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Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 1037-1039

Acute Migration Following Dissociation of Components of Cervical Disc Arthroplasty


1 Department of Orthopedics, AIIMS, Bhubaneswar, Odisha, India
2 Department of Anatomy, AIIMS, Bhubaneswar, Odisha, India

Date of Web Publication2-Sep-2021

Correspondence Address:
Mantu Jain
Departments of Orthopedics, 106, Mahadev Orchid, Cosmopolis Road, Dumduma, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.323895

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 » Abstract 


Cervical disc arthroplasty (CDA) is a newer alternative to the traditional fusion, in patients with prolapsed cervical disc in the younger eligible patient aiming to provide mobility similar to the native disc and by some ways preventing the adjacent segment disease. The rising popularity of its early success has seen emergence of a number of products in the market. In a country where cost remains an important constraint for the patients, local design products are available to cater to these lesser privileged patients. The present complication is an acute dissociation of components from such a product wherein the implant was retrieved and fusion was done. The patient was subsequently discharged uneventfully.


Keywords: Acute migration, cervical disc arthroplasty, dissociation
Key Message: Cervical disc arthroplasty is a newer alternative to the traditional fusion and the rising popularity has flooded the market with number of products. There is continuous attempts to advancement in making the product affordable yet safe for the patients. Our case is a complication in form of acute dissociation of components on second post-operative day that was retrieved and converted to a fusion.


How to cite this article:
Jain M, Doki SK, Gaikwad M, Khutia S. Acute Migration Following Dissociation of Components of Cervical Disc Arthroplasty. Neurol India 2021;69:1037-9

How to cite this URL:
Jain M, Doki SK, Gaikwad M, Khutia S. Acute Migration Following Dissociation of Components of Cervical Disc Arthroplasty. Neurol India [serial online] 2021 [cited 2021 Sep 25];69:1037-9. Available from: https://www.neurologyindia.com/text.asp?2021/69/4/1037/323895





 » Introduction Top


Anterior cervical discectomy and fusion (ACDF) is the standard surgical procedure for degenerative cervical disease management.[1] Cervical disc arthroplasty (CDA) is the motion-sparing alternative that has evolved over the last decade for cervical radiculopathy and myelopathy in younger patients.[2] Theoretical advantages of the CDA over ACDF are preservation of motion of affected vertebral segment and decreased strain over contiguous level leading to decreased progressive degeneration of adjacent level.[3] More than 90% of patient resume their preoperative level of activity and complete relief of symptoms with CDA.[4] It appears to fare better the ACDF in some of studies.[4] However, every new procedure has its own novel set of complications and so is CDA. Certain short-term complications are similar to the ACDF, which are procedure related like dysphagia, dysphonia, posterior neck pain, recurrent laryngeal nerve palsy, esophageal injury, tracheal injury, dural tear, hematoma and spinal cord injury. Some long-term specific complications include the peri-device osteolysis and the heterotrophic ossification.[2],[4] Migration of the implant (posterior more than anterior) is an uncommon complication of the procedure.[2],[5] Literature suggests that migration occur at least 4 weeks after surgery.[5] We report a case where CDA done for single-level cervical myelopathy, presented with acute migration due to dissociation of the implants in the second postoperative day that was subsequently managed with an ACDF.


 » Case Presentation Top


A 40-year-old male with Nurick's grade 2 cervical myelopathy presented with neck pain and spasticity for past 1 year. On examination, the deep tendon reflex (upper limbs: triceps and finger flexors; and lower limbs: knee and ankle) were exaggerated, Hoffman's sign and Babinski sign were positive bilaterally. The power of wrist extensors (right) was MRC 4/5 with no other associated motor or sensory deficit. Plain X-ray showed small posterior osteophytes from C5 vertebrae with preservation of movement and no instability. Computed tomography (CT) did not reveal any calcification of posterior spinal ligament. Magnetic resonance imaging (MRI) showed compression at C5-C6 level with right-sided neural foraminal stenosis and edematous changes of the cord at same level. The patient underwent C5-C6 discectomy followed by CDA (C-disc, GESCO India). The correct placement of implant was confirmed by intraoperative fluoroscopy [Figure 1]. The wound was closed in layers and a soft cervical collar applied postoperatively. The patient started on liquid diet 6 hours post surgery and soft diet on subsequent day and mobilized. On the second postoperative day, the patient had an episode of repeated cough during feeding and complained some dysphagia since then. The wound was inspected and check X-ray was done which showed dissociation of the CDA components and anterior migration [Figure 2]. Patient was returned to emergency operation theatre where the CDA was retrieved and ACDF using a standalone cage (C-fix, GESCO India) was done [Figure 3]. Intraoperative assessment of esophagus was done to see for any laceration [Figure 4] due to sharp edges on components of CDA [Figure 5]. A postoperative barium swallow CT followed to confirm any inadvent injury [Figure 6]. The patient recovered uneventfully and was discharged from hospital after 5 days. At 6 months follow-up, patient is doing well with no complaints.
Figure 1: Intraoperative fluoroscopy showing the antero-posterior and lateral views with a well-placed CDA

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Figure 2: Check X-ray showing dissociation of components and anterior migration of implant

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Figure 3: X-ray showing revision with ACDF using C-fix (cage with screws)

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Figure 4: Clinical picture showing an eryhrematous area (arrow) in the outer layer (adventitia) of the esophagus

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Figure 5: Photographs of the removed CDA showing the sharp edges (arrow)

