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Plating for ACDF
Readers’ Comment
PLATING FOR ACDF RE: Portnoy HD. Anterior cervical discectomy and fusion. Surg Neurol 2001;56:178 – 80. To the Editor: I found this report of particular interest in respect to the need for a plate in anterior cervical fusion (ACDF). In the past decade spine surgeons in our community began to use a plate in multilevel ACDF, citing references [4] showing a higher pseudoarthrosis rate in multilevel fusion. After examining the 5 or 6 papers often cited to support this concept, I do not find the data to support this conclusion. Of these reports, Bohlman et al [1] have the largest series, consisting of 60 patients with multilevel fusion. They calculate their nonunion rate on the basis of failed fusions per patient, rather than failed fusion per level operated. When Bohlman’s series is converted to failed fusions per level operated (instead of per patient), his nonunion rates are 11% and 13%, respectively, for single level and multiple level fusion. The same applies to two other papers (White and Connolly). Moreover, some authors have reported high fusion rates in multilevel ACDF. DePalma [2] reported on 150 patients (70% were multilevel) with a combined fusion rate of 93% for both single and multilevel. Gore [3] reported on 177 multilevel cervical fusion cases using autogenous fibula without a plate, achieving a fusion rate of 93% in two-level and 84% in three-level fusions. I reported to the Southern Neurosurgical Society Annual Meeting in June 2000, on 45 multilevel ACDF cases using fibula allografts without a plate with a fusion rate of 93% (7 nonunion out of 99 levels). In this article, Portnoy finds the use of a plate unnecessary for ACDF, although not specifically mentioning the multilevel distinction. Although initially used only in multilevel fusion, using plates for all ACDF procedures has now become common practice. Supposedly, a plate obviates the need for a hard collar. Portnboy describes his practice evolving to a point where he abandoned the rigid use of a postoperative collar. In my series a postoperative collar was not prescribed, except an optional soft collar for comfort. I find Dr Portnoy’s experience to be further evidence that ACDF, if performed with exacting technique, is a 0090-3019/02/$–see front matter
simple and effective operation that does not require the addition of a plate or the use of a postoperative collar. Amos Stoll, M.D. Ft. Lauderdale, Florida PII S0090-3019(01)00692-9
REFERENCES 1. Bohlman HH, Emery SE, Goodfellow DB, Jones PK. Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. J Bone Joint Surg 1993;75A: 1298 –307. 2. DePalma AF, Rothman LH, Lewinnek GE, Kanale TA. Anterior interbody fusion for cervical disc disease. Surg Gynecol Obstet 1972;134:755– 8. 3. Gore DR. The arthrodesis rate in multilevel cervical fusions using autogenous fibula. Spine 2001;26:1259 – 63. 4. Heary RF, Benzel EC, Vaicys C. Single and multiple single interbody fusion techniques. In: Benzel EC, ed. Spine surgery: techniques, complication avoidance, and management, Vol. 1. Philadelphia: Churchhill Livingstone, 1999:237.
Response: I agree with Dr Stoll that there is no good evidence that application of a plate is necessary as a part of the procedure of anterior cervical discectomy and fusion. The medical profession MUST take on the responsibility of determining scientifically whether plating is necessary. Without a well-constructed study showing the advantage of plating, the only reason for plating appears to be financial. In Michigan, a one-level ACDF with allograft is paid $2786 by Blue Shield. If a plate is added (about 10 –15 minutes more work) the surgeon is paid $411 (15%) more. I have suggested to several university spine surgeons in casual conversation that a proper study be conducted in which the postoperative examiner does not know whether a plate has been inserted as well as radiological criteria. Surprisingly, one spine neurological surgeon told me that it would be “unethical”. I suppose that inserting thousands of useless plates is “ethical”. As neurosurgeons, let us take on this responsibility! Harold D. Portnoy, M.D. Pontiac, Michigan © 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
PLATING FOR ACDF RE: Portnoy HD. Anterior cervical discectomy and fusion. Surg Neurol 2001;56:178 – 80. To the Editor: I found this report of particular interest in respect to the need for a plate in anterior cervical fusion (ACDF). In the past decade spine surgeons in our community began to use a plate in multilevel ACDF, citing references [4] showing a higher pseudoarthrosis rate in multilevel fusion. After examining the 5 or 6 papers often cited to support this concept, I do not find the data to support this conclusion. Of these reports, Bohlman et al [1] have the largest series, consisting of 60 patients with multilevel fusion. They calculate their nonunion rate on the basis of failed fusions per patient, rather than failed fusion per level operated. When Bohlman’s series is converted to failed fusions per level operated (instead of per patient), his nonunion rates are 11% and 13%, respectively, for single level and multiple level fusion. The same applies to two other papers (White and Connolly). Moreover, some authors have reported high fusion rates in multilevel ACDF. DePalma [2] reported on 150 patients (70% were multilevel) with a combined fusion rate of 93% for both single and multilevel. Gore [3] reported on 177 multilevel cervical fusion cases using autogenous fibula without a plate, achieving a fusion rate of 93% in two-level and 84% in three-level fusions. I reported to the Southern Neurosurgical Society Annual Meeting in June 2000, on 45 multilevel ACDF cases using fibula allografts without a plate with a fusion rate of 93% (7 nonunion out of 99 levels). In this article, Portnoy finds the use of a plate unnecessary for ACDF, although not specifically mentioning the multilevel distinction. Although initially used only in multilevel fusion, using plates for all ACDF procedures has now become common practice. Supposedly, a plate obviates the need for a hard collar. Portnboy describes his practice evolving to a point where he abandoned the rigid use of a postoperative collar. In my series a postoperative collar was not prescribed, except an optional soft collar for comfort. I find Dr Portnoy’s experience to be further evidence that ACDF, if performed with exacting technique, is a 0090-3019/02/$–see front matter
simple and effective operation that does not require the addition of a plate or the use of a postoperative collar. Amos Stoll, M.D. Ft. Lauderdale, Florida PII S0090-3019(01)00692-9
REFERENCES 1. Bohlman HH, Emery SE, Goodfellow DB, Jones PK. Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. J Bone Joint Surg 1993;75A: 1298 –307. 2. DePalma AF, Rothman LH, Lewinnek GE, Kanale TA. Anterior interbody fusion for cervical disc disease. Surg Gynecol Obstet 1972;134:755– 8. 3. Gore DR. The arthrodesis rate in multilevel cervical fusions using autogenous fibula. Spine 2001;26:1259 – 63. 4. Heary RF, Benzel EC, Vaicys C. Single and multiple single interbody fusion techniques. In: Benzel EC, ed. Spine surgery: techniques, complication avoidance, and management, Vol. 1. Philadelphia: Churchhill Livingstone, 1999:237.
Response: I agree with Dr Stoll that there is no good evidence that application of a plate is necessary as a part of the procedure of anterior cervical discectomy and fusion. The medical profession MUST take on the responsibility of determining scientifically whether plating is necessary. Without a well-constructed study showing the advantage of plating, the only reason for plating appears to be financial. In Michigan, a one-level ACDF with allograft is paid $2786 by Blue Shield. If a plate is added (about 10 –15 minutes more work) the surgeon is paid $411 (15%) more. I have suggested to several university spine surgeons in casual conversation that a proper study be conducted in which the postoperative examiner does not know whether a plate has been inserted as well as radiological criteria. Surprisingly, one spine neurological surgeon told me that it would be “unethical”. I suppose that inserting thousands of useless plates is “ethical”. As neurosurgeons, let us take on this responsibility! Harold D. Portnoy, M.D. Pontiac, Michigan © 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010