Going Anterior With A Corpectomy is the Only Way to Solve the Problem Gregory D. Schroeder, MD Assistant Professor, Orthopaedic Surgery The Rothman Institute at Thomas Jefferson University
Goals of surgery • Decompress cord • Relieve kyphosis • Decompress foramen • Avoid complication • Restore Cervical Alignment
Outcomes • Fehlings. Spine. 2013. • Mutlicentered observational study • Multi-center Prospective observational study • 264 patients (169 anterior, 95 posterior) • JOA was less improved in anterior group, but patients in anterior group had less severe symptoms to begin with
Outcomes • Kato. JBJS. 2017. • Propensity matched study of AOSpine prospective observational study on cervical myelopathy • No difference in outcomes between anterior and posterior • mJOA score (15.1 versus 15.3, p = 0.53), • Neck Disability Index (20.5 versus 24.1, p = 0.44), • Short Form-36 (SF-36) Physical Component Summary (PCS) score (41.9 versus 40.9, p = 0.30)
Outcomes • Kato. JBJS. 2017. • Propensity matched study of AOSpine prospective observational study on cervical myelopathy • No difference in total complication rate • 16% versus 11%, p = 0.48 • dysphagia/dysphonia was reported only in the anterior group • surgical site infection and C5 radiculopathy were reported only in the posterior group
Outcomes • Nagoshi. JBJS. 2017 • AOSpine prospective mutlicentered observational study • 470 patients underwent anterior or AP surgery for CSM • Overall prevalence rate was 6.2% • Odds ratio of 6.51 for AP surgery (p < 0.001) • Odds ratio of 1.82 Multilevel procedure (p = 0.02) • Other significant factors • Comorbidities, Age, and baseline SF-36 PCS score
Outcomes • Nagoshi. JBJS. 2017 • 79.3% presented with mild dysphagia; • 13.8% with moderate symptoms • 6.9% with severe • total of 2/470 patients, or 0.4% total risk • None needed tube feeding
Outcomes • Sun. Clinical Neurology and Neurosurgery. 2015. • Meta-analysis • Statically significance final JOA score and shorter length of stay of anterior approaches • Lawrence. Spine 2013 • Meta-analysis • No difference in neurologic outcome between approaches • Infection rates were lower in anterior surgery • Dysphagia/dysphonia was lower with posterior surgery
Outcomes
Outcomes Doctor, my throat is sore
Outcomes I’m sorry, let Doctor, my me grab throat is sore another drink
Outcomes Doctor, is it normal that my wound looks like this
Outcomes • Back to the OR
Outcomes Doctor, is it normal that I can’t move my shoulders
When is Anterior Absolutely Needed
When is Anterior Absolutely Needed • Microangiography • Dynamic flex-ext • Kyphosis • Blood flow reduced • Anterior sp art • Radicular feeders • Intramedullary Brieg. J Neurosurgery. 1966
When is Anterior Absolutely Needed • Tension on neural elements • Decrease caliber of intramedullary vessels • Reduction collateral circulation – Radicular feeders • Spinal cord injury • Increased apoptosis Epstein Spine 1990
When is Anterior Absolutely Needed • Ames. JNS Spine. 2015
When is Anterior Absolutely Needed • Attempt to translate principles of thoracolumbar deformity surgery to the cervical spine. • Unclear what the normal value for cervical lordosis (CL) should be, what is a problematic SVA
When is Anterior Absolutely Needed • Lee. JSDT 2012 • Described that the relationship between T-1 Slope (TS) and CL is similar to the relationship between PI and LL • Increase in TS necessitates an increased CL to balance the head over the thoracic inlet
When is Anterior Absolutely Needed • Ames. JNS Spine. 2015 “Expert Opinion”
When is Anterior Absolutely Needed • Tang. Neurosurgery. 2012 • Retrospective review of 113 patients who underwent a multilevel PCF for myelopathy • C2-C7 SVA negatively correlated with SF-36 physical component scores (r = -0.43, P < .001 and r = -0.36, P = .005, respectively). • C2-C7 SVA positively correlated with NDI scores (r = 0.20, P = .036). • For significant correlations between C2-C7 SVA and NDI scores, regression models predicted a threshold C2-C7 SVA value of approximately 40 mm
When is Anterior Absolutely Needed • Roguski. Spine. 2014 • A prospective, nonrandomized cohort of 49 patients undergoing surgery for CSM. • Postoperative C2–C7 SVA measurements were observed to be negatively correlated with SF-36 PCS scores ( ρ = −0.39, P = 0.008) and with mJOA scores ( ρ = −0.45, P = 0.002) at 1 -year follow-up.
When is Anterior Absolutely Needed • Hyun. Spine. 2016. • Retrospective review of 38 patients who underwent a multilevel posterior cervical decompression and fusion • C2-C7 SVA positively correlated with neck disability index (NDI) scores (r = 0.495). • C2-C7 lordosis (P = 0.001) and T1S-CL (P = 0.002) changes correlated with NDI score changes after surgery. • Regression models predicted a threshold C2-C7 SVA value of 50 mm, beyond which correlations were most significant for correlations between C2-C7 SVA and NDI scores
When is Anterior Absolutely Needed • Hyun. Spine. 2017. • Retrospective review of 31 patients who underwent a multilevel posterior cervical decompression and fusion • 2-C7 SVA positively correlated with neck disability index (NDI) scores (r = 0.550). • For significant correlations between C2-C7 SVA and NDI scores, regression models predicted a threshold C2-C7 SVA value of 43.5 mm • The T1S-CL also correlated positively with C2-C7 SVA and NDI scores (r = 0.827 and r = 0.618, respectively). • Results of the regression analysis indicated that a C2-C7 SVA value of 43.5 mm corresponded to a T1S-CL value of 22.2°.
Corpectomy is Best • Lau. JNS Spine. 2015 • 20 patients 2-level corpectomy vs 35 patients 3- level ACDF • No differences • postoperative lordosis (7.2° vs 12.1°, p = 0.173), • operative ASD (6.3% vs 3.6%, p = 0.682) • Complications (20.0% vs 5.7%, p = 0.102) • Similar improvement • VAS neck pain scores (3.4 vs 3.2 for ACCF vs ACDF, respectively; p = 0.860) • Similar improvement Nurick scores (0.8 vs 0.7, p = 0.925
Corpectomy is Best • Park. Spine. 2010 • 50 patients 1-level corpectomy vs 45 patients 2- level ACDF • No differences • sagittal alignment • cervical lordosis • graft collapse • adjacent-level ossification
Corpectomy is Best • Uchida. JNS Spine. 2009 • 56 patients with myelopathy and 10 degrees or more of kyphosis
Corpectomy is Best • Park. Spine. 2016 • NIS database to look at reoperation rate
Conclusion • Go from the front so you can get it right • Restore the alignment • Address the location where the compression is • Less complications • Or at least less severe complications
Thank You
Recommend
More recommend
