Background The number of surgical techniques for decompression and solid interbody fusion as treatment for cervical spondylosis has increased rapidly, but the rationale for the choice between... Show moreBackground The number of surgical techniques for decompression and solid interbody fusion as treatment for cervical spondylosis has increased rapidly, but the rationale for the choice between different techniques remains unclear. Objectives To determine which technique of anterior interbody fusion gives the best clinical and radiological outcomes in patients with single-or double-level degenerative disc disease of the cervical spine. Search strategy We searched CENTRAL (The Cochrane Library 2009, issue 1), MEDLINE (1966 to May 2009), EMBASE (1980 to May 2009), BIOSIS (2004 to May 2009), and references of selected articles. Selection criteria Randomised comparative studies that compared anterior cervical decompression and interbody fusion techniques for participants with chronic degenerative disc disease. Data collection and analysis Two review authors independently assessed risk of bias using the Cochrane Back Review Group criteria. Data on demographics, intervention details and outcome measures were extracted onto a pre-tested data extraction form. Main results Thirty-three small studies (2267 patients) compared different fusion techniques. The major treatments were discectomy alone, addition of an interbody fusion procedure (autograft, allograft, cement, or cage), and addition of anterior plates. Eight studies had a low risk of bias. Few studies reported on pain, therefore, at best, there was very low quality evidence of little or no difference in pain relief between the different techniques. We found moderate quality evidence for these secondary outcomes: no statistically significant difference in Odom's criteria between iliac crest autograft and a metal cage (6 studies, RR 1.11 (95% CI 0.99 to 1.24)); bone graft produced more effective fusion than discectomy alone (5 studies, RR 0.22 (95% CI 0.17 to 0.48)); no statistically significant difference in complication rates between discectomy alone and iliac crest autograft (7 studies, RR 1.56 (95% CI 0.71 to 3.43)); and low quality evidence that iliac crest autograft results in better fusion than a cage (5 studies, RR 1.87 (95% CI 1.10 to 3.17)); but more complications (7 studies, RR 0.33 (95% CI 0.12 to 0.92)). Authors' conclusions When the working mechanism for pain relief and functional improvement is fusion of the motion segment, there is low quality evidence that iliac crest autograft appears to be the better technique. When ignoring fusion rates and looking at complication rates, a cage has a weak evidence base over iliac crest autograft, but not over discectomy alone. Future research should compare additional instrumentation such as screws, plates, and cages against discectomy with or without autograft. Show less
Jacobs, W.; Willems, P.C.; Kruyt, M.; Limbeek, J. van; Anderson, P.G.; Pavlov, P.; ... ; Oner, C. 2011
Study Design. A systematic review of randomized controlled trials. Objective. To determine which technique of anterior cervical inter-body fusion (ACIF) gives the best outcome in patients with... Show moreStudy Design. A systematic review of randomized controlled trials. Objective. To determine which technique of anterior cervical inter-body fusion (ACIF) gives the best outcome in patients with cervical degenerative disc disease. Summary of Background Data. The number of surgical techniques for decompression and ACIF as treatment for cervical degenerative disc disease has increased rapidly, but the rationale for the choice between different techniques remains unclear. Methods. From a comprehensive search, we selected randomized studies that compared anterior cervical decompression and ACIF techniques, in patients with chronic single-or double-level degenerative disc disease or disc herniation. Risk of bias was assessed using the criteria of the Cochrane back review group. Results. Thirty-three studies with 2267 patients were included. The major treatments were discectomy alone and addition of an ACIF procedure (graft, cement, cage, and plates). At best, there was very low-quality evidence of little or no difference in pain relief between the techniques. We found moderate quality evidence for few secondary outcomes. Odom's criteria were not different between iliac crest autograft and a metal cage (risk ratio [RR]: 1.11; 95% confidence interval [CI]: 0.99-1.24). Bone graft produced more fusion than discectomy (RR: 0.22; 95% CI: 0.17-0.48). Complication rates were not different between discectomy and iliac crest autograft (RR: 1.56; 95% CI: 0.71-3.43). Low-quality evidence was found that iliac crest autograft results in better fusion than a cage (RR: 1.87; 95% CI: 1.10-3.17); but more complications (RR: 0.33; 95% CI: 0.12-0.92). Conclusion. When fusion of the motion segment is considered to be the working mechanism for pain relief and functional improvement, iliac crest autograft appears to be the golden standard. When ignoring fusion rates and looking at complication rates, a cage as a golden standard has a weak evidence base over iliac crest autograft, but not over discectomy. Show less
