Article Figures & Data
Figures
- Figure 1
(A) Preoperative and (B) postoperative lateral x-ray images of a patient surgically treated with self-locking stand-alone anterior cervical discectomy and fusion technique for cervical spine degenerative disease. The cervical regional sagittal balance parameters measured for the present study are shown: cCobb, C2-C7 Cobb’s angle; HCA, C2-C7 angle measured with the Harrison’s method; sCobb, cervical segmental Cobb angle; cSVA, C2-C7 sagittal vertical axis; T1s, T1 slope; C0-C2, C0-C2 angle. HCA, Harrison cervical angle; cSVA, cervical sagittal vertical axis.
- Figure 2
(A) Lateral x-ray image of a patient treated with 3-level stand-alone anterior cervical discectomy and fusion (ACDF) technique who developed bony fusion between intervened cervical levels. (B) Sagittal plane T2-weighted magnetic resonance image of a patient treated with single-level stand-alone ACDF technique who developed adjacent segment disease. (C) Lateral x-ray image of a patient treated with 2-level stand-alone ACDF technique who developed subsidence of intervened cervical levels.
- Figure 3
Cervical cages: (A) Coalition, Globus Medical, PA, USA and (B) Aleutian, Stryker, MI, USA.
- Figure 4
Error-bar charts showing the mean changes in regional cervical sagittal balance parameters during time, measured in preoperative (Preop), postoperative (Postop), and follow-up (last evaluation [Last Ev]) periods. (A) cCobb, C2-C7 Cobb’s angle; (B) T1s, T1 slope; (C) HCA, C2-C7 angle measured with the Harrison’s method; (D) C0-C2, C0-C2 angle; (E) cSVA, C2-C7 sagittal vertical axis; and (F) sCobb, cervical segmental Cobb angle. P values were obtained with Student’s t test for independent values, and significant values are highlighted in boldface.
- Figure 5
Scatterplots show the correlation between T1 slope (T1s) and C2-C7 Cobb’s angle (cCobb), cervical sagittal vertical axis (cSVA) and C0-C2 angle (C0-C2) in preoperative (A), (B), and (C); postoperative (D), (E), and (F); and last follow-up evaluations (G), (H), and (I). CI, Pearson’s correlations coefficient. Statistical significant values were highlighted in bold.
- Figure 6
Foster plot with relative risk (RR) of developing (A) subsidence, (B) adjacent segment degeneration, (C) fusion, and (D) the need of reoperation in the presence of multilevel surgery, age >60 years, smoking, and osteoporosis. P value was calculated with Pearson’s square X test, and significant results are highlighted in bold.
- Figure 7
Error-bar charts showing the mean value of clinical parameters for evaluation of patients with cervical spine degenerative disease and their relationship with postoperative subsidence, adjacent segment degeneration (Adj segment), and bony fusion (Fusion) following cervical sagittal vertical axis anterior cervical discectomy and fusion technique. (A) NDI, Neck Disability Index; (B) cervical VAS, cervical pain visual analog scale; (C) radicular VAS, radicular pain visual analog scale. + indicates that the factor (fusion, adjacent segment degeneration or fusion) was present; − indicates that the factor (fusion, adjacent segment degeneration or fusion) was absent. P values were obtained with Student’s t test for independent values, and significant values were highlighted in bold numbers.
- Figure 8
Error-bar charts showing the cervical radiological angles during preoperative (Preop), postoperative (Postop), and last evaluation (Last Ev), comparing both surgical implants, Aleutian and Coalition cages. On boxes below the charts, the P value is shown comparing the Aleutian vs Coalition groups. (A) cCobb, Cervical Cobb angle; (B) T1s, T1 slope; (C) HCA, Harrison’s cervical angle; (D) C0-C2, C0 – C2 Cobb’s angle; (E) cSVA, cervical sagittal vertical axis; and (F) sCobb, segmental Cobb’s angle of surgically treated level.
