Anterior cervical discectomy and fusion prognosis [Neurosurgery Wiki]

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====== Anterior cervical discectomy and fusion prognosis ======

[[Anterior cervical discectomy and fusion]] (ACDF) has demonstrated good results in terms of [[pain]] relief and patient [[satisfaction]]
((Alrawi MF, Khalil NM, Mitchell P, Hughes SP. The value of neurophysiological
and imaging studies in predicting outcome in the surgical treatment of cervical
radiculopathy. Eur Spine J. 2007 Apr;16(4):495-500. Epub 2006 Aug 30. PubMed
PMID: 16944228; PubMed Central PMCID: PMC2229822.)).


Several groups report their results of [[Anterior cervical discectomy and fusion]] (ACDF) using different techniques: [[allograft]], [[autograft]], [[cage]]s with different designs and [[anterior cervical plate]]s dynamic or not, with as most important outcome that the use of [[autograft]] is superior to [[allograft]] and that the postoperative [[neck pain]] after surgery is relieved quicker after ACDF
((Baskin DS, Ryan P, Sonntag V, Westmark R, Widmayer MA. A prospective,
randomized, controlled cervical fusion study using recombinant human bone
morphogenetic protein-2 with the CORNERSTONE-SR allograft ring and the ATLANTIS
anterior cervical plate. Spine (Phila Pa 1976). 2003 Jun 15;28(12):1219-24;
discussion 1225. PubMed PMID: 12811263.
))
((Löfgren H, Johannsson V, Olsson T, Ryd L, Levander B. Rigid fusion after
cloward operation for cervical disc disease using autograft, allograft, or
xenograft: a randomized study with radiostereometric and clinical follow-up
assessment. Spine (Phila Pa 1976). 2000 Aug 1;25(15):1908-16. PubMed PMID:
10908933.
))
((Madawi AA, Powell M, Crockard HA. Biocompatible osteoconductive polymer versus
iliac graft. A prospective comparative study for the evaluation of fusion pattern
after anterior cervical discectomy. Spine (Phila Pa 1976). 1996 Sep
15;21(18):2123-9; discussion 2129-30. PubMed PMID: 8893437.
))
((McConnell JR, Freeman BJ, Debnath UK, Grevitt MP, Prince HG, Webb JK. A
prospective randomized comparison of coralline hydroxyapatite with autograft in
cervical interbody fusion. Spine (Phila Pa 1976). 2003 Feb 15;28(4):317-23.
PubMed PMID: 12590203.
)).

It has been considered as the golden standard for this kind of surgery. However, ACDF has not been proven to be better than [[anterior cervical discectomy]] without fusion (ACD)
((Jacobs WC, Anderson PG, Limbeek J, Willems PC, Pavlov P. Single or
double-level anterior interbody fusion techniques for cervical degenerative disc 
disease. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004958. Review. Update in:
Cochrane Database Syst Rev. 2011;(1):CD004958. PubMed PMID: 15495130.)).

===== Workers' Compensation Population =====
Despite length of symptom duration prior to [[anterior cervical discectomy and fusion]] in [[Workers' Compensation]] patients, demonstrated improvements in disability and arm pain. Patients with a lesser symptom duration (SD) also demonstrated improvements in physical function and [[neck pain]]. Patients with a lesser SD demonstrated superior scores in physical function, [[pain]], [[disability]], and mental health and were more likely to achieve clinically significant improvement in physical function. Patients with a greater symptom duration SD were more likely to achieve clinically significant improvement in [[mental health]]
((Hartman TJ, Nie JW, Federico VP, MacGregor KR, Oyetayo OO, Zheng E, Massel DH, Sayari AJ, Singh K. Does Symptom Duration Prior to ACDF for Disc Herniation Influence Patient-Reported Outcomes in a Workers' Compensation Population? World Neurosurg. 2023 Mar 8:S1878-8750(23)00303-0. doi: 10.1016/j.wneu.2023.03.008. Epub ahead of print. PMID: 36898631.)).

===== Work Ability =====
Purpose Information on [[work ability]] after [[ACDF]] and postoperative [[rehabilitation]] is lacking. The aim of a study is therefore to investigate the work ability benefits of a structured postoperative treatment (SPT) over a standard care approach (SA) in patients who underwent [[anterior cervical decompression]] and [[fusion]] (ACDF) for [[cervical radiculopathy]] and factors important to the 2-year outcome. 
Secondary outcome and prediction model of a prospective randomized controlled multi-centre study with a 2-year follow-up (clinicaltrials.gov NCT01547611). The [[Work Ability Index]] (WAI) and [[Work Ability Score]] (WAS) were measured at baseline and up to 2 years after ACDF in 154 patients of working age who underwent SPT or SA after surgery. Predictive factors for the WAI at 2 years were analysed. Results Both WAI and WAS significantly improved with SPT and SA (p < 0.001), without any between-group differences. Thoughts of being able to work within the next 6 months, [[Neck Disability Index]] (NDI), and work-related neck load explained 59% of the variance in WAI at the 2-year follow-up after ACDF. Conclusions Patients improved over time without group differences, suggesting the improvement to be surgery related. Expectation to work within the next 6 months, self-reported neck functioning and work-related neck load were important to work ability and are central factors to ask early after ACDF, to identifying further interventions promoting return to work
((Peolsson A, Wibault J, Löfgren H, Dedering Å, Öberg B, Zsigmond P, Wåhlin C. Work Ability After Anterior Cervical Decompression and Fusion Followed by a Structured Postoperative Rehabilitation: Secondary Outcomes of a Prospective Randomized Controlled Multi-Centre Trial with a 2-year Follow-up. J Occup Rehabil. 2021 Dec 11. doi: 10.1007/s10926-021-10015-6. Epub ahead of print. PMID: 34894316.)).


