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The Journal of Bone and Joint Surgery 79:523-32 (1997)
© 1997 The Journal of Bone and Joint Surgery, Inc.

Failed Anterior Cervical Discectomy and Arthrodesis. Analysis and Treatment of Thirty-five Patients*

THOMAS A. ZDEBLICK, M.D.{dagger}, STEVEN S. HUGHES, M.D.{ddagger}, K. DANIEL RIEW, M.D.§ and HENRY H. BOHLMAN, M.D.¶, CLEVELAND, OHIO

Investigation performed at The University Hospitals Spine Institute, Department of Orthopaedic Surgery, University Hospitals of Cleveland and Case Western Reserve University School of Medicine, Cleveland


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Thirty-five patients were managed operatively after failure of an anterior cervical discectomy and arthrodesis. Failure was classified as the absence of fusion without deformity but with neck pain or radiculopathy, or both; the absence of fusion after anterior or posterior dislodgment of the graft; or kyphosis due to collapse of the graft or to an unrecognized posterior soft-tissue injury. Twenty-three patients had failure of the arthrodesis without deformity (with neck pain only, neck and arm pain, radiculopathy, or myelopathy). Four patients had dislodgment of the graft; in two of them the graft migrated anteriorly after a multilevel Robinson arthrodesis, and in two it migrated posteriorly after a Cloward arthrodesis. Eight patients had a failure because of a kyphotic deformity. Five of them had had a Cloward arthrodesis; one, a discectomy; and two, a Robinson arthrodesis. Six had received allograft bone. Operative treatment of the pseudarthrosis consisted of repeat resection of the disc space in the area of the failed arthrodesis followed by repeat anterior Robinson arthrodesis with decompression of the nerve root if the patient had radiculopathy. It consisted of anterior corpectomy or vertebral-body resection and strut-grafting with reduction of the deformity if the patient had migration of the graft and kyphosis. The reoperations were performed four months to fourteen years (average, thirty-two months) after the initial operation. The duration of follow-up after the second operation averaged forty-four months (range, twenty-four to 216 months). The result was excellent for twenty-nine patients, good for one, fair for four, and poor for one. We concluded that, in patients who have persistent symptoms after an anterior cervical arthrodesis, an excellent result can be achieved with repeat anterior decompression and autogenous bone-grafting.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Since it was introduced in the 1950's by Robinson, the anterior approach to the cervical spine has been widely used for the operative treatment of disc herniation, spondylosis, and injuries. The removal of herniated discs through the anterior approach is safe when performed by an experienced surgeon and allows decompression of both the spinal cord and the cervical nerve roots4. The rectangular iliac-crest bone grafts first used by Robinson et al., the dowel grafts first employed by Cloward, and the keystone-graft technique developed by Simmons and Bhalla all have allowed the surgeon to distract the disc space, enlarge the neural foramen, and achieve a solid anterior fusion. Such a fusion theoretically diminishes neurological irritation by limiting motion and by allowing the resorption of osteophytes21.

However, anterior cervical arthrodesis has not been universally successful. In retrospective studies, the rates of non-union have ranged from three (4 per cent) of eighty-four patients (in the largest reported series) to one of five patients for a single-level arthrodesis1,2,6,8,16,19,21,23,27 and from thirteen (27 per cent) of forty-eight patients to eleven (50 per cent) of twenty-two patients for a multilevel arthrodesis21,26. Although a non-union does not preclude a good or excellent result, most authors have stated that a solid union should be the goal of the procedure13,14.

Treatment of a failed anterior cervical arthrodesis has not been reported in detail, to our knowledge. Of the four patients who were reoperated on by Robinson et al. because of a symptomatic non-union, two had successful repeat bone-grafting anteriorly and two had a posterior arthrodesis with subsequent anterior consolidation21. Riley et al. reported that a posterior arthrodesis at the level of the non-union relieved neck pain in eight patients.

