Anterior cervical corpectomy and fusion for cervical spine disorders: Institutional insights

Abstract

Introduction:

Cervical radiculomyelopathy may result from degenerative, traumatic, or infectious causes, leading to spinal cord compression. Anterior cervical corpectomy and fusion (ACCF) is a well-established surgical technique for decompressing the spinal cord and stabilizing the cervical spine. This study aims to evaluate the clinical and radiological outcomes of ACCF in patients with cervical spondylotic myelopathy (CSM), traumatic cervical spine injuries, and infectious conditions.

Methodology:

A retrospective study was conducted on 86 patients who underwent ACCF at a tertiary care center, between May 2019 and April 2023. Patients were grouped into three categories based on etiology: CSM, trauma, and infection. Surgical reconstruction was performed using either autologous iliac crest grafts with anterior plate and screw fixation or titanium mesh cage (TMC) with/without additional instrumentation. All patients were followed clinically and radiologically at 3 months and 1 year postoperatively.

Results:

Neck pain was the most common symptom across all groups. Significant improvement in neck pain and neurological deficits was observed at follow-up, especially in the CSM and trauma groups. Radiologically, proper graft alignment was achieved in the majority, with minimal graft migration noted in a few cases. Two patients required revision surgery due to instability. Complications included dysphagia, cerebrospinal fluid leak, recurrent laryngeal nerve palsy, and donor site infection. Fusion was achieved in all cases by the 1-year follow-up.

Conclusion:

ACCF is a safe and effective procedure for managing cervical spine pathologies, offering good neurological recovery and high fusion rates. TMCs reduce donor site morbidity and are a viable alternative to autografts.

INTRODUCTION

Cervical radiculomyelopathy results from intervertebral disc herniation, spinal instability cervical spondylosis, ossified posterior longitudinal ligament, traumatic injury, or, in rare cases, neoplastic lesions.[1]

Anterior cervical corpectomy and fusion (ACCF) is an effective surgical treatment option for various cervical pathologies causing anterior spinal cord compression.[2] Smith and Robinson approach is commonly used to access anterior cervical spine.[3] Corpectomy, also referred to as vertebrectomy, involves the removal of most or all of the vertebral body. The resulting corpectomy defect is typically reconstructed using autologous bone grafts, commonly harvested from the iliac crest, fibula, or rib to restore structural integrity and maintain cervical spinal alignment and curvature.[4] Recently, vertebral body prostheses such as expandable cylindrical cages (ECCs) with or without additional instrumentation like plates and screws have gained popularity. Despite the advent of these alternatives, autologous bone grafts are still widely regarded as the gold standard for anterior cervical reconstruction following corpectomy by several authors.[5] This is attributed to their superior biological properties, including osteogenesis, osteoinduction, and osteoconduction, as well as their association with higher fusion rates and fewer graft-related complications.[6]

ACCF is often considered the treatment of choice for several cervical pathologies.[7,8] Although ACCF is effective in decompressing the spinal cord, there remains ongoing debate regarding its ability to provide sufficient cervical stability, particularly in cases involving multilevel corpectomies. In some situations, supplemental posterior fixation may be necessary.[9,10] The choice of surgical approach and fixation strategy should be tailored to the specific underlying pathology.

The aim of study was to describe our clinical experience of ACCF in conditions such as cervical spondylotic myelopathy (CSM), traumatic cervical spine injury, and infectious processes.

METHODOLOGY

Patient selection

A retrospective analysis was conducted on 86 patients who underwent surgical intervention at the department of neurosurgery in a tertiary care center over a 5-year period from May 2019 to April 2023. Before surgery, each patient received a comprehensive explanation of the operative procedure and its complications, and written informed consent was duly obtained for the same. All patients included in the review were treated using the single or multilevel ACCF technique.

Inclusion criteria

Patients exhibiting clinical signs of moderate-to-severe cervical myelopathy, as well as those with mild myelopathy demonstrating progressive neurological worsening, were deemed appropriate candidates for cervical corpectomy.

Patients were categorized into three distinct groups based on their underlying pathology:

• (1)CSM
• (2)Traumatic cervical spine injury
• (3)Infectious conditions.

In the CSM and infection condition, preoperative evaluation typically included magnetic resonance imaging (MRI) along with computed tomography (CT) in most instances. All patients underwent thorough neurological assessment before surgery. For individuals in the trauma cervical spine, an initial CT scan was performed as part of the trauma protocol, followed by an MRI for further spinal cord and soft tissue evaluation.

