Anterior cervical discectomy and fusion for the management of axial neck pain in the absence of radiculopathy or myelopathy

 

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ABSTRACT

Study design: Systematic review

Study rationale: Anterior cervical discectomy and fusion (ACDF) is a proven, effective treatment for relieving neck pain due to degenerative conditions of the cervical spine. Since most patients also present with radiculopathy or myelopathy, little is known as to the effectiveness of ACDF to relieve pain and improve function in patients without radicular or myelopathic symptoms.

Objective: To examine the clinical outcome in patients undergoing (ACDF) for axial neck pain without radicular or myelopathic symptoms.

Methods: A systematic review was undertaken for articles published up to March 2010. Electronic databases and reference lists of key articles were searched to identify studies evaluating ACDF for the treatment of axial neck pain only. Radiculopathy and myelopathy, patients who suffered severe trauma, or with tumor / metastatic disease or infection were excluded. Two independent reviewers assessed the strength of evidence using the grading of recommendations assessment, develop­ment and evaluation (GRADE) system, and disagreements were resolved by consensus.

Results: No comparative studies were identified. Three case series met our inclusion criteria and were evaluated. All studies showed a mean improvement of pain of at least 50 % approximately 4-years following surgery. Functional outcomes improved between 32 % and 52 % from baseline. Most patients reported satisfaction with surgery, 56 % in one study and 79 % in another. Complications varied among studies ranging from 1 % to 10 % and included pseudoarthrosis (9 %), nonunion and revision (3 %) and screw removal (1 %).

Conclusion: There is low evidence suggesting that patients with axial neck pain without radicular or myelopathic symptoms may receive some improvement in pain and function following ACDF. However, whether this benefit is greater than nontreatment or other treatments cannot be determined with the present literature.

STUDY RATIONALE AND CONTEXT ACDF is a commonly performed procedure for degenerative conditions of the cervical spine with a successful fusion rate of approximately 95 % and with overall good to excellent results 1, 3. The majority of patients present with combined complaints of axial neck pain with associated upper extremity radicular or myelopathic symptoms. There is considerable controversy, however, regarding the role of ACDF for neck pain without radiculopathy or myelopathy, and clinical outcome studies of ACDF with validated outcome measures in this patient population are scarce. OBJECTIVES To analyze the clinical outcome in patients treated with ACDF for axial neck pain in the absence of radiculopathy or myelopathy, especially with regard to changes in pain and function.

REFERENCES

• 1 Brodke D S, Zdeblick T A. Modified Smith-Robinson procedure for anterior cervical fusion for spondylotic myeloradiculopathy.  Spine. 1993;  19 2167-2173
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• 2 Eck J C, Humphreys S C, Hodges S D. et al . A comparison of outcomes of anterior cervical discectomy and fusion in patients with and without radicular symptoms.  J Surg Orthop Adv. 2006;  15 (1) 24-26
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• 3 Emery S E, Bolesta M J, Banks M A. et al . Robinson anterior cervical fusion: comparison of the standard and modified techniques.  Spine. 1994;  19 (6) 660-663
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• 4 Garvey T A, Transfeldt E E, Malcolm J R. et al . Outcome of anterior cervical discectomy and fusion as perceived by patients treated for dominant axial-mechanical cervical spine pain.  Spine. 2002;  27 (17) 1887-1895; discussion 1895
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EDITORIAL STAFF PERSPECTIVE

The subject of treatment for neck pain with anterior cervical discectomy and fusion and the methodology and findings of our authors evoked considerable debate among our reviewers. The inclusion of only three articles with a limited overall cohort was mentioned as a considerable limitation to the ability to conduct meaningful data analysis. Of course the vast mainstay of the available scientific literature reflects the overwhelming clinical indication for an anterior cervical discectomy and fusion in the setting of a degenerative disc disease. As is apparent in this formal systematic review, few authors have ventured beyond the accepted gold standards for ACDF to date.

The second biggest controversy revolved around a subject, which will become increasingly contentious in the future, of the degree of improvement as measured in clinically related health outcomes questionnaires. In the three studies that met the inclusion criteria of the authors, the objective percentage of improvement in neck pain was between 50 % and 60 % at 4 years; the patient satisfaction was 56 % and 79 % in the two studies from which the data can be abstracted, and functional outcomes improved between 32 % and 52 % from baseline. Are these differences meaningful enough to warrant performing these procedures? The questions of level selection, restoration of normal sagittal alignment and actually achieving a solid fusion were felt to be considerable variables potentially affecting patient outcomes. Furthermore, how long do these results last? And the as yet unanswered question: does the presence of a rigidly fused level in the lower C-spine set an affected patient up for a cascade effect on other levels later on?

Certainly ACDF seems to have a positive treatment effect on patients who have failed nonoperative care for symptomatic cervical disc disease. The presented results do provide a justification of more formal study of this subject area.