Modes of failure (other than non-union) after anterior cervical arthrodesis have included collapse of the graft and the disc space with kyphosis, migration of the graft, and residual nerve-root or spinal-cord compression resulting in pain with or without paralysis29.

We believe that a repeat anterior approach for decompression and bone-grafting is most likely to solve these problems and to achieve a solid union after a symptomatic failure of an arthrodesis. We report the long-term results of this approach in thirty-five patients.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
A consecutive series of thirty-five patients were managed operatively at our institution because of a failed anterior cervical discectomy and arthrodesis (Table I). Twenty-four of the patients were referred by other physicians, and eleven had been managed at our institution. The ages of the seventeen men and eighteen women ranged from thirty-one to sixty-eight years (average, fifty years) at the time of the index procedure. To assemble the data for this study, two of us (T. A. Z. and S. S. H.) independently reviewed the hospital and office records and the radiographs of each patient.


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  		TABLE I DATA ON THE THIRTY-FIVE PATIENTS

 
In order to analyze the factors concerning failure after anterior cervical arthrodesis, we separated the patients into three groups according to the predominant mechanism of failure: failure of the anterior cervical arthrodesis without deformity but with neck pain or radiculopathy, or both; migration of the bone graft in the period immediately after the operation; and kyphotic deformity. The patients in whom collapse of the bone graft had resulted in a kyphotic deformity were included in the kyphotic deformity group.

The interval between the initial presentation and the index operation ranged from four months to fourteen years (average, thirty-two months).

Radiographic Studies
For twenty-eight patients, radiographs made at the time of the initial operation were analyzed to document the diagnosis and the type of initial procedure. For the remaining seven patients, the diagnosis and the initial procedure were documented by operative notes and follow-up data. Radiographs made after the initial bone-grafting procedure were assessed to determine the size (height and depth), type, and position of the bone graft that had been used and to ascertain whether the vertebral osteophytes had been resected when the graft was inserted. In order to standardize magnification, only standard-distance radiographs made with the patient in the upright position were used. For patients who had had a multilevel anterior arthrodesis, whether the arthrodesis had failed superior to, through the middle of, or inferior to the graft was reported.

At the time of presentation and examination for the reoperation, all patients had anteroposterior, oblique, and flexion and extension lateral radiographs of the cervical spine as well as cervical myelography and tomography. Patients who were seen after 1980 also had enhanced computed tomography and myelography, and patients seen after 1984 also had magnetic resonance imaging of the entire cervical spine to exclude abnormalities at other levels and to confirm the failure of the arthrodesis on the T2-weighted images. Failure to obtain fusion was defined as more than two millimeters of motion between the tips of the spinous processes on radiographs made with the spine in flexion, with a radiolucent line or space seen at the involved disc level on the lateral and anteroposterior radiographs. After a failed arthrodesis in association with myelopathy or radiculopathy had been diagnosed, we ascertained the symptomatic level by performing myelography to rule out the presence of other involved segments. If encroachment on the spinal canal or the foramen was demonstrated on magnetic resonance imaging or myelography and an appropriate radicular pattern was identified on examination, then the failed level was confirmed as the cause of the pain by excluding other levels of cord or nerve-root compression that might account for it. In patients who had axial neck pain not associated with neurological compression, the level of failure of the arthrodesis was determined to be the cause of the pain by radiographically excluding degenerative changes in adjacent cephalad or caudad segments.

Methods of Treatment
If nerve-root or spinal-canal compression with myelopathy was found, then operative treatment was offered initially. If the arthrodesis had failed but there was no deformity or neurological compression, the patient initially had a trial of non-operative management with prolonged immobilization in a semirigid cervical collar.

Twenty-two patients were managed with anterior block resection and autogenous bone-grafting at the level at which the arthrodesis had failed. Thirteen patients had anterior cervical corpectomy with autogenous strut-grafting to achieve more extensive decompression of the spinal canal and nerve roots as well as correction of the kyphosis.