Tables
Characteristics Value Age, y, mean (SD) (range) 53.15 (10.73) (30–78) ≥60 y, n (%) 24 (30%) Gender: female, n (%) 43 (53.7%) Smokers, n (%) 28 (35%) Osteoporosis, n (%) 15 (18.8%) Outcome measure VAS cervical pain, mean (SD) 7.15 (2.1) VAS radicular pain, mean (SD) 7.35 (2) Myelopathy symptoms (Nurick >1), n (%) 15 (18.75%) NDI, mean (SD) (range) 40.21 (13.2) (14–80) JOA, mean (SD) 15.67 (1.47) Symptom duration, mo, median (IQR) 11.6 (0.4–22.8) Type of spinal fusion, n (%) Single-level fusion 43 (53.8%) Multiple-level fusion 37 (46.2%) C3-C4 6 (7.5%) C4-C5 11 (13.8%) C5-C6 20 (25%) C6-C7 8 (10%) C3-C5 2 (2.5%) C4-C6 3 (3.8%) C5-C7 25 (31.3%) C4-C7 5 (6.3%) Myelopathic changes on MRI 21 (26.3%) Abbreviations: IQR, interquartile range; JOA, Japanese Orthopedic Association Scale; MRI, magnetic resonance imaging; NDI, Neck Disability Index; VAS, visual analog scale.
Note: Statistically significant differences are shown in boldface.
a Evaluation on first postoperative mo; in parentheses, P value of independent samples t test comparing preoperative vs postoperative evaluation.
b Last follow-up evaluation; in parentheses, P value of independent samples t test comparing postoperative vs last follow-up evaluation.
Outcomes N (%) Surgical technique Stand-alone cages 35 (43.8%) Self-locking stand-alone cages 45 (56.2%) Follow-up, mo, median (IQR) 22.5 (12–32.1) Surgical complications 2 (2.5%) Postoperative dysphagia Transient (<1 month) 16 (20%) Long term 4 (5%) Fusion achieved 68 (85%) Adjacent segment degeneration 5 (6.3%) Subsidence 26 (32.5%) Required new surgery 6 (7.5%) Pseudoarthrosis/subsidence 2 (2.5%) Adjacent segment degeneration 4 (5%) Postoperativea Last Evaluationb Outcome measure VAS cervical Pain 4.26 (0.001) 4.6 (0.147) VAS radicular pain 3.91 (0.001) 4.3 (0.1) Myelopathy symptoms (Nurick 1) 15 (18.7%) 14 (17.5%) NDI 27.4 (0.001) 29.33 (0.07) JOA 16.97 (0.001) 16.95 (0.7) Abbreviations: IQR, interquartile range; JOA, Japanese Orthopaedic Association Scale; NDI, Neck Disability Index; VAS, visual analog scale.
Note: Data presented as n (%) unless otherwise indicated. Statistically significant differences are shown in boldface.
↵a Evaluation on first postoperative month; in parenthesis, P value of independent samples t test comparing preoperative evaluation vs postoperative evaluation.
↵b Last follow-up evaluation; in parenthesis, P value of independent samples t test comparing postoperative evaluation vs last follow-up evaluation.
- Table 3
Correlation between cervical spine levels surgically treated, cervical alignment, and clinical/radiological outcome.
Single Level, Mean (SD) Multilevel, Mean (SD) P a Postoperative Clinical Status NDI 25.4 (13.9) 29.7 (19.2) 0.25 Cervical VAS 4.1 (2.3) 4.4 (2.7) 0.5 Radicular VAS 3.9 (2.2) 3.9 (2.6) 0.9 JOA 16.9 (1.2) 17 (1.5) 0.8 Last Evaluation Clinical Status NDI 27.5 (15) 31.4 (19.8) 0.3 Cervical VAS 4.3 (2.4) 4.8 (2.9) 0.4 Radicular VAS 4.2 (2.7) 4.4 (2.8) 0.7 JOA 17 (1.2) 16.8 (1.5) 0.6 Postoperative Cervical Angles C2-C7 Cobb’s angle −13 (15.5) −16 (10.8) 0.2 T1 slope 27.7 (13.3) 27.8 (9.5) 0.9 C0-C2 angle 18.8 (12.6) 18.7 (10.8) 0.9 Cervical segmental Cobb angle −5.1 (7.1) −9.2 (9.4) 0.02 Harrison cervical angle 17.6 (11.4) 17.8 (9.7) 0.9 Cervical sagittal vertical axis 25.4 (9.9) 23 (9.9) 0.2 Abbreviations: JOA, Japanese Orthopedic Association; NDI, Neck Disability Index; VAS, visual analog scale.
