{"paper_id":"6088777b-f8d5-40cf-aa0d-954fc4da854c","body_text":"Evaluation of Results of Anterior Cervical Discectomy and Fusion by Stand- alone PEEK Cage for the Treatment of Double level Cervical Spondylotic Myelopathy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Results of Anterior Cervical Discectomy and Fusion by Stand- alone PEEK Cage for the Treatment of Double level Cervical Spondylotic Myelopathy Md. Anowarul Islam, Wayez Mahbub, Suvradev Saha, Afia Ibnat Islam This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2908735/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To evaluate the results of Anterior Cervical Discectomy and Fusion by Stand-alone PEEK cage for the treatment of double level cervical spondylotic myelopathy. Background: Cervical spondylotic myelopathy is a common cause of neck pain and radiating arm pain which develops when one or more of the intevertebral discs in the cervical spine start to degenerate. Anterior cervical discectomy and fusion (ACDF) is the gold standard treatment for degenerative cervical spine disease.Multiple techniques and modalities of fixation are used in ACDF, among them use of Stand-alone PEEK cage is standard one. To counteract the complications with the plating for ACDF, Stand-alone cage concept was constructed and favourable outcomes have been described with a low rate of dysphagia. Stand-alone PEEK cage provides immediate load bearing support to the anterior column and may facilitate fusion. Materials & methods: This retrospective study was conducted in the spine unit of Orthopaedic Surgery department of Bangabandhu Sheikh Mujib Medical University, Shahbag and other private hospitals in Dhaka, Bangladesh from January 2016 to December 2021. A total number of 50 patients with cervical spondylotic myelolopathy with two level involvement confirmed by MRI were selected for the study who were failed to improve after conservative treatment. Outcome was evaluated by usingvisual analog score (VAS), Modified Odom`s criteria, Nurick’s grading and fusion rate by Bridwell’s criteria. Results: Mean patient age was 48.4 ± 6.49 years. Male: female ratio 2:1. Pre-operatively, mean VAS score was 7.13±1.51 whereas post-operatively VAS score was decreased significantly to 0.47±0.64 after 12 months of follow up (p value <0.001). Neurological outcome was assessed by Nurick grading system, where all patients were in grade I (80%), grade II (14%) & grade III (6%) pre-operatively. Post-operatively at 12 months follow up, maximum patients (92%) were in grade 0 (p value <0.001). Radiological fusion was assessed by Bridwell fusion criteria, fusion was found in 80% and 90% of patients after 6 and 12 months follow up. Overall improvement was assessed by modified Odom’s score; excellent improvement was seen in majority patients after 12 months of post-operative follow up (86%) Conclusion: ACDF by stand-alone PEEK cage is the best technique for the treatment of double level cervical spondylotic myelopathy with excellent functional outcome. This can be used with minimum risk as well excellent fusion rate. Figures Figure 1 Figure 2 Introduction Cervical spondylotic myelopathy (CSM) is a disorder of the spinal cord due to compression of the cord by degenerative disease depicted at radiological examinations [1]. Myelopathic or upper motor neuron lesion findings (e.g., hyper-reflexia and gait disturbance) are the typical manifestations of this disorder [2]. Patients may also present with radiculopathy due to degenerative process including bulging or tear of annulus, herniation of disc material into the canal causing pressure effect over the spinal cord and nerve roots [3]. Myelopathic hand signs, Grip release sign, Hoffman’s sign, Romberg test along with gait disturbances (broad based and hesitant) are common in advanced conditions. Changes in the pattern of bladder and bowel dysfunction are also found in about 20% -50% of the patients [4]. Surgical procedures performed in cervical myelopathy are aimed at relieving spinal cord compression, as well as achieving stabilization. Anterior cervical discectomy and fusion (ACDF) is the established gold standard treatment for degenerative cervical spine disease both for radiculopathy and for myelopathy [5]. Interbody fusion rate is about 92% by ACDF [6]. Various techniques for performing ACDF depending on surgeon preference are available. Cervical cages of different materials have been used like titanium, PEEK cage and carbon fiber [7]. ACDF with PEEK cage provides good functional outcome and fusion rate following surgery [8]. ACDF by stand-alone PEEK cage provides immediate load bearing support to the anterior column and may facilitate fusion and also has the advantage of mitigating the complications associated with anterior plating [9]. The aim of this study is to evaluate the results of ACDF by Stand-alone PEEK cage for the treatment of double level cervical spondylotic myelopathy. Materials and methods This retrospective study was conducted in the spine unit of Orthopaedic Surgery department of Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka from January 2016 to December 2021. A total number of 50 patients with cervical spondylotic myeloradiculopathy