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Treatment of spinal stenosis caused by anterolisthesis with Baastrup disease by lumbar interbody fusion surgery: Case report

Soo Eun, M.D.* David Del Curto M.D.* Sang-Ho Lee, M.D., Ph.D**. Gun Choi, M.D., Ph.D.


Mansoura university hospital, Egypt.

Address for Correspondence:

ehab Y Hassanin
Mansoura university hospital, Egypt.


Objective:  To compare the radiological and clinical outcomes of cages with the conventional autogenous iliac crest graft in anterior cervical discectomy and interbody fusion for single level cervical disc disease.

Patients and Methods: A total of 48 patients with single level cervical discogenic radiculopathy were randomly divided into two groups. Patients in Group A (24 patients) underwent anterior cervical discectomy and fusion with a cage filled with autogenous iliac cancellous bone), and patients in Group B (24 patients) were treated with discectomy and autogenous iliac crest graft (AICG) fusion. There were 30 men and 18 women with a mean age of 41.2 years (range, 25–62). We evaluated the patients for cervical lordosis, the amount of interspace collapse and fusion status on the basis of x-rays, the patient’s neurological and functional outcomes were assessed on the basis of Odom’s criteria,

Results:  The two groups had similar clinical results and fusion rates. However, the loss of cervical lordosis (2.5º) was less in the cage group than in the autograft group (5.25º). Additionally, the anterior interspace collapse (1.53 mm) in the cage group was less than the collapse recorded in the autograft group (2.72 mm). The operative time, the blood loss and hospitalization time was less in the cage group.

Conclusion:  Our results showed that the cage is superior to the autograft in maintaining cervical interspace height and cervical lordosis after one-level anterior cervical decompression procedure with reduction of the operative time and no bone graft donor site complications.

J.Orthopaedics 2009;6(1)e2


cervical discogenic radiculopathy;cervical cage; autogenous iliac crest graft


Since Cloward’s (1958)1 and Smith and Robinson’s (1958)2 innovations in anterior approaches to the cervical spine, a variety of surgical techniques have evolved for the treatment of cervical disc herniation and spondylosis causing radiculopathy and myelopathy. Anterior cervical discectomy and interbody iliac autograft fusion procedures (ACDF) have become widely accepted for these conditions.

Anterior interbody fusion is intended to provide immediate biomechanical support, restore physiologic disc height, maintain cervical lordosis, and achieve fusion. Bone autograft has the advantages of not requiring the implantation of foreign bodies and achieving complete bony fusion. However, various complications have been reported for bone autografts, including graft collapse, graft dislodgment, pseudarthrosis and cervical kyphosis3,4. Donor-site complications also have been reported, including. Haematoma, abdominal hernia, lateral cutaneous nerve injury, infection, fracture and chronic pain 5-7.
Donor site morbidity has stimulated the search for non autologus materials as alternatives for cervical interbody fusion. Many bone graft substitutes have been investigated, but none have been conclusively proven superior to autologous bone in cervical fusion8. Since 1999, Interbody fusion cages has been widely used for the treatment of degenerative cervical spine disease9. It has been reported that the interbody cage fusion prevent disc space collapse, maintain cervical lordosis and avoid donor-site morbidity10,11. Complications, however, have been reported, including subsidence of cages into the adjacent vertebrae, with collapse of the intervertebral space and kyphotic deformation of the affected segment, cage dislocation, and non-union with instability12.
The most effective bone graft fusion substrate currently is uncertain. Therefore, we compared the differences among the two most commonly used options; autologous iliac crest grafts; and cages. We attempted to clarify which fusion approach is the best for one-level anterior cervical interbody fusion procedures. We wanted to find out which fusion substrate creates the best clinical result, which achieves the highest fusion rate, which achieves the quickest fusion, which has the best maintenance of the interbody space (including interspace height and segmental lordosis), and which has the least complications. Radiographic and clinical results of surgical treatment of patients with discogenic radiculopathy were collected.

Patients and Methods:

This prospective study was conducted by an orthopaedic spine surgeon in Mansoura university hospital from January 2004 to May 2006. We analyzed the clinical outcomes of patients who underwent treatment with interbody cage (Group A, 24 patients) and patients who were treated with AICG fusion (Group B, 24 patients). In Group A, we enrolled 14 men and 10 women (age range, 25–60 yr; mean age, 42.2 yr); in Group B, we enrolled 16 men and 8 women (age range, 28–62 yr; mean age, 39.8 yr). The demographic data and levels of discectomy are shown in Table 1.