↵a t test for independent samples.
Postoperative Clinical Status NDI Cervical VAS Radicular VAS C a P C a P C a P cCobb 0.049 0.66 −0.15 0.16 −0.062 0.58 T1s −0.098 0.38 −0.056 0.62 0.02 0.98 C0-C2 0.08 0.67 −0.005 0.9 −0.022 0.84 sCobb 0.06 0.56 −0.054 0.634 −0.036 0.75 HCA −0.122 0.28 0.045 0.69 0.032 0.78 cSVA −0.059 0.6 −0.29 0.009 −0.18 0.11 Clinical Status on Last Follow-Up Evaluation NDI Cervical VAS Radicular VAS C a P C a P C a P cCobb 0.16 0.147 0.06 0.54 0.11 0.31 T1s −0.16 0.156 −0.1 0.33 −0.06 0.55 C0-C2 0.011 0.92 −0.11 0.3 −0.25 0.02 sCobb 0.184 0.1 −0.04 0.69 0.096 0.4 HCA −0.09 0.4 0.045 0.69 0.038 0.73 cSVA 0.035 0.75 −0.12 0.26 −0.068 0.54 Reoperation Yesb Nob P c cCobb −4.7 −15.4 0.05 T1s 31.4 27.4 0.42 C0-C2 28.5 18 0.03 sCobb −5.6 −7.1 0.6 HCA 15.6 17.9 0.6 cSVA 26.3 24.1 0.6 Abbreviations: C0-C2, C0-C2 angle; cCobb, C2-C7 Cobb’s angle; cSVA, cervical sagittal vertical axis; HCA, Harrison cervical angle; NDI, Neck Disability Index; sCobb, cervical segmental Cobb angle; T1s, T1 slope; VAS, visual analog scale.
↵a Pearson’s correlation coefficient.
↵b Mean value.
↵c t Test for independent samples.
- Table 5
Comparative analysis of clinical and radiological outcomes between patients surgically treated with Aleutian and Coalition cervical cages.
Characteristic Aleutian Coalition P Age, y, mean (SD) 52.7 (10.6) 53.4 (10.9) 0.56 Gender, women, % 65.7% 44.4% 0.06 Cervical levels, multilevel, n (%) 18 (51.4) 19 (42.2) 0.5 Smokers, % 37.1% 37.5% 0.9 Osteoporosis, % 22.5% 14.1% 0.06 Surgical complications, % 2.8% 2% 0.8 Follow time, mo, mean (SD) 23.8 (19) 11.5 (7.3) < 0.0001 Neck Disability Index, mean (SD) Preoperative 39.2 (10.4) 40.9 (15) 0.5 Postoperative 23.4 (13.4) 30.5 (18.3) 0.05 Last evaluation 27.2 (15.5) 31 (18.7) 0.3 Cervical VAS, mean (SD) Preoperative 6.9 (2.2) 7.2 (2.1) 0.5 Postoperative 3.5 (2.2) 4.8 (2.5) 0.02 Last evaluation 4.1 (2.3) 4.9 (2.8) 0.2 Radicular EVA, mean (SD) Preoperative 7.4 (2.2) 7.2 (2) 0.7 Postoperative 3.4 (2.2) 4.2 (2.5) 0.1 Last evaluation 4 (2.4) 4.5 (3) 0.4 Japanese Orthopedic Association Scale, mean (SD) Preoperative 15.7 (0.9) 15.6 (1.7) 0.7 Postoperative 17.2 (1) 16.8 (1.6) 0.2 Last evaluation 17 (0.9) 16.8 (1.5) 0.5 Fusion rate, % 91.4% 80% 0.15 Subsidence rate, % 45.7% 22.2% 0.02 Adjacent segment rate, % 8.5% 4.4% 0.4 Required new surgery, n (%) 4 (11.4%) 2 (4.4%) 0.2
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