Clinical and surgical results related to anterior-only multilevel cervical decompression and instrumented fusion for degenerative disease

Heiko Koller; Felix C Stengel; Isabel C Hostettler; Juliane Koller; Tamas Fekete; Luis Ferraris; Wolfgang Hitzl; Axel Hempfing

doi:10.1016/j.bas.2023.101716

Clinical and surgical results related to anterior-only multilevel cervical decompression and instrumented fusion for degenerative disease

Brain Spine. 2023 Jan 26:3:101716. doi: 10.1016/j.bas.2023.101716. eCollection 2023.

Authors

Heiko Koller^{1

2}, Felix C Stengel^{1

3}, Isabel C Hostettler^{1

3}, Juliane Koller⁴, Tamas Fekete⁵, Luis Ferraris⁶, Wolfgang Hitzl⁷, Axel Hempfing⁴

Affiliations

¹ Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.
² Department for Traumatology and Sports Injuries, Paracelsus Medical University Salzburg, Austria.
³ Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
⁴ Department for Orthopedic Surgery, Schoen Clinic Vogtareuth, Vogtareuth, Germany.
⁵ Department for Spine Surgery, Schulthess Clinic Zurich, Zurich, Switzerland.
⁶ Spine Center, Werner-Wicker-Clinic, Bad Wildungen, Germany.
⁷ Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria.

Abstract

Introduction: Anterior-only multilevel cervical decompression and fusion surgery (AMCS) on 3-5-levels is challenging due to potential complications. Also, outcome predictors after AMCS are poorly understood.

Research question: We hypothesize that in patients with at most mild/moderate cervical kyphosis (CK) of the cervical spine, restoration of cervical lordosis (CL) positively influences clinical outcomes.

Methods: Analysis of consecutive patients presenting with symptomatic degenerative cervical disease or non-union undergoing AMCS. We measured CL from C2 to C7, Cobb angle of fused levels (fusion angle, FA), C7-Slope, and sagittal vertical axis C2-7 (cSVA, stratified into ≤4cm∖>4cm). Patients with excellent outcome were grouped in BEST-outcomes and with moderate/poor outcomes in WORST-outcomes.

Results: We included 244 patients. Fifty-four percent had 3-, 39% 4-level and 7% had 5-level fusion. At mean follow-up of 26 months, 41% of patients achieved BEST-outcome and 23% WORST-outcome. Complications and reoperation rates did not significantly differ. Non-union significantly influenced outcomes. The number of patients with non-union was significantly higher in patients with a preoperative cSVA>4cm (OR 13.1 (95%CI:1.8-96.8). Our model, based on the multivariable analysis with WORST-outcome as outcome variable showed a high accuracy (NPV=73%, PPV=77%, specificity=79%, sensitivity=71%).

Discussion and conclusion: In 3-5-level AMCS, improvement of FA and cSVA were independent predictors of clinical outcome. Improvement of CL positively influenced clinical outcomes and rates of non-union.

Keywords: ACDF; Alignment; Cervical spine; Multilevel fusion; Outcomes.