Surgical revision for failed anterior cervical fusions. Articular pillar plating or anterior revision?

This retrospective study reviewed one surgeon's experience in treating symptomatic anterior cervical pseudarthrosis by three methods: anterior revisions, posterior revisions, and circumferential procedures.

To determine whether anterior revision and plating achieves a higher probability of radiographic fusion and better clinical outcomes compared with posterior fusion and articular pillar plating. The role of circumferential procedures was evaluated.

Management of cervical pseudarthrosis by a repeat anterior procedure requires a difficult dissection in a previously operated area, resection of a nonunion site, and regrafting. Because the incidence of failure is reported to be high, posterior cervical fusion has been proposed as a treatment for anterior pseudarthrosis.

The second author has performed 44 surgical revisions for symptomatic anterior cervical pseudarthrosis. Before this surgical revision, all patients had pain and a radiographic nonunion that was confirmed during surgery. The average follow-up period after the secondary procedure was 28 months with a range of 12-60 months. All patients (100%) were available for follow-up evaluation. Twenty patients had anterior pseudarthrosis repair and anterior plating. Seventeen patients underwent posterior cervical fusion and articular pillar plating. Seven patients had a circumferential repair with anterior revision and posterior articular pillar plating.

All seven patients (100%) who had circumferential procedures achieved a solid radiographic fusion. Clinically, five patients felt better than before surgery, and two patients felt the same. Sixteen of 17 patients (94%) with posterior repairs achieved a solid fusion. Fourteen patients felt better; two patients felt the same, and one patient with a nonunion felt worse than before surgery. A solid fusion was obtained in only 45% of the patients after anterior repair alone.

Posterior cervical articular pillar plating and fusion result in a higher probability of fusion than repeat anterior procedures, even with the addition of anterior plate stabilization. Posterior fusion and articular pillar plating, whether alone or part of a circumferential procedure, provides the added fixation required to successfully repair failed anterior cervical fusions.