Anterior Controllable Antedisplacement and Fusion (ACAF) for Cervical Stenosis Patients With Hyperextension Injury: A Retrospective Study

Abstract

Objective: Central cord syndrome (CCS) is an incomplete spinal cord injury (SCI) causing severe motor weakness, and timely decompression via surgical intervention facilitates better recovery. Anterior controllable antedisplacement and fusion (ACAF) is a novel decompression technique and achieved satisfactory outcomes in treating cervical degenerated diseases. However, the clinical effects of ACAF on CCS remains unknown. This present study aimed to investigate the clinical outcomes of ACAF for cervical stenosis patients with CCS due to hyperextension injury.

Methods: This is a retrospective study, and patients who underwent ACAF due to CCS in our institution from July 2021 to December 2022 were enrolled based on the inclusion and exclusion criteria. All patients underwent x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) before and after surgery. The duration of follow-up was at least 12 months. The radiological parameters included associated pathologies, prevertebral hyperintensity (HI), intramedullary signal intensity (ISI), and Torg–Pavlov ratio (TPR). The cervical stability was also evaluated. Neurological function was assessed using the American Spinal Injury Association (ASIA) grading system and Japanese Orthopaedic Association (JOA) score. The Mann–Whitney U test was used to compare the clinical outcomes preoperatively and postoperatively.

Results: Finally, 13 patients (7 male and 6 female) with the minimum of 12-month follow-up were finally enrolled in this study, with the mean age of 56.6 ± 12.5 years (range, 39–74 years). There were eight patients suffered CCS due to fall, three due to vehicle accident, and two due to diving injuries. The average delay from injury to surgery was 2.23 days (range, 1–4 days), and the mean duration of follow-up was 16.1 ± 3.5 months. In terms of prevertebral HI and ISI, C4–C6 were the most affected region. In addition, 76.9% (10 of 13) patients were observed to have cervical stenosis indicated by TPR. Associated pathologies were herniated nucleus pulposus (HNP) in five patients, OPLL in three cases, and HNP-osteophyte complexes (HNP-OC) in six patients. At the final follow-up, 13 patients were improved to E. The mean JOA score improved to 15.4 ± 1.0, with the recovery rate of 77.0% ± 12.0%. Two patients experienced postoperative dysphagia, two patients had hoarseness, and one patient suffered postoperative hematoma.

Conclusions: ACAF can be a good option for treating CCS patients due to hyperextension injury with underlying cervical spondylosis and stenosis.

Keywords

acute central cord syndrome / anterior controllable antedisplacement and fusion / clinical outcomes / hyperextension injury

References

[1] L. Xu, W. Zhong, C. Liu, et al., “Timing of Decompression in Central Cord Syndrome: A Systematic Review and Meta-Analysis,” European Spine Journal 33 (2024): 3593–3601.

[2] D. D. Nowak, J. K. Lee, D. E. Gelb, K. A. Poelstra, and S. C. Ludwig, “Central Cord Syndrome,” Journal of the American Academy of Orthopaedic Surgeons 17 (2009): 756–765.

[3] A. Bosch, E. S. Stauffer, and V. L. Nickel, “Incomplete Traumatic Quadriplegia: A Ten-Year Review,” Journal of the American Medical Association 216 (1971): 473–478.

[4] K. Hirabayashi, J. Miyakawa, K. Satomi, T. Maruyama, and K. Wakano, “Operative Results and Postoperative Progression of Ossification Among Patients With Ossification of Cervical Posterior Longitudinal Ligament,” Spine (Phila Pa 1976) 6 (1981): 354–364.

[5] S. A. Sattari, A. Antar, J. N. Theodore, et al., “Early Versus Late Surgical Decompression for Patients With Acute Traumatic Central Cord Syndrome: A Systematic Review and Meta-Analysis,” Spine Journal 24 (2024): 435–445.

[6] O. Bin-Alamer, J. Qedair, H. Abou-Al-Shaar, et al., “Surgical Intervention ≤24 Hours Versus >24 Hours After Injury for the Management of Acute Traumatic Central Cord Syndrome: A Systematic Review and Meta-Analysis,” Journal of Neurosurgery Spine 40 (2024): 653–661.

