Comparison of clinical and radiographic outcome in instrumented anterior cervical discectomy and fusion with or without direct uncovertebral joint decompression

Abstract

Background context: Anterior cervical discectomy and fusion (ACDF) is an established procedure for the operative treatment of cervical disc disease in patients with radiculopathy resulting from impingement from uncovertebral joint osteophytes. Studies demonstrate that direct decompression of the lesion provides good result. However, known complications include vertebral artery injury, dural tears, nerve root injury, loss of biomechanical stability and increased operative time. Other studies suggest that disc space distraction may play an important role by indirectly decompressing neural elements. Therefore, if equivalent functional outcomes can be achieved without sacrificing the uncovertebral joint, then potential morbidity and mortality could be decreased. Purpose: To assess and compare clinical and radiographic outcomes of patients with neck pain and cervical radiculopathy who underwent instrumented ACDF with or without direct uncovertebral joint decompression. Study design/setting: Retrospective clinical chart and radiographic review to assess clinical outcome and graft fusion in 109 patients who underwent one- or two-level ACDF with rigid anterior plate fixation. Patient sample: Radiographs and clinical charts for 109 patients (mean, 46 years; range, 27 to 83) who underwent ACDF with rigid anterior plate fixation were retrospectively reviewed at a single institution. Patients with radiculopathy resulting from herniated disc, spondylosis or a combination of both refractory to conservative treatment underwent surgery using a standard Smith-Robinson left-sided approach. Seventy-one patients who received direct uncovertebral joint decompression (Group 1) were compared with 38 patients without direct decompression but indirect decompression by disc space distraction (Group 2). In Group 1, 37 one-level and 34 two-level ACDFs were performed. In Group 2, 11 and 27 were one-level and two-level ACDFs, respectively. Smoking and work-related injuries involved 26.7% and 38.0% of Group 1 and 28.9% and 28.9% of Group 2, respectively. Autologous iliac crest grafts were used in 51 patients, whereas 58 patients received allograft. Outcome measures: Independent blinded analyses of plain lateral neutral, flexion and extension radiographs were conducted to assess fusion, evaluate graft and plate and screw integrity (mean, 12 months). Clinical outcomes were reported as excellent, good, fair or poor (mean, 23 months) based on Odom's criteria. Methods: Postoperative clinical outcome and radiographic studies of graft and instrument integrity were assessed in 71 patients undergoing ACDF with uncovertebral joint decompression and 38 patients without uncovertebral joint decompression, but with indirect decompression through disc space distraction. Results: Fusion occurred in 95.8% of Group 1 and 100% of Group 2. In Group 1, 26.8% of the patients reported excellent results, 57.7% reported good results, 12.7% reported fair results and 2.8% reported poor results. In Group 2, 23.7% of the patients reported excellent results, 60.5% reported good results and 15.8% reported fair results. All nonunions reported good outcomes. Postoperative respiratory distress developed in one patient and dysphagia developed in another both from Group 1. No other complications were noted. The presence or absence of direct uncovertebral joint decompression and clinical outcome was not statistically significant (p>.05). The use of graft-type, operative level, presence of smoking and work-related injury in relation to clinical outcome was not found to be significant (p>.05). Conclusion: Good to excellent results were obtained in 84.5% and 84.2% of patients for Groups 1 and 2, respectively. Indirect foraminal decompression through distraction remains somewhat controversial during ACDF. However, sacrificing the uncovertebral joint can increase operative time and potentially increase complication rates. This study demonstrates that ACDF with or without direct uncovertebral joint decompression can provide good clinical results for neck pain with cervical radiculopathy. Therefore, routine direct uncovertebral joint decompression should not be undertaken during ACDF. © 2004 Elsevier Inc. All rights reserved.