Outcomes of posterior cervical fusion and decompression: a systematic review and meta-analysis

Abstract

Background context: Posterior cervical fusion (PCF) with decompression is a treatment option for patients with conditions such as spondylosis, spinal stenosis, and degenerative disc disorders that result in myelopathy or radiculopathy. The annual rate, number, and cost of PCF in the United States has increased. Far fewer studies have been published on PCF outcomes than on anterior cervical fusion (ACF) outcomes, most likely because far fewer PCFs than ACFs are performed.

Purpose: To evaluate the patient-reported and clinical outcomes of adult patients who underwent subaxial posterior cervical fusion with decompression.

Study design/setting: Systematic review and meta-analysis.

Patient sample: The total number of patients in the 31 articles reviewed and included in the meta-analysis was 1,238 (range 7-166).

Outcome measures: Preoperative to postoperative change in patient-reported outcomes (visual analog scales for arm pain and neck pain, Neck Disability Index, Japanese Orthopaedic Association [JOA] score, modified JOA score, and Nurick pain scale) and rates of fusion, revision, and complications or adverse events.

Methods: This study was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a preapproved protocol. PubMed and Embase databases were searched for articles published from January 2001 through July 2018. Statistical analyses for patient-reported outcomes were performed on the outcomes' raw mean differences, calculated as postoperative value minus preoperative value from each study. Pooled rates of successful fusion, revision surgery, and complications or adverse events, and their 95% confidence intervals, were also calculated. Two subgroup analyses were performed: one for studies in which only myelopathy or radiculopathy (or both) were stated as surgical indications and the other for studies in which only myelopathy or ossification of the posterior longitudinal ligament (or both) were stated as surgical indications. This study was funded by Providence Medical Technology, Inc. ($32,000).

Results: Thirty-three articles were included in the systematic review, and 31 articles were included in the meta-analysis. For all surgical indications and for the 2 subgroup analyses, every cumulative change in patient-reported outcome improved. Many of the reported changes in patient-reported outcome also exceeded the minimal clinically important differences. Pooled outcome rates with all surgical indications were 98.25% for successful fusion, 1.09% for revision, and 9.02% for complications or adverse events. Commonly reported complications or adverse events were axial pain, C5 palsy, transient neurological worsening, and wound infection.

Conclusions: Posterior cervical fusion with decompression resulted in significant clinical improvement, as indicated by the changes in patient-reported outcomes. Additionally, high fusion rates and low rates of revision and of complications and adverse events were found.

Keywords: Clinical outcomes; Fusion rate; Meta-analysis; Myelopathy; Ossification of the posterior longitudinal ligament (OPLL); Patient-reported outcomes; Posterior cervical fusion; Radiculopathy; Subaxial; Systematic review.