Anterior cervical discectomy and fusion (ACDF) is a well-established spinal operation for cervical disc degeneration disease with neurological compromise. The procedure involves an anterior approach to the cervical spine with discectomy to relieve the pressure on the impinged spinal cord to slow disease progression. The prosthetic cage replaces the disc and can be inserted stand-alone or with an anterior plate that provides additional stability. The literature demonstrates that the cage-alone (CA) is given preference over the cage-plate (CP) technique due to better clinical outcomes, reduced operation time and resultant morbidity. This retrospective case-controlled study compared CA versus CP fixation used in single and multilevel anterior cervical discectomy and fusion for myelopathy in a tertiary centre in Wales. A retrospective clinico-radiological analysis was undertaken, following ACDF procedures over seven years in a single tertiary centre. Inclusion criteria were patients over 18 years of age with cervical myelopathy who had at least six-month follow-up data. SPSS was used to identify any statistically significant difference between both groups. The data were analysed to evaluate the consistency of our findings in comparison to published literature. Eighty-six patients formed the study cohort; 28 [33%] underwent ACDF with CA and 58 [67%] with CP. The patient demographics were similar in both groups, and fusion was observed in all individuals. There was no statistical difference between the two constructs when assessing subsidence, clinical complication (dysphagia, dysphonia, infection), radiological parameters and reoperations. However, a more significant percentage [43% v 61%] of patients improved their cervical lordosis angle with CP treatment. Furthermore, the study yielded that surgery to upper cervical levels results in a higher incidence of dysphagia [65% v 35%]. Finally, bony growth across the cage was observed on X-ray in 12[43%] patients, a unique finding not mentioned in the literature previously. Our study demonstrates no overall difference between the two groups, and we recommend careful consideration of individual patient factors when deciding what construct to choose

Scoliosis correction surgery is one of the longest and most complex procedures of all orthopedic surgery. The complication rate is therefore not negligible and is particularly high when the surgery is performed in patients with neuromuscular or connective tissue disease or complex genetic syndromes. In fact, these patients have various comorbidities and organ deficits (respiratory capacity, swallowing / nutrition, heart function, etc.), which can compromise the outcome of the surgery. In these cases, an accurate assessment and preparation for surgery is essential, also making use of external consultants. To make this phase simpler, more effective and homogeneous, a multidisciplinary path of peri-operative optimization is being developed in our Institute, which also includes the possibility of post-operative hospitalization for rehabilitation and recovery. The goal is to improve the basic functional status as much as possible, in order to ensure faster functional recovery and minimize the incidence of peri-operative complications, to be assessed by clinical audit. The path model and the preliminary results on the first patients managed according to the new modality are presented here. The multidisciplinary path involves the execution of the following assessments / interventions: • Pediatric visit with particular attention to the state of the upper airways and the evaluation of chronic or frequent inflammatory states • Cardiological Consultation with Echocardiogram. • Respiratory Function Tests, Blood Gas Analysis and Pneumological Consultation to evaluate indications for preoperative respiratory physiotherapy cycles, Non-Invasive Ventilation (NIV) cycles, Cough Machine. Possible Polysomnography. • Nutrition consultancy to assess the need for nutritional preparation in order to improve muscle trophism. • Consultation of the speech therapist in cases of dysphagia for liquids and / or solids. • Electroencephalogram and Neurological Consultation in epileptic patients. • Physiological consultation in patients already being treated with a cough machine and / or NIV. • Availability of postoperative hospitalization in the rehabilitation center (with skills in respiratory and neurological rehabilitation) for the most complex cases. When all the appropriate assessments have been completed, the anesthetist in charge at our Institute examines the clinical documentation and establishes whether the path can be considered complete and whether the patient is ready for surgery. At the end of the surgery, the patient is admitted to the Post-operative Intensive Care Unit of the Institute. If necessary, a new program of postoperative rehabilitation (respiratory, neuromotor, etc.) is programmed in a specialist reference center. To date, two patients have been referred to the preoperative optimization path: one with Ullrich Congenital Muscular Dystrophy, and one with 6q25 Microdeletion Syndrome. In the first case, the surgery was performed successfully, and the patient was discharged at home. In the second case, after completing the optimization process, the surgery was postponed due to the finding of urethral malformation with the impossibility of bladder catheterization, which made it necessary to proceed with urological surgery first. The preliminary case series presented here is still very limited and does not allow evaluations on the impact of the program on the clinical practice and the complication rate. However, these first experiences made it possible to demonstrate the feasibility of this complex multidisciplinary path in which a network of specialists takes part

