Objective: To extend the follow up period of previous studies undertaken by the senior author, looking at the clinical outcome and radiological changes observed in patients with either myelopathy or radiculopathy, following anterior cervical discectomy without fusion. Design: Prospective, observational cohort study of patients undergoing anterior cervical discectomy without fusion and followed up for five years, radiologically, with serial plain radiographs, and clinically, using validated outcome measures including SF36, neck disability index and analogue visual pain scores. Subjects: 109 Patients undergoing anterior cervical dis-cectomy without fusion under the senior author’s care. Outcome measures:. Radiological. Occurrence of segmental cervical kyphosis. Loss of overall cervical alignment. Clinical. SF36, Neck disability index, Visual analogue neck and arm pain scores. Results: A total cohort of 109 patients, of mean age 56 years, were followed up after anterior cervical discectomy without fusion, for up to 5 years. Segmental kyphosis was demonstrated on 44%, and loss of overall cervical alignment on 60% of follow up plain radiographs during the third postoperative year. In the cohorts of patients with either loss of cervical alignment or segmental kyphosis at one year the mean clinical outcome scores (Wilcoxon’s matched pairs signed ranks test) continued to improve at the 5 year follow up. The annual rate of loss of cervical alignment in patients unaffected at the first post operative year was around 10% but there was no significant rate of progression of segmental kyphosis. Comparison of the relationship between these radiological changes and clinical outcome (Mann-Whitney U test) did not show any significant correlation. Conclusions: This study assesses patients over the period during which the anticipated alignment changes associated with undertaking simple anterior cervical discectomy could be having progressive detrimental clinical effects. Where such radiological changes occur they most commonly occur during the first post operative year. However, clinical outcome measures in these patients all improve at one year follow up, and still continue to improve or plateau up to five years post operatively. As anticipated, the most significant clinical improvement, occurs during the first post operative year. During the longer follow up period there is no significant detrimental effect of the radiological changes discussed on clinical outcome

Study Design: Retrospective review. Objectives: Rugby union has recently become a highly-paid professional sport. Players requiring anterior cervical discectomy wish to know the effect this will have on their career. To answer this question, the result of the above procedure in professional rugby players was studied. Methods: A retrospective notes review and telephone interview were conducted on 19 professional rugby players who had a cervical discectomy between 1998 and 2003. Pre and post operative symptoms and numbers returning to rugby after surgery were assessed. Results: Neck pain was eradicated in eight (42%) of the players, nine (47%) achieved partial relief and two were not helped. Brachalgia was eradicated in fifteen (79%) individuals, improved in two (10.5%) and two (10.5%) had no relief. Fourteen (74%) returned to rugby union, the majority at six months post operatively (range – five to 17 months). Thirteen (68.5%) returned to their pre-operative level of rugby; one dropped to a lesser division and five have never played rugby again (three due to physical inability, one due to club reluctance to insure and one because of a separate injury). Two of the players that returned to rugby have subsequently retired because of neck symptoms. They played three and two years post-operatively at first-class level. Conclusion: Return to rugby union after anterior cervical discectomy is both likely and safe and therefore need not be a career ending procedure

Introduction. Degeneration of the cervical spine can lead to neurological symptoms that require surgical intervention. Often, an anterior cervical discectomy (ACD) with fusion is performed with interposition of a cage. However, a cage substantially increases health care costs. The polymer polymethylmethacrylate (PMMA) is an alternative to cages, associated with lower costs. The reported high-occurrence of non-fusion with PMMA is often seen as a drawback, but evidence for a correlation between radiological fusion and clinical outcome is absent. To investigate if the lower rate of fusion with PMMA has negative effects on long-term clinical outcome, we assessed the clinical results of ACD with PMMA as a intervertebral spacer with a 5–10 year follow-up. Methods. A retrospective cohort study among all patients who underwent a mono-level ACD with PMMA for degenerative cervical disease, between 2007–2012, was performed. Patients filled out an online questionnaire, developed to assess clinical long-term outcome, complications and re-operation rates. The primary outcome measure was the Neck Disability Index (NDI), secondary outcome measures were re-operation and complication rates. Results. Of 196 eligible patients, 90 patients were assessed (response rate 53%). The average NDI score at follow-up (mean 7.5 years) was 19.0 points ± 18.0 points. Complications occurred in 10% and re-operation in 8.8%. Conclusion. This study provides evidence of good long-term clinical results of ACD with PMMA, as the results were similar with long-term outcomes of ACD with a cage as spacer. Therefore, the results of this study may suggest that the use of PMMA is an lower-cost alternative. No conflicts of interests. No funding obtained

