THE EDITORIAL DEBATE: PROS AND CONS
|Year : 2016 | Volume
| Issue : 1 | Page : 23--24
Functional and radiological outcome in patients undergoing a three-level corpectomy for multilevel cervical spondylotic myelopathy and ossified posterior longitudinal ligament
Dilip K Sengupta
Department of Orthopedics, Texas Back Institute, Plano, Texas, USA
Dilip K Sengupta
Department of Orthopedics, Texas Back Institute, Plano, Texas
|How to cite this article:|
Sengupta DK. Functional and radiological outcome in patients undergoing a three-level corpectomy for multilevel cervical spondylotic myelopathy and ossified posterior longitudinal ligament.Neurol India 2016;64:23-24
|How to cite this URL:|
Sengupta DK. Functional and radiological outcome in patients undergoing a three-level corpectomy for multilevel cervical spondylotic myelopathy and ossified posterior longitudinal ligament. Neurol India [serial online] 2016 [cited 2021 Oct 25 ];64:23-24
Available from: https://www.neurologyindia.com/text.asp?2016/64/1/23/173633
The authors presented a retrospective study of three-level anterior cervical corpectomy and fibular autograft stabilization in 33 cases with cervical spondylotic myelopathy (CSM, n = 14) or myelopathy due to ossification of the posterior longitudinal ligament [OPLL] (n = 19). They used “floating off” technique in some OPLL cases where the dura was adherent. The first 10 patients were kept on bed rest for 1 week while the others were mobilized out of bed in the immediate postoperative period. A cervical collar was used for 6 months. Twenty-nine cases had a clinical follow-up ranging from 12 to 138 months and 20 cases had a radiological follow-up.
The authors reported an impressive outcome with 90% radiological fusion. They did not report any incidence of graft extrusion despite not using plate fixation. The reported complications were cerebrospinal fluid leak in 15.2% (5/33 cases), transient dysphagia in 13.7% (4/29 cases), and C5 palsy in 6.8% (2/29 cases). Functional outcome and cervical alignment restoration was also reported to be comparable to the literature reports. No reoperation was reported in their series.
The overall positive note in this case series is encouraging. What stands out different from the literature are the low complication rates after a relatively extensive anterior surgery, the high fusion rate, and no graft extrusion despite an uninstrumented fusion. The other difference from the literature is the use of fibular autograft and prolonged cervical collar immobilization. The authors concluded that, “Three-level cervical corpectomy with uninstrumented fusion is a relatively safe surgery in experienced hands.”
Most reports in the literature for corpectomy involve two levels because of a high complication rate, and reports alluding to a three-level corpectomy are much less common. Use of fibular autograft is uncommon, and most reports in the literature involve either a fibular allograft, an expandable cage, or a titanium mesh. Plate fixations have been used in most literature reports.
Song et al., reported a study of 15 patients with an anterior cervical corpectomy and fusion, of which only five had a three-level surgery, and he used an autograft (iliac crest or fibula without any plating), and a halo immobilization. Their minimum follow-up was 5 years, and the reported incidence of graft dislodgement occurred in 13%, dysphagia lasting for >6 weeks occurred in 20%, and nonunion requiring revision surgery occurred in 6.7% cases.
Liu et al., reported a series of multilevel CSM with anterior surgeries that included 87 cases with two level corpectomies. They used a titanium mesh or cage filled with autograft, with 3 weeks of cervical collar immobilization, and a minimum of 2 year follow-up. The authors reported nonunion in 8% (7/87), severe graft dislodgement in 2.3% (2/87), dysphagia in 2.3% (2/87), and C5 palsy in 11.5% (10/87) patients. They achieved fusion in 92% cases. The authors concluded that the long corpectomy approach should be selected prudently because of the high rate of complications.
Zhu et al., in a review article with a meta-analysis of eight studies comparing anterior versus posterior surgical approach for a multilevel CSM, reported a much higher complication rate with the anterior approach (odds ratio: 2.60). Out of the 245 patients in the eight studies, 21 (8.57%) received reoperation. The authors concluded that surgical trauma associated with corpectomy was significantly higher than that associated with laminoplasty/laminectomy in the treatment of multilevel CSM. Dysphagia is often underreported in retrospective series. In a prospective cohort study on 310 patients with a minimum 2 year follow-up, Lee et al., reported an overall prevalence of dysphagia at 1, 2, 6, 12, and 24 months at 54.0%, 33.6%, 18.6%, 15.2%, and 13.6%, respectively. The prevalence rate was even higher in patients who had more than two-level surgery (19.3%) at a 2-year follow-up.
Graft dislodgment is a frequent complication after a multilevel anterior corpectomy. Epstein  reported graft extrusions in 3 of 22 patients who had no anterior plate fixation but had additional posterior wire fixation and halo-vest immobilization for a two- to four-level surgery for OPLL.
A notable fact in the current series was that anterior surgery was performed despite only four patients (12.5%) having a kyphotic cervical spine and the remaining having either a straight or a lordotic curvature prior to surgery. The other important fact is that multilevel anterior surgery was preferred despite majority of the patients (19/33) having an OPLL, where posterior surgery is usually advocated to avoid dural injury.
With due regard to the experience of the authors in performing multilevel anterior corpectomy with superior results and fewer complications, a note of caution may be raised. The short follow-up duration (minimum 20 months) and the missing follow-up (only 60.6% available for radiological follow-up) may lead to missing cases who may have had complications and an inadequate outcome. The authors may like to exercise more restraint before recommending a three-level corpectomy without plate fixation or halo immobilization in patients who may have a safer alternative surgical approach.
|1||Gupta A, Rajshekhar V. Functional and radiological outcome in patients undergoing three-level corpectomy for multi-level cervical spondylotic myelopathy and ossified posterior longitudinal ligament. Neurol India 2016;64:90-6.|
|2||Song KJ, Lee KB, Song JH. Efficacy of multilevel anterior cervical discectomy and fusion versus corpectomy and fusion for multilevel cervical spondylotic myelopathy: A minimum 5-year follow-up study. Eur Spine J 2012;21:155-7.|
|3||Liu Y, Qi M, Chen H, Yang L, Wang X, Shi G, et al. Comparative analysis of complications of different reconstructive techniques following anterior decompression for multilevel cervical spondylotic myelopathy. Eur Spine J 2012;21:2428-35.|
|4||Zhu B, Xu Y, Liu X, Liu Z, Dang G. Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy: A systemic review and meta-analysis. Eur Spine J 2013;22:1583-93.|
|5||Lee MJ, Bazaz R, Furey CG, Yoo J. Risk factors for dysphagia after anterior cervical spine surgery: A two-year prospective cohort study. Spine J 2007;7:141-7.|
|6||Epstein N. Anterior approaches to cervical spondylosis and ossification of the posterior longitudinal ligament: Review of operative technique and assessment of 65 multilevel circumferential procedures. Surg Neurol 2001;55:313-24.|