The August 2015 Spine Roundup360 looks at: Steroids may be useful in avoiding dysphagia in anterior cervical discectomy and fusion (ACDF); Perhaps X-Stop ought to stop?; Is cervical plexus block in ACDF the gateway to day case spinal surgery?; Epidural past its heyday?; Steroids in lumbar back pain; Lumbar disc replacement improving; Post-discectomy arthritis

This study was performed to evaluate the clinical and radiographic outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF) with rhBMP-2 and polyetheretherketone (PEEK) cages with our standard treatment of allograft spacers and demineralised bone matrix. Forty-six patients who underwent primary ACDF were included in the study. Twenty two patients with PEEK spacers and rhBMP-2 were compared to twenty four patients with allograft spacers and demineralised bone matrix all supplemented with an anterior locking plate. All patients were examined preoperatively and at two, six, twelve and twenty-four weeks and one and two years following surgery. Their cervical Oswestry scores,VAS for neck and arm pain and a pain diagram were recorded at every visit. A radiographic examination was also performed and patients were questioned for dysphagia, hoarseness of voice and any other difficulties. Radiographs were evaluated for prevertebral swelling, bone formation, subsidence and likelihood of fusion. CT scans were performed in any individual at twelve months if there was a concern of non union. There was no significant difference in pain scores between rhBMP-2 and allograft spacer patients. There was improvement in both groups from their preoperative scores. Incidence of hoarseness of voice was also similar in both groups. There were statistically significant more patients with dysphagia in the rhBMP-2 group at two and six weeks following surgery. All patients in the rhBMP-2 group achieved a radiological diagnosis of probable fusion at their latest follow up (thirty-eight levels). In the allograft group 23/24 patients achieved a diagnosis of probable fusion (39/40 levels). End plate resorption was observed radiologically in 100% of the levels where rhBMP-2 was used. Prevertebral swelling on lateral radiographs was significantly greater in patients with rhBMP-2 causing dysphagia. The cost of implants was three times higher in patients with PEEK cage and rhBMP-2. The use of rhBMP-2 leads to consistent fusion in the cervical spine. Significantly higher rates of prevertebral swelling, dysphagia and s higher cost are major drawbacks. End plate resorption was an unusual radiographic finding with the use of rhBMP-2

The February 2014 Spine Roundup. 360 . looks at: single posterior approach for severe kyphosis; risk factors for recurrent disc herniation; dysphagia and cervical disc replacement or fusion; hang on to your topical antibiotics; cost-effective lumbar disc replacement; anxiolytics no role to play in acute lumbar back pain; and surgery best for lumbar disc herniation

Purpose of the study: To determine the safety of the use of bone morphogenetic protein-7 (BMP-7) in anterior cervical surgery. Methods and results: A prospective consecutive cohort of 132 patients underwent anterior cervical discectomy and fusion using interbody cages. In 123 of these patients BMP-7 was also used. The dose of BMP-7 was controlled (one half to one unit; 1.75–3.5 mg BMP-7 & 0.5–1.0 gm collagen) and contained (no BMP-7 was placed outside the cage). The primary outcome measure was the presence of clinical adverse events during the first 30 days. The secondary outcome was the extent of radiological soft tissue swelling at the C6 level as measured on plain radiographs in the early post-operative period and compared to a historical post-operative anterior cervical fusion cohort. There was no mortality and no re-operation in this series. 2.4% of patients experienced complications: transient brachalgia (1/123), persistent dysphagia (1/123), sudden dysphagia and dysphonia (1/123). Mean pre-vertebral soft-tissue measurement in 20 patients from the BMP-7 group was 20.9 mm (16–27 mm). This compared with 18.7 mm (15–25 mm) in 7 patients from the non-BMP-7 group, and 18 mm in the historical control group. Conclusions: BMP-7 can be used safely in anterior cervical fusion surgery. A slight increase in post-operative pre-vertebral swelling was not clinically significant. The effect of BMP-7 on the rate and timing of fusion, as well as clinical outcome, is yet to be elucidated. Ethics approval: None-audit. Interest Statement: None

