Overpowering the Previously Posterior Instrumented Cervical Spine With Cage-Assisted Anterior Cervical Discectomy and Fusion: A Cadaveric Study

Purpose Cervical spines previously posteriorly instrumented and fused with a kyphotic deformity represent a surgical challenge. Current treatment strategies include C7 pedicle subtraction osteotomy or a posterior-anterior-posterior approach, which carry the risk of significant complications. The objective of this study was to attempt to achieve lordosis with multiple anterior cervical discectomy and fusion (ACDF) cages to overpower the posterior instrumentation. Methods Four adult cadaveric specimens were selected and underwent C3–C7 posterior laminectomy with posterior instrumentation in a kyphotic alignment using a 3.5-mm titanium screw-rod system. Next, ACDF from C3 to C7 was performed with 15° lordotic cages to restore cervical lordosis. Posterior instrumentation was then inspected for failure. Fluoroscopic images were obtained to calculate total construct lordosis and change in segmental lordosis. CT scans were obtained after ACDF to assess for loosening, instrumentation failure, endplate damage, or impaction. Bone mineral density was calculated on CT scans. Results Age ranged from 59 to 82, and all specimens were male. No gross instrumentation failure was observed. Mean pre-ACDF lordosis between C3 and C7 was 0° (–5° to 5°). Post-ACDF lordosis increased to 37° (35°–38°). Mean segmental lordosis achieved with no endplate destruction was 13.1° (8°–17°). T scores for the cadavers were –0.5, –0.5, –3.2, and –5.1. Two levels of impaction were observed (12.5%). Failure of bone screw interface occurred in the cadaver, with a T score of –5.1 in the middle of the construct. Conclusion Our study demonstrates the validity of overpowering posterior instrumentation through multiple level ACDF with lordotic cages. This may obviate the need to perform posterior-anterior-posterior procedures. Level of Evidence Level III