Abstract
Introduction
Anterior cervical decompression and fusion (ACDF) is considered a standard surgical treatment to degenerative discogenic diseases. Lately, the question arises whether or not ACDF significantly influences the progression of adjacent disc degeneration (ADD). The etiology of ADD is obscure and it has not been fully understood whether ADD is a consequence of fusion or it represents the aging pathway of the degenerative cervical process, thus making it a controversial topic [1-3]. There have been several discussions about the possibility of ACDF altering biomechanical conditions at adjacent segments, therefore resulting in increased load and excessive motion [3,4]. The purpose of this study was to compare the cervical segmental motion pre- and post-ACDF using novel 3D analytical techniques.
Methods
Nine patients (2F/7M, mean age: 54.1 years, range 36–76 y.o.) underwent ACDF due to symptomatic cervical degenerative discogenic disease. One-level ACDF was performed in 4 patients, whereas 2-level ACDF was done in five, using cylindrical titanium porous cage implants. Pre- and post (postoperative periods ranged from 11-months, 25 days to 12-months, 22 days, mean postoperative period: 12.09 months) surgery, dynamic-CT examinations were conducted in neutral, flexion and extension positions. Subject-based 3D CT models were created for segmental motion analysis (Fig. 1). Six-degrees-of-freedom 3D segmental movements were analyzed using a validated Volume-Merge methods (accuracy: 0.1 mm in translation, 0.2°in rotation) [5]. The segmental translation was evaluated by the segmental translations of gravity centers of endplates (Fig. 2). Disc-height distribution was measured using a custom-written Visual C++ routine implementing a lease-distance calculation algorithm. The mean translation distance was calculated for the each adjacent level (Fig. 2). Differences of segmental motions and mean disc height between pre- and post-surgery at each level were compared by the Wilcoxon signed rank test. Results were presented mean±SEM.
Results
Regarding the fusion level, the data shows decreases in both the flexion/extension (F/E) angular range of motion (ROM) (7.46±1.17°preoperatively vs. 3.14±0.56°post-operatively, p<0.003) and the segmental translation in the anterior/posterior direction (AP translation) after surgery (1.22±0.20 mm pre-operatively and 0.32±0.11 mm post-operatively, p<0.01). For the adjacent levels category (inferior and superior combined), the E/F angular ROM was larger after surgery (6.74±1.22°pre-operatively vs. 8.48±0.56°post-operatively, p<0.03). The lateral and axial rotational angular ranges of motion pre- and post-surgery did not show any statistically differences at the adjacent levels. The AP translation at the adjacent levels did not change after surgery (1.22±0.26 mm pre-operatively and 1.45±0.29 mm post-operatively). Translations in lateral and cranio-caudal directions also did not show change following surgery. The mean disc height in the adjacent level (2.39±0.14 mm) showed no differences with respect to the post-surgical measurements (2.40±0.19 mm).
Conclusions
The use of a high-accuracy in vivo 3D kinematic analysis method enabled the detection of subtle changes in segmental movement between pre- and post-ACDF conditions. The result of the current study showed increased segmental movements in F/E angles at the adjacent level. These results are consistent with the some previous studies in the literature [4,6-11]. The magnitude of the increased movement, however, was only 1.74°from full-full-flexion to full-extension and no increase was found in AP translation. No disc height loss associated with disc degeneration was observed during a 1-year period after ACDF. Longer follow-up studies with larger patient cohorts will be required to investigate whether the increased F/E angle at the adjacent level effectively causes symptomatic ADD