The clinical symptoms included intractable radiculopathy, caused by nerve root compression. Surgery was done when the patient had radiculopathy with severe or progressive neurologic deficit (weakness or numbness), or failure of conservative treatment (a minimum of 3 months). The findings of magnetic resonance imaging (MRI) and the clinical level of neurologic deficit were correlated to determine the level of surgery. Only patients requiring one level surgery at levels between C3 and C7 were considered eligible for this study. Exclusion Criteria  included myelopathy, diagnosis of cervical fracture or posttraumatic instability, previous surgery at the same vertebral level (Table 2).

Preoperatively, the clinical findings included neck pain with pain radiating to the right arm (22 patients), pain radiating to the left arm (15 patients), pain radiating to both arms (5 patients), neck pain without radiating pain (4 patients) and motor weakness (2 patients)

The patients were randomly allocated between either fusion with cage or with a tricortical graft harvested from the iliac crest. The method of randomisation was based upon the order of the patient in the series. For odd numbers, the patient underwent a cage fusion and for even numbers, a tricortical graft was used.

Group A underwent anterior discectomy with PEEK (polyetheretherketone) cage. We drilled out a core of cancellous bone for grafting using a T-shaped cannulated driver through the iliac crest. The wound was about 1 cm in length and 2 cm in depth. The extracted cancellous bone was packed into the cage cavity. The amount of harvested marrow through 1 drill tract is sufficient to pack 1 cage. A Caspar distraction device enlarged the disc space. The proper size of cages was impacted into the disc space for fusion. The cage size is available in heights of 6, 8, 10 and 12 mm.

Group B underwent anterior discectomy through the Smith-Robinson method. The wound over iliac bone was made about 5 cm in length to allow for proper bone extraction. Autografts were harvested from the anterior iliac crest with a low-speed oscillating saw. The tricortical graft was formed using a typical Smith-Robinson model, and impacted into the previously prepared interspace. All grafts were placed with the cortical face placed anteriorly.

An anterior approach to the cervical spine, intraoperative identification of the vertebral level and removal of the disc and osteophytes using pituitary rongeurs and high-speed burrs. For tricortical graft fusions, we used a Smith-Robinson technique.15 A transverse curvilinear skin incision was used. We used the Caspar screw distractor to allow careful distraction of the disc space throughout the whole procedure. This is enough in one level disc openings for decompression and smoothly impacting the graft into the disc space. All end-plate cartilage was removed with a curette after decompression. Additionally, a high-speed burr was used to carve the margins of end plates for better graft fitting. The subchondral bone of the central end plate was preserved as much as possible. Furthermore, one 3-mm perforated hole was driven through the end plate above and below the interspace.

After surgery, all patients wore a Philadelphia collar for 6 weeks postoperatively, followed by a soft cervical collar for 4 weeks.  Neck exercises were initiated 3 months after surgery, and a gradual return to normal activity levels was permitted. Patients with iliac autografts were allowed to walk after the removal of the drainage tube from the donor site. The patients with cage fusion with cancellous bone extraction by trocar were allowed to walk immediately after recovering from the anaesthesia.

Radiological evaluation

For 2 months after the operation, follow-up radiographs were taken every 2 weeks and at 3, 6, 9, 12 and 24 months postoperatively. Brantigan’s method was used to confirm radiological bone union.13 The bone was considered fused when there was proof of uniform bone mass, a bone bridge was found on the plain lateral radiograph and no movement seen on the flexion and extension lateral radiograph and when the lordotic and kyphotic angles of the cervical spine were stable. The change in Cobb’s angle was assessed by the method designed by Wetzel et al.14 The last follow-up radiograph was compared with the postoperative radiograph to assess the cervical lordosis. To assess changes in interbody space height, the distance between the superior midpoint of the upper vertebra and the inferior midpoint of the lower one was measured on both the postoperative radiograph and the last one taken in follow-up after bone fusion was complete (Fig. 1). The lordotic angle (postoperative, last follow-up) and interbody height (postoperative, last follow up) values used in this study were measured by the author three times every 2 weeks.