Dysphagia is said to occur in 2% of patients immobilized in a Halo-Vest for the treatment of cervical injuries. This has been reported to lead to aspiration pneumonia which has a significant mortality rate in the elderly. In our experience dysphagia is a far greater problem than reported and is proportional to the degree of cervical spine extension. The aim of our study was to ascertain the effect of cervical spine extension on swallowing in normal volunteers immobilized in a Halo- vest. A halo vest was used to immobilize the cervical spine and to vary the degree of extension in ten volunteers. Videoflouroscopic studies were performed for each volunteer using three consistencies – liquid, paste and biscuit. The study was performed in neutral, 20° and 40° of extension. A subjective rating scale was completed by each volunteer. Videoflouroscopic study were blindly analysed by a radiologist and a speech and language therapist. Fourteen parameters were measured and recorded for each swallow. Subjectively there was significantly increasing level of difficulty experienced for each swallow. At both degrees of extension there was a significant difference in oral transit time, piecemeal deglutition, Laryngeal penetration (a highly significant risk factor for aspiration), amount of residue occurring at the level of the valleculae and the number of successive clearance swallows compared to control. In conclusion this study has clearly demonstrated significant impairment in deglutition following halo vest application. This impairment is directly related to the degree of neck extension. These findings should be taken into careful consideration when managing patients in cervical orthoses

Introduction: In 1971, Cloward wrote that after anterior cervical surgery, dysphagia occurs in all patients and is due to pressure on the oesophagus by the retractors. Recent studies indicate that dysphagia occurs in 54% of patients at 1 month and 13.6 % at 2 years. Recurrent laryngeal nerve injury occurs in 15 – 23 % producing hoarseness in one third of these. The continuing frequency of these complications even in experienced hands suggests that a review of retractor design and consideration of new designs is worthwhile. Methods: A Medline search of unlimited years in English using terms: retractors, surgical instruments, development and history was performed. Described retractors and their design principles were reviewed and a novel principle identified from which an anterior cervical device was developed and tested. Results: The novel general principle states that superior retraction is achieved by combining fixation onto bone with variable rotation of the retractor blade. Bone stabilization within the wound provides optimal stability and mechanical advantage for retraction while variable rotation allows retraction or tissue relaxation. Excluding the ubiquitous handheld retractors which lack stability, 7 different designs of anterior cervical retractors have been described. Anecdotally self retaining retractors are the most commonly used, but to be stable they require equal bilateral tissue counterforce and tissues that do not stretch. They are thus doubly ill suited for the asymmetrical anterior approaches to the anterior cervical spine. In the new anterior cervical retractor a small internal frame is fixed to the spine using standard Caspar screws. The frame slides with distraction. Routine surgery including plating is carried out within the frame. The frame provides stable axes for the independently rotating medial and lateral retractor blades. Discussion: In the spine intermittent relaxation of retraction has recently been shown to reduce muscle injury and pain after lumbar surgery. This is the first retractor system that can be released without sacrificing stability or exposure. Despite numerous authors implicating cervical retractors as a source of complications there are few investigations and no studies investigating different designs. Rather than accepting or denying common complications we should investigate even our most familiar tools

Aims

Autologous bone graft (ABG) is considered the ‘gold standard’ among graft materials for bone regeneration. However, complications including limited availability, donor site morbidity, and deterioration of regenerative capacity over time have been reported. P-15 is a synthetic peptide that mimics the cell binding domain of Type-I collagen. This peptide stimulates new bone formation by enhancing osteogenic cell attachment, proliferation, and differentiation. The objective of this study was to conduct a systematic literature review to determine the clinical efficacy and safety of P-15 peptide in bone regeneration throughout the skeletal system.

