Comparison between repeat anterior and posterior decompression and fusion in the treatment of two-level symptomatic adjacent segment disease after anterior cervical arthrodesis

Abstract

Background: Two-level symptomatic adjacent segment disease (ASD) is rarely reported, but remains a challenge after anterior cervical arthrodesis. The purpose of this study was to compare the clinical and radiological outcomes of repeat anterior and posterior decompression and fusion procedures for two-level symptomatic ASD. Methods: Thirty-two patients with two-level symptomatic ASD were retrospectively reviewed and underwent repeat anterior cervical discectomy and fusion (ACDF) or posterior decompression and fusion (PDF). Clinical outcomes (JOA, NDI, and VAS scores), perioperative parameters (blood loss, operation time, and length of hospital stay), radiological parameters (cervical lordosis and ROM), and complications were compared. Results: Eighteen patients underwent ACDF, and 14 patients underwent PDF. Patients who underwent PDF were older, more frequently presented with myelopathic deficits, and were fused at more levels. Patients who underwent ACDF experienced significantly shorter surgery time (p < 0.001), lower blood loss (p < 0.001), and reduced hospital stay (p = 0.002). Both groups exhibited significant increases in JOA scores and decreases in NDI and both neck pain and arm pain VAS scores (p < 0.05), but patients who underwent PDF had significantly higher NDI scores (p = 0.012), neck pain VAS scores (p = 0.019), loss of cervical lordosis (p < 0.001), and loss of ROM (p = 0.001). Three patients developed dysphagia in the ACDF group, and two patients had C5 root palsy and one had hematoma in the PDF group. Recurrent ASD after the second operation occurred in two patients in the ACDF group but no patients in the PDF group. Conclusions: For patients with two-level symptomatic ASD, both anterior and posterior decompression and fusion were effective for improving the neurological function. For patients with radicular symptoms, ACDF had less surgical trauma, better restoration of lordosis, and less postoperative neck pain, but higher chance of recurrent ASD. PDF was an effective surgical option for older patients with myelopathy developing in adjacent segments.

Biomechanical Evaluation of Different Surgical Approaches for the Treatment of Adjacent Segment Diseases After Primary Anterior Cervical Discectomy and Fusion: A Finite Element Analysis

“…ASD can occur in the superior, inferior, or both adjacent levels, depending on the levels affected. Considering the clinical situation and secondary preoperative imaging findings, ASD can be treated by second ACDF, laminoplasty, and posterior fusion ( Wang F. et al, 2017 ; Cao et al, 2020 ). ACDF decompresses the nerve roots and myelopathy by removing the herniated disc and posterior osteophytes, followed by restoration of the disc height and cervical lordosis by cages and bone graft ( Schroeder et al, 2016 ; Muzević et al, 2018 ).…”

Spinal fusion surgery blood loss: a narrative review abstract

“…There were selected nine studies about different techniques of spine arthrodesis, being two of them (Cao et al, 2020;Bydon et al, 2014) about cervical fusion, two (Liu et al, 2014;Li et al, 2019) of them about thoracic fusion and five (Fujimori et al, 2014;Hung et al, 2021;Campbell et al, 2018;Goodnough et al, 2019;Kim et al, 2021) of them about lumbar fusion. When analyzing the spine pathology treated, two of the studies were about spondylosis (Fujimori et al, 2014;Campbell et al, 2018), another two were about spondylolisthesis (Hung et al, 2021;Goodnough et al, 2019), two were about spinal tuberculosis (Liu et al, 2014;Li et al, 2019), two were about adjacent segment disease (ASD) (Cao et al, 2020;Bydon et al, 2014), and one of the studies did not specify the disease (Kim et al, 2021).…”

“…For decades, ACDF has been considered the golden standard procedure to treat cervical spine degenerative diseases due to its safety and efficacy, however, this procedure presents itself with some complications, such as rapid degeneration of the adjacent level (Cao et al, 2020;Bydon et al, 2014). Therefore, Cao et al (2020) and Bydon et al (2014) conducted studies to compare ACDF and PDF approaches to spine diseases.…”

“…For decades, ACDF has been considered the golden standard procedure to treat cervical spine degenerative diseases due to its safety and efficacy, however, this procedure presents itself with some complications, such as rapid degeneration of the adjacent level (Cao et al, 2020;Bydon et al, 2014). Therefore, Cao et al (2020) and Bydon et al (2014) conducted studies to compare ACDF and PDF approaches to spine diseases. Both studies concluded that ACDF was a safer technique, since the blood loss in this procedure was considerably lower than the one in PDF procedure, adding to that, ACDF was a faster procedure and the patient's hospitalization time was also lower.…”

Adjacent Segment Disease After Spinal Fusion

“…There are little data on this phenomenon. In the cervical spine, Cao et al compared 18 patients undergoing ACDF with 14 patients with posterior decompression and fusion, all for the indication of multilevel adjacent segment pathology above and below the fused segment 56 . While both groups exhibited significant improvements in patient-reported outcomes, the rate of additional reoperation was higher in the ACDF group compared with the posterior decompression and fusion group.…”