International Journal of Medicine and

Pharmaceutical Sciences (IJMPS)

ISSN (P): 2250-0049; ISSN (E): 2321-0095
Vol. 11, Issue 1, Jun 2021, 71-78
© TJPRC Pvt. Ltd.

FUNCTIONAL OUTCOME OF ANTERIOR CERVICAL DECOMPRESSION AND

FUSION (ACDF) WITH STAND-ALONE CAGE FIXATION IN DEGENERATIVE
CERVICAL DISC DISEASE.A PROSPECTIVE OBSERVATIONAL STUDY

Dr. KUMAR SAMBHAV1, Dr. M. CHANDRASEKARAN2

Dr. S. RAMKUMAR3 & Prof. MANOHARAN4
1
Ortho Pg Resident, MGMCRI & Pondicherry
2
Dr. M. Chandrasekaran Professor, Department of Orthopaedics, MGMCRI Pondicherry, India
3
Dr. S. Ramkumar, Assistant Professor, Department of Orthopaedics, MGMCRI Pondicherry. India
4
Dr. M. Manoharan Professor, Department of Orthopaedics, MGMCRI Pondicherry. India
ABSTRACT

INTRODUCTION: Degenerative disc disease (DDD) of the cervical spine is defined as age-related changes in the
cervical spine producing either cord compressive myelopathy or nerve root compressive radiculopathy. Anterior Cervical
Decompression and Fusion (ACDF) is considered as the gold standard surgical management of cervical myelopathy or
radiculopathy, refractory to non – operative treatment. The requirement for a thorough decompression is mandatory for

Original Article
cord compression. Anterior cervical discectomy without fusion leads to empty disc space which collapses, leading to
kyphosis, decreased disc height associated with increased kyphosis can lead to a loss of neural foramen height, and
hence, anterior cervical discectomy with fusion (ACDF) is needed. Interbody fusion has traditionally been augmented
with a plate which leads to complications. The cervical intervertebral disc replacement by a stand-alone cage provides
immediate load-bearing support to the anterior column.

METHODOLOGY: A total of 14 patients were included after fulfilling inclusion criteria between January 2019 and
June 2020. All patients underwent ACDF with stand-alone cage using Smith and Robinson's approach and were
accessed by mJOA and NDI at 1month; 3months and 6 months follow up and were also looked for any complications
during these visits.

RESULTS: The average age of the cohort was 52.43 years. Out of 14 patients, the majority were male. The most
common level of disc involvement was C6-C7, followed by C5-C6. mJOA from 14.71 to 17.07 at 6 months and NDI 24.57
to 5.79 showed better functional outcomes at 1 month, 3 months, 6 months compared to preoperative scores. Cage
subsidence did not correlate with functional outcome.

CONCLUSION- Anterior Cervical Decompression and fusion with a stand-alone cage is a safe alternative surgical
option in single-level cervical disc disease with radiculopathy or myelopathy. It shows good functional outcomes and is
not associated with significant complications.

KEYWORDS: ACDF, Radiculopathy & Myelopathy

Received: Apr 08, 2021; Accepted: Apr 28, 2021; Published: May 12, 2021; Paper Id.: IJMPSJUN20219

INTRODUCTION

Degenerative disc disease (DDD) of the cervical spine is defined as age-related changes in the cervical spine
producing either cord compressive myelopathy or nerve root compressive radiculopathy. Pathogenesis of

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72 Dr. Kumar Sambhav, Dr. M. Chandrasekaran
Dr. S. Ramkumar & Prof. Manoharan

degenerative disc disease depends on various factors like physical activities, nutrition, smoking, genetics and advancement
of age. (1) Conservative management in form of analgesics, physical therapy, rest and immobilization provide satisfactory
to excellent results in a majority of the population generally given for a period of 6 weeks. Surgical management is
indicated in case of failure of conservative management. Anterior cervical decompression and fusion (ACDF) are
considered as gold standard treatment for surgical management of cervical myelopathy or radiculopathy, refractory to non
– operative treatment.1