[7] J. H. Badhiwala, C. D. Witiw, J. R. Wilson, L. B. da Costa, A. B. Nathens, and M. G. Fehlings, “Treatment of Acute Traumatic Central Cord Syndrome: A Study of North American Trauma Centers,” Neurosurgery 94 (2024): 700–710.

[8] K. Sun, S. Wang, J. Sun, et al., “Analysis of the Correlation Between Cerebrospinal Fluid Space and Outcomes of Anterior Controllable Antedisplacement and Fusion for Cervical Myelopathy due to Ossification of the Posterior Longitudinal Ligament,” World Neurosurgery 122 (2019): e358–e366.

[9] J. C. Sun, J. G. Shi, X. M. Xu, et al., “Anterior Controllable Antidisplacement and Fusion Surgery for the Treatment of Multilevel Severe Ossification of the Posterior Longitudinal Ligament With Myelopathy: Preliminary Clinical Results of a Novel Technique,” European Spine Journal 27 (2018): 1469–1478.

[10] H. Yang, J. Sun, J. Shi, G. Shi, Y. Guo, and Y. Yang, “Anterior Controllable Antedisplacement Fusion (ACAF) for Severe Cervical Ossification of the Posterior Longitudinal Ligament: Comparison With Anterior Cervical Corpectomy With Fusion (ACCF),” World Neurosurgery 115 (2018): e428–e436.

[11] K. Sun, S. Wang, L. Huan, et al., “Analysis of the Spinal Cord Angle for Severe Cervical Ossification of the Posterior Longitudinal Ligament: Comparison Between Anterior Controllable Antedisplacement and Fusion (ACAF) and Posterior Laminectomy,” European Spine Journal 29, no. 5 (2020): 1001–1012,

[12] H. Pavlov, J. S. Torg, B. Robie, and C. Jahre, “Cervical Spinal Stenosis: Determination With Vertebral Body Ratio Method,” Radiology 164 (1987): 771–775.

[13] L. H. Schlicke, A. A. White, 3rd, M. M. Panjabi, A. Pratt, and L. Kier, “A Quantitative Study of Vertebral Displacement and Angulation in the Normal Cervical Spine Under Axial Load,” Clinical Orthopaedics and Related Research 140 (1979): 47–49.

[14] Y. Ishida and T. Tominaga, “Predictors of Neurologic Recovery in Acute Central Cervical Cord Injury With Only Upper Extremity Impairment,” Spine (Phila Pa 1976) 27 (2002): 1652–1658.

[15] R. C. Schneider, G. Cherry, and H. Pantek, “The Syndrome of Acute Central Cervical Spinalcord Injury; With Special Reference to the Mechanisms Involved in Hyper-Extension Injuries of Cervical Spine,” Journal of Neurosurgery 11 (1954): 546–577.

[16] R. C. Schneider, J. M. Thompson, and J. Bebin, “The Syndrome of Acute Central Cervicalspinal Cord Injury,” Journal of Neurology, Neurosurgery, and Psychiatry 21 (1958): 216–227.

[17] R. L. Waters, R. H. Adkins, I. H. Sie, and J. S. Yakura, “Motor Recovery Following Spinal Cord Injury Associated With Cervical Spondylosis: A Collaborative Study,” Spinal Cord 34 (1996): 711–715.

[18] L. E. Penrod, S. K. Hegde, and J. F. Ditunno, Jr., “Age Effect on Prognosis for Functional Recovery in Acute, Traumatic Central Cord Syndrome,” Archives of Physical Medicine and Rehabilitation 71 (1990): 963–968.

[19] N. P. Brooks, “Central Cord Syndrome,” Neurosurgery Clinics of North America 28 (2017): 41–47.

[20] E. J. Roth, M. H. Lawler, and G. M. Yarkony, “Traumatic Central Cord Syndrome: Clinical Features and Functional Outcomes,” Archives of Physical Medicine and Rehabilitation 71 (1990): 18–23.

