Pseuarthrosis Post Cervical Surgery

Transcription

1 Pseuarthrosis Post Cervical Surgery Don Moore, MD Center for Spine Health Cleveland Clinic May 12, 2018 Pseudarthrosis Post Cervical Surgery Patient factors Surgeon factors Efficacy of index procedure Diagnosis: Radiographic vs. clinical Revision options

2 Leven D, Cho SK. Pseudarthrosis of the Cervical Spine: Risk Factors, Diagnosis and Management. Asian spine journal. 2016;10(4): Not all patients with pseudarthrosis are symptomatic asymptomatic in approximately 30% of cases leading cause of pain postoperatively (45% 56% of revisions) Hilibrand AS, Fye MA, Emery SE, Palumbo MA, Bohlman HH. Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. The Journal of bone and joint surgery American volume. 2001;83-a(5): patients for at least two years 59 ACCF, 131 ACDF 55 smokers; 15 ACCF, 40 ACDF No internal fixation, autogenous iliac crest or fibular strut grafts 20/40 ACDF smokers fused vs 69/91 nonsmokers (p<0.02) 14/15 ACCF smokers and 41/44 nonsmokers fused (93%) clinical outcome for smokers Subtotal corpectomy with autogenous strut-grafting for multilevel for smokers Zhu B, Xu Y, Liu X, Liu Z, Dang G. Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy: a systemic review and meta-analysis. European spine journal. 2013;22(7): Non-RCT reviews 21/245 (8.57 %) reoperation in anterior surgery, 1/285 (0.3 %) in posterior surgery. 13 (5.3 %) for pseudoarthrosis/non-union of the graft ACCF: EBL and OR time vs. LM or LP ACDF vs LM or LP? Anterior: postop neural function without difference in RR

3 Samartzis D, Shen FH, Matthews DK, Yoon ST, Goldberg EJ, An HS. Comparison of allograft to autograft in multilevel anterior cervical discectomy and fusion with rigid plate fixation. The spine journal. 2003;3(6): Tricortical allograft vs tricortical AICBG in 2- and 3-level ACDF 78/80 (97.5%) fused; 2 nonunions in allograft pts (not sig) Similar clinical outcomes ~ 88% excellent and good Samartzis et al.: One level ACDF + plate with allograft and autograft 35 allograft (100%), 31 autograft (90.3%), (p>0.05) Contrary to allograft having higher pseudarthrosis Buttermann GR. Prospective nonrandomized comparison of an allograft with bone morphogenic protein versus an iliac-crest autograft in anterior cervical discectomy and fusion. The spine journal : official journal of the North American Spine Society. 2008;8(3): Primary 1- to 3-level ACDF with ICBG (36) or BMP allograft (30; 0.9 mg BMP per level) Comparable preop disability VAS pain, pain drawing, Oswestry index, pain medication use, opinion of treatment success, and neurological recovery 2 pseudo in ICBG, 1 pseudo in BMP 50% neck swelling in BMP vs 14% in ICBG BMP: implant and hospitalization, OR time Not FDA approved Diagnosis Difficult prior to a surgical exploration High rates of asymptomatic patients and diagnostic tests lacking high sensitivity and specificity History and physical examination mechanical neck pain worsened by motion Disease progression, infection, implant failure, ASD, and postoperative pain syndromes High percentage of asymptomatic pseudo (20-30%) Surgical exploration

4 Imaging Studies X-rays Absence of bridging trabeculae between the host bone and graft, Motion > 1 mm or 2 mm between spinous processes on F/E Cannada et al.; specificity of 89% and sensitivity of 91% Changes in the Cobb angles» >2 degrees, specificity of 39% and a sensitivity of 82%.» >4 degrees, a positive predictive value of 100%. CT; nonconclusive on x-rays Fine-cut CT > flexion-extension x-rays (despite artifact) Highest concordance with operative findings MRI; fair interobserver reliability, moderate agreement with intraoperative findings (Buchowski et al.) Choi SH, Cho JH, Hwang CJ, Lee CS, Gwak HW, Lee DH. Preoperative Radiographic Parameters to Predict a Higher Pseudarthrosis Rate After Anterior Cervical Discectomy and Fusion. Spine (Phila Pa 1976). 2017;42(23): > 12º segmental motion mv, >T1 sagittal slope, and C6-7 level mv Surgeon Factors

5 Kaiser MG, Haid RW, Jr., Subach BR, Barnes B, Rodts GE, Jr. Anterior cervical plating enhances arthrodesis after discectomy and fusion with cortical allograft. Neurosurgery. 2002;50(2): ; discussion Retrospective, 251 pts with 1- or 2-level plate vs 289 without Goldberg G, Albert TJ, Vaccaro AR, Hilibrand AS, Anderson DG, Wharton N. Short-term comparison of cervical fusion with static and dynamic plating using computerized motion analysis. Spine (Phila Pa 1976). 2007;32(13):E level ACDF Static plate + AICBG (21), 87.8% per 10 months, (76.2%). Dynamic plate + fibular allograft (22), 89.7% per 9.5 months (81.8%) (P 0.469) Fusion rate increased over time; 84.7% vs months, respectively Digitized angular measurement > 2 Dynamic plate performed at least as well as the static plate, despite the use of allograft Li H, Min J, Zhang Q, Yuan Y, Wang D. Dynamic cervical plate versus static cervical plate in the anterior cervical discectomy and fusion: a systematic review. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 2013;23 Suppl 1:S Cochrane Library, EMBASE, PubMed, and CBM Five studies, 172 pts dynamic and 143 static 4 studies: Radiographic and clinical outcome in 1- and 2-levels 1 with multilevels 2 with AICBG, 3 with allografts 2 studies with similar clinical outcome Dynamic plate: Better for multiple-level Similar clinical outcome was found in the one-level The two RCT studies: 4 static pts with HW complications None in dynamic