Surgical procedure

All surgical procedures were performed by a neurosurgeon at the same institution. Preoperatively, all patients received intravenous prophylactic antibiotics (cephalosporins). Eighty-six patients who were included in this study were operated on under general anesthesia in the supine position. In ACCF, a standard Smith–Robinson approach was performed from the right side, providing optimal access to the anterior cervical spine. A C-arm fluoroscope was utilized to localize the operative level and guide the skin incision. Microsurgical techniques were employed intraoperatively.

Following strict aseptic protocols, including cleaning, painting, and draping, a linear incision was made along the anterior border of the sternocleidomastoid muscle. The cervical spine was accessed through the anatomical plane between the trachea–esophagus medially and the carotid sheath laterally. After splitting the longus colli muscle, a Cloward retractor was applied to expose the target level, which was confirmed using fluoroscopy or intraoperative X-ray.

Single or multilevel discectomies were performed as needed, followed by vertebral body corpectomy. The endplates were meticulously prepared to accommodate the graft or implant. In degenerative cases, bone graft material was collected from the corpectomy site itself, whereas in infectious cases, autologous bone was harvested from the iliac crest. The final position of the graft was confirmed intraoperatively using fluoroscopic imaging to ensure appropriate alignment and placement. Reconstruction was carried out using an ECC, either with or without screws, or with an autologous graft and anterior plate fixation, depending on the case.

Hemostasis was achieved, and closure was performed in layers. Postoperatively, all patients were immobilized with a firm cervical collar for 6 weeks to ensure spinal stabilization and facilitate fusion. All patients were followed up 3 months after discharge with postoperative CT scan.

RESULTS

In this study, neck pain was the most common presenting symptom, followed by motor or sensory deficits, while bowel and bladder symptoms were the least common across all cervical pathologies [Table 1].

Table 1.

Demographic data and symptom analysis

Variable	CSM	Traumatic cervical spine	Infection
Age (years)
Mean	54.7	38.5	57.5
Range	34–73	18–65	48–70
Gender
Male	22	21	8
Female	16	13	6
Total	38	34	14
Preoperative symptoms
Neck pain	33	30	9
Motor deficit	25	24	5
Sensory deficit	27	25	4
Bowel/bladder involvement	4	2	1
Segment level involved
Single level	24	22	6
Multiple level	14	12	8
Myelomalacia	20	19	5

CSM - Cervical spondylotic myelopathy

There were 38 cases of cervical spondylotic myelopathy, of which 22 patients underwent corpectomy with cage reconstruction, while 16 patients were treated with corpectomy and iliac bone grafting. Similarly, among patients with traumatic spinal injuries, 23 underwent corpectomy with cage reconstruction, while 11 were treated with corpectomy and iliac crest bone grafting supplemented by plate and screw fixation. In infectious condition, nine patients were operated on as corpectomy with cage and five patients were operated on for corpectomy with iliac bone graft [Table 2].

Table 2.

Distribution of surgical procedure in etiological subsets

Surgical indication	Fusion technique	Number of patients
CSM	Corpectomy and Iliac crest graft with plate and screw fixation	16
	Corpectomy and cage with/without screw	22
Traumatic cervical spine	Corpectomy and Iliac crest graft with plate and screw fixation	11
	Corpectomy and cage with/without screw	23
Infection	Corpectomy and iliac crest graft with plate and screw fixation	5
	Corpectomy and cage with/without screw	9

CSM - Cervical spondylotic myelopathy

In CSM, one patient had transient dysphagia and one patient developed cerebrospinal fluid (CSF) leak, which was managed conservatively with IV antibiotics and lumbar punctures. In traumatic cervical spine, one patient developed transient recurrent laryngeal nerve (RLN) palsy, whereas CSF leak developed in two cases. A postoperative hematoma occurred in one patient with traumatic spine injury. In infection, one patient developed cervical surgical site infection, which was managed conservatively with antibiotics and dressing [Table 3].

Table 3.

Complication in our series

Complications	CSM	Traumatic cervical spine	Infection	Total
Hematoma	0	1	0	1
Dysphagia	1	1	0	2
RLN palsy	0	1	0	1
Infection
Cervical site infection	0	1	1	2
Donor site infection	0	1	0	1
CSF leak	1	2	0	3

CSM - Cervical spondylotic myelopathy; RLN - Recurrent laryngeal nerve; CSF - Cerebrospinal fluid

Clinical outcome

At 3-month follow-up period, 12 cases of CSM, 12 cases of traumatic spine, and 6 patients of infection had improved neck pain. Whereas, motor deficit improved in 7, 5, and 2 cases of CSM, traumatic spine, and infectious pathology, respectively. There was only one case of traumatic spine patient who had improvement in urinary symptoms postoperatively [Table 4].

Table 4.

