Background
Methods
Inclusion criteria (1 + 2)
Exclusion criteria
Diagnostic work-up
ACDF
Iliac crest auto graft
Postoperative care
Prospective registration of clinical parameters
Surgery-related complications
Database and statistical analyses
Ethics
Results
Baseline clinical characteristics
ACDF | Study group N = 258 | Total group N = 390 | p-value |
---|---|---|---|
Females - no of patients (%) | 114 (44) | 178 (46) | 0.72prop
|
Median age (range) - (years) | 47.5 (28.3-82.8) | 47.7 (26.9- 82.8) | 0.73 |
Levels per procedure - no of patients (%) | |||
One level | 152 (59) | 240 (61) | 0.50 |
Two levels | 104 (40) | 148 (38) | 0.55 |
Three levels | 2 (1) | 2 (1) | 0.68 0.75χ2
|
Level - no of patients (%) | |||
C3/C4 | 7 (3) | 7 (2) | 0.43 |
C4/C5 | 38 (15) | 56 (14) | 0.90 |
C5/C6 | 182 (71) | 266 (68) | 0.53 |
C6/C7 | 137 (53) | 207 (53) | 0.99 |
C7/Th1 | 2 (1) | 6 (2) | 0.39 0.85χ2
|
Method of fusion - no of patients (%) | |||
Autologous bone graft | 181 (70) | 278 (71) | 0.76 |
PEEK* cage | 77 (30) | 112 (29) | 0.76 0.76χ2
|
Symptoms - no of patients (%) | |||
Radiculopathy | 206 (80) | 309 (79) | 0.85 |
Radiculopathy and myelopathy | 36 (14) | 50 (13) | 0.86 |
Myelopathy | 9 (3) | 18 (5) | 0.48 |
No radiculopathy or myelopathy | 7 (3) | 13 (3) | 0.66 |
Previous ACDF - no of patients (%) | 11 (4) | 18 (5) | 0.83 |
Previous neck trauma - no of patients (%) | 23 (9) | 26 (7) | 0.29 |
Pain relief after surgery
Paired differences | ||||||
---|---|---|---|---|---|---|
95% Confidence interval
| ||||||
Paired samples
|
N
|
Mean
|
Mean
|
Lower
|
Upper
|
Sig. (two-tailed)
|
Preop radicular pain | 258 | 7.47 | ||||
3.05 | 2.65 | 3.45 | 0.000 | |||
Postop radicular pain | 258 | 4.42 | ||||
Preop neck pain | 255 | 6.45 | ||||
2.30 | 1.90 | 2.71 | 0.000 | |||
Postop neck pain | 255 | 4.15 | ||||
Preop headache | 254 | 3.63 | ||||
0.55 | 0.22 | 0.89 | 0.001 | |||
Postop headache | 254 | 3.08 |
Delta radicular pain | Delta neck pain | Delta headache | ||||
---|---|---|---|---|---|---|
Univariate | Multivariate | Univariate | Multivariate | Univariate | Multivariate | |
Sex | 0.25 [-0.56, 1.05] | 0.031 [-0.73, 0.79] | 0.40 [-0.41,1.22] | 0.18 [-0.49, 0.85] | 0.34 [-0.34, 1.01] | 0.15 [-0.45,0.74] |
Age | -0.035 [-0.08, 0.01] | 0 . | 0.0095 [-0.03, 0.05] | 0 . | -0.000059 [-0.04, 0.04] | 0 . |
Type of fusion | 0.0077 [-0.87, 0.88] | 0.21 [-0.61, 1.04] | 0.096 [-0.78, 0.98] | -0.069 [-0.79, 0.66] | -0.21 [-0.94, 0.52] | -0.040 [-0.69, 0.61] |
No of levels | 0.40 [-0.38, 1.19] | 0.35 [-0.49, 1.18] | 0.23 [-0.56, 1.02] | 0.14 [-0.60, 0.87] | 0.32 [-0.34, 0.98] | 0.37 [-0.28, 1.03] |
Level | 0.088 [-0.46, 0.64] | 0.055 [-0.53, 0.64] | 0.35 [-0.20, 0.91] | 0.068 [-0.45, 0.58] | 0.019 [-0.44, 0.48] | -0.18 [-0.64, 0.28] |