Aims

Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre.

Aims

The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent.

We retrospectively reviewed the results of patients having undergone single or two level Anterior Cervical Discectomy and Fusion with the use of the Cervios Cage (SYNTHES). Participants were sent a questionnaire which included generic questions relating to ACDF such as dysphagia, hoarseness of voice and resolution of arm pain in addition to Oswestry Disability scores. Most patients underwent AP/Lateral and flexion/extension radiographs

Aim. To assess the safety of Zero Profile Interbody fusion (Zero P) device in Anterior Cervical Decompression and fusion (ACDF) for degenerative cervical stenosis. Method. 89 consecutive patients treated with Zero P interbody device from September 2009 to September 2012 were included in this retrospective study. Inclusion criterion: degenerative cervical stenosis with myelopathy, persistent radiculopathy after at least 3 months of failed conservative management. Exclusion criterion: Paediatric population; patients with infection, metastatic disease and trauma. There were 39 females, 50 males with mean age of 55 (ranging from 24 to 84 years). 56 (64%) had surgery at 1 level, 31 (35%) at 2 levels, 1 (1%) at 3 levels. Total number of levels operated were 121. Common levels operated were C56 (62%) and C67 (47%). Majority were operated due to radicular symptoms, 56 (64%) had radicular symptoms, 28(31%) had myelopathy and 5 (5%) Myeloradiculopathy. Results. All had a minimum of 6 months follow up (maximum 2 years). No patient had cage subsidence or extrusion. 1 had superficial infection which settled with antibiotics, 10 (11%) had dysphagia which settled in 6 to12 weeks. Conclusions. Our study demonstrates that ACDF with Zero P can be considered a safe option in management of patients with cervical degenerative stenosis. We would will also recommend a prospective randomised study as a follow on to this retrospective study. Preoperative kyphosis or lordosis did not change the outcome or make the surgical technique any more difficult, hence this implant can also be used in these circumstances. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Introduction. Recently ventral plating implants made of carbon/PEEK composite material have been developed with apparently superior material properties in terms of implant fatigue and imaging suitability. In this study we assessed the outcome of the first clinical application of this new implant. Methods. Retrospective, single-center case series of 16 consecutive patients between 2011 and 2013 undergoing ventral stabilization surgery with a new carbon plating system (see figure 1). We collected data in terms of safety of the procedure (screw positioning, blood loss, operation time), quality and reliability of the implant (revisions, dislocations, screw loosening, fusion, adjacent segment degeneration), clinical outcome and biological tolerance (cervical pain / discomfort, dysphagia). Results. All patients were available for clinical and radiological follow up. Mean surgery time was 128 minutes, in 11 cases one in 5 cases 2 segments were treated. The clinical findings and patient's satisfaction were good in 14 and fair in two cases. All patients who completed the 6 months control had a radiographically confirmed interbody fusion; no implant loosening or failure and no infections were observed. (see figure 2). There was one implant related complication (dysphagia due to malpositioning of the plate which was removed 4 days after implant insertion) and one complication related to the approach (Horner's syndrome). Conclusion. In this retrospective study of 16 patients we found that the use of a carbon-composite plating system lead to results comparable to the “gold standard” metal plates in terms of safety / clinical outcome and reliability of the implant. There was one revision due to dysphagia. The MR imaging of the patients who have been operated with the carbon/PEEK system showed superior quality with reduced artifacts and improved diagnostical properties, especially when evaluating the neurogical structures. (see figure 3). The overall clinical outcome and patient acceptance of the implant was good. The radiologic findings on follow up of 2, 6 and 12 months have shown a high fatigue strength with no signs of implant failure in terms of dislocation, loosening or breakage. Therefore we conclude that the use of the carbon/PEEK plating system is suitable for ventral stabilization in trauma and degenerative disease