Symptom variation after surgery

Symptoms	Preoperative (number of patients)			3-month follow-up (number of patients)
	CSM	Traumatic cervical spine	Infection	CSM	Traumatic cervical spine	Infection
Neck pain	33	30	9	21	18	3
Motor deficit	25	24	5	18	19	3
Sensory deficit	27	25	4	20	18	2
Bowel/bladder involvement	4	2	1	4	1	1

CSM - Cervical spondylotic myelopathy

Functional outcome

All patients were evaluated for neurological recovery using the modified Japanese Orthopaedic Association (mJOA) score at baseline and during follow-up. The mean preoperative mJOA score across the cohort was 9.7 ± 2.2, which improved significantly to 13.5 ± 2.1 at 1 year (P < 0.05).

The recovery rate was calculated using the Hirabayashi formula. The overall mean recovery rate was 50%, with the highest improvement in the CSM group (60%), followed by trauma (47%), and the least in infection (43%) [Table 5].

Table 5.

Functional outcome at 1-year follow-up

Group	n	Preoperative mJOA (mean±SD)	Postoperative mJOA at 1 year (mean±SD)	Recovery rate % (Hirabayashi)
CSM	38	10.1±2.2	14.3±1.9	60.9
Traumatic cervical spine	34	9.6±2.3	13.1±2.1	47.3
Infection	14	8.9±2.0	12.4±1.9	43.2
Overall	86	9.7±2.2	13.5±2.1	50.6

CSM - Cervical spondylotic myelopathy; mJOA - Modified Japanese Orthopaedic Association; SD - Standard deviation

Radiological outcome

During the immediate postoperative period, a CT scan performed 24 hours after surgery revealed minimal graft migration in one case of traumatic cervical spine injury, which was managed conservatively.

At the 3-month follow-up, significant graft migration with instability was observed in one case each of cervical spondylotic myelopathy and traumatic cervical spine injury, both of which required re-exploration and revision surgery.

At the 1-year follow-up, the majority of patients demonstrated good radiological outcomes. Minimal graft migration was observed in one case each of cervical spondylotic myelopathy and infectious pathology, whereas three cases of traumatic spine injury showed minimal migration [Table 6].

Table 6.

Radiological outcome at 3-month and 1-year follow-up

Variable	Postoperative			3-month follow-up			1-year follow-up
	CSM	Traumatic cervical spine	Infection	CSM	Traumatic cervical spine	Infection	CSM	Traumatic cervical spine	Infection
Proper graft alignment	38	33	14	36	30	14	37	31	13
Minimal graft migration	0	1	0	1	3	0	1	3	1
New-onset instability requiring revision	0	0	0	1	1	0	0	0	0

CSM - Cervical spondylotic myelopathy

Illustrative cases

Case 1

A 52-year-old male laborer by occupation presented with neck pain with a weakness in all four limbs. MRI showed ossification of the posterior longitudinal ligament at the C4-C5 level. Anterior partial corpectomy at the C4-C5 level with autologous bone graft fusion was done. The patient improved following surgery. Postoperative MRI showed a decompression of the cord and fusion with autologous bone [Figure 1].

Figure 1.

(a) Sagittal T2-weighted (T2W) magnetic resonance imaging showing ossification of the posterior longitudinal ligament at the C3-C4 level. (b) The postoperative T2W image with bone graft fusion and showing cord decompression

Case 2

A 26-year-old female presented with loss of weight, neck pain, and weakness in all four limbs. MRI showed the C4-6 destruction of the body due to Kochs. The patient was operated through anterior approach. Fusion with expandable cage and screw was done. The patient improved symptomatically following surgery [Figure 2].

Figure 2.

(a) Sagittal postcontrast image with body destruction. (b) Postoperative X-ray showing corpectomy with bony fusion with expandable cage with screw with a restoration of cervical lordosis

Case 3

A 26-year-old male with a history of road traffic accident presented with severe neck pain and weakness in all four limbs. CT showed a C5 burst fracture with cord compression. C5 corpectomy with fusion was done with an expandable cage with a screw. In the immediate postoperative period, the patient’s neck pain improved, but power improved at a 3-month interval [Figure 3].

Figure 3.

(a) Sagittal computed tomography (CT) showing burst fracture at the C5 level. (b) Postoperative sagittal CT with fixation with expandable cage with screws with a restoration of sagittal alignment

DISCUSSION

Corpectomy or vertebrectomy refers to the surgical removal of most or all of the vertebral bodies. The width of the area removed during the procedure can vary based on the patient’s individual anatomy, typically ranging from 15 mm to over 20 mm. In most cases, a corpectomy width of 16–18 mm is sufficient to achieve adequate spinal cord decompression.[4] Corpectomies are generally classified into two types: median central corpectomy and limited oblique corpectomy.