Introduction: Anterior cervical discectomy and inter-body fusion (ACDF) is recognised as an effective surgical treatment for cervical degenerative disc disease. The goals of anterior discectomy, interbody graft placement, and subsequent fusion, are to improve and maintain intervertebral height, establish and maintain physiological cervical lordosis, and achieve arthrodesis so as to eliminate pathological motion. Establishing the most clinically effective and cost effective operative approach to achieve these goals while, at the same time, minimising post-operative complications, is currently an evolving process. One view is that the use of anterior cervical plates reduces graft-related complications, maintains the cervical alignment, and leads to a higher incidence of fusion. In addition, there is evidence to suggest that there is a direct cost benefit of earlier return to pre-operative function and employment. Bone graft: Iliac crest autograft would be regarded as the gold standard source of bone for ACDF. However, donor site complications (due to harvesting autograft) are not insignificant and range from 1% to a sizeable 29%. These complications include iliac crest fracture, infection, persisting pain, neural injury, bowel injury, etc. With the advent of bone banks, allograft has become available and eliminates the problem of graft-harvest related complications. There is a theoretical risk of disease transmission and a corresponding difficulty with patients accepting donated tissue. To date, no HIV cases transmission has occurred from ACDF allograft. There are several studies that demonstrate a significant difference in fusion rates when comparing allograft and autograft. The preponderance of data from the literature supports the conclusion that the use of allograft in ACDF can lead to a higher incidence of graft collapse, pseudarthrosis, and possible subsequent revision surgery. Bishop et al., (Spine 1991 16:726–9): have documented a higher increase in pseudarthrosis rate, graft collapse, and interspace angulation in the allograft group compared to the autograft group. Therefore, the dilemma of allograft being preferred as a basis of eliminating graft harvesting complications, while at the same time being associated with a higher incidence of fusion failure and deformity, have led some surgeons to trial the combination of allograft with anterior plate fixation. Shapiro (J Neurosurg 1966 84:161–5) has reported no incidences of fusion failure, graft collapse, progressive kyphosis, or plate-related complications in 82 consecutive single and multiple level ACDF’s using allograft and anterior plating. Treatment failure: The incidence of the following complications have been reported in the literature. (Graham JJ. Spine 1989 14:1046–50). Pseudarthrosis – 3%–36%. Graft collapse – 3%–14%. Graft extrusion – 0.5%–4%. These figures are regardless of the graft source and are significant. Recent studies show that the combination of graft and anterior plate fixation virtually eliminates the complication of graft extrusion, and also decreases the risk of graft collapse and development of pseudarthrosis. There are also studies that contend that plate fixation can maintain proper lordotic alignment of the spine more effectively than can ACDF without plating. I contend that the use of contemporary cervical plates significantly decreases the rate of fusion failure and graft-related complications without imparting significant implant-related complications. As a result, there is decreased overall risk to the patient. The current type of plates which are available are unicortical with locking systems that substantially decrease the risk of screw loosening or hardware migration

Background: To assess the clinical and radiological results of motion-segment sparing anterior cervical partial discectomy and foraminotomy surgery in patients with at least 1 year of follow-up. Methods: The study is a prospective, non-randomized, observational study. The patients all had symptoms of intrusive nerve root irritation with or without motor symptoms, refractory to conservative management for greater than 6 weeks duration. Patients were asked to complete questionnaires capturing) VAS (visual analogue) pain scores, NDI (neck disability index) and European myelopathy scores, patient satisfaction, and return to work details. Radiographic assessments were collected preoperatively, at 4 weeks, 3 months, 6 months, 1 and 2 years postoperatively. Results: 58 patients have been assessed with at least 1year follow-up. The mean duration of symptoms prior to surgery was 24 weeks (6–20 weeks). 55 patients had single level surgeries (C5/C6-15, C6/C7-38, C7-T1-2), 3 patients had two level surgeries (C4/C5& C5/C6-1, C5/C6& C6/C7-2). In 34 patients sugery was for soft disc prolapse, in 12 patients surgery was for hard osteophytes and in 12 patients both pathologies contributed equally. Operation time ranged from 50–85 minutes. Average in patient stay was 2.6 days. There were no complications apart from 1 patient who had to return early to theatre for evacuation of haematoma and then made a full recovery. All patients reported pain intensity reductions. Pain decreased from 6.7 to 1.4 for arm pain on a 10-point scale. NDI scores improved from a preop mean of 42 to 16 on a 100 point score at 6 months post-surgery. All patients returned to their usual occupations with the exception of 2 patients who are involved in litigation against an employer or third party. No patient required repeat surgeries. Radiographic analysis at 1 year shows preservation of segmental motion in 75% patients, preservation of interbody height in 60% patients, spontaneous fusion in 12% patients. Conclusion: A clinical success rate of 90% was achieved (clinical success being defined as a patient rating of very satisfied or satisfied on a 5-point patient self-scoring outcome scale). 56 out of 58 patients would undergo the same procedure again and recommend it to friend