[21] R. C. Schneider, G. Cherry, and H. Pantek, “The Syndrome of Acute Central Cervical Spinal Cord Injury, With Special Reference to the Mechanisms Involved in Hyperextension Injuries of Cervical Spine,” Journal of Neurosurgery 11 (1954): 546–577.

[22] J. H. Badhiwala, J. R. Wilson, J. S. Harrop, et al., “Early vs Late Surgical Decompression for Central Cord Syndrome,” JAMA Surgery 157 (2022): 1024–1032.

[23] J. S. Harrop, A. Sharan, and J. Ratliff, “Central Cord Injury: Pathophysiology, Management, and Outcomes,” Spine Journal 6 (2006): 198S–206S.

[24] C. S. Carrier, C. M. Bono, and D. R. Lebl, “Evidence-Based Analysis of Adjacent Segment Degeneration and Disease After ACDF: A Systematic Review,” Spine Journal 13 (2013): 1370–1378.

[25] J. D. Oliver, S. Goncalves, P. Kerezoudis, et al., “Comparison of Outcomes for Anterior Cervical Discectomy and Fusion With and Without Anterior Plate Fixation: A Systematic Review and Meta-Analysis,” Spine (Phila Pa 1976) 43 (2018): E413–E422.

[26] S. Wang, J. Shi, and J. Sun, “How Cervical Curvature Changes After ACAF and ACDF: A Radiological Retrospective Study,” Neurosurgical Review 46, no. 1 (2023): 188.

[27] A. G. Zavras, J. R. Acosta, K. J. Holmberg, et al., “Effect of Device Constraint: A Comparative Network Meta-Analysis of ACDF and Cervical Disc Arthroplasty,” Spine Journal 24, no. 10 (2024): 1858–1871.

[28] H. Wang, T. Xia, R. Qu, et al., “Interspinous Motion Measurement Could Serve as a Quantitative Method for Assessing Bony Fusion After Anterior Cervical Corpectomy and Fusion (ACCF),” Spine (Phila Pa 1976) (2024).

[29] M. Iwasaki, S. Okuda, A. Miyauchi, et al., “Surgical Strategy for Cervical Myelopathy due to Ossification of the Posterior Longitudinal Ligament: Part 2: Advantages of Anterior Decompression and Fusion Over Laminoplasty,” Spine (Phila Pa 1976) 32 (2007): 654–660.

[30] C. H. Lee, J. Lee, J. D. Kang, et al., “Laminoplasty Versus Laminectomy and Fusion for Multilevel Cervical Myelopathy: A Meta-Analysis of Clinical and Radiological Outcomes,” Journal of Neurosurgery Spine 22, no. 6 (2015): 589–595.

[31] J. R. Wilson, L. A. Tetreault, J. Kim, et al., “State of the Art in Degenerative Cervical Myelopathy: An Update on Current Clinical Evidence,” Neurosurgery 80 (2017): S33–S45.

[32] B. M. Ozgur, J. E. Florman, S. M. Lew, W. P. Taylor, and C. Gross, “Laminectomy Contributes to Cervical Spine Deformity Demonstrated by Holographic Interferometry,” Journal of Spinal Disorders & Techniques 16 (2003): 51–54.

[33] G. P. Nowinski, H. Visarius, L. P. Nolte, and H. N. Herkowitz, “A Biomechanical Comparison of Cervical Laminaplasty and Cervical Laminectomy With Progressive Facetectomy,” Spine (Phila Pa 1976) 18 (1993): 1995–2004.

[34] P. Guigui, M. Benoist, and A. Deburge, “Spinal Deformity and Instability After Multilevel Cervical Laminectomy for Spondylotic Myelopathy,” Spine (Phila Pa 1976) 23 (1998): 440–447.

[35] A. Singh, S. Blixt, E. Edström, A. Elmi-Terander, and P. Gerdhem, “Outcome and Health-Related Quality of Life After Combined Anteroposterior Surgery Versus Anterior Surgery Alone in Subaxial Cervical Spine Fractures: Analysis of a National Multicenter Data Set,” Spine (Phila Pa 1976) 48, no. 12 (2023): 853–858.