with two level involvement confirmed by MRI were selected for the study who were failed to improve after conservative treatment. Patients having involvement of one level, infection, tumor or fracture of vertebra were excluded from the study. Patients were followed up at 3 months, 6 months, 12 months and finally at 24 months. Outcome was measured by using visual analogue score (VAS) for pain, Nurick Grading for neurological status, Bridwell criteria for radiological fusion & finally overall improvement was evaluated by Modified Odom´s criteria. All the data were compiled and sorted properly and the quantitative data was analyzed statistically by using Statistical Package for Social Science (SPSS-26). The results were expressed as percentage and mean ± SD and p<0.001 was considered as the level of significance. Comparison of continuous variables was made with Student’s t-tests. Comparison of categorical data was made with Chi-Square tests. Surgical procedure: Patient was positioned in supine. The Gardener-wells tong traction was applied. A sandbag was placed in between shoulder blades to extend the neck. Patient’s head was rotated slightly to the opposite of the planned approach site. Transverse skin incisions were made over the targeted disc levels. The platysma muscle was identified and incised longitudinally. The esophagus was identified and retracted medially, while the sternocleidomastoid and underlying carotid sheath was retracted laterally. The pre-vertebral fascia was divided, and the longus colli musculature was further retracted. Intra-operative radiograph was obtained to confirm the appropriate cervical levels. The offending disc was removed with a rongeur. The entire disc, vertebral body endplates were decorticated. Stand-alone PEEK cages were inserted and fixed with screw in desired position after measuring with template. Position was checked by fluoroscope. Hemostasis was ensured by gel foam and electrocautery. A drain tube was kept in situ. Platysma, subcutaneous layer and skin were closed in layers. Sterile dressing was applied over the wound and cervical collar was applied before extubation. Patients were encouraged to ambulate on the 5 th post-operative day. Results Mean patient age was 48.4 ± 6.49 years. Among them, 33 were men and 17 were women with a male: female ratio 2:1. Patient demographic characteristics are illustrated in Table I. C5-6, C6-7 were most commonly involved disc levels (56%), following in decreasing order C4/5, C5/6 (26%), C4/5, C6/5 (18%). All of the study patients had neck pain and motor weakness in upper and lower extremities. 44 patients (88%) had myelopathic signs and 42 patients (84%) had gait difficulty. Sensory changes in both extremities were seen in 33 patients (66%). Pre-operatively, mean VAS score of all patients was 7.13±1.51 (5-10) whereas post-operatively VAS score was decreased significantly after 6 and 12 months of follow up 1.06±0.88 and 0.47±0.64 respectively. (p value <0.001). Neurological outcome was assessed by Nurick grading system, where all patients were in grade I (80%), grade II (14%) & grade III (6%) pre-operatively. Post-operatively at 3, 6, 9 and 12 months follow up, maximum patients were in grade 0 (80%, 86% and 92% respectively) with significant difference compared to pre-operative status (p value <0.001). Radiological outcome was assessed by Bridwell fusion criteria, radiological fusion was found in majority of patients after 6 and 12 months follow up (80% and 92%, respectively) (p value <0.001). Overall improvement was assessed by modified Odom’s score, excellent improvement was seen in majority patients after 3, 6 and 12 months of post-operative follow up (70%, 80% and 86%, respectively) (p value <0.001). Perioperative complications were seen in 10 (20%) patients wherein 4 (8%) patients had transient paraparesis, 3 (6%) patients had transient dysphagia, 3 (6%) patients had dural injury. Average postoperative hospital stay was 3±1.2 days which was ranged 3-5 days. Table 1: Demographic characteristics of patients (n=50) Patient characteristics Sex: Male 33(66%) Female 17(34%) Age (years): 48.4±6.49 Level of disc space involvement: C4/5, C5/6 13(26%) C5/6, C6/7 28(56%) C4/5, C6/7 9(18%) Occupation: Service holder 13(26%) Day labourer 15(30%) Housewife 5(10%) Farmer 10(20%) Businessman 7(14%) Clinical presentation: Neck pain Motor weakness in upper and lower extremities Myelopathic Signs Gait difficulty Sensory disturbance in upper and lower extremities 50(100%) 50(100%) 44(88%) 42(84%) 33(66%) Table II: Mean VAS score in all patients at different time points (n=50) Time point Mean ± SD Range (Minimum-Maximum) P value Pre-operative 7.13 ± 1.51 5-10 After 1 month 2.87 ± 0.52 2-4 After 3 months 1.53 ± 1.06 0-3 After 6 months 1.06 ± 0.88 0-3 After 12 months 0.47 ± 0.64 0-2 <0.001 Table III: Comparison of Nurick grading at different time points (n=50) Nurick grading Pre-operative n (%) After 1 month n (%) After 3 months n (%) After 6 months n (%) After 12 months n (%) Grade 0 0 (0) 20 (40) 40 (80) 43 (86) 46(92) Grade I 40 (80) 23 (46) 10 (20) 7 (14) 3 (6) Grade II 7 (14) 7 (14) 3 (6) 0 (0) 0 (0) Grade III 3 (6) 0 (0) 0 (0) 0 (0) 0 (0) Grade IV 