The requirement for a thorough decompression is mandatory for cord compression and the need for fusion is
debatable. Anterior cervical discectomy without fusion leads to empty disc space which collapses, leading to kyphosis.
Decreased disc height is associated with increased kyphosis and can lead to a loss of neural foramen height and increased
pain in the neck and scapular regions2. Hence anterior cervical discectomy supplemented with fusion (ACDF) is a common
technique for the treatment of cervical radiculopathy and myelopathy for many decades. Interbody fusion has traditionally
been augmented with a plate. Plate leads to complications like dysphasia, esophageal perforation and implant prominence
and failure, pseudoarthrosis and adjacent segment disease (ASD). 3.the advantages of the stand-alone cage are reduced rate
of dysphagia, decreased intraoperative time and reduced adjacent segment degeneration as compared to plate construct.
The disadvantages are subsidence and loss of segmental lordosis. 4 the cervical intervertebral disc replacement by a stand-
alone cage provides immediate load-bearing support to the anterior column.5 In our study we wanted to assess the
functional outcome of anterior cervical decompression and fusion in degenerative disc disease.

MATERIAL AND METHODS

This prospective observational study was done in the department of orthopaedics of a tertiary care center in South India
from January 2019 to October 2020 after obtaining ethical clearance.

Patients with degenerative cervical disc disease refractory to conservative management were taken as the study population.
Age 40-70 years, symptomatic single-level cervical disc disease with radiculopathy or myelopathy, and the diagnosis
confirmed by an MRI were included in the study. Patients with a history of trauma, previous spine surgeries and pre-
existing dysphagia were excluded from the study. Participants were informed about the nature and purpose of the study
before obtaining informed consent. Clinical findings, diagnosis, mJOA (modified Japanese orthopaedic association score)
and Neck Disability Index (NDI) scores were recorded. ACDF with stand-alone cage fixation was done after the failure of
conservative therapy for 6 weeks. Smith and Robinson's method was used for the approach to the anterior cervical spine.
ACDF was performed via a standard anterolateral approach from the right side. Distraction screws were placed into the
adjacent vertebral bodies and distraction was applied using a Casper distractor. The size of the cage was determined
preoperatively and intraoperatively using a vernier calliper. After satisfactory decompression an appropriate sized cage
filled with the local autologous bone graft and was seated into the intervertebral space. Postoperatively, the patients were
encouraged to resume their normal activities as soon as possible with a soft collar for 3-6 weeks.

Follow-up was done at intervals of 1month, 3month and 6 months. Patient accessed during these follow-ups by
MJOA and NDI, complications (dysphagia, hoarseness, surgical site infection, implant failure) were also accessed during
these follow-ups.

Primary outcome measures included mJOA and NDI scores. Secondary outcome measures involved measurement
of cage subsidence in lateral radiographs at 6 months and dividing subjects into subsidence and non-subsidence groups.

Impact Factor (JCC): 7.8387 NAAS Rating: 4.14

Functional Outcome of Anterior Cervical Decompression and Fusion (Acdf) with Stand-Alone 73
Cage Fixation in Degenerative Cervical Disc Disease.A Prospective Observational Study

Functional outcome was compared in these two groups.

STATISTICAL ANALYSIS

All statistical analysis was performed using Statistical Package for Social Science (SPSS, version 17) for Microsoft
windows. The continuous data were expressed as mean and SD and categorical data were expressed as a percentage. Paired
t-test was used within groups for pre and post-comparison. A two-sided p-value < 0.05 was considered statistically
significant.

RESULTS

Table 1
mJOA Mean Std deviation p-value
Preoperative 14.71 3.539
Postoperative
1 month 15.50 2.674 0.04
3 months 16.64 1.946 0.01
6 months 17.07 1.328 <0.01

Table 2
NDI Mean Std deviation P value
Preoperative 24.57 6.802
Postoperative
1 months 9.79 3.725 0.05
3months 7.14 3.371 <0.01
6 months 5.79 2.822 <0.01

Table 3
NDI Subsidence group Non-subsidence group P-value
Pre operative 26.78+ 4.98 22.56+ 6.01 0.20
1 month 10.10+ 3.33 9.70+ 3.21 0.28
3 month 8.10+ 3.01 6.60+2.69 0.31
6 month 6.10+ 2.55 5.50+ 2.47 0.67

