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Does rigid instrumentation increase the fusion rate in one-level anterior cervical discectomy and fusion?

BACKGROUND CONTEXT: Although plate fixation enhances the fusion rate in multilevel anterior cervical discectomy and fusion (ACDF), debate exists regarding the efficacy of nonplating to rigid plate fixation in one-level ACDF.

PURPOSE: To determine the efficacy of nonplating to rigid plate fixation in regards to fusion rate and clinical outcome in patients undergoing one-level ACDF with autograft.

STUDY DESIGN: A review of 69 consecutive patients who underwent one-level ACDF with autograft and with or without rigid anterior cervical plate fixation.

PATIENT SAMPLE: Sixty-nine patients who underwent one-level ACDF (mean age, 45 years) were evaluated for radiographic evidence of fusion (mean, 14 months) and for clinical outcome. All patients received tricortical iliac crest autografts. Disc space distraction was 2 mm, the grafts were inserted with the cortical surface positioned anteriorly, and each graft was countersunk 2 mm from the anterior vertebral border. Thirty-eight patients underwent nonplated ACDF and 31 patients underwent plated ACDF. Eighteen Orion (Sofamor-Danek, Memphis, TN), eight Atlantis (Sofamor-Danek) and five PEAK polyaxial (Depuy-Acromed, Rayham, MA) anterior cervical plating systems were used. Rigid plate fixation was used in all patients with instrumentation. Postoperatively, hard collars were worn 6 to 8 weeks in nonplated patients and soft collars were worn for 3 to 4 weeks in plated patients. Twenty-four patients were smokers (54.2% nonplating; 45.8% plating) and work-related injuries entailed 23 patients (47.8% nonplating; 52.2% plating).

OUTCOME MEASURES: Fusion was assessed based on last follow-up of lateral neutral, flexion and extension radiographs. Radiographs were evaluated blindly to assess fusion and instrumentation integrity between nonplated and plated patients. Clinical outcomes were assessed with the Cervical Spine Outcomes Questionnaire and also assessed on last follow-up as excellent, good, fair or poor based on Odom's criteria.

METHODS: Fusion rate and postoperative clinical outcome were assessed in 69 patients who underwent one-level ACDF with autograft and with or without rigid anterior plate fixation. Additional risk factors were also analyzed. Statistical significance was established at p<.05.

RESULTS: Sixty-six patients (95.7%) achieved a solid fusion (100% nonplated; 90.3% plated). Nonunions occurred in three patients (1 smoker; 2 nonsmokers) with Orion instrumentation. Slight screw penetration into the involved and uninvolved interbody spaces occurred in one patient who was a nonsmoker and did not achieve fusion. One superficial cervical wound infection was noted in a nonplated patient. No other intraoperative or postoperative complications were noted. No statistically significant difference was noted between nonplating to rigid plating upon fusion rate (p>.05). All nonunions occurred at the C5-C6 level. Mean estimated intraoperative blood loss was significantly greater in plated patients (p=.043). Revision surgery involved 9.7% of the plated patients, whereas none of the nonplated patients required reoperation. Postoperative clinical outcome was assessed in all patients (mean, 21 months). Excellent results were noted in 18.8%, good results in 72.5% and fair results in 8.7% of the patients. Nonunion patients reported satisfactory clinical outcome. No statistical significance was noted between clinical outcome of fused and nonfused patients, the presence of a work-related injury and the use of plating (p>.05). Demographics and history of smoking were not factors influencing fusion or clinical outcome in this series (p>.05). The effect on fusion by various plate types could not be discerned from this study.

CONCLUSION: A 100% and 90.3% fusion rate was obtained for one-level nonplated and plated ACDF procedures with autograft, respectively. The effects of smoking or level of fusion could not be discerned from these one-level cases. Excellent and good clinical outcome results were obtained for 91.3%. Nonplating or rigid plate fixation for ACDF in properly selected patients to treat radiculopathy with or without myelopathy has a high fusion rate and yields a satisfactory clinical outcome. Although controversy exists as to the efficacy of rigid plate fixation in one-level ACDF, solid bone fusion can be adequately obtained without plate fixation and instrumentation-related complications can be avoided. In line with the literature, plate fixation should be reserved for patients unwilling or unable to wear a hard orthosis postoperatively for an extended period of time or for those patients who seek a quicker return to normal activities. Proper patient selection, meticulous operative technique and postoperative care is essential to promote optimal graft-host incorporation.

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