Crossing the Cervicothoracic Junction During Posterior Cervical Decompression and Fusion: Is It Necessary?

Abstract

BACKGROUND Posterior cervical fusion (PCF) is performed to treat cervical myelopathy, radiculopathy, and/or deformity. Constructs ending at the cervicothoracic junction (CTJ) may lead to higher rates of adjacent segment disease, and much debate exists regarding crossing the CTJ due to paucity of data in the literature. OBJECTIVE To determine whether extension of PCF constructs across the CTJ decreases incidence of adjacent segment disease and need for revision surgery. METHODS A single-center retrospective case series of patients undergoing multilevel PCFs since 2011 with at least 6-mo follow-up was conducted. Outcomes were analyzed and compared based on caudal extent of instrumentation via multivariate regression. RESULTS A total of 149 patients underwent PCF, with a mean follow-up of 18.9 mo. A total of 15 (10.1%) revisions were performed, 7 (4.7%) of which were related to the construct. Five (8.3%) revisions were performed for constructs ending at C6, 1 (5.3%) at C7, 1 (2.6%) at T1, and none (0%) at T2 (P = .035). Mean procedure duration was 215 min at C6, 214 min at C7, 239 min at T1, and 343 min at T2 (P = .001). Mean estimated blood loss was 224 mL at C6, 178 mL at C7, 308 mL at T1, and 575 mL at T2 (P = .001). There was no difference in length of stay, disposition, surgical site infection, or radiographic parameters. CONCLUSION Extension of PCFs across the CTJ leads to lower early revision rates, but also to increased procedure duration and estimated blood loss. As such, decisions regarding caudal extent of instrumentation must weigh the risk of pseudarthrosis against that of longer procedures with higher blood loss.

Crossing the Cervicothoracic Junction During Posterior Cervical Laminectomy and Fusion for The Treatment of Multilevel Cervical Ossification of The Posterior Longitudinal Ligament

“…The incidence of postoperative progression reported in the literature varied from 3.3% to 74.5%. [20] As Sakai K et al presented, postoperative progression of OPLL was observed in 5% of the anterior decompression and fusion with oating method group and 50% of the laminoplasty group. [21] Lee et al reported that the incidence progression of OPLL was 45.5%, 62.5%, and 30% for laminoplasty, laminectomy, and laminectomy with fusion, respectively.…”

“…The substantial difference between mobility in cervical and thoracic spine may amplify rates of adjacent segment disease at the cervicothoracic junction when multilevel cervical fusions are terminated in the lower cervical spine. [16,17] So, routine extension of posterior cervical fusions into the thoracic spine has been suggested. The bene ts of extension into the thoracic spine include greater surface area for the fusion mass and the larger screws typically employed in the thoracic spine which may offer greater construct rigidity and a more stable mechanical environment.…”

“…Progression of OPLL was de ned as an increased ossi cation of≥2 mm in length or thickness. [20] Kyphosis line (K-line) was de ned as a line connecting the center of the canal at C2 to the center at C7 on neutral radiographs. The K-line (-) was de ned when the OPLL exceeded the K-line and K-line (+) was de ned when the OPLL did not exceed the K-line.…”

Surgical challenges in posterior cervicothoracic junction instrumentation

“…The published 'in vivo' studies however provide contrasting evidences. Articles by Schroeder et al [41], Ibaseta et al [24] and Fayed et al [15] found that posterior cervical constructs ending at C7, have increased risks of adjacent segment disease, while Huang et al [22] and Lee et al [32] found no signi cant increase in adjacent segment disease when stopping the construct at C7. At the same time, instrumentations that cross the CTJ have been reported to be associated with increased operative times and intraoperative blood loss [15,22].…”

Long-segment posterior cervical decompression and fusion: does caudal level affect revision rate?

“…Some studies suggest that there is a major increase in fusion rates if the construct is extended down to T1-however, there seem to be discrepancies in this evidence throughout the available literature. 9,[13][14][15] The length of the construct has not been reliably found to be associated with the incidence of ASD or pseudarthrosis cases.…”