Aims: Presentation and evaluation of clinical outcomes of patients with cervical degenerative disc disease treated by Smith – Robinson method with interbody fusion by Cornerstone Carbon Cage (CCS) in own clinical experience. Methods: We operated 37 patients by anterior cervical discectomy with interbody stabilisation by CCS in the last 11 months. 31 patients were operated for the first time. In 6 cases, patients were reoperated after surgical treatment in other hospitals. The Smith – Robinson cervical discectomy with anterior interbody fusion by CCS was performed in all patients. Additionally, in 12 patients titan cervical plates were used. Follow-up examinations were performed in 2 and 6 months after the treatment. Results: All treated patients experienced total pain termination. In patients with posttraumatical discopathy and heavy cervical spondylosis with ligamental instability (33% all patients) additional internal stabilisation by cervical plate was performed. Neurological or local long-term postoperative complications were not observed. Conclusions: Patients who underwent treatment by anterior cervical discectomy met. S-R with interbody stabilisation by CCS benefited from the treatment and present good clinical outcome with pain termination and gradual disappearance of neurological disabilities. Using of cornerstone carbon cage allows to obtain good stabilisation without the necessity of allogenic bone graft insertion. This kind of stabilisation is sufficient without external collar stabilisation

Study design: Retrospective review of patients with cervical spondylosis treated with three-level anterior cervical discectomy and fusion with plate fixation. Objective: To assess the radiographic and clinical outcome of three-level instrumented anterior cervical discectomy. Summary of Background data: Three-level cervical discectomy without plate fixation has shown high rates of pseudarthrosis and poor outcomes. The addition of internal fixation may improve these parameters. Methods: 46 patients were observed for an average of 17.6 months (range, 6–51). All had three level anterior cervical discectomy and fusion with tricortical iliac crest autograft (4 cases), fibular ring allograft (38 cases), or titanium cage (four cases). Allografts and cages were filled with iliac crest autograft. All patients had semi-rigid plating. Clinical and radiographic follow-up data were obtained. Clinical outcomes were measured as described by Robinson and with the Nurick scale. Results: Forty-four patients achieved solid fusion. Two patients had additional surgery for junctional disease, and in one of them pseudarthrosis repair was also performed. One asymptomatic pseudarthrosis was noted. With a successful result defined as an excellent or good outcome accompanied by significant pain relief, 38 patients had a successful result (83%). Radiographic adjacent level disease was diagnosed in 11 patients postoperatively and was symptomatic in 5. Conclusion: Three-level anterior cervical discectomy with plate fixation has a high rate of fusion, a low complication rate, and acceptable outcome in the treatment of multilevel cervical spondylosis

Introduction: A prospective, randomized, controlled study has been conducted to compare the clinical outcomes of patients treated with an artificial cervical disc to patients who receive fusion after cervical discectomy for the treatment of primary cervical disc disease. It is hypothesized that maintenance of motion after anterior cervical discectomy will prevent the high rate of adjacent level premature degeneration. The primary purpose of the study is to prove equivalence (non inferiority) of outcome of the disc prosthesis in the short term compared with fusion. Enrolment has closed and this is a report of the data with 50 cases with 6 month follow-up and 9 cases having reached 24 month final follow-up. Methods: In four centres, 52 patients with primary, single level cervical disc disease producing radiculopathy and/or myelopathy were randomised prospectively to receive anterior cervical discectomy with either fusion or artificial cervical disc replacement. The patients were evaluated with pre- and post-operative serial flexion-extension cervical x-rays at 6 weeks, 3, 6, 12, and 24 months. At the same intervals, the patients had pre and postoperative neck disability indexes, visual pain analogue scales, European myelopathy scores, SF-36 general health scores, and neurological status examinations assessing the patient’s reflex, motor and sensory function. Results: At 6 weeks the neck disability index reduced by 34.1 for the investigational group compared to 35.2 for the fusion group. The pain score had reduced by 7.7 for the investigational group and by 9.7 for the control group. This improvement appeared to be maintained until the 12 month follow-up. The mean pain scores at 24 months were similar (4.3 and 5.6 respectively) In general there appeared to be a slightly better outcome for the investigational group, though the investigational group showed slightly less preoperative pain (p=0.091) and disability (p=0.055) than the fusion group. Both pain score and disability scores improved statistically significantly compared to the pre op scores (p< 0.001 all comparisons). Analysis of non-inferiority of outcome for the investigational group using ANCOVA with the preoperative score as the covariate and a non-inferiority margin of 5 points (5%) showed statistical significance at 12 weeks for Neck Disability Index. Discussion: Anterior cervical discectomy and fusion has a good short-term outcome though there is a high incidence of failure at adjacent levels over time. It is hypothesized that the maintenance of motion of a segment will prevent adjacent premature degeneration. It will take long term follow-up studies however to prove this. In the mean time, the justification to insert artificial cervical prostheses rests on being able to prove equivalence of outcome between fusion and prosthesis in the short term. This paper shows that the outcomes appear to be equivalent. Though there is insufficient power to prove equivalence with a clinical margin of 5%

