months; 11 (42.3%) of 26 patients at 6 months; 15 (62.5%) of 24 patients at 12 months; and 17 (77.3%) of 22 patients at 24 months. Cervical ROM was preserved in Grades I and II HO but was restricted in Grades III and IV HO. Clinical improvement according to the VAS and NDI was not significantly correlated with the occurrence of HO.

Conclusions

The overall incidence of HO after cervical TDR was relatively high. Moreover, HO began unexpectedly to appear early after surgery. Heterotopic ossification progression was proportional to the time that had elapsed postoperatively. Grade III or IV HO can restrict the cervical ROM and may lead to spontaneous fusion; however, the occurrence of HO did not affect clinical outcome. The results of this study indicate that a high incidence of HO with the possibility of spontaneous fusion is to be expected during long-term follow-up and should be considered before performing cervical TDR.

Abbreviations used in this paper: ACDF = anterior cervical discectomy with fusion; HO = heterotopic ossification; NDI = Neck Disability Index; NSAID = nonsteroidal antiinflammatory drug; PLL = posterior longitudinal ligament; ROM = range of motion; TDR = total disc replacement; VAS = visual analog scale.

Article Information

Address correspondence to: Chun Kee Chung, M.D., Department of Neurosurgery, Seoul National University College of Medicine, 28 Yeongun-Dong, Jongro-Gu, Seoul 110-744, Korea. email: chungc@snu.ac.kr.

Please include this information when citing this paper: published online October 14, 2011; DOI: 10.3171/2011.8.SPINE11303.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Early development and progression of HO on radiographs obtained in a 45-year-old man. A: Herniated intervertebral disc at C6–7. B: Immediate postoperative lateral radiograph showing TDR at C6–7. C: One-month postoperative radiograph showing no HO. D: Three-month postoperative radiograph showing Grade I HO. Although the HO is detectable, it is not in the intervertebral space. E: Six-month postoperative radiograph showing Grade II HO growing into the disc space. F: One-year postoperative radiograph showing Grade III HO. Bridging ossification is present, but flexion and extension movement is still possible. G and H: Two-year and 3-year postoperative radiographs showing progression of HO toward near-complete fusion at C6–7.

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    Graph showing progression of HOs. Months 1, 3, 6, 12, and 24 are represented on the x axis. The y axis represents the percentage of HO.

  • View in gallery

    Graph showing postoperative ROM changes during the follow-up period. The y axis represents the angle of the ROM.

  • View in gallery

    Graphs showing the associations between the VAS score (upper) and the NDI value (lower) with clinical outcomes. The y axis represents the score.

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