Failure in Cervical Spinal Fusion and Current Management Modalities

Abstract

Failed fusion in the cervical spine is a multifactorial problem stemming from a combination of patient and surgical factors. Patient-related risk factors such as steroid use, poor bone quality, and smoking can be optimized preoperatively. Age, prior radiation, prior surgery, and underlying genetics are nonmodifiable patient-centered risk factors. Surgical risks for failed fusion include the number of segments fused, anterior versus posterior approach for fusion, the type of bone graft, and the instrumentation utilized. Many symptomatic cases of failed fusion (pseudarthrosis) result in pain, neurological deficits, or loosened hardware necessitating a revision surgery consisting of extending the prior construct and utilizing additional allografts or autografts to augment the fusion. Given the relatively mobile nature of the cervical spine, pseudoarthrosis (either known or anticipated) must be recognized by the spine surgeon, and steps should be considered to optimize the likelihood of future fusion. This consists of both performing a rigid fixation and using appropriate bone graft to enhance the environment for arthrodesis. Vascularized bone grafts are a useful tool to augment fusion and provide added structural stability in cases at high risk of pseudoarthrosis.

Keywords: cervical pseudarthrosis; neurosurgery; plastic surgery; spine surgery; spinoplastic reconstruction.

Fig. 1

Computed tomography of the cervical spine showing anterior cervical discectomy and fusion with plating at C5 to T1, pseudarthrosis (failed fusion), subsidence (interbody cage migration), and loosening of hardware (screws and plate).

Fig. 2

Patient underwent C4 to T2 decompression, fixation, and fusion with the use of autografts and allografts for fusion. ( A ) Anterior/posterior X-rays and ( B ) lateral X-rays showing instrumentation from C4 to T2.