The utility of cervical spine bracing as a postoperative adjunct to single-level anterior cervical spine surgery

Abstract

Background Context: Use of cervical bracing/collar subsequent to anterior cervical spine discectomy and fusion (ACDF) is variable. Outcomes data regarding bracing after ACDF are limited. Purpose: The purpose of the study is to study the impact of bracing on short-term outcomes related to safety, quality of care, and direct costs in single-level ACDF. Study Design/Setting: This retrospective cohort analysis of all consecutive patients ( n = 578) undergoing single-level ACDF with or without bracing from 2013 to 2017 was undertaken. Methods: Patient demographics and comorbidities were analyzed. Tests of independence (Chi-square, Fisher's exact, and Cochran–Mantel–Haenszel test), Mann–Whitney–Wilcoxon tests, and logistic regressions were used to assess differences in length of stay (LOS), discharge disposition (home, assisted rehabilitation facility-assisted rehabilitation facility, or skilled nursing facility), quality-adjusted life year (QALY), surgical site infection (SSI), direct cost, readmission within 30 days, and emergency room (ER) visits within 30 days. Results: Among the study population, 511 were braced and 67 were not braced. There was no difference in graft type ( P = 1.00) or comorbidities ( P = 0.06–0.73) such as obesity ( P = 0.504), smoking (0.103), chronic obstructive pulmonary disease hypertension ( P = 0.543), coronary artery disease ( P = 0.442), congestive heart failure ( P = 0.207), and problem list number ( P = 0.661). LOS was extended for the unbraced group (median 34.00 + 112.15 vs. 77.00 + 209.31 h, P < 0.001). There was no difference in readmission ( P = 1.000), ER visits ( P = 1.000), SSI ( P = 1.000), QALY gain ( P = 0.437), and direct costs ( P = 0.732). Conclusions: Bracing following single-level cervical fixation does not alter short-term postoperative course or reduce the risk for early adverse outcomes in a significant manner. The absence of bracing is associated with increased LOS, but cost analyses show no difference in direct costs between the two treatment approaches. Further evaluation of long-term outcomes and fusion rates will be necessary before definitive recommendations regarding bracing utility following single-level ACDF.

Spine Bracing: When to Utilize—A Narrative Review

“…Bracing following cervical procedures can even become harmful as cervical collars have been associated with pain, muscle atrophy, decubitus ulceration, breathing or swallowing discomfort, and difficulty driving [ 99 ]. Cervical collars can be expensive, ranging in price from USD25 to USD750, contributing to their questionable use [ 96 , 100 ]. With respect to lumbar procedures, the American Association of Neurological Surgeons (AANS) specifically recommends against the use of bracing postoperatively due to their lower efficacy rating [ 98 , 101 ].…”

“…With respect to lumbar procedures, the American Association of Neurological Surgeons (AANS) specifically recommends against the use of bracing postoperatively due to their lower efficacy rating [ 98 , 101 ]. Decrease in the perceived effectiveness of bracing following spine surgery may result from recent improvements in surgical techniques and instruments used in spinal procedures such as anterior cervical discectomy and fusion (ACDF) [ 98 , 100 ]. With improved technology and technique, high levels of internal spinal stabilization are achieved with surgery alone, rendering additional postoperative bracing redundant.…”

“…With improved technology and technique, high levels of internal spinal stabilization are achieved with surgery alone, rendering additional postoperative bracing redundant. However, postoperative bracing may still have utility in patients with poor levels of stabilization or fusion following surgery [ 100 ]. One such patient population includes patients who smoke, as cigarettes are detrimental to bone health and healing [ 102 ].…”

The Impact of Rigid Cervical Collars on Outcome of Patients Who Underwent Posterior Cervical Laminectomy and Fusion: A Retrospective Comparative Study

“…However, reviewing the literature, there is scarce data supporting these hypotheses. Caplan et al [ 3 , 4 ] examined patients who underwent single and multilevel anterior cervical discectomy and fusion (ACDF) showed that there is no superiority of those who used cervical collars over the controls. Moreover, Overley et al [ 5 ] showed no advantage in wearing a cervical brace following one- or two-level ACDF in a prospective randomized study.…”

“…Another concern for health systems is the cost effectiveness of cervical collar use and its impact on the global burden of diseases. However, there are some reports that cervical collar administration after ACDF surgery leads to a lower hospital stay length with no significant effect on the total cost of the patient [ 4 ].…”