Clinical outcomes were assessed by comparing the preoperative and postoperative neurologic status and correlated subjective complaints. They were graded from excellent to poor using the criteria of Odom et al.15 (Table 3). Successful treatment was defined as the patient achieving improvement of symptoms, including excellent or good outcome. Failed treatment was defined as only slightly improving, persisting, or worsened preoperative symptoms, meaning a fair or poor outcome.

Data that were collected included patient demographics, union time, radiographic parameters, clinical outcome, operation duration, blood loss, hospital days and complications. The data were analyzed using ANOVA, the paired t test, the chi square test and the Fisher exact test. Differences were considered to be significant when p < 0.05.

Results :

Clinical Outcomes:  In group A, 23 cases had an excellent and good clinical outcomes according to odom’s criteria , similar outcomes were repoted for Group B (Table 4).

Time taken to achieve good fusion: The two groups had similar rates of final fusions. The fusion rates were 100% (24 of 24 levels) in the autograft group, and 95.84 % (23 of 24 levels) in the cage group. The mean time taken to achieve a good fusion in the cage group was 5.54 months (1.8 to 10) and in the tricortical graft group 4.2 months (1.5 to 6). There was no significant difference between the two groups (Student’s t-test, p > 0.05).

Change in the interbody height ratio. The anterior interspace collapse of 1.53 mm in the cage group is less than the 2.72 mm recorded in the autograft group (p = 0.062). The rate of collapse in the cage group was less than (p = 0.006) the rate of collapse in the autograft group.

Cervical lordosis

The lordotic and kyphotic angles were assessed by measuring the change in Cobb’s angle on both the postoperative and the last follow-up radiographs. Group A patients with cage fusion had significantly better recovery of normal lordosis than those in group B. The loss of cervical lordosis of 2.75° in the cage group is less than  the 5.25° recorded in the autograft group (Table 5).

Complications, In the autograft group, the complication rate was 12.9% (3 of 24 patients), including one patient with a broken graft, one patient with graft dislodgment and one patient with hematoma and paresthesia at the donor site. No avascular necrosis occurred in the implanted autografts. In the cage group, the complication rate was 8.1%, with one patient having pseudarthrosis and one patient with transient dysphagia. In the autograft group, although graft fracture occurred, all of these patients finally achieved union. The patient with pseudarthrosis in the cage group had no obvious symptoms and no additional surgery was done. Fibrous union was impressed for this patient because no angular change was seen on the stress views. No wound infections occurred in our series.

The average operative time was 75 minutes for group A (range, 60–90), and 92 minutes for group B procedures (range, 75–110). There was no statistical difference detected between the treatment groups (P = 0.05). The average blood loss for group A was 115 mL (range 75-160 mL) and 180 mL (range 120-300 mL) for group B was 1.5 days. no statistical difference between the groups.

The mean hospital stay was 1.75 days (range, 1–5) for group A; 3.75 days (range, 2–8) for group B. There was no statistically significant difference among the two groups (p = 0.509)

Discussion :

The anterior cervical discectomy with interbody fusion is an effective and practical procedure for treating patients with segmental degenerative disease of the cervical spine. Cervical spine interbody fusion using an autograft from the iliac crest has achieved favorable clinical outcomes and is the gold standard for treating patients with degenerative cervical disease. Robinson et al16 reported the first large series of patients with cervical radiculopathy treated with anterior interbody fusion, 94  percent of the patients with single level disc disease in his series achieved good or excellent outcomes. The overall succsess rate in our series was comparable and the two groups had similar clinical results.

Brown et al.17 reviewed serial x-rays after anterior cervical fusion was performed in an aggregate total of 139 levels in 98 patients and found arthodesis in 97% of patients who underwent autograft procedures. Savolainen et al.18 found a 98% fusion rate in patients who underwent procedures with autograft but reported donor site complications in 16% of the patients. Matge10 reviewed patients who had undergone AICG fusion procedures and found that there were many graft related complications, including migration (2.1–4.6%), kyphosis (3–10%), pseudoarthrosis (1–3%), and donor site hematoma, pain, or infection with donor site complication rate of 22% in their series. We had fusion of all the 24 cases of the autograft but with one case with donor site morbidity.