Introduction: A prospective, randomized, controlled study has been conducted to compare the clinical outcomes of patients treated with an Artificial Cervical Disc to patients who receive fusion after cervical discectomy for the treatment of primary cervical disc disease. It is hypothesized that maintenance of motion after anterior cervical discectomy will prevent the high rate of adjacent level premature degeneration. The primary purpose of the study is to prove equivalence (non inferiority) of outcome of the disc prosthesis in the short term compared with fusion. Methods: In four centers, 60 patients with primary, single level cervical disc disease producing radiculopathy and/or myelopathy are randomized prospectively to receive anterior cervical discectomy with either fusion or artificial cervical disc placement. The patients are evaluated with pre and postoperative serial flexion-extension cervical x-rays at 6 weeks, 3, 6, 12, and 24 months. At the same intervals, the patients have pre and postoperative neck disability indexes, visual pain analogue scales, European myelopathy scores, SF-36 general health scores, and neurological status examinations assessing the patient’s reflex, motor and sensory function. Results: Data is presented for the first 47 patients. At 6 weeks the neck disability index reduced by 36.1 for the investigational group compared to 34.8 for the fusion group. The pain score had reduced by 8.2 for the investigational group and by 9.9 for the control group. This improvement appeared to be maintained until the 12 month followup. In general there appeared to be a slightly better outcome for the investigational group. Both pain score and disability scores improved statistically significantly compared to the pre op scores (p< 0.001 all comparisons). Analysis of non inferiority of outcome for the investigational group using ANCOVA with the preoperative score as the covariate and a non inferiority margin of 5 points showed statistical significance at 6 and 12 weeks for Neck disability index. Operative time appeared slightly less (2.3 hrs) for the investigational group compared to the fusion group(2.5hrs). Blood loss also appeared higher in the fusion group (165 mls compared to 91 mls). Hospital stay was equivalent (2.8 days and 2.9 days). Discussion: Anterior cervical discectomy and fusion has a good short term outcome though there is a high incidence of failure at adjacent levels over time. It is hypothesized that the maintenance of motion of a segment will prevent adjacent premature degeneration. It will take long term followup studies however to prove this. In the mean time, the justification to insert artificial cervical prostheses rests on being able to prove equivalence of outcome between fusion and prosthesis in the short term. This paper shows that the outcomes appear to be equivalent. Early statistical evidence is available for some of the outcome measures at early post op followup. Further statistical power will be available when the full 60 cases are available for study and this may give further weight to the hypothesis of equivalence of outcome

INTRODUCTION: A prospective, randomised, controlled study has been conducted to compare the clinical outcomes of patients treated with an Artificial Cervical Disc to patients who receive fusion after cervical discectomy for the treatment of primary cervical disc disease. It is hypothesised that maintenance of motion after anterior cervical discectomy will prevent the high rate of adjacent level premature degeneration. The primary purpose of the study is to prove equivalence (non inferiority) of outcome of the disc prosthesis in the short term compared with fusion. METHODS: In four centres, 60 patients with primary, single level cervical disc disease producing radiculopathy and/or myelopathy are randomised prospectively to receive anterior cervical discectomy with either fusion or artificial cervical disc placement. The patients are evaluated with pre- and post-operative serial flexion-extension cervical X-rays at six weeks, three, six, 12, and 24 months. At the same intervals, the patients have pre- and post-operative neck disability indexes, visual pain analogue scales, European myelopathy scores, SF-36 general health scores, and neurological status examinations assessing the patient’s reflex, motor and sensory function. RESULTS: Data are presented for the first 47 patients. At six weeks the neck disability index reduced by 36.1 for the investigational group compared to 34.8 for the fusion group. The pain score had reduced by 8.2 for the investigational group and by 9.9 for the control group. This improvement appeared to be maintained until the 12 month follow-up. In general there appeared to be a slightly better outcome for the investigational group. Both pain score and disability scores improved statistically significantly compared to the pre-operative scores (p< 0.001 all comparisons). Analysis of non inferiority of outcome for the investigational group using ANCOVA with the pre-operative score as the covariate and a non inferiority margin of five points showed statistical significance at six and 12 weeks for Neck disability index. Operative time appeared slightly less (2.3 hours) for the investigational group compared to the fusion group (2.5 hours). Blood loss also appeared higher in the fusion group (165 mls compared to 91 mls). Hospital stay was equivalent (2.8 days and 2.9 days). DISCUSSION: Anterior cervical discectomy and fusion has a good short term outcome though there is a high incidence of failure at adjacent levels over time. It is hypothesised that the maintenance of motion of a segment will prevent adjacent premature degeneration. It will take long term follow-up studies however to prove this. In the meantime, the justification to insert artificial cervical prostheses rests on being able to prove equivalence of outcome between fusion and prosthesis in the short term. This paper shows that the outcomes appear to be equivalent. Early statistical evidence is available for some of the outcome measures at early post-operative follow-up. Further statistical power will be available when the full 60 cases are available for study and this may give further weight to the hypothesis of equivalence of outcome

