Complications of Multilevel Cervical Corpectomies and Reconstruction With Titanium Cages and Anterior Plating

Hee, Hwan Tak; Majd, Mohammad E.; Holt, Richard T.; Whitecloud, Thomas S.; Pienkowski, David

doi:10.1097/00024720-200302000-00001

Cited by 111 publications

(117 citation statements)

References 24 publications

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“…Several investigators confirmed complications frequently encountered with multilevel strut grafting and end-construct plate fixation spanning the strut graft without posterior fixation (graft/ cage or plate dislodgement, loosening at the screw-plate or screw-bone interfaces, postsurgical kyphosis, and pseudoarthrosis). Failures increased as the number of decompressed levels increased [10,22,23,26,29,48,62,90,91,96,100,104,105,114,115,117,121]. Some of the consequences can encounter vascular, esophageal or neurologic injury [51,55,98].…”

Section: Biomechanical Considerationsmentioning

confidence: 99%

“…However, in some cases multilevel corpectomies can not be avoided. Unfortunately, long strut grafts are known to be biomechanically inferior [105], and vulnerable to failure requiring revision [23,40,48,92,115]. Accordingly, a challenging problem that the orthopedic surgeon faces is the patient who has had a multilevel decompressive surgery that has failed (Fig.…”

Section: Biomechanical Considerationsmentioning

confidence: 99%

“…Because long fixed-moment arm constructs tend to load the caudal screw-bone interface far more than the rostral [98,115], the failures are mostly observed at the caudal rather than cephalad ends of the construct (Fig. 7a) [4,47,48,56,98,106] with the graft or cage telescoping and cavitating into the caudal vertebra as well as ''kicking out'' of the graft/ cage or plate [2,4,23,34,49,90,91,95,121]. Accordingly, in a study of Wang et al [121] seven of 71 (9.9%) 3-level grafts and one of six (16.7%) 4-level grafts showed graft migration, particularly if the fusion ended at the C7 vertebral body.…”

Section: Biomechanical Considerationsmentioning

confidence: 99%

“…Screw toggling accompanied with telescoping of the implants and graft/cage subsidience at the end-levels was observed in eight of our patients treated with NC-plates, whereas Spivak et al [108] also observed a higher primary stability, particularly after cyclic loading, for CS-plates, and Lowery et al [67] reported on significantly fewer failures for CS-plates than for NC-ones. Nowadays, with constrained ACPs (with/without dynamic features) the clinically observed failures usually do not occur by breakage or bending of the implants, but at the interface between bone and instrumentation [47,48,56,98]. A reason of screw loosening even in CS-plate might be that the rigid long fixed-moment arm cantilever beam implanted may not adequately resists translational forces, resulting in degradation of the screw-bone interface and subsequent failure.…”

Section: Biomechanical Considerationsmentioning

confidence: 99%

“…Oppositively, cervical lordosis is difficult to be reconstructed effectively using large cages or grafts in case of multilevel corpectoEur Spine J (2007) 16:2055-2071 2065 mies, because of the rectangular shape of most current devices or the design of the grafts [6,48,70]. Mean correction in patients with 2-and 3-level corpectomies was 6.8°in our series, resembling a similar value compared to other series [48,52,103], and mainly representing the lordotic shape of currently used ACPs (Fig. 7b).…”

Section: Influence Of Cervical Lordosismentioning

confidence: 99%

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4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results