6 Rhee JM, Basra S. Posterior surgery for cervical myelopathy: laminectomy, laminectomy with fusion, and laminoplasty. Asian Spine J 2008;2: Not for kyphosis. Pain, cosmesis, unable to access anterior pathology (Rhee, et al) Lower pseudarthrosis than anterior procedures NV injury, screw malposition, iatrogenic NFS >>> pseudarthrosis 3.0 x ASD vs anterior Posterolateral bone-grafting and wiring fusion rates of 96% (50/52). Callahan et al. Clinically similar outcome Revision Options Carreon L, Glassman SD, Campbell MJ. Treatment of anterior cervical pseudoarthrosis: posterior fusion versus anterior revision. The spine journal : official journal of the North American Spine Society. 2006;6(2): Complications: Anterior; a bone graft donor site infection. Posterior; 4 patients wound infections, 3 bone graft site infection Posterior: fusion rate, incidence of repeat revision

7 Kaiser MG, Mummaneni PV, Matz PG, et al. Management of anterior cervical pseudarthrosis. Journal of neurosurgery Spine. 2009;11(2): The National Library of Medicine and Cochrane Database Variable incidence of symptomatic and asymptomatic pseudarthroses Revision may be considered to improve clinical outcome Both posterior and anterior approaches have proven successful Posterior approaches with higher fusion rates All class III level of evidence Koerner JD, Kepler CK, Albert TJ. Revision surgery for failed cervical spine reconstruction: review article. HSS journal. 2015;11(1): /353 articles from 1993 through January 22, Pain is the most common presenting symptom for pseudarthrosis After laminectomy and fusion, the pseudarthrosis rate was found to range from 1% to 38% In multilevel anterior cervical fusion, commonly occurs at the lowest fusion level, the rate is approximately 10% 4 of intervertebral body motion on flexion/extension radiographs Infection, medical comorbidities, malnutrition, and smoking status If patients are asymptomatic, treatment of pseudarthrosis may be nonoperative Anterior revision: Vocal cord status McAnany SJ, Baird EO, Overley SC, Kim JS, Qureshi SA, Anderson PA. A Meta- Analysis of the Clinical and Fusion Results following Treatment of Symptomatic Cervical Pseudarthrosis. Global spine journal. 2015;5(2): Sixteen studies (out of 281) with reported fusion outcomes 10 anterior, 10 posterior, 3 with A/P combined All the studies were level IV evidence. Fusion rate: 86.4% HT in anterior and 97.1% HM in posterior (p ) Clinical success rate: 77.0% HT for anterior and 71.7% HT for posterior Limitations: Variety of surgical techniques» Anterior: plate vs no plate, type of grafts» Posterior: wires, screw + plates, screw + rods Number of Levels treated, number of levels of nonunion

8 Leven D, Cho SK. Pseudarthrosis of the Cervical Spine: Risk Factors, Diagnosis and Management. Asian spine journal. 2016;10(4): Anterior Alone vs. Combined Anterior and Posterior Fusion alignment correction and maintenance Pseudarthrosis (20% vs. 0%, p=0.034) Cage subsidence (40% vs. 6.7%, p=0.025) Hardware-related complications (26.7% vs. 0%, p=0.013) Clinical outcomes (p=0.046) Operative time (86 minutes versus 266 minutes, p<0.05) EBL (188 ml vs. 329 ml, p<0.05) Piazza BR, Pace GI, Knaub MA, Bible JE. Anterior Cervical Discectomy and Fusion Pseudarthrosis: Posterior Versus "Redo" Anterior. Clinical spine surgery. 2017;30(3): Posterior: Significantly higher fusion rates, ~100% Carreon et al., 27 anterior and 93 posterior ACDF revisions. 44% of anterior revision group (plate with ICBG) and 2.1% of posterior revision group (34 wires, 32 plates, and 27 rods) required a second revision for persistent nonunion 217 patients anteriorly and 280 patients posteriorly. 96.0% [confidence interval (CI), 89.1% 98.6%] in the posterior group and 64.2% (CI, 47.3% 78.1%) in the anterior group (P =0.028). Large fusion bed, more vascular, presence of bone stock, avoid repeat approach morbidity Piazza BR, Pace GI, Knaub MA, Bible JE. Anterior Cervical Discectomy and Fusion Pseudarthrosis: Posterior Versus "Redo" Anterior. Clinical spine surgery. 2017;30(3): Tribus et al.: 16 patients with revision anterior surgery using anterior plating, 81% fusion rate. Coric et al.: 19 consecutive patients with anterior revision using allograft and plating. 100% Solid osseous fusion, 83% good or excellent clinical results Zdeblick et al.; 23 patients with a repeat ACDF All with a solid osseous fusion. Twenty patients had an excellent result and 3 patients had a fair result Surgeon and patient-specific factor driven for anterior revision Advantages: Direct visualization and removal, decompression, sagittal restoration, decrease axial pain, decrease infection, shorter hospital stay

9 Factors To be Considered in Treatment of Pseudarthrosis Pseudarthrosis alone is not an indication for revision. Nutritional counseling, smoking cessation, and the stabilization of medical comorbidities Factors To be Considered in Treatment of Pseudarthrosis Biology Smoking cessation, optimize health status Autograft, allograft, BMP(?) Instrumentation Static vs. Dynamic for anterior Salvage Redo anterior Posterior fusion Combined anterior and posterior Biological agents Benign neglect Don t hate the player, hate the game

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