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Introduction. Anterior reconstruction has the advantage of conferring immediate stability to the cervico-thoracic junction. Aims and objectives. Assess clinical and radiological outcome in cervico-thoracic kyphosis treated with anterior reconstruction. Material and methods. 62 cases were treated with anterior reconstruction from 1996-2007. Minimum follow-up was 2years (2-6). Indications included tuberculosis (45), dysplastic(10), neoplastic (3) and traumatic (4). Average age was 28.6 years (13-72 years). Average pre-operative kyphosis was 26.4 degrees (5-84). Patients were grouped as long-neck (35) and short-neck (27) according to classification proposed by Bapat and Laheri. The caudal normal vertebra (CNV) matched on plain radiology and MRI in 40 (64.51%). In 22 level of fixation was extended due to poor bone mass in the adjacent vertebral body (caudal 17, cranial 5). Pre-operative neurological deficit was seen in 57 (91.3%) and average Nurick's grade was 3.8 (0-5). Results. 32 long-neck patients required strap-muscle tenotomy to expose the CNV. In 3(9.3%) manubriotomy was required (large neck girth 1, thyroid goitre 2). 26 short-neck patients required manubriotomy for plate placement. In 42 (67.8%) patients a standard anterior cervical plate was used. In 22 locking plate was used. Commonest cranial and caudal vertebrae instrumented were C7 (32) and T2 (20) respectively. Post-operative kyphosis averaged 14.68 degrees (0-78) and correction averaged 11.72 degrees. Average post-operative Nurick's grade was 2.8. One patient with fracture dislocation of T1-T2 and traumatic oesophageal rupture died. In 1 the implant loosened and was revised with posterior construct. In 1, screw loosening was observed but implant position remained unaltered. 2 patients had recurrent laryngeal palsy. Iatrogenic pleural rent occurred in 2 patients. Transient dysphagia was noticed in 12. The scar hypertrophy was seen in 30(48.38%). The loss of correction averaged 2.3mm (0-4mm) at the final follow-up. Conclusion. Anterior reconstruction allows excellent reconstruction of cervico-thoracic junction obviating need for a posterior construct

Introduction. Sternoclavicular dislocations are well-known adult injuries. The same traumatism causes growth-plate fracture of the medial clavicle in children and young adults. At this location, the emergence of the secondary ossification center and its bony fusion are late. We report the results of 20 cases hospitalized in the Toulouse University Hospital Center that were treated surgically. Materials & Methods. 20 patients were treated between 1993 and 2007, 17 boys and 3 girls, 16 years old (6–20). The traumatism was always violent (rugby 75%). Two physeal fractures were anteriorly displaced, and 18 posteriorly. The follow-up is 64 month (8–174). Clinical, radiographic and therapeutic characteristics were assessed. The long-term results were analysed with: an algo-functional scale (Oxford shoulder score), the subjective Constant score, a functional disability scale (Shoulder simple test), a quality of life scale (DASH), and global indicators (SANE and global satisfaction). Results. all the patients were symptomatic before surgery: pains, oedema and partial functional impotence. Only 2 dysphagia, 1 dyspnea and 1 venous circulation alteration were observed. The first clinical and radiological examination, before CT scan, didn't diagnose the injury in 8 cases. The CT scan were realized for all the patients: it diagnosed the physeal fracture and showed 4 cases of vascular or respiratory compressions. There were 5 attempts of closed reduction, without success: all the patients were surgically-treated. The open reduction were completed by pinning (12 cases) or cerclage with absorbable suture (3 cases). Per-operatory findings lead to realize costo-clavicular repair plasties with the sub-clavicular muscle (3 cases) and/or capsular-ligamentous-perosteal selective plasties (13 cases). Two cases of broken Kirschner wires were noticed, without migration. Functional outcomes are largely good or excellent: STT 11,74/12 (10–12)–OSS 12,95/60 (12–19)–DASH 2,07/100 (0–17,6)–SANE 93,16% (60–100). Discussion and Conclusion. we present the largest case series in the literature. CT scanner is the essential element of the diagnostic process and may allow the distinction between true sterno-clavicular dislocation and displaced physeal fractures. This distinction is difficult at younger ages and is facilitated by the progression of ossification. Very good results were obtained, but classical pitfalls of treatment were found: instability after closed reduction, broken K-wires, recurrent anterior instability, inesthetic scars