The patients were followed regularly and examined neurologically. Radiographs were made at regular intervals until the fusion was solid and again at the latest follow-up evaluation. A fusion was considered solid when osseous trabeculae bridged the disc space anteriorly on lateral radiographs and when no motion was detected on radiographs made with the spine in flexion and extension.

The results were classified, according to the system of Odom et al., as excellent, good, fair, or poor; this rating system was modified by the addition of radiographic criteria. An excellent result was defined as a solid fusion on radiographs, no neck or arm pain, and normal findings on neurological examination; a good result, as a solid fusion, no neck pain, and neurological improvement with mild residual problems; a fair result, as a solid fusion but persistent pain, even though postoperative myelography or magnetic resonance imaging revealed no additional neurological compression; and a poor result, as a continued symptomatic non-union, neurological worsening, or the need for a reoperation.

No patient was lost to follow-up. The duration of follow-up averaged forty-four months (range, twenty-four to 216 months).

Operative Technique
All patients were reoperated on with use of the anterior cervical approach, described in previous reports2,4.

If there was a non-union or compression of the spinal cord at one level, we performed a hemicorpectomy of the adjacent vertebral bodies at that level, first using rongeurs and curets and then a high-speed burr to remove the fibrocartilaginous tissue that had formed in the disc space as well as on both adjacent sclerotic end plates (Figs. 1-A, 1-B, 1-C through 1-D). We made parallel resection surfaces by removing bone from both vertebral bodies and using the diamond burr to thin out any posteriorly protruding osteophytes. With a small angled curet, we then removed any spurs or adherent fibrous tissue back to the posterior longitudinal ligament, which was not violated in order to protect the spinal cord. Use of an intervertebral spreader facilitated the decompression and the insertion of the graft.



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  		Figs. 1-A through 1-D: Illustrations of types of failure of anterior cervical arthrodesis and of types of operative treatment. Fig. 1-A: A typical non-union with fibrocartilage compromising the canal.

 


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  		Fig. 1-B: Collapse of the graft can lead to a sharp angular kyphosis, which, combined with the non-union, causes compression of the cord.

 


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  		Fig. 1-C: Decompression is carried out through the anterior approach. A hemicorpectomy is performed cephalad and caudad to the disc space with use of a high-speed burr to create parallel surfaces of cancellous bone. The decompression of the canal is completed with angled curets.

 


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  		Fig. 1-D: Anterior bone-grafting is performed with a tricortical Smith-Robinson bone graft countersunk into position.

 
If an angular kyphosis had been present preoperatively, it was usually reduced with use of intraoperative skeletal traction and extension of the head and neck after decompression had been completed. (Spinal cord monitoring was used if decompression of the cord and reduction of a kyphosis had been planned.) The height and depth of the space was measured with a malleable probe so that, when the graft was inserted, there would be enough room to countersink it beneath the anterior cortices while still maintaining three millimeters of space posteriorly between it and the posterior longitudinal ligament.

If adjacent levels necessitated decompression of the spinal canal or if the vertebral body had collapsed and kyphosis was present, then a vertebral corpectomy, as previously described for traumatic fractures of the cervical spine3, was carried out. If more than two vertebrae were resected, then a fibular graft was used. A two-poster rigid orthosis (Denison, Baltimore, Maryland) or a halo vest was used for eight weeks postoperatively for patients who had had a laminectomy or disruption of the posterior ligament.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Thirty-four of the thirty-five patients ultimately had a solid osseous fusion. The result was excellent for twenty-nine patients, good for one, fair for four, and poor for one. Of the twenty-three patients who had repair because of non-union, twenty had an excellent result and three had a fair result. For example, one patient (Case 1) who had had failure at one level of a two-level Robinson anterior arthrodesis without deformity had a solid fusion after anterior decompression and arthrodesis with insertion of a Robinson graft at the site of the non-union (Figs. 2-A and 2-B).



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  		Figs. 2-A and 2-B: Radiographs of Case 1. Fig. 2-A: This man initially had a Robinson anterior cervical arthrodesis between the fifth and sixth and the sixth and seventh cervical vertebrae. There was an obvious non-union (arrow) at the level between the fifth and sixth cervical vertebrae, and the neck pain persisted. The end plates of the fifth and sixth cervical vertebrae were sclerotic and irregular.