The anterior approach using ACCF is generally regarded as a reliable and effective surgical method for decompressing the spinal cord and achieving solid fusion, both in degenerative conditions and traumatic spinal injuries.[11,12]

Multiple clinical studies have validated the effectiveness of this approach in treating patients with ventral spinal cord compression caused by lesions extending beyond the intervertebral disc space and involving the vertebral body.[13,14]

The aim of study was to analyze our clinical experience of ACCF in 86 cases of CSM, traumatic cervical spine injury, and infectious processes.

Using autografts with plating offers the benefit of higher fusion success rates. However, this method has drawbacks such as complications like donor site infection, hematoma formation, potential injury to nerves, and persistent pain at the harvest site. In contrast, expandable cages, with or without accompanying plates or screws, provide immediate spinal stability and eliminate donor site complications. Their serrated edges also help reduce the risk of graft migration. Nonetheless, this approach may lead to a reduction in segmental height, loss of natural spinal curvature (lordosis), and generally lower fusion rates compared to autografts.[4]

In this study, the most common symptom was neck pain, followed by motor or sensory deficits, while bowel and bladder symptoms were the least common across all cervical pathologies. This result is comparable to a study conducted by Tatter et al.[15]

In the follow-up period, neck pain showed the greatest symptomatic improvement, while bowel and bladder symptoms were the least likely to improve over time in this study.

In this study, functional recovery was evaluated using the mJOA score, which is widely accepted for assessing neurological improvement in patients with cervical myelopathy. The mean preoperative mJOA score was 9.7 ± 2.2, which improved significantly to 13.5 ± 2.1 at 1-year follow-up (P < 0.05), corresponding to an overall recovery rate of 50% based on the Hirabayashi formula. The highest recovery rate was observed in the CSM group (60%), followed by traumatic cervical spine injuries (47%) and infectious pathology (43%). These findings are consistent with previously reported outcomes of ACCF, where substantial improvement in neurological function was documented following adequate decompression and stabilization of the cervical spine.[4,15]

Lack of movement between the spinous processes on flexion–extension radiographs is a reliable indicator for evaluating cervical subaxial fusion and ruling out pseudoarthrosis.[14]

We observed a 100% fusion rate with both autografts and cage, consistent with previously reported outcomes for one- and two-level anterior cervical corpectomy in the management of spondylotic myelopathy.[16,17,18]

Nowadays, anterior and posterior fusion with instrumentation is rarely indicated after performing one- or two-level corpectomies.[19]

Titanium mesh cages (TMCs) were used as grafts in the majority (63%) of cases. While earlier studies reported a higher incidence of subsidence associated with TMC use in ACCF,[7] a recent meta-analysis conducted by Zhao et al. found no significant difference in subsidence rates between ACCF and anterior cervical discectomy and fusion.[11] Our findings support the use of TMC in ACCF, as it offers strong biomechanical stability and high fusion rates, when also eliminating the risks related to donor site morbidity due to autograft.

Although major instrument failures and significant subsidence can cause spinal cord injury and worsen neurological outcomes, minor shifts in the hardware appear to have minimal clinical impact,[7,10,11] as also confirmed by the results of our study. In most instances, minor implant migration did not worsen over time and was deemed clinically insignificant.

Complication rates were slightly higher for corpectomy with autograft compared to corpectomy with TMC, although this difference was not statistically significant. Donor site complications from harvesting tricortical iliac bone graft occurred in one patient within the autograft group. These findings align with recent literature reporting complication rates after iliac bone harvesting between 4% and 39%.[4,20,21]

With regard to complications, the incidence was relatively higher in cases of traumatic cervical spine injury compared to other pathologies. However, occurrences of prevertebral hematoma and RLN palsy remained rare.

All patients underwent routine follow-up CT scans 3 months postdischarge, followed by an outpatient clinic visit at 1 year. This follow-up schedule allowed the identification of two cases requiring surgical revision at the 3-month mark. Therefore, a 12-week follow-up period appears sufficient for monitoring after this type of surgery.

CONCLUSION

ACCF is a safe and effective surgical technique for managing various cervical spine pathologies, including CSM, traumatic cervical injuries, and infectious conditions. In our 5-year institutional experience involving 86 patients, ACCF achieved significant clinical and radiological improvements, particularly in alleviating neck pain and motor deficits. Both autologous iliac crest grafts and ECCs (TMCs) provided reliable structural reconstruction and high fusion rates, although the use of cages helped avoid donor site complications and was associated with slightly fewer postoperative issues. The choice between autograft and cage reconstruction should be individualized based on patient condition with underlying pathology, surgeon experience, and intraoperative findings. A structured follow-up protocol with clinical, functional, and radiological evaluation at 3 months and 1 year is essential for identifying potential complications and ensuring optimal outcomes.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.