Introduction: Adjacent level disc degeneration post cervical fusion has been well reported, mostly due to altered spinal biomechanics, and it poses a major treatment dilemma. The potential application of cervical arthroplasty in such patients is virtually unknown, with few studies in the literature. Our initial experience at identifying clinical and radiological assessment in such patients, who suffered new or persistent arm/neck symptoms related to neural compression by adjacent segment disease, treated with arthroplasty is being presented.
Methods: During a 5 year period, 6 patients with previous anterior cervical discectomy and fusion (ACDF), who presently developed recurrent neck or arm pain related to adjacent level cervical disc disease were treated with cervical arthroplasty. A total of 10 devices were implanted encompassing between one to three levels.
Clinical evaluation was performed both before and after surgery, using the Visual Analog Scale (VAS) pain scores and Neck Disability Index (NDI) scores. Radiological outcomes were analysed using pre- and post-operative flexion / extension lateral X-rays measuring Cobb’s angle (overall sagittal alignment), Functional Spinal unit (FSU) and Range of Motion (ROM).
Results: There were no major perioperative complications or immediate device-related failures. No patient required surgery for the same level during the follow up period which ranged from 1 to 3 years. Statistically significant results obtained in all cases, reflected by an improvement in VAS for neck/arm pain and NDI scores for neck pain. Radiologically, statistically significant increase in the overall lordosis in Cobb’s angle and individual disc ROM were observed.
Conclusions: Artificial cervical disc replacement, in patients with previous cervical fusion surgery, appears to be generally safe, with encouraging early clinical results. Long term, accelerated device-related wear will need further study. However, in carefully selected patients post cervical fusion, arthroplasty may provide an additional tool in the management of adjacent cervical disc disease.
Patient Care: An adequate and effective treatment for adjacent segment degeneration following cervical fusion surgery is a subject of much debate. Our research in this area has led to the understanding that the management of such patients with artificial cervical disc replacement might be a better alternative to the current accepted standards (i.e. repeat fusion surgeries), which might have improved clinical outcomes in terms of disabling pain and overall quality of life.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the importance of cervical adjacent segment degeneration with its clinical and radiological implications,
2) Discuss, in small groups, the role of cervical arthroplasty in the management of adjacent level degeneration,
3) Identify an effective treatment protocol for such patients with the need for further long-term prospective randomised controlled studies.
References: 1. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis, The Journal of Bone and Joint Surgery, Vol. 81-A, No. 4, April, 1999
2. Ishihara H Kanamori M, Kawaguchi Y, Nakamura H, Kimura T. Adjacent segment disease after anterior cervical interbody fusion, The Spine Journal 4 (2004) 624-628
3. Sekhon LH. Cervicothoracic junction arthroplasty after previous fusion surgery for adjacent segment degeneration: case report, Operative Neurosurgery, Volume 56, January, 2005
4. Phillips, Frank M., Todd R. Allen, John J. Regan, Todd J. Albert, Andrew Cappuccino, John G. Devine, Jeanette E. Ahrens, John A. Hipp, and Paul C. McAfee. Cervical disc replacement in patients with and without previous adjacent level fusion surgery: a prospective study, Spine 34, no. 6 (2009) 556-565