Table 4
Mjoa Subsidence Group Non Subsidence Group P-Value
Preoperative 15.50+1.75 14.45+1.90 0.06
1 month 15.80+1.63 16.01+1.66 0.10
3 Month 16.60+1.43 16.80+ 1.38 0.19
6 month 16.90+1.31 17.15+1.27 0.18

The mean age of the study population was 52.43 years; the majority of patients were in between 40-50 years. The study
population were predominantly male nine (64.2%) of the fourteen patients and five were females.C6-C7 was the most
common level of disc involved six (42.58%) of fourteen patients followed by C5-C6 four (28.57%) of fourteen mJOA
scores was preoperatively was 14.7 which showed improvement at all follow-ups as shown in table 1 at the end of 6
months was 17.07 with a p-value of <0.01. NDI preoperatively was found to be 24.57 which showed improvement at all
follow-ups as shown in table 2, at the end of 6 months was 5.50 with p-value <0.01. Cage subsidence was accessed during

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74 Dr. Kumar Sambhav, Dr. M. Chandrasekaran
Dr. S. Ramkumar & Prof. Manoharan

follow-ups and was found in 4 patients (28.57%). Scores were compared in subsidence and non-subsidence and group.

One patient developed hoarseness of voice in the postoperative period due to recurrent laryngeal nerve palsy and
recovered in a period of 3 months with conservative therapy. No other complications such as infections, vascular injury,
failure of fixation, oesophageal perforation, etc were noted.

DISCUSSIONS

Cervical spondylotic myeloradiculopathy is a chronic age-related degenerative condition. The disease is associated with
disability due to pain and neurological deficit affecting the activities of daily living. The most commonly affected age
group was between 40-50 years in our study. This was comparable to the reports of Azimi et al., whose results reported a
range of 54+8.3 years. 69 (64.2%) of our patients were male patients, it was comparable to series of to Kelly et al, where
male patients were predominantly affected. C6-C7 disc which was contrary to many studies which show more involvement
of C5-C6 Shenyang et al, Azimi et al however some studies show increased prevalence of C6-C7 Radhakrishnan et al.7

In our study NDI index preoperatively was found to be 24.57 and subsequently at 6 months was found to be 5.79
with a p-value <0.01 in all three months. This was similar to the study conducted by Siddiui et al 8who found the mean
NDI preoperative to be 38 and at 6 months 16 with a p-value of <0.01. Faldini et al9 in his study on one-level anterior
cervical discectomy found preoperative NDI to be 34 which was reduced to 10 postoperatively at 6 months.

Roberto Alfonso in his study found the mean preoperative mJOA to be 15.3 which increased to 16.3
postoperatively with a P-value of 0.016.10 Sharma et al in their study of 30 patients undergoing ACDF with stand-alone
cage found the average preoperative mJOA to be 10.83 which increase to 12.00, 13.53, 14.10 at 3 months, 6 months and 1
year with all p <0.001 which was similar to our study. 11

In our study subsidence and found the incidence to be 28.57%. Results were similar to a study by Bartels et al;
Kast et al12 which showed a 30% incidence of subsidence. There was no difference in functional outcome in the subsidence
and non-subsidence groups.

Dysphonia was noted in one patient 7.18% in an immediate postoperative period which was treated conservatively
and resolved at one month follow up. This is comparable to a reporting rate of 3% due to recurrent laryngeal nerve palsy as
a study by Liao JC et al.13 No other complications like implant failure or infection, wound haematoma were noted in any of
our cases. Limitations of our study were smaller sample size, short duration of follow-up, a single level of surgery. A
comparative study could be done in the future to substantiate a stand-alone cage as an alternative surgical option in
degenerative disc disease.

CONCLUSIONS

Anterior Cervical Decompression and fusion with a stand-alone cage is a safe surgical option with good clinical and
functional outcomes in a degenerative single-level disc disease with minimal complications.