Introduction A prospective, randomised, controlled study has been conducted to compare the clinical outcomes of patients treated with a Presige® artificial cervical disc (Medtronic Sofamor Danek, Memphis, TN) to patients who receive fusion after cervical discectomy for the treatment of primary cervical disc disease. It is hypothesized that maintenance of motion after anterior cervical discectomy will prevent the high rate of adjacent level premature degeneration. The primary purposes of the study are to (1) prove equivalence (non inferiority) of outcome of the disc prosthesis in the short term compared with fusion; and (2) to asses the ability of the prosthesis to maintain motion. Enrolment has closed and this is a report of the data with 50 cases with 6 month follow-up and 9 cases having reached 24 month final follow-up. Methods In four centres, 52 patients with primary, single level cervical disc disease producing radiculopathy and/or myelopathy were randomised prospectively to receive anterior cervical discectomy with either fusion or artificial cervical disc replacement. The patients were evaluated with pre and postoperative serial flexion-extension cervical x-rays at 6 weeks, 3, 6, 12, and 24 months. At the same intervals, the patients had pre and postoperative neck disability indexes, visual pain analogue scales, European myelopathy scores, SF-36 general health scores, and neurological status examinations assessing the patient’s reflex, motor and sensory function. Results At 6 weeks the neck disability index reduced by 34.1 for the investigational group compared to 35.2 for the fusion group. The improvement seen in the treatment groups was statistically equivalent (p < 0.05, non-inferiority margin = 10) up to the 24-month follow-up interval. The pain score had reduced by 7.7 for the investigational group and by 9.7 for the control group. Both groups improved statistically from preoperatively though statistical equivalence could not be shown. This improvement appeared to be maintained until the 12 month follow-up. Mean arm pain scores improved in both groups with statistical equivalence being demonstrated (p < 0.05, non-inferiority margin = 10). The adverse events in both groups were similar. Analysis of range motion showed a mean preoperative range of motion in the arthroplasty group of 5.9 degrees and 6.3 degrees in the fusion group. At twelve months the arthroplasty group had a mean range of motion of 5.9 degrees and the fusion group had a mean range of motion of 1.1 degrees. Discussion Anterior cervical discectomy and fusion has a good short term outcome though there is a high incidence of failure at adjacent levels over time. It is hypothesised that the maintenance of motion of a segment will prevent adjacent premature degeneration. It will take long term follow-up studies however to prove this. In the mean time, the justification to insert artificial cervical prostheses rests on being able to prove equivalence of outcome between fusion and prosthesis in the short term. This paper shows that, in the short to medium term, the clinical outcomes appear to be equivalent to fusion. And that range of motion is maintained

Aims: Presentation of modified anterior cervical discectomy by Smith- Robinson method with stabilisation by Cornerstone Carbon Cage (CCS). Methods: Since November 2001, we have been performing unique anterior intervertebral stabilisation procedures with use of carbon implants. Cornerstone Carbon Cage is an artificial intervertebral graft with empty space inside to be filled by bone chips. Cages are from 5 to 7millimetres high, with a higher anterior edge for restoration of physiological lordosis. During the operation we use typical right-side approach to vertebral column. Using intervertebral retractor we perform very wide discectomy until obtaining complete decompression of lateral recesses with exposition of joints of Luschka, which are anatomical lateral limits of the disc space. Afterwards, the wedge-shaped resection of posterior edges of the upper and lower vertebral body which are formed by osteophytes, is performed. Then, we fill the cage by bone chips and osteophytes, and using intervertebral retractor we wedge it into intervertebral space. Results: The procedure allows us to obtain the restoration of lordosis, good stabilisation of vertebral column, and additionally, through a minor distraction, procures decompression of spinal roots in intervertebral foramina. Conclusions: Through a wide intra-operational view, after discectomy and wedge-shaped resection of the vertebral body, it is possible to entirely decompress spine and nerve roots. The above modification of Smith-Robinson method creates ideal conditions for use of CCS