===== Sagittal alignment =====

Segmental alignment in cervical spine instrumented segments is an independent factor in the analysis of results after ACDF procedure and can be modified during follow-up by cage subsidence, nonunion, and adjacent segment degeneration. It has been reported that local kyphosis at the fused segment is observed in only 13% of patients with single-level fusion, but in 53% of patients with multiple-level fusion
((Katsuura A, Hukuda S, Saruhashi Y, Mori K. Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels. Eur Spine J. 2001 Aug;10(4):320-4. doi: 10.1007/s005860000243. PMID: 11563618; PMCID: PMC3611517.)).
----

Sagittal profiles of the spinal cord have been hypothesized to influence loads on spinal tissue and influence outcome after spinal surgery 
((Kawakami M, Tamaki T, Ando M, Yamada H, Yoshida M. Relationships between
sagittal alignment of the cervical spine and morphology of the spinal cord and
clinical outcomes in patients with cervical spondylotic myelopathy treated with
expansive laminoplasty. J Spinal Disord Tech. 2002 Oct;15(5):391-7. PubMed PMID: 
12394663.
))
((Keller TS, Colloca CJ, Harrison DE, Harrison DD, Janik TJ. Influence of spine 
morphology on intervertebral disc loads and stresses in asymptomatic adults:
implications for the ideal spine. Spine J. 2005 May-Jun;5(3):297-309. PubMed
PMID: 15863086.
)).
It is believed that ACDF surgery maintains sagittal alignment superiorly to ACD surgery, which should result in a better outcome after surgery and thus on the long term in less disability for the patients. Studies on sagittal alignment in the cervical spine have mainly focused on laminoplasty or arthroplasty ((Johnson JP, Lauryssen C, Cambron HO, Pashman R, Regan JJ, Anand N, Bray R.
Sagittal alignment and the Bryan cervical artificial disc. Neurosurg Focus. 2004 
Dec 15;17(6):E14. PubMed PMID: 15636571.
))
((Keller TS, Colloca CJ, Harrison DE, Harrison DD, Janik TJ. Influence of spine 
morphology on intervertebral disc loads and stresses in asymptomatic adults:
implications for the ideal spine. Spine J. 2005 May-Jun;5(3):297-309. PubMed
PMID: 15863086.
))
showing a proper radiological position on the short term. Despite these radiological findings, clinically there has been no significant improvement in outcome on the longer term
((Pickett GE, Mitsis DK, Sekhon LH, Sears WR, Duggal N. Effects of a cervical
disc prosthesis on segmental and cervical spine alignment. Neurosurg Focus. 2004 
Sep 15;17(3):E5. PubMed PMID: 15636561.
)).
Moreover, it has also been published that single-level procedures may lead to a local kyphosis, but do not influence the sagittal alignment as much as multi-level surgery
((Johnson JP, Lauryssen C, Cambron HO, Pashman R, Regan JJ, Anand N, Bray R.
Sagittal alignment and the Bryan cervical artificial disc. Neurosurg Focus. 2004 
Dec 15;17(6):E14. PubMed PMID: 15636571.
)).

Although, initially the postoperative outcome is good in more than 90% of the patients, the outcome score on the longer term gradually decreased as the follow up time after surgery increased in a subgroup of the patients. Patients who are doing well after surgery are found without a significant difference at all time points, however patients with moderate to severe complaints can be found increasingly in time after surgery. The increase of complaints at the time of the survey may be the result of ongoing degenerative effects. Only a few studies have been published focusing on a long follow-up period after cervical spine procedures compared to ACDF and therefore it is hard to address the ongoing degenerative effects in the cervical spine
((Nandoe Tewarie RD, Bartels RH, Peul WC. Long-term outcome after anterior
cervical discectomy without fusion. Eur Spine J. 2007 Sep;16(9):1411-6. Epub 2007
Jan 30. PubMed PMID: 17262184; PubMed Central PMCID: PMC2200758.
)).

===== Case series =====

see [[Anterior cervical discectomy and fusion case series]].