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Figure 6: Contrast CT scan with barium swallow showing no rent in esophagus, barium in stomach can be seen (arrow)

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 » Discussion Top


ACDF, posterior lamino-foraminotomy, laminoplasty, and laminectomy with fusion (with/without instrumentation) have been the traditional surgical option for management of cervical radiculopathy and myelopathy.[6] The last decade has seen evolution of CDA as an attractive alternative particularly in younger individuals. CDA is supposed to preserve motion between the affected vertebral segments, which decrease strain, and reduce the chances of adjacent vertebrae degeneration.[2],[3] The results are similar to the ACDF in terms of relief of symptoms, though allowing early return to preoperative level of activity.[2],[4] Current indications for CDA include single cervical radiculopathy or myelopathy with underlying degenerative disc disease, which has been unresponsive to conservative treatment.[6] Our patient fulfilled the eligibility criterion as he had failed conservative treatment for 1 year. The short-term complications of CDA includes bleeding, hematoma, dysphonia, dysphagia, esophageal injury, tracheal injury, recurrent laryngeal nerve injury, dural tear and spinal cord injury.[2],[4] Mid and long-term complications include mainly adjacent segment degeneration, heterotrophic ossification and peri-device osteolysis leading to implant failure (1). Migration of implant in CDA is an uncommonly reported complication.[2],[5],[7],[8] Out of the eleven cases mentioned in the literature, eight cases presented with posterior migration of the device (leading to paralysis in one case) and rest three are anterior dislocation.[2] In all cases migration occurred few weeks post surgery and a recent trauma was the usual cause for migration except one.[2] In this solitary atraumatic migration case, poor integration of bone to implant was speculated as the cause. In contrast to previous reported cases, our migration of device occurred acutely in the second postoperative period without any direct trauma. Patient reported an episode of violent cough during feeding. This could have led to dissociation of the implant components as there is no locking mechanism per se (unconstrained) in this implant as opposed to other manufacturers that have some constraining system.[2],[9] The C-disc comes as two broad-based rectangular metal (titanium) on poly (with metal-titanium backing) components where the poly has a convexity and metal surface is concave. The components are assembled and this opposing congruity makes it a single unit prior to implantation. There are sharp edges on metal component that press fit into the milled endplates for immediate fixation before bony integration. Our patient was young and non-osteoporotic and implant fixation was satisfactory. Persistent cough following cervical spine surgery is known due to impingement of vagus nerve by osteophytes.[10] Our patient was asymptomatic for 2 days on normal diet and a sudden burst occurred during feeding indicating a protective mechanism to prevent food entering wrong tract. The patient was re-operated wherein the implant was removed followed by ACDF in the emergency. The sharp edges on surfaces for immediate implant holding may cause injury to adjacent vital structures particularly the esophagus or trachea. We explored the esophagus and found a small area of erythema on the outer adventitia layer. Even though this was not significant, next day we did a contrast CT before allowing food orally. When migration occurs slowly, there may not be injury to vital structures as the sharp edges may be covered by fibrous tissue. Our case was acute and an episode of cough that was severe to cause dissociation needed complete investigation. On the 6 months, follow-up patient was doing well with no more signs of myelopathy and complications.


 » Conclusion Top


Anterior migration of the CDA may occur in early postoperative periods with dissociation among the components in the unconstrained devices like ours. Thorough investigations are warranted in such cases to rule out any injury to vital structures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Park CK, Ryu KS. Are controversial issues in cervical total disc replacement resolved or unresolved?: A review of literature and recent updates. Asian Spine J 2018;12:178-92.  Back to cited text no. 1
    
2.
Wagner SC, Kang DG, Helgeson MD. Traumatic migration of the bryan cervical disc arthroplasty. Glob Spine J 2015;6:e15-20.  Back to cited text no. 2
    
3.
Auerbach JD, Jones KJ, Fras CI, Balderston JR, Rushton SA, Chin KR. The prevalence of indications and contraindications to cervical total disc replacement. Spine J 2008;8:711-6.  Back to cited text no. 3
    
4.
Goffin J. Complications of cervical disc arthroplasty. Semin Spine Surg 2006;18:87-97.  Back to cited text no. 4
    
5.
Anderson PA, Sasso RC, Rouleau JP, Carlson CS, Goffin J. The bryan cervical disc: Wear properties and early clinical results. Spine J 2004;4 (6 Suppl):S303-9.  Back to cited text no. 5
    
6.
Leven D, Meaike J, Radcliff K, Qureshi S. Cervical disc replacement surgery: Indications, technique, and technical pearls. Curr Rev Musculoskelet Med 2017;10:160-9.  Back to cited text no. 6
    
7.
Wagner S, Kang D, Helgeson MD. Implant migration after Bryan cervical disc arthroplasty. Spine J 2014;14:2513-14.  Back to cited text no. 7
    
8.
Zhang Z, Zhu W, Zhu L, Du Y. Midterm outcomes of total cervical total disc replacement with Bryan prosthesis. Eur J Orthop Surg Traumatol 2014;24(Suppl 1):1-2.  Back to cited text no. 8
    
9.
Sekhon LHS, Ball JR. Artificial cervical disc replacement: Principles, types and techniques. Neurol India 2005;54:445-50.  Back to cited text no. 9
    
10.
Orhan K, Acar S, Ulusan M, Aydoseli A, Guldiken Y. Persistent cough associated with osteophyte formation and vagus nerve impingement following cervical spinal surgery: Case report. J Neurosurg Spine 2013;19:167-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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