 


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  		Fig. 2-B: Two years after the revision, which was performed at the age of forty-three years, a solid fusion was seen at the level between the fifth and sixth cervical vertebrae. The neck pain had completely resolved.

 
Of the four patients who had migration of the graft, three had an excellent result and one had a fair result. The patient (Case 22) who had a fair result had initially had an anterior discectomy and a Cloward arthrodesis for herniation of the disc between the fifth and sixth cervical vertebrae, with non-union at that level (Fig. 3-A). Repeat anterior arthrodesis had been carried out elsewhere, with insertion of a tall Cloward dowel-type graft. Postoperatively, the radiculopathy persisted and myelopathy developed (Fig. 3-B). Computed tomography with use of contrast medium showed that the dowel graft had been impacted into the spinal canal, causing flattening of the spinal cord (Fig. 3-C). We performed hemicorpectomies of the fifth and sixth cervical vertebrae and replaced the intrusive graft with a Robinson-type graft. A solid union resulted (Fig. 3-D).



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  		Figs. 3-A through 3-D: Case 22. Fig. 3-A: This man initially had a herniated disc between the fifth and sixth cervical vertebrae, which was treated with an anterior discectomy and a Cloward arthrodesis. A non-union occurred after collapse of the graft at the level between the fifth and sixth cervical vertebrae, with narrowing of the disc space and sclerosis.

 


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  		Fig. 3-B: Radiograph made after repeat anterior arthrodesis with a Cloward dowel-type graft (arrowheads), performed elsewhere. Postoperatively, the radiculopathy persisted and signs of myelopathy developed.

 


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  		Fig. 3-C Computed tomography scan made with contrast medium, showing that the dowel graft had been impacted into the spinal canal, flattening the spinal cord (arrowhead).

 


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  		Fig. 3-D Radiograph made after hemicorpectomies of the bodies of the fifth and sixth cervical vertebrae, performed at the age of thirty-nine years with use of a high-speed burr to ensure complete decompression of the canal. The Cloward graft was removed, and a tall Robinson graft was inserted. The patient had a solid union, with complete resolution of the symptoms.

 
Another patient (Case 35) had initially had a Cloward procedure for herniation of the disc between the fourth and fifth cervical vertebrae. There was inadequate decompression of an osteophyte that was protruding posteriorly into the spinal canal, causing flattening of the spinal cord and myelopathy (Figs. 4-A and 4-B). Myelography also revealed herniation of the disc between the third and fourth and the fifth and sixth cervical levels (Fig. 4-C). Corpectomy at the fourth, fifth, and sixth cervical levels with fibular strut-grafting resulted in relief of the symptoms (Fig. 4-D)



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  		Figs. 4-A through 4-D: Case 35. Fig. 4-A: In this woman, an initial Cloward arthrodesis with an inadequate decompression of an osteophyte at the level of the fourth and fifth cervical vertebrae led to myelopathy and persistence of the preoperative radiculopathy.

 


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  		Fig. 4-B Computed tomography scan made with contrast medium, showing the posterior position of the osteophyte (arrowhead) and the resulting compression of the spinal cord.

 


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  		Fig. 4-C Myelogram revealing compression at the level between the third and fourth cervical vertebrae.

 


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  		Fig. 4-D Radiograph made after fibular strut-grafting and corpectomies of the fourth, fifth, and sixth cervical vertebrae, performed at the age of fifty-two years, which resulted in a solid union and relief of the symptoms.

 
Of the eight patients who had a reconstructive procedure because of kyphosis, six had an excellent result, one had a good result, and one had a poor result. The kyphosis was reduced from an average of 45 degrees (range, 30 to 87 degrees) to an average of 15 degrees (range, 0 to 40 degrees).