Introduction: In comparison to anterior cervical decompression and fusion (ACDF), cervical disc arthroplasty has the potential of maintaining normal segmental lordosis, anatomical disc space height, and physiological motion patterns that may reduce or delay the onset of degenerative disc disease at adjacent cervical spinal motion segments. Aim: The objective of this study was to determine patient satisfaction post cervical disc arthroplasty. by evaluating each patient both clinically and radiologically. Materials and Methods: A retrospective study was performed on all patients with symptomatic cervical radiculopathy and/or myelopathy who had undergone cervical disc arthroplasty by a single surgeon after a standard anterior cervical discectomy. Outcome measures included the Short Form-36 (SF-36) and Neck Disability Index (NDI) questionnaires, neurological status, and radiographic status. Results: Over a 32 month period, 15 patients underwent cervical disc arthroplasty, with 12 patients undergoing single level arthroplasty. 2 patients undergoing 2 level arthroplasty and one patient undergoing a 3 level arthroplasty. The C5/C6 level was involved in 9 cases (60%). The male female ratio was 7:8. The mean age at presentation was 45 years (range, 28–59). The mean follow up was 24 months (range, 5–31). The mean improvement in NDI scores was 34.8. The mean PCS and MCS scores of the SF-36 test improved by 12.8 and 7.7 respectively. There was no neurological deficit. There were no cases of implant failures, migrations or subsidence. Conclusion: High patient satisfaction levels highlight the efficacy and safety of cervical disc arthroplasty, but longer term follow up is required to assess the long term functionality of the prosthesis and its protective influence on adjacent levels

Objective: Anterior cervical discectomy (ACD) has been established for 40 years. Most surgeons introduce an interbody spacer despite randomised evidence, which suggests this is unnecessary. Surgeons are concerned about the effects of discectomy on cervical spine alignment causing neck pain and accelerated degenerative changes at adjacent levels. In this study we have investigated the relationships between pre-operative disc height, post-operative radiological changes and clinical outcome following ACD. Design: Prospective cohort study of patients undergoing ACD. Subjects: Seventy-three patients undergoing ACD for the treatment of cervical myelopathy or radiculopathy. Minimum follow up one year. Outcome measures: SF 36, Neck Disability Index, visual analogue scores for neck and arm pain, cervical spine alignment, segmental kyphosis, and disc height. Results: Greater pre-op disc height predicts greater post op percentage loss of disc height but does not correlate with poor outcome (p> 0.05 all measures). Post- op X-rays revealed disturbed alignment in 54% of patients. Analysis of clinical outcome showed no statistical differences in any of the clinical outcome measures between patients with and without radiological abnormalities (p> 0.05) SF 36 scores were significantly worse than population controls in patients with and without radiological abnormalities. Conclusions: Large discs collapse more than small discs but this does not compromise outcome. Radiological changes occurred in a significant number of patients in this cohort. These abnormalities do not appear to influence clinical outcome at 12–24 months. The study continues and will report outcomes at five years

Background: Smaller versions of threaded lumbar cages were developed for cervical spine to obviate the need for allograft, iliac autograft use and to provide initial stability before fusion. Clinical trials of threaded cervical fusion cages have shown higher fusion rates and lower rates of graft-donor site complications. Study design/Aims: Prospective. Radiological and clinical outcomes of an age, sex and diagnosis matched patient population who underwent cervical fusion with (A) BAK/C cages filled with autograft reamings (Center-pulse Spine-tech Inc., Minneapolis, MN) (N=50) were compared with (B) Anterior cervical decompression and fusion (ACDF, N=50). Methods: Patients with symptomatic cervical discogenic radiculopathy were treated with either anterior cervical discectomy with uninstrumented bone-only fusion (ACDF) or BAK/C fusion cage(s). Independent radiographic assessment of fusion was made and patient-based outcome was assessed by a Short Form (SF)-36 Health Status Questionnaire. All patients had minimum follow up of at least 2 years. Results: Similar outcomes were noted for duration of surgery, hospital stay, improvements in neck pain and radicular pain in the affected limb, improvements in the SF-36 Physical Component subscale and Mental Component subscale, and the patients’ perception of overall surgical outcome. Symptom improvements were maintained at 2 years. Iliac crest harvesting was carried out as a standard procedure in all cases of ACDF whereas only 2 cases in BAK/C group required the same. Average operative time of 115 minutes and 145 minutes, blood loss of 110ml and 175ml and hospital stay of 1.5 and 3.5 days were noted for BAK/C and ACDF groups respectively. Successful fusion was achieved in 49 cases in BAK/C and 46 patients in ACDF group. None of the patients in the BAK/C group had reappearance of symptoms while 3 patients in ACDF group had developed symptomatic adjacent level disc disease. The complication rate for the ACDF group was 9% compared with an overall complication rate of 3% with BAK/C. Complications that necessitated a second operative procedure included. Graft dislodgement (N=3) and. Cage subsidence, both requiring re-operation in the form of ACDF with plate supplementation. Conclusions: These results demonstrate that outcomes after a cervical fusion procedure with a threaded cage are the same as those of a conventional uninstrumented bone-only anterior discectomy and fusion with a low risk of complications, less operative time and rare need for autogenous bone graft harvest