et al. 2007

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In the future, there will be an increased number of cervical revision surgeries, including 4-and more-levels. But, there is a paucity of literature concerning the geometrical and clinical outcome in these challenging reconstructions. To contribute to current knowledge, we want to share our experience with 4-and 5-level anterior cervical fusions in 26 cases in sight of a critical review of literature. At index procedure, almost 50% of our patients had previous cervical surgeries performed. Besides failed prior surgeries, indications included degenerative multilevel instability and spondylotic myelopathy with cervical kyphosis. An average of 4.1 levels was instrumented and fused using constrained (26.9%) and non-constrained (73.1%) screw-plate systems. At all, four patients had 3-level corpectomies, and three had additional posterior stabilization and fusion. Mean age of patients at index procedure was 54 years with a mean follow-up intervall of 30.9 months. Preoperative lordosis C2-7 was 6.5°in average, which measured a mean of 15.6°at last follow-up. Postoperative lordosis at fusion block was 14.4°in average, and 13.6°at last follow-up. In 34.6% of patients some kind of postoperative change in construct geometry was observed, but without any catastrophic construct failure. There were two delayed unions, but finally union rate was 100% without any need for the Halo device. Eleven patients (42.3%) showed an excellent outcome, twelve good (46.2%), one fair (3.8%), and two poor (7.7%). The study demonstrated that anterior-only instrumentations following segmental decompressions or use of the hybrid technique with discontinuous corpectomies can avoid the need for posterior supplemental surgery in 4-and 5-level surgeries. However, also the review of literature shows that decreased construct rigidity following more than 2-level corpectomies can demand 360°instrumentation and fusion. Concerning construct rigidity and radiolographic course, constrained plates did better than non-constrained ones. The discussion of our results are accompanied by a detailed review of literature, shedding light on the biomechanical challenges in multilevel cervical procedures and suggests conclusions.

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Section: Biomechanical Considerationsmentioning

confidence: 99%

Section: Biomechanical Considerationsmentioning

confidence: 99%

Section: Biomechanical Considerationsmentioning

confidence: 99%

Section: Biomechanical Considerationsmentioning

confidence: 99%

Section: Influence Of Cervical Lordosismentioning

confidence: 99%

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4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results

et al. 2007

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Anterior decompression for cervical spondylotic myelopathy

Pavlov

The Aging Spine

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IntroductionIn cervical spondylotic myelopathy (CSM) there is dysfunction of the spinal cord because of degenerative changes in the spine. The pathophysiology of neural loss is still a subject of some debate. Essentially there are two major mechanisms which cause myelopathy: direct compression of the cord and ischemic changes because of alterations in the local blood flow [10, 14, 41, 42, 55]. Since studies have demonstrated that the pathology of CSM is located predominantly anteriorly [47], it seems logical to approach the spine where the lesion is and choose an anterior approach. Removal of extruding intervertebral disc, spurs, osteophytes and calcified posterior longitudinal ligament relieves the compression of the anterior cord and improves to some extent the blood supply to the cord. The surgical approach as described by Smith and Robinson [86] covers the area between the vertebral bodies of C2 and T1. In patients with long slender necks the vertebral body of T3 may be within reach by this approach. The Smith and Robinson approach allows atraumatic dissection of the anterior aspect of the cervical spine. There is a low potential risk for injuries of the esophagus, trachea, the recurrent laryngeal nerve, and the carotid artery. The direct visualization of the offending pathology allows atraumatic and extensive decompression. Surgical strategyThe goal of surgical treatment is to achieve a maximum of decompression without compromising the spinal stability and respecting the sagittal profile of the spine. Depending on the affected area the decompression may be executed through a simple discectomy, with or without fusion, or through extensive vertebrectomy with grafting and internal fixation. There are reports in the literature, advocating a discectomy without fusion [60, 90], but the majority of patients included in those studies had disc herniation and not CSM. The nonfusion discectomy eliminates the radicular symptoms in most of the cases but results for a long time in axial neck pain and compromises the lordotic curvature of the spine. This is the reason why discectomy is predominantly combined with interbody fusion today.In a systematic review covering the literature until 1996 we were not able to identify the anterior interbody fusion as a gold standard for the treatment of degenerative disc disease [56] Nevertheless, the anterior discectomy and interbody fusion is the time-honored procedure in treatAbstract Cervical spondylotic myelopathy is a clinical entity that manifests itself due to compression and ischemia of the spinal cord. The goal of treatment is to decompress the spinal cord and stabilize the spine in neutral, anatomical position. Since the obstruction and compression of the cord are localized in front of the cord, it is obvious that an anterior surgical approach is the preferred one. The different surgical procedures, complications, and outcome are discussed here.

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