Interbody cages have been developed to replace autografts.10, 19-24 Interbody cages provide various advantages, including immediate stability, maintenance of a constant height (constant interbody space), containment of material permitting osteoconduction, and improvement of cervical lordosis. Interbody cages also have a lower profile than plate constructs, and are associated with a low failure rate. Cho et al 21 and Vavruch et al 24 reported that interbody cages could provide solid fusion, increased cervical lordosis, and increased disc height with few complications; however, cage subsidence25 may occur and cause decreased disc height. In our study, the collapse rate in the cage group (6%) was significantly less than the collapse rate in the autograft group (16.1%). Moreover, loss of anterior disc height and loss of cervical lordosis were significantly less in the cage group. 

In our study, the wound incision at the donor site in the cage group was small. The harvest of bone marrow through a small, T-shaped bone graft harvesting set was simple and produced less trauma than other methods, therefore minimizing donor site complications in our cage group. In our study, no pseudoarthrosis or cage migration was encountered. In our study  the fusion rates in the PEEK and AICG groups were comparable and the clinical results were satisfactory.

Comparison of Hospital Stay

Giovanni et al.26 reported that the use of  cages in the cervical spine reduced length of hospitalization and allowed earlier return to daily activities by providing immediate fixation and pain reduction and maintaining the correct interbody space. In particular, they found that the use of a cage provided early stability with no collapse or dislodgment on follow-up examination, and eradicated donor site complications. In our study, patients, who underwent anterior cervical discectomy with cage fusion, showed a significantly better recovery of normal lordosis than the other group  and significantly better preservation of the interbody space. Although the operating time was shorter in group A, the clinical results were not statistically different between the two groups (p = 0.360). The reason for the longer operating time in group B is the required meticulous preparation of the iliac bone,

In comparison with non instrumented anterior cervical discectomy and fusion (ACDF) with cervical cages is expected to improve upon such variables as procedure time, duration of hospital stay and postoperative blood loss. Procedure times for ACDF ranged from 77 to 174 minutes in three studies11,18,27, In contrast, operative time for one level Cage operations was reported by Hacker et al.28 to average 92 minutes, although no significant difference was found between operative times for the Cage groups and the (ACDF) group.

Regarding hospital stay duration, Castro et al27 reported that hospital stay and operative time were reduced significantly by the use of a cage. However, there was no difference among the two groups in terms of hospital stay. Hacker et al.28 reported an even shorter average hospital stay for his cervical cage patients (1.5 days), which compares favorably with reported hospital stays of 1.6 to 2.2 days for plate patients27. Similar results have been reported for clinical trials of multiple cage types lending support to the conclusion that cage implantation results in shorter hospital stay and earlier return to work, improving the cost-effectiveness of anterior cervical arthrodesis procedures29.

Reporting of intraoperative blood loss for cervical fusion cages is scarce in the literature; Hacker et al.28  reported significantly less average intraoperative blood loss for the cervical cage patients over other groups. Results from the present study are largely consistent with those in the literature: Cage procedures had blood loss similar to dowel procedures (Cage, 142 cc; Tricotical autogenous iliac graft, 121 cc; plate, 289 cc).

The ideal cervical fusion approach would offer fusion rates and clinical success of 100% with minimal expense, avoid painful autograft sites, incorporate quickly, obviate the need for a cervical orthosis, and have no associated soft tissue morbidity. Cages had similar fusion success rates to the tricortical autogenous iliac graft with a concomitant improvement in clinical outcomes. Furthermore, the use of the fusion cage may mitigate the need for painful hip graft harvest.

The cervical fusion cage was not associated with the breakage or dislodgment in this study that has been noted to occur other authors. The obvious advantage of the cage over current available options is the ability to use cancellous autograft leading to potentially more rapid bone incorporation while avoiding a painful remote donor site. Other considerations include a no profile internal fixation device and ease of operative technique as evidenced by no additional operative time to that needed for the standard graft technique.


Although cervical spine surgery is an evolving technical challenge, the results presented here suggest interbody fusion cages are as good as, if not better than, autogenous iliac bone-only fusions for the treatment of disc related disorders. Cage can be used as an alternative surgical treatment modality after one-level anterior cervical decompression procedure for single-segment degenerative cervical spine and can provide early stability, maintain the interbody space and cervical lordosis, reduce operation time and minimize complications at the bone graft donor site.

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This is a peer reviewed paper 

Please cite as: ehab Y Hassanin: Cage Versus Autogenous Tricortical Iliac Bone Graft in the Treatment of Single Level Cervical Disc Prolapse

J.Orthopaedics 2009;6(1)e2




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