Previous symptom duration | -0.0019 [-0.01, 0.01] | -0.0016 [-0.01, 0.01] | 0.0028 [-0.00, 0.01] | -0.00088 [-0.01, 0.01] | 0.0018 [-0.00, 0.01] | -0.0014 [-0.01, 0.00] |
Previous neck surgery | -0.62 [-2.59, 1.36] | -0.50 [-2.37, 1.36] | -1.75 [-3.73, 0.23] | -1.82* [-3.45, -0.18] | -1.31 [-3.03, 0.41] | -1.02 [-2.54, 0.51] |
Previous neck trauma | 0.24 [-1.17, 1.64] | -0.098 [-1.42, 1.23] | -0.58 [-1.99, 0.83] | -0.37 [-1.53, 0.79] | 0.011 [-1.16, 1.18] | -0.53 [-1.56,0.51] |
Preop radicular pain | 0.60*** [0.44, 0.76] | 0.63*** [0.45, 0.81] | 0.31*** [0.13, 0.48] | -0.030 [-0.19, 0.13] | 0.065 [-0.08, 0.21] | -0.021 [-0.16, 0.12] |
Preop neck pain | 0.14 [-0.00, 0.28] | -0.075 [-0.23, 0.08] | 0.66*** [0.54, 0.78] | 0.75*** [0.62, 0.89] | 0.16** [0.04, 0.28] | -0.035 [-0.16, 0.09] |
Preop headache | 0.078 [-0.07,0.22] | 0.041 [-0.11, 0.19] | 0.087 [-0.06, 0.23] | -0.22** [-0.35, -0.09] | 0.52*** [0.41, 0.62] | 0.54*** [0.42, 0.66] |
Observations | 256 | 255 | 252 | |||
Adjusted R
2
| 0.150 | 0.350 | 0.261 |
Delta VAS = preoperative - postoperative | |||
---|---|---|---|
Pain category | Worsened (≤ -2VAS) | Unchanged | Improved (≥ 2 VAS) |
Radicular pain | 16 (6.2%) | 78 (30.2%) | 164 (63.6%) |
Neck pain | 26 (10.1%) | 91 (35.3%) | 141 (54.7%) |
Headache | 41 (15.9%) | 136 (52.7%) | 81 (31.4%) |
Paresis
Myelopathy
Working status
Patient satisfaction
Patient satisfaction | |
---|---|
Sex | -0.19 [-0.85, 0.46] |
Age | -0.031 [-0.07, 0.00] |
Previous symptom duration | 0.00014 [-0.01, 0.01] |
Delta radiculopathy | 0.33*** [0.24, 0.42] |
Delta neck pain | 0.22*** [0.12, 0.31] |
Delta headache | 0.20** [0.08, 0.31] |
Observations |
Discussion
Symptom relief after ACDF
Working status
Patient satisfaction
Prognostic factors
Fusion with PEEK cage versus AICG
Optimal surgical procedure for CDD
Limitations of the study
-
The patients were not randomized to fusion with either AICG or PEEK-cage. The type of fusion was in each case decided by the surgeon. This may cause a bias in the material.
-
Ideally the outcome after ACDF for CDD should have been compared with an equivalent group managed with conservative measures.
-
The follow-up evaluation was done by the surgeons and not an independent investigator, this may have influenced the final result.
Conclusions
-
ACDF is an effective treatment for radicular pain in selected patients with CDD (patients evaluated 6 months after surgery).
-
Because of similar clinical outcome and lack of donor site morbidity when using PEEK, we now prefer fusion with PEEK-cage to AICG.
-
Lengthy symptom duration was not a negative prognostic marker in our patient population.
-
The number of patients who returned to work 6 months after surgery was lower than expected.