Aims

We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture.

Introduction: Although anterior cervical discectomy and fusion is a well-established technique for arthrodesis of the cervical spine, there are limited data on the use of allograft with plate in large series. There are even fewer such studies that incorporate three and four level fusions. We report our experience with 252 patients (530 levels). Methods: 252 patients underwent anterior cervical discectomy and fusion (ACDF) with plate and allograft (91-one level, 74-two levels, 57-three levels, 30-four levels; 530 total levels) via a modified Smith-Robinson technique. Radiographic fusion was determined with plain X-rays at predetermined intervals. Fusion was defined as no lucent line and no hardware failure. Average follow-up was 22.5 months. Average age was 50 years (M 26, F 19). Comorbidities included 58 smokers and 16 diabetics. Patients wore an external orthosis for six weeks. Results: There were six reoperations for junctional disease outside the original fusion construct. 16 patient developed junctional disease. 28 levels had residual radiographic lucent lines and/or hardware failure at most recent follow-up for a fusion rate of 94.7% (502/530). Complications occurred in 32 patients (6.0%). There included 16 instances of hardware failure and/or pseudoarthrosis, nine of which occurred in the three and four level group, dysphagia (9), vocal cord dysfunction (2), respiratory distress (2), wound hematoma (2), wound infection (1). Conclusion/discussion: Extremely high fusion rates were recorded in this series, including three and four level constructs, with an acceptable complication rate. We believe that outstanding results are obtainable with allograft and plate, even at three or four levels. The principles of precise fit and fill of the interspace with a contoured graft and fixation with compression and instrumentation must be employed

Orthopaedic pathology at the craniocervical junction (CCJ) is uncommon. This is a retrospective analysis of 37 patients who underwent transoral surgery. The indications were fixed rotatory subluxation in 12 patients, myelopathy following nonunion of the dens in 15, tuberculous abscesses in seven, congenital anomalies in two and chordoma in one. There were 29 males and the mean age was 24 years (3 to 57). Neurological deficit was present in 19 patients. Other symptoms included hoarseness, difficulty swallowing, neck pain and limitation of movement. All patients had a CT scan, MR angiography, MRI and dental consultation to exclude oral sepsis. After the transoral release, 29 patients underwent atlanto-axial fusion and two occipito-axial fusion. Following nasal intubation the skull was immobilised in tongs with 2-kg traction. A Jacques catheter was used to retract the uvula. The CCJ was located with an image intensifier and the posterior pharyngeal wall was infiltrated with 5 cc of local anaesthetic and Por-8. The atlanto-axial joints (AAJ) were released and in children with fixed rotatory subluxation the atlantodentate interval was cleared of fibrous tissue. The 15 patients with non-union of the dens underwent anterior release of the AAJs and the fracture site. The seven patients with abscesses had incision and drainage. Two patients with basilar invagination required excision of the dens. The chordoma was partially excised. One patient required a partial excision of the dens to reduce a posterior dislocation of the AAJ. A patient with chronic atlanto-axial subluxation owing to a type-I fracture required a partial excision of the superior part of atlas. Two patients with CSF leaks were treated successfully. There were cases of sepsis. Two patients developed occipital pressure sores. One patient died 5 days after surgery because of pulmonary embolus. The transoral approach is safe and effective in treating pathology at the CCJ