[36] F. L. Acosta, Jr., H. E. Aryan, D. Chou, and C. P. Ames, “Long-Term Biomechanical Stability and Clinical Improvement After Extended Multilevel Corpectomy and Circumferential Reconstruction of the Cervical Spine Using Titanium Mesh Cages,” Journal of Spinal Disorders & Techniques 21 (2008): 165–174.

[37] X. Zhou, P. Cai, Y. Li, H. Wang, S. Xia, and X. Wang, “Posterior or Single-Stage Combined Anterior and Posterior Approach Decompression for Treating Complex Cervical Spondylotic Myelopathy Coincident Multilevel Anterior and Posterior Compression,” Clinical Spine Surgery 30 (2017): E1343–E1351.

[38] B. Zhang, J. Sun, X. Xu, et al., “Skip Corpectomy and Fusion (SCF) Versus Anterior Controllable Antedisplacement and Fusion (ACAF): Which Is Better for Patients With Multilevel Cervical OPLL,” Archives of Orthopaedic and Trauma Surgery 139 (2019): 1533–1541.

[39] D. H. Lee, S. Park, C. G. Hong, et al., “Fusion and Subsidence Rates of Vertebral Body Sliding Osteotomy: Comparison of 3 Reconstructive Techniques for Multilevel Cervical Myelopathy,” Spine Journal 21 (2021): 1089–1098.

[40] M. Wang, G. Yang, B. Zhou, et al., “Anterior Cervical Controllable Antedisplacement and Fusion (ACAF) Versus Anterior Cervical Corpectomy and Fusion (ACCF) for Ossification of the Cervical Posterior Longitudinal Ligament (OPLL) in Chinese Population: A Systematic Review and Meta-Analysis,” Neurosurgical Review 47, no. 1 (2024): 783.

[41] H. Yang, J. Sun, J. Shi, et al., “In-Situ Decompression to Spinal Cord During Anterior Controllable Antedisplacement Fusion Treating Degenerative Kyphosis With Stenosis: Surgical Outcomes and Analysis of C5 Nerve Palsy Based on 49 Patients,” World Neurosurgery 115 (2018): e501–e508.

[42] C. Yan, T. Y. Zhao, C. L. Ji, et al., “Anterior Controllable Antedisplacement and Fusion: Quantitative Analysis of a Single Surgeon’s Learning Experience,” Spine Journal 22, no. 6 (2022): 941–950.

[43] S. Park, D. H. Lee, J. Ahn, et al., “How Does Ossification of Posterior Longitudinal Ligament Progress in Conservatively Managed Patients,” Spine (Phila Pa 1976) 45, no. 4 (2020): 234–243.

[44] C. H. Lee, M. J. Sohn, C. H. Lee, C. Y. Choi, S. R. Han, and B. W. Choi, “Are There Differences in the Progression of Ossification of the Posterior Longitudinal Ligament Following Laminoplasty Versus Fusion? A Meta-Analysis,” Spine (Phila Pa 1976) 42, no. 12 (2017): 887–894.

[45] Y. Chen, J. Sun, X. Yuan, et al., “Comparison of Anterior Controllable Antedisplacement and Fusion With Posterior Laminoplasty in the Treatment of Multilevel Cervical Ossification of the Posterior Longitudinal Ligament: A Prospective, Randomized, and Control Study With at Least 1-Year Follow Up,” Spine (Phila Pa 1976) 45, no. 16 (2020): 1091–1101.

[46] Y. Ogawa, K. Chiba, M. Matsumoto, et al., “Long-Term Results After Expansive Open-Door Laminoplasty for the Segmental-Type of Ossification of the Posterior Longitudinal Ligament of the Cervical Spine: A Comparison With Nonsegmental-Type Lesions,” Journal of Neurosurgery. Spine 3, no. 3 (2005): 198–204.

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2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.