Elsevier

The Spine Journal

Volume 6, Issue 2, March–April 2006, Pages 154-156
The Spine Journal

Clinical Study
Treatment of anterior cervical pseudoarthrosis: posterior fusion versus anterior revision

https://doi.org/10.1016/j.spinee.2005.07.003Get rights and content

Abstract

Background context

Posterior fusion has been advocated as the most effective treatment of anterior cervical pseudoarthrosis. Authors cite the benefits of increased stability and avoiding the risk of dissection through anterior scar tissue. Despite these advantages, posterior fusion is a more extensive procedure from the standpoint of perioperative and postoperative recovery.

Purpose

The objective of this study is to compare the results of posterior fusions to revision anterior fusions for repair of anterior cervical pseudoarthrosis.

Study design/setting

This is a retrospective case series from a single institution.

Patient sample

120 patients with nonunion documented on flexion-extension radiographs, computed tomography (CT) scan or tomograms after an anterior cervical discectomy and fusion with at least 2-year follow-up.

Outcome measures

Surgical data, status of fusion, complications, and any revision surgeries.

Methods

Hospital and office records were reviewed to determine demographic data, surgical data, status of fusion, and any revision surgeries. Nonunion was confirmed during surgery.

Results

Of the 120 patients included in the study, 27 had repeat anterior procedures and 93 had posterior procedures. The proportion of smokers, the number of surgical levels, and the average time to revision in each group were similar. The average operative time for the anterior revision surgery was 134.9 minutes (range 49 to 232 minutes) with an estimated blood loss of 102.7 cc. In the posterior revision surgery the average operative time was 138.9 minutes (range 35 to 356 minutes) and an average estimated blood loss of 282.1 cc. The patients in the anterior revision group had an average hospital stay of 2.3 days (1 to 5 days), whereas those in the posterior revision group had an average hospital stay of 4.4 days (3 to 8 days). There was a 4% complication rate in the anterior revision group and an 8% complication rate in the posterior revision group. Twelve of 27 patients (44%) in the anterior revision group, and 2 of 93 patients in the posterior revision group required a second revision surgery for persistent nonunion.

Conclusions

Based on these results, posterior fusion is more effective in treating anterior cervical pseudoarthrosis than revision anterior fusion. The higher fusion rate and lower incidence of repeat revision surgery offset the increased blood loss and longer recovery time associated with posterior cervical fusions.

Introduction

Nonunion rates after anterior cervical discectomy and fusion (ACDF) vary with the number of levels fused, the type of bone graft, and the surgical procedure. Reported rates range from 0% to 20% in single-level noninstrumented Smith-Robinson fusions with autograft [1], [2], [3], to 63% in multilevel noninstrumented fusions with allograft [4]. Repair of the anterior nonunion can be done through a repeat anterior approach or through a posterior approach.

Previously published studies demonstrated that anterior revision surgery was successful in 59% to 79% of patients with anterior cervical nonunions [2], [5]. However, performing a repeat anterior surgery entails dissection through scar tissue, putting vital structures at risk. Riley et al. [3] published the first study on treating anterior cervical nonunions with posterior cervical fusion using wires. They and other authors report a fusion rate of 94–100% [3], [4], [6] after posterior fusions.

The purpose of this paper is to compare the results of posterior fusions to revision anterior fusions for repair of anterior cervical pseudoarthrosis.

Section snippets

Methods

We identified 120 patients with the diagnosis of nonunion after an ACDF seen from 1992 to 2001 with at least 2-year follow-up. The initial diagnoses for these cases were degenerative conditions of the cervical spine, including disc herniations, spondylosis, and degenerative disc disease. Cases of trauma and tumor were excluded. All had symptomatic nonunion documented on flexion-extension radiographs or computed tomographic scan and had failed nonoperative treatment. Twenty-seven had repeat

Results

Of the 120 patients identified, 27 patients underwent a repeat anterior procedure and 93 patients underwent a posterior fusion (Table 1). The proportion of smokers in each group was similar, with 13 (48%) in the anterior revision group and 51 (55%) in the posterior revision group. There were 9 males and 18 females in the anterior revision group and 38 males and 55 females in the posterior revision group. The average number of surgical levels was 1.48 levels (range, 1 to 2) in the anterior

Discussion

Although comparing the results of a revision procedure (in this study a revision of anterior cervical nonunion) to a primary fusion procedure such as a posterior cervical fusion may not seem just, this is a clinical decision that spine surgeons have to make. Treatment of anterior cervical nonunions through a repeat anterior approach involves dissection through scar tissue with the associated risk of injuring the recurrent laryngeal nerve [7], the carotid or vertebral arteries, the esophagus,

References (20)

  • B. Bose

    Anterior cervical fusion using Caspar plating: analysis of results and review of the literature

    Surg Neurol

    (1998)
  • D.S. Brodke et al.

    Modified Smith-Robinson procedure for anterior cervical discectomy and fusion: posterior versus anterior repair

    Spine

    (1992)
  • A.E. Brodsky et al.

    Repair of symptomatic pseudoarthrosis of anterior cervical fusion: posterior versus anterior repair

    Spine

    (1992)
  • L.H. Riley et al.

    The results of anterior interbody fusion of the cervical spine

    J Neurosurg

    (1969)
  • R.W. Lindsey et al.

    Nonunion following two-level anterior cervical discectomy and fusion

    Clin Orthop

    (1987)
  • G.L. Lowery et al.

    Surgical revision for failed anterior cervical fusions: articular pillar plating or anterior revision?

    Spine

    (1995)
  • I.D. Farey et al.

    Pseudoarthrosis of the cervical spine after anterior arthrodesis

    J Bone Joint Surg [Am]

    (1990)
  • W.J. Beutler et al.

    Recurrent laryngeal nerve injury with anterior cervical spine surgery risk with laterality of surgical approach

    Spine

    (2001)
  • H. Bertalanffy et al.

    Complications of anterior cervical discectomy without fusion in 450 consecutive patients

    Acta Neurochir (Wien)

    (1989)
  • E.H. Simmons et al.

    Anterior cervical discectomy and fusion

    J Bone Joint Surg

    (1969)
There are more references available in the full text version of this article.

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    McAnany et al.28 showed the best fusion rate with a posterior approach. Carreon et al.32 reported a greater incidence of nonunion after anterior revision requiring surgery. Other studies have confirmed these results, with fewer approach-related complications with posterior revisions.33

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Research grant support received from Norton Healthcare.

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