Four patients (Cases 6, 22, 32, and 34) had chronic residual neck pain at the latest follow-up evaluation. Three of these patients continued to use non-narcotic pain medication and remained disabled, receiving Workers' Compensation. The fourth patient (Case 22) had had a corpectomy to decompress a Cloward dowel graft that had protruded into the spinal canal; the graft had healed, but the patient had not returned to work because of the neck pain.

One patient (Case 30) was rated as having a good result and had improved neurologically, but he had a residual deficit at the latest follow-up evaluation. This patient had had a severe kyphosis after a two-level anterior cervical arthrodesis performed in 1975, at which time a traumatic injury of the posterior longitudinal ligament had not been recognized. He then had a corpectomy and strut-grafting, which resulted in a solid fusion. At the latest follow-up evaluation, he continued to have grade 4 of 5 strength of the right triceps, and he had returned to work part time.

The patient (Case 29) who had a poor result had initially had a discectomy without an arthrodesis at the fifth and sixth cervical levels for herniation of the disc and radiculopathy. During the next three years, an angular deformity developed after collapse of the graft, and the myelopathy recurred. Anterior discectomies and arthrodeses were performed from the third to the seventh cervical level, with placement of Robinson tricortical grafts. The patient had a fibrous non-union that became symptomatic after she was involved in an automobile accident. During the next two years, the myelopathy recurred, and repeat studies showed that segments of the posterior longitudinal ligament had become ossified behind the fourth, fifth, and sixth cervical vertebrae. A reoperation consisting of a three-level corpectomy and fibular strut-grafting was performed. At the latest follow-up evaluation, eighteen months later, she had a solid fusion and the myelopathy had decreased. The result of the index procedure was rated as poor because of the reoperation, but the patient was able to walk and had no neck pain.

Complications
Four patients had complications, all of which were temporary. One patient had a recurrent laryngeal-nerve palsy. Two patients had prolonged drainage from the incision made to obtain bone for the graft; the drainage resolved over time. The fourth patient (Case 23), who had absence of the dura, ossification of the posterior longitudinal ligament24, and posterior protrusion of a previously inserted Cloward graft, had leakage of cerebrospinal fluid postoperatively; this was treated successfully with a reoperation, which included muscle-grafting and closure with a lumbar spinal fluid shunt.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
A considerable amount of data have been accumulated with regard to the success of anterior cervical discectomy and arthrodesis with many different techniques, including placement of tricortical autogenous grafts, dowel-shaped autogenous grafts, xenografts, and grafts with hydroxyapatite1,2,5-7,12,14,16,17,20-23,25-28. These studies also documented instances of failure of anterior cervical discectomy and arthrodesis. However, very little has been written about the operative treatment of these failures. In 1994, Emery et al. reported an increase in the rate of fusion after burring of the cervical end plates before placement of the autogenous graft. At least three reports have indicated that posterior foraminotomy and arthrodesis may be indicated for the treatment of anterior non-unions10,11,15. The results in smaller series have suggested that repeat anterior arthrodesis may lead to a good outcome as well19,21,27.

The current analysis of failures after they had been divided into groups led to some insight into their cause. Anterior migration of the graft occurred only in association with multilevel Robinson-type arthrodeses, and analysis of the heights of these bone grafts showed that they tended to be excessive. All extruded grafts were at least nine millimeters in height, which could have caused overdistraction and have forced the grafted level into extension, leading to anterior expulsion of the graft. Stretching of the posterior longitudinal ligament and the lateral ligaments with a Cobb elevator before insertion of the graft makes it easier to seat the graft correctly. We use a tricortical graft that is six or seven millimeters in height, and we are careful to countersink the graft (without undue tension) beneath the anterior cortex rather than beneath the anterior osteophytes. Cloward grafts, which do not tilt the vertebrae into extension if they are overdistracted, do not seem to be prone to anterior migration.

