Increased In-hospital Complications After Primary Posterior versus Primary Anterior Cervical Fusion

Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021, USA.
Clinical Orthopaedics and Related Research (Impact Factor: 2.77). 03/2011; 469(3):649-57. DOI: 10.1007/s11999-010-1549-4
Source: PubMed


Although anterior (ACDF) and posterior cervical fusion (PCDF) are relatively common procedures and both are associated with certain complications, the relative frequency and severity of these complications is unclear. Since for some patients either approach might be reasonable it is important to know the relative perioperative risks for decision-making.
The purposes of this study were to: (1) characterize the patient population undergoing ACDF and PCDF; (2) compare perioperative complication rates; (3) determine independent risk factors for adverse perioperative events; and (4) aid in surgical decision-making in cases in which clinical equipoise exists between anterior and posterior cervical fusion procedures.
The National Inpatient Sample was used and entries for ACDF and PCDF between 1998 and 2006 were analyzed. Demographics and complication rates were determined and regression analysis was performed to identify independent risk factors for mortality after ACDF and PCDF.
ACDF had a shorter length of stay and their procedures were more frequently performed at nonteaching institutions. The incidence of complications and mortality was 4.14% and 0.26% among patients undergoing ACDF and 15.35% and 1.44% for patients undergoing PCDF, respectively. When controlling for overall comorbidity burden and other demographic variables, PCDF was associated with a twofold increased risk of a fatal outcome compared with ACDF. Pulmonary, circulatory, and renal disease were associated with the highest odds for in-hospital mortality.
PCDF procedures were associated with higher perioperative rates of complications and mortality compared with ACDF surgeries. Despite limitations, these data should be considered in cases in which clinical equipoise exists between both approaches.
Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Download full-text


Available from: Stavros G Memtsoudis
    • "Case 2 demonstrates that the anterior Smith-Robinson approach may be an attractive alternative in patients suffering from painful atlantoaxial osteoarthritis. Additional benefits of this technique include a lower risk of post-operative infection by avoiding posterior approaches to the cervical spine[20] and decreased risk of vertebral artery injury during screw insertion.[24] The avoidance of exposure of the C1-C2 joint from the posterior aspect may also decrease occipital neuralgia.[31] "
    [Show abstract] [Hide abstract]
    ABSTRACT: The sequelae of atlantoaxial instability (AAI) range from axial neck pain to life-threatening neurologic injury. Instrumentation and fusion of the C1-2 joint is often indicated in the setting of clinical or biomechanical instability. This is the first clinical report of anterior Smith-Robinson C1-2 transarticular screw (TAS) fixation for AAI. The first patient presented with ischemic brain tissue secondary to post-traumatic C1-2 segment instability from a MVC 7 years prior to presentation. The second patient presented with a 3 year history of persistent right-sided neck and upper scalp pain. Both were treated with transarticular C1-2 fusion through decortication of the atlantoaxial facet joints and TAS fixation via the anterior Smith-Robinson approach. At 16 months follow-up, the first patient maintained painless range of motion of the cervical spine and denied sensorimotor deficits. The second patient reported 90% improvement in her pre-operative symptoms of neck pain and paresthesia. Anterior Smith-Robinson C1-2 TAS fixation provides a useful alternative to the posterior Goel and Magerl techniques for C1-2 stabilization and fusion.
    No preview · Article · Jul 2013 · Journal of craniovertebral junction and spine
    • "In one series involving 81 patients (averaging 57 years of age; range 32–88 years) with cervical spondylotic myelopathy (CSM), complications in 18.5% of cases were more prevalent in the “significantly older” patients with more comorbidities and more Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9) codes.[13] In an analysis of the National Inpatient Sample, posterior approaches to the cervical spine correlated with greater morbidity and mortality rates compared with anterior surgery (posterior cervical fusion morbidity 15.35% and mortality 1.44% versus anterior cervical discectomy/fusion morbidity 4.14% and mortality 0.26%).[17] Comorbid factors that increased the complication rate included pulmonary, renal and circulatory diseases, more commonly noted in older patients. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Although the frequency of spinal surgical procedures has been increasing, particularly in patients of age 65 and over (geriatric), multiple overlapping comorbidities increase their risk/complication rates. Nevertheless, sometimes these high-risk geriatric patients are considered for "unnecessary", too much (instrumented fusions), or too little [minimally invasive surgery (MIS)] spine surgery. In a review of the literature and reanalysis of data from prior studies, attention was focused on the increasing number of operations offered to geriatric patients, their increased comorbidities, and the offers for "unnecessary" spine fusions, including both major open and MIS procedures. In the literature, the frequency of spine operations, particularly instrumented fusions, has markedly increased in patients of age 65 and older. Specifically, in a 2010 report, a 28-fold increase in anterior discectomy and fusion was observed for geriatric patients. Geriatric patients with more comorbid factors, including diabetes, hypertension, coronary artery disease (prior procedures), depression, and obesity, experience higher postoperative complication rates and costs. Sometimes "unnecessary", too much (instrumented fusions), and too little (MIS spine) surgeries were offered to geriatric patients, which increased the morbidity. One study observed a 10% complication rate for decompression alone (average age 76.4), a 40% complication rate for decompression/limited fusion (average age 70.4), and a 56% complication rate for full curve fusions (average age 62.5). Increasingly, spine operations in geriatric patients with multiple comorbidities are sometimes "unnecessary", offer too much surgery (instrumentation), or too little surgery (MIS).
    No preview · Article · Dec 2011 · Surgical Neurology International
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The design of frequency synthesizers is especially challenging for wireless applications due to the requirements for high spectral purity, high frequency range, and fast tuning together with reasonable power consumption. The idea of combining digital and analog synthesis techniques for achieving these goals is discussed and analyzed. The proposed architecture uses I/Q modulation to translate a digitally synthesized tuneable low frequency tone to the final frequency range. In practical implementations, however, unavoidable mismatches between the amplitudes and phases of the I and Q branches result in imperfect sideband rejection degrading the spectral purity of the synthesized signal. A compensation structure based on digital pre-distortion of the low frequency tone is presented to enhance the signal quality. Furthermore, practical algorithms for updating the compensator parameters are proposed based on minimizing the envelope variation of the synthesizer output signal. Simulation results are also presented to illustrate the efficiency of the proposed synthesizer concept.
    Full-text · Conference Paper · Feb 2002
Show more