Clinical StudyTreatment of anterior cervical pseudoarthrosis: posterior fusion versus anterior revision
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,
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Long-term outcomes in patients treated with tissue-sparing posterior cervical fusion to revise a 1-level pseudarthrosis following ACDF
2024, Journal of Clinical NeuroscienceComparison of revision surgery for pseudarthrosis with or without adjacent segment disease after anterior cervical discectomy and fusion
2023, North American Spine Society JournalConsiderations for revision cervical spine surgery
2019, Seminars in Spine SurgeryCervical Interfacet Spacers to Promote Indirect Decompression and Enhance Fusion in Degenerative Spine: A Review
2019, World NeurosurgeryCitation Excerpt :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.