Posterior migration of the graft into the spinal canal was seen only after Cloward arthrodeses performed at other institutions. The trephine technique proposed by Cloward does not leave a protective lip posteriorly, as the Robinson technique does, and it frequently involves removal of the posterior longitudinal ligament. Thus, posterior migration of the graft can occur with either vigorous impaction or postoperative flexion. This is one reason why we prefer the Robinson technique.

Failure due to collapse of the graft with kyphosis occurred primarily in patients who had had a Cloward arthrodesis. Of the eight procedures that failed in this way, six had been performed with use of frozen allograft bone dowels. In addition, three of these patients had had a previous laminectomy, which certainly contributed to the kyphotic collapse. We recommend that the Cloward technique of anterior arthrodesis not be used in patients who have had a previous laminectomy. We also advise against the use of frozen allograft bone for arthrodesis because of the high rate of collapse and failure.

We believe that patients who have recurrent symptoms after an initial relief of pain following an anterior cervical arthrodesis should have repeat myelography and computed tomography, tomography, or magnetic resonance imaging, or some combination of these modalities. Patient who have residual compromise of the canal or nerve-root compression need a repeat anterior decompression. A failed anterior cervical arthrodesis can be repaired safely and effectively through the anterior approach with use of a Smith-Robinson tricortical graft. Resection of a portion of each adjacent vertebral body allows complete decompression and preparation of the vascular bone surfaces and parallel planes to accept a new bone graft. Distraction of the foraminal space is accomplished with use of a Smith-Robinson tricortical graft approximately eight to ten millimeters in height.

Our approach to the operative management of patients who have had failure of an anterior cervical arthrodesis, and our expectations regarding the results, are guided by our classification of the predominant presenting problem. For patients who have neck pain only because of a non-union, a high rate of excellent results can be expected with débridement of the non-union site and repeat arthrodesis. For patients who have failure of the arthrodesis with radicular symptoms, we recommend decompression of osteophytes or fibrous tissue through hemicorpectomies, which generate parallel bone surfaces for a subsequent arthrodesis. A solid fusion was achieved in all eighteen patients who had these symptoms, and the symptoms resolved in seventeen. We believe that this high rate of success was related to our preparation of the vertebral end plates with a high-speed burr, which provided bleeding bone surfaces and parallel planes for good deposition of the graft.

If dislodgment of the graft has not led to kyphosis, then a repeat Robinson arthrodesis with débridement of the vertebral end plates works well; if kyphosis has occurred because of loss of the graft support, then the deformity must be corrected to reduce tension in the spinal cord and to improve blood flow to the cord2. As noted in an earlier report29, compromise of the canal associated with kyphosis can be corrected safely and effectively with corpectomy and fibular strut-grafting. The neurological compression and compromised blood flow to the cord will thereby be corrected. This in turn will result in relief of pain and, if there was a neurological deficit preoperatively, in improvement in neurological function during the follow-up period.

In summary, we believe that, if the graft and the graft bed are prepared meticulously with power instruments, the graft is inserted with good osseous apposition of the opposing vascular bone surfaces, and rigid immobilization is used postoperatively, a successful result can be achieved in many patients in whom a previous cervical discectomy and arthrodesis has failed.


   Footnotes
 

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

{dagger}Division of Orthopaedic Surgery, University of Wisconsin, 600 Highland Avenue, Madison, Wisconsin 53792.

{ddagger}Division of Spinal Surgery, Department of Orthopaedic Surgery, Bowman Gray School of Medicine, Wake Forest University, Medical Center Boulevard, Winston-Salem, North Carolina 27157.

§Department of Orthopaedic Surgery, Washington University Medical Center, One Barnes Hospital Plaza, Suite 11300, West Pavilion, St. Louis, Missouri 63110.

¶The University Hospitals Spine Institute, Department of Orthopaedic Surgery, University Hospitals of Cleveland and Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, Ohio 44106. Please address requests for reprints to Dr. Bohlman.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Aronson, N.; Filtzer, D. L.; and Bagan, M.: Anterior cervical fusion by the Smith-Robinson approach. J. Neurosurg., 29: 396-404, 1968.[Medline]
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