Impact Factor (JCC): 7.8387 NAAS Rating: 4.14

Functional Outcome of Anterior Cervical Decompression and Fusion (Acdf) with Stand-Alone 75
Cage Fixation in Degenerative Cervical Disc Disease.A Prospective Observational Study

Clinical images

Preoperative X-ray and MRI

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76 Dr. Kumar Sambhav, Dr. M. Chandrasekaran
Dr. S. Ramkumar & Prof. Manoharan

Immediate postoperative

At 6 months

Impact Factor (JCC): 7.8387 NAAS Rating: 4.14

Functional Outcome of Anterior Cervical Decompression and Fusion (Acdf) with Stand-Alone 77
Cage Fixation in Degenerative Cervical Disc Disease.A Prospective Observational Study

REFERENCES

1. Sambrook P.N, MacGregor A.J, Spector T.D. Genetic influences on cervical and lumbar disc degeneration: A magnetic
resonance imaging study in twins. Arthritis Rheum. 1999; 42(2):366–72.

2. Bertalanffy H, Eggert H.R. Complications of anterior cervical discectomy without fusion in 450 consecutive patients. Acta
Neurochir (Wien). 1989;99(1–2):41–50.

3. Ning X, Wen Y, Xiao-Jian Y, Bin N, De-Yu C, Jian-Ru X, et al. Anterior cervical locking plate-related complications;
prevention and treatment recommendations. Int Orthop. 2008;32(5):649–55.

4. Yang S, Yu Y, Liu X, Zhang Z, Hou T, Xu J, et al. Clinical and radiological results comparison of allograft and
polyetheretherketone cage for one to two-level anterior cervical discectomy and fusion: A CONSORT-compliant article.
Medicine (Baltimore). 2019 Nov 1;98(45):e17935.

5. Yang S, Yu Y, Liu X, Zhang Z, Hou T, Xu J, et al. Clinical and radiological results comparison of allograft and
polyetheretherketone cage for one to two-level anterior cervical discectomy and fusion: A CONSORT-compliant article.
Medicine (Baltimore). 2019 Nov 1;98(45):e17935.

6. Azimi P, Shahzadi S, Benzel EC, Montazari A. Functional evaluation using the modified Japanese Orthopedic Association
score (mJOA) for cervical spondylotic myelopathy disease by age, gender, and type of disease. J Inj Violence Res.
2012;4(3):2012.

7. Radhakrishnan K, Litchy WJ, Michael O’fallon W, Kurland LT. Epidemiology of cervical radiculopathy. Vol. 117, Brain.
1994.

8. Seng C, Tow BPB, Siddiqui MA, Srivastava A, Wang L, Yew AKS, et al. Surgically treated cervical myelopathy: A functional
outcome comparison study between multilevel anterior cervical decompression fusion with instrumentation and posterior
laminoplasty. Spine J. 2013 Jul;13(7):723–31.

9. Faldini C, Chehrassan M, Miscione MT, Acri F, D’Amato M, Pungetti C, et al. Single-level anterior cervical discectomy and
interbody fusion using PEEK anatomical cervical cage and allograft bone. J Orthop Traumatol. 2011 Dec 17;12(4):201–5.

10. De Leo–Vargas RA, Muñoz–Romero I, Mondragón–Soto MG, Martínez–Anda JJ. Locking Stand-Alone Cage Constructs for
the Treatment of Cervical Spine Degenerative Disease. Asian Spine J . 2019 Aug 31;13(4):630–7.

11. Sharma A, Kishore H, Singh V, Shawky Abdelgawaad A, Sinha S, Kamble PC, et al. Comparative Study of Functional
Outcome of Anterior Cervical Decompression and Interbody Fusion With Tricortical Stand-Alone Iliac Crest Autograft Versus
Stand-Alone Polyetheretherketone Cage in Cervical Spondylotic Myelopathy. Glob Spine J. 2018 Dec 1;8(8):860–5.

12. Bartels RHMA, Donk RD, Feuth T. Subsidence of Stand-alone Cervical Carbon Fiber Cages. Neurosurgery. 2006 Mar
1;58(3):502–8.

13. Liao JC, Niu CC, Chen WJ, Chen LH. Polyetheretherketone (PEEK) cage filled with cancellous allograft in anterior cervical
discectomy and fusion. Int Orthop. 2008;32(5):643–8.

14. 11. Liao J C, Niu C. C, Chen W J, Chen L H. Polyether-etherketone (PEEK) cage filled [13] with cancellous allograft in
anterior cervical discectomy and fusion. Int Orthop. 2008;32(5):643-48.

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