Introduction Locking plates are the most used devices for achieving anterior cervical spinal fusion and offer considerable advantages such as faster and easier implantation and fewer implant-related failures than older plate systems. Recently polyaxial locking screws were introduced to make the implantation of these plates even easier by facilitating the implantation of the screw in all directions. However polyaxial screws may have the disadvantage of losing the angular stability with subsequent failure of the plate. The aim of this study was the radiological follow up of the patients with polyaxial screw and to compare them with the conventional looking plates. Methods Patients underwent anterior cervical discectomy and fusion in which either ventral cervical locking plates or a polyaxial locking screw were used for indications including cervical spondylotic radiculopathy, disc herniation, trauma, and myelopathy. Patients underwent anterior cervical discectomy and interbody fusion and / or corpectomy. Preoperative and postoperative radiographic data included sagittal angle, translation, and settling of the graft. Results One hundred and forty patients were investigated (mean age of 49 years) with an average follow up period of 21.5 months (range from 4 to 50 months). All underwent anterior cervical plate fusion as a component of the surgical treatment for symptomatic degenerative cervical spinal disease (55%) or for vertebral destruction caused by trauma (45%).100 (71%) of patients were treated with a conventional locking plate and 29 % with a plate with polyaxial screw fixation. Besides plate fixation, 4 of the 140 patients had a combined ventrodorsal fusion. In 46 cases (25%), one or more vertebral bodies were removed and replaced with either iliac bone graft (two levels, 21% of all cases) or fibula strutgraft (4%). In the group with conventional locking plates no patient had to be revised, 3 showed a subluxation (up to 1/3 of the vertebral body diameter) and 2 screw back out posteriorly without clinical relevance. In the group with the plate with polyaxial screw fixation two patient had to be revised (posterior stabilisation) because of subluxation due to loss of angular stability of the screws and one patient developed subluxation of 1/3 of the vertebral body also due to loss of angular stability. Discussion The complication rate and the revision rate for anterior cervical discectomy and fusion with plates with and without polyaxial screw fixation were similarly low. Polyaxial screw may have the theoretical disadvantage of loosening with loss of the angular stability and subsequent failure necessitating revision

Introduction: Anterior cervical spine surgeries are associated with high incidence (up to 60%) of early postoperative dysphagia and hoarseness of voice. These symptoms have been attributed to retraction injury on the larynx, trachea and oesophagus. Pressure from retractors producing ischaemia might explain the soft tissues complications following anterior cervical approach. Conventional retractor systems rely on the soft tissues for stability and create a vertical surgical channel but a novel system (Seex retractor) is fixed directly to the spine and rotates to allow an oblique approach. This may reduce retraction pressure by the Seex retractor on tissues This is the first investigation of retraction pressures using any two different retractor systems for anterior cervical spine surgery. The aims of this study were to measure the retraction pressure on the larynx, trachea and oesophagus during the anterior surgical approach to the cervical spine, in cadavers using conventional (Cloward) retractor and Seex retractor and to investigate the effect of flat or curved blades on retraction pressure. Methods: In a cadaveric model, through a standard anteriomedial approach simulated anterior cervical discectomy procedure was performed in cadavers at C3/4, C4/5, C5/6 and C6/7 levels using Cloward retractor with curved blade (Cervical Large Retractor Set. No. C50-1380: Cloward Instrument Corporation), Seex retractor with flat blade and Seex retractor with curved blade (Patent holder Dr. K. Seex, No PCT/AU05/001205). An online pressure transducer (Tekscan pressure measurement system) was applied between the retractor blade and medial tissues. Retraction pressures were recorded for all the retractors at each level on two separate occasions. Average retraction pressure (ARP), average peak retraction pressure (APRP), pressure distribution along the area of retraction, pressure difference at the edge and surface of the retractor blades, pressure variation with flat and curved blades were determined and compared. Results: A total of 40 sets of pressure recordings were made from 5 cadavers. Cloward retractor system generated an ARP of 33 mmHg (range 16 – 66 mmHg). ARP of Seex retractor with curved blade was 20 mmHg (range 9 – 50 mmHg) and that of Seex retractor with flat blade was 25 mmHg (range 10 – 74 mmHg). At one level ARP was same for all the three retractors. At another level ARP was same for Cloward retractor and Seex retractor with flat blade but higher than that of Seex retractor with curved blade. At two other levels Seex retractor with flat blade showed higher ARP than others. At 36 levels Cloward retractor showed highest ARP. This was statistically significant with Pearson’s Chi-square test (X2=10.023, degree of freedom=1, p = 0.0015) and Fisher exact test, p = 0.0005. Cloward retractor system showed an APRP of 124 mmHg (37 – 255 mmHg). While that of the Seex retractor with curved blade was 69 mmHg (14 – 254 mmHg) and that of Seex retractor with flat blade was 94 mmHg (18 – 255 mmHg). Of the 40 sets of the recordings at 32 levels Cloward retractor system generated highest APRP. With the Seex retractor itself flat blade generated more APRP than curved blade in 31 sets of measurements; it was reverse in 3 sets and in 6 sets APRP was same. Only at one level curved blade generated higher ARP than flat blade, at 11 levels it was same. At 28 levels ARP was higher with flat blade. Discussion: Cloward retractor generated significantly high retraction pressure (peak and average contact pressure) than Seex retractor in majority of the cases. Curved blades generate less retraction pressure than the flat ones. Based on these findings a prospective randomised study is underway in live patients

