Article Type : Research Article
Authors : Rahman M, Khan KN, Khan RA, Sarker MH and Sobuj MS
Keywords : Mesh cage; Discectomy; Cervical; Disc
Background: Surgical considerations for symptomatic cervical
disc prolapse are many. Anterior cervical discectomy and fusion is the gold
standard. Using cage, peek cage, mesh cage with or without plate screws are
surgeon’s choice. The anterior cervical approach is direct, addresses the
pathology and retains the biomechanics comparing posterior approach which is at
least partially hampering the facet joints. Minimally invasive procedures are
now technically demanding and challenging as well.
Objective: The study aims to assess the outcome of surgery
using mesh cage with or without plate and screws stabilisation.
Method: This is a retrospective study which was conducted in
a single private hospital (Comfort Hospital), Dhaka, Bangladesh. Total of 94
cases was included in the study. Of this population 70 were male and 24 were
female. Results: Out of 94 patients- 88 patients had a satisfactory outcome. 3
patients needed revision surgery for palate-screw readjustment. 1 patient had a
mesh cage infection. 2 patients had adjacent level disc prolapse.
Conclusion: Use of a mesh cage for the single-level cervical
disc is safe and effective in comparison to plate-screws stabilisation.
Achievement of fusion is the same in two groups although using only mesh cage
is minimally invasive having shorter hospital stay, less blood loss and quick
recovery.
Jürgen Harms and Lutz
Biederman developed surgical titanium mesh in 1986. Smith, Robinson and Cloward
first described anterior discectomy and fusion in a separate paper for the
treatment of diseases affecting the cervical spine [1,2]. Modifications of
these pioneering techniques were identified in the literature in the following
decades, with the most notable inclusion of anterior plating by Orozco and
Llovet Topes [3]. Multiple authors who followed reported excellent results
regarding anterior discectomy with or without fusion for the treatment of
single-level cervical pathology [4-10]. For degenerative spinal diseases,
anterior cervical discectomy and fusion (ACDF) have been one of the most
usually performed procedures [11]. Historically the anterior cervical fusion
has been used to treat multiple cervical spine degenerative diseases, including
secondary weakness to trauma or infection. It is most commonly done after
removal of herniated discs, osteophytes, or corpectomy. Screw loosening,
screwing back out, and breaking of screws or plates remain clinical
hardware-related complications that warrant concern. Such problems are thought
to be caused in part by bone resorption during fusion; this mechanism leads to
the collapse of the graft, which imposes an increased bending moment at the
interface of the screw-plate and precipitates fatigue and eventual build failure.
Titanium mesh cage style is cylindrical, with optional rings for reinforcement.
The wide openings have excellent endplate to promote interface healing. For
many years, surgical titanium mesh has been used extensively in cervical disc
prolapse discectomy. Previous authors documented the use of operational
titanium mesh for fusion in a model of human deformity and anterior lumbar
interbody fusion in a model of human circumferential lumbar fusion [12-15]. Titanium
mesh cages have become common and it is minimally invasive as well. Recently,
anterior cervical reconstruction using an anterior plated titanium mesh cage
has been implemented as an effective and safe technique that provides
immediate, solid anterior column support while reducing complications in the
hardware. This research had the aim of evaluating the outcome of both place
screw stabilisation and mesh cage surgery. We have therefore retrospectively
analyzed the surgical outcomes of 94 patients who underwent surgery using mesh
cage and plate screws.
The study aims to assess
the outcome of surgery using mesh cage with or without plate and screws
stabilisation.
Study type: Retrospective study
Study place: A single private hospital (Comfort Hospital), Dhaka,
Bangladesh
Study period: 2009 to 2019
Sample size: Total of 94 patients. Of this population 70 were male
and 24 were female (Figure 1)
Figure 1: Ratio of male and female
patients.
Inclusion criteria:
·
Having
single-level cervical discogenic pain
·
Not
improved by more than six weeks of conservative treatment
Exclusion criteria: Having more than one level cervical disc
prolapse
Out of 94 patients- 88 patients
had a satisfactory outcome (Figure 2).
The complication rate,
that three patients needed revision surgery for plate screw readjustment. One
patient had mesh cage infection and two patients had adjacent level disc
prolapse (Figure 3).
In the mesh cage surgery case, it took only 60-120 minutes and the hospital stay was not more than 2-3 days. But the plate screws surgery took 100-220 minutes and the patients needed to stay a bit longer times in the hospital (Table 1) (Figures 4-6).
Type of Surgery |
Operation time |
Hospital stay |
Mesh Cage only |
60-120 minutes |
2-3 days |
Plate-Screws |
100-220 minutes |
3-4 days |
The plate is a rigid
structure that provides a secure interface between the plate and the implant.
In the elderly population, to intervene surgically requires special consideration
that is based to balance the risks and benefits linked to the surgical
treatment [16]. The authors have shown in many recent studies that inserting a
plate screw helps to reduce the complication and may even shorten the
recumbency span [17-20]. There were three problems (3.19%) linked to the plate
screw in our study. It was described in another study that the incidence of
early plate failure increases substantially [21]. In 1955 Robinson and Smith
initially introduced cervical anterior fusion [22]. There is however still a
significant incidence of plate breakage or migration and back-out screwing.
We used a mesh cage for
single-level cervical disks and compared to plate-screw stabilization it was
much more effective. Titanium mesh and a locking plate device for cervical disc
prolapse discectomy were used here. We hypothesized that attaching the cage to
the cervical disk might serve as a load-sharing tool, resulting in lower stress
at the interface between the screw and the plate. During the follow-up span,
there were no cases of building failure. The transition has remained stable in
the patients who were followed for more than 12 months. For the cages to
maintain significantly a longer follow-up period is needed, and follow-up
results should be compared with those reported for traditional methods.
Titanium mesh cages were also used with satisfactory performance in anterior
spine reconstruction for trauma and tumours. The main advantage of the titanium
mesh cage is a reduction in morbidity at the donor site. Such cages are unusual
buildings in that, unlike threaded cages, they still have a large surface area
of exposed cancellous bone to recover after proper preparation. Cages are
significantly more expensive today. Depending on the size and number of cages
used, implanting titanium mesh cages will add about one to several thousand
dollars to the surgical costs. Although the authors have yet to clinically
experience the issue, revision surgery in the presence of a cage can be more
difficult. Titanium is relatively soft, a carbide burr is readily able to cut
through cages. Considering the risk factors, single-level discectomy in
cervical disc prolapse using titanium mesh cage can provide good clinical
results and help prevent complications. Cervical discectomy and fusion with
cage and plate screw fixation is an approved procedure for cervical discernment
therapy and has been documented to alleviate pain and enhance motor and sensory
deficits [23-26]. To avoid complications of the donor site, intervertebral body
spacers made from titanium, carbon and peek were created and are increasingly
being used. Moreover, our study showed the limited operating time with mesh
cage surgery than plate screw stabilisation. Patients had fewer complications,
blood loss with mesh cage surgery. Thus they had to stay in the hospital a
shorter time than plate screw surgery patients.
Anterior cervical
reconstruction single-level discectomy in cervical disc prolapse essentially
produced good clinical results using titanium mesh cage and helped a lot to
prevent complications. Among the two groups of patients, we found it is
minimally invasive to use only a mesh cage. It has given shorter hospital stay
and rapid recovery. Nonetheless, risk factors related to the process should be
carefully considered. Thus the mesh cage has given us comparatively the safer
and better performance than the stability of the plate screw.?