Failure in Cervical Spinal Fusion and Current Management Modalities

Abstract

Failed fusion in the cervical spine is a multifactorial problem stemming from a combination of patient and surgical factors. Patient-related risk factors such as steroid use, poor bone quality, and smoking can be optimized preoperatively. Age, prior radiation, prior surgery, and underlying genetics are nonmodifiable patient-centered risk factors. Surgical risks for failed fusion include the number of segments fused, anterior versus posterior approach for fusion, the type of bone graft, and the instrumentation utilized. Many symptomatic cases of failed fusion (pseudarthrosis) result in pain, neurological deficits, or loosened hardware necessitating a revision surgery consisting of extending the prior construct and utilizing additional allografts or autografts to augment the fusion. Given the relatively mobile nature of the cervical spine, pseudoarthrosis (either known or anticipated) must be recognized by the spine surgeon, and steps should be considered to optimize the likelihood of future fusion. This consists of both performing a rigid fixation and using appropriate bone graft to enhance the environment for arthrodesis. Vascularized bone grafts are a useful tool to augment fusion and provide added structural stability in cases at high risk of pseudoarthrosis.

Keywords

cervical pseudarthrosis - spinoplastic reconstruction - neurosurgery - spine surgery - plastic surgery

Publikationsverlauf

Artikel online veröffentlicht:
10. Mai 2021

• References

• 1 Saifi C, Fein AW, Cazzulino A. et al. Trends in resource utilization and rate of cervical disc arthroplasty and anterior cervical discectomy and fusion throughout the United States from 2006 to 2013. Spine J 2018; 18 (06) 1022-1029
• 2 Pennington Z, Mehta VA, Lubelski D. et al. Quality of life and cost implications of pseudarthrosis after anterior cervical discectomy and fusion and its subsequent revision surgery. World Neurosurg 2020; 133: e592-e599
• 3 Lowery GL, Swank ML, McDonough RF. Surgical revision for failed anterior cervical fusions. Articular pillar plating or anterior revision?. Spine 1995; 20 (22) 2436-2441
• 4 Cannada LK, Scherping SC, Yoo JU, Jones PK, Emery SE. Pseudoarthrosis of the cervical spine: a comparison of radiographic diagnostic measures. Spine 2003; 28 (01) 46-51
• 5 Phillips FM, Carlson G, Emery SE, Bohlman HH. Anterior cervical pseudarthrosis. Natural history and treatment. Spine 1997; 22 (14) 1585-1589
• 6 Bolesta MJ, Rechtine II GR, Chrin AM. One- and two-level anterior cervical discectomy and fusion: the effect of plate fixation. Spine J 2002; 2 (03) 197-203
• 7 Hilibrand AS, Fye MA, Emery SE, Palumbo MA, Bohlman HH. Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am 2001; 83 (05) 668-673
• 8 Lau D, Chou D, Ziewacz JE, Mummaneni PV. The effects of smoking on perioperative outcomes and pseudarthrosis following anterior cervical corpectomy: clinical article. J Neurosurg Spine 2014; 21 (04) 547-558
• 9 Samartzis D, Shen FH, Matthews DK, Yoon ST, Goldberg EJ, An HS. Comparison of allograft to autograft in multilevel anterior cervical discectomy and fusion with rigid plate fixation. Spine J 2003; 3 (06) 451-459
• 10 Wang JC, McDonough PW, Endow KK, Delamarter RB. Increased fusion rates with cervical plating for two-level anterior cervical discectomy and fusion. Spine 2000; 25 (01) 41-45
• 11 Wang JC, McDonough PW, Kanim LE, Endow KK, Delamarter RB. Increased fusion rates with cervical plating for three-level anterior cervical discectomy and fusion. Spine 2001; 26 (06) 643-646 , discussion 646–647
• 12 Brodsky AE, Khalil MA, Sassard WR, Newman BP. Repair of symptomatic pseudoarthrosis of anterior cervical fusion. Posterior versus anterior repair. Spine 1992; 17 (10) 1137-1143
• 13 Farey ID, McAfee PC, Davis RF, Long DM. Pseudarthrosis of the cervical spine after anterior arthrodesis. Treatment by posterior nerve-root decompression, stabilization, and arthrodesis. J Bone Joint Surg Am 1990; 72 (08) 1171-1177
• 14 Kuhns CA, Geck MJ, Wang JC, Delamarter RB. An outcomes analysis of the treatment of cervical pseudarthrosis with posterior fusion. Spine 2005; 30 (21) 2424-2429