Background: Cervical myelopathy and radiculopathy has been treated commonly with anterior cervical decompression and fusion with autologous bone graft and anterior cervical plating. Long term results have shown excellent pain relief and 73%–90% fusion rates. However, the development of late adjacent-level disease has been reported following anterior cervical arthrodesis which recently have been correlated to clinical findings. The Bryan disc arthroplasty device was developed to preserve the kinematics of the functional spine unit thus preventing adjacent level disease. There have been few studies comparing the incidence of adjacent level changes in patients undergoing ACDF compared to implantation of a Bryan disc arthroplasty device. Objectives: The object of this study is to compare the clinical results and radiographic outcomes of anterior cervical decompression and fusion versus cervical disc replacement using the Bryan Cervical Disc Prosthesis (Medtronic Sofamor Danek, Memphis, TN) in terms of overall range of motion (ROM) of the cervical spine; ROM, anterior intervertebral height (AIH), posterior intervertebral height (PIH) and radiographic changes at the implanted and adjacent levels. Methods: The study consisted of 105 patients with symptomatic single or two-level cervical disc disease. Fifty-one received the Bryan Cervical Artificial Disc Prosthesis (Medtronic Sofamor Danek, Memphis, TN). A total of 63 Bryan disc were placed in these 51 patients. A single-level procedure was performed in 39 patients and a two-level procedure in the other twelve. The patient group who underwent ACDF totaled 54 patients which consisted of 26 single level cases and 28 double level cases. The Bryan group had a mean follow-up 19 months (12–38). The mean follow-up for the ACDF group was 20 months (12–40 months). All patients were evaluated using static and dynamic cervical spine radiographs as well as MR imaging. All patients underwent anterior cervical discectomy followed by anterior cervical plating or implantation of the Bryan artificial disc prosthesis, done by one surgeon. Clinical evaluation included the visual analogue scale (VAS), and neck disability index (NDI). Radiographic evaluation included static and dynamic flexion-extension radiographs in an upright position using the computer software (Infinitt PiviewSTAR 5051) program. Range of motion/disc space angle and inter vertebral height were measured at the operative site and adjacent levels. Functional spinal unit (FSU) and overall sagittal alignment (C2–C7) were also measured pre-operatively, postoperatively and at final follow-up. ROM was calculated for all 3 areas and data collected were compared from pre operative to last follow-up as well as between the two groups. Radiographic assessment for adjacent level changes was also done. Radiologic change was analyzed using chi square test (95% confidence interval). Other data were analyzed using the mixed model. (SAS enterprise guide 4.1 version). Results: There was clinical improvement within each group in terms of VAS and NDI scores from pre-op to final follow-up for both single (VAS: p=0.8371, NDI: p=0.2872) and double (VAS: p=0.2938, NDI: p=0.6753) level surgeries but not significantly between the two groups. Overall, ROM and intervertebral height was relatively well maintained during the follow-up in the Bryan group compared to ACDF. Comparing the pattern of ROM measurements from pre-op to final follow-up between the two arms regardless of the number of levels operated on; significant differences were noted for overall ROM of the cervical spine (p< .0001) and all other levels except at the upper level for single level surgeries (p=0.2872). In terms of inter vertebral height measurements from pre-op to final follow-up, statistically significant (p< 0.0001 and p=0.0172) differences in the pattern between the two groups were noted at all levels except for the AIH of single level surgeries at the upper (p=0.1264) and lower (p=0.7598) levels as well as PIH for double level surgeries at the upper (p=0.8363) level. Radiologic change was 3.5 times more observed for the ACDF group compared to the Bryan group. Conclusion: Clinical status of both groups, regardless of the number of levels, showed improvement. Although clinical outcomes between the two groups were not significantly different at final follow-up, radiographic parameters, namely ROM and intervertebral heights at the operated site, some adjacent levels as well as FSU and overall sagittal alignment of the cervical spine were relatively well maintained in our Bryan group compared to our ACDF group. We surmise that to a certain degree, the maintenance of these parameters could contribute to reduce development of adjacent level change. Noteworthy is that radiographic change was 3.5 times more observed for ACDF surgeries. A longer period of evaluation is needed, to see if all these radiographic changes will translate to symptomatic adjacent level disease