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Grade V 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) p value >0.05 <0.001 <0.001 <0.001 Table IV: Assessment according to Bridwell fusion criteria (n=50) Bridwell grade After 3 months n (%) After 6 months n (%) After 12 months n (%) p value Grade I 0 (0) 40 (80) 46 (92) <0.001 Grade II 40 (80) 7 (14) 3 (6) Grade III 10 (20) 3 (6) 0 (0) Grade IV 0 (0) 0 (0) 0 (0) Table V: Assessment according to modified Odom’s criteria (n=50) Status After 1 month n (%) After 3 months n (%) After 6 months n (%) After 12 months n (%) p value Excellent 30 (60) 35 (70) 40 (80) 43 (86) <0.001 Good 13 (26) 6 (12) 6 (12) 3 (6) Fair 6 (12) 6 (12) 3 (6) 3 (6) Poor 0 (0) 0 (0) 0 (0) 0 (0) Discussion In this study, average age of all patient was 48.4 ± 6.49 years (ranging from 35-62 year) with majority belonged to 50-59 years of age (53.3%). Almost similar result was found by Moon et al. (2010) [10]. In this study, most of the patients were male (66%) with a male to female ratio was 2:1. Kim also found male to female ratio of 2:1 in their study (Kim et al. 2017) [11]. In present study, maximum patients were day labourer (30%) who have to carry heavy objects that may contribute to cervical disc prolapse which was also suggested by Kelsey et al. (1984) [12]. All of the study patients had neck pain and motor weakness in upper and lower extremities. 44 patients (88%) had myelopathic signs and 42 patients (84%) had gait difficulty. Sensory changes in both extremities were seen in 33 patients (66%). These are nearer to the study of Shiban et al. (2015) [13]. C5-6, C6-7 were most commonly involved disc levels (56%), following in decreasing order C4/5, C5/6 (26%), C4/5, C6/5 (18%). Quite similar result was observed by Moon et al. (2010) [10] and Topuz et al. (2009) [14] in two different studies. In this study, mean preoperative VAS score was 7.13±1.51 (5-10) whereas post-operatively VAS score was decreased significantly after 1, 3, 6 and 12 months of follow up (2.87±0.52, 1.53±1.06, 1.06±0.88 and 0.47±0.64 respectively), which is statistically significant (P <0.001). Similar result was observed by Choi et al. (2016) [15]. According to Nurick grading system at 12 months of post-operative follow up, 46 patients (92%) were in grade 0 level and 3 patient (6%) in grade I level. Islam et al. (2020) [16] reported 90.6% in grade 0 level and 6 patients (9.4%) in grade I level in follow up according to Nurick grading in a study on 64 patients. According to Bridwell fusion grading system, radiological fusion (grade I) was found in majority patients after 6 and 12 months of follow up (80% and 92% respectively) which is similar to the study of Wang et al. (2013) [17]. Overall improvement was assessed by modified Odom’s score where postoperative outcome at 12 months follow-up demonstrated 86% patients had excellent outcome and 6% had good outcome. Almost similar result was found by Liao et al. (2008) [18] Perioperative complications were seen in 10 patients (20%). 4 patients (8%) developed transient paraparesis who all improved within 6 months. 3 patients (6%) had transient dysphagia which resolved within 2 weeks. 3 patients (6%) had dural injury which was treated per operatively by application of gel foam and no further leakage of CSF postoperatively. No patient developed surgical site infection. Choi et al. (2016) [19] found smilar results. Postoperative average hospital stay was 3 ± 1.2 days (range: 3-5 days) in this study which was comparable to Niu et al. (2010) [20]. Conclusion The use of a stand-alone PEEK cage in a 2-level cervical interbody fusion achieves satisfactory improvements in both clinical outcomes and fusion. So it can be concluded that ACDF with standalone PEEK cage can be an ideal technique for the treatment of patients with double level cervical spondylotic myelopathy with excellent postoperative outcome and good fusion rate. Declarations Disclosure: It is not a matter of conflict. Any financial benefit not taken from anywhere. Any part of this article previously has not been published or submitted any of the journal. Ethical Approval In this study, keeping compliance with Helsinki Declaration for Medical Research Involving Human Subjects 1964, the nature and purpose of the study was informed in detail to all participants. Voluntary participation was encouraged. There was physical, psychological risk to the subjects. Informed and understood written consent was taken from every patient before enrollment. Privacy, anonymity and confidentiality of data information identifying any patient was maintained strictly. Each patient enjoyed every right to participate or refuse or even withdraw from the study at any point of time. Before starting this study ethical clearance was taken from Institutional Review Board (IRB) of BSMMU. Data taken from the participants was regarded as confidential and kept locked under investigator for purposeful use only. Due respect was given to all the subjects. The ethical committee included the following members 1.Professor Dr. Md. Abu Zaffar Chowdhury, Department of Orthopaedic Surgery, BSMMU 2.Professor Dr. Md. Shafiqul Alam, Department of Orthopaedic Surgery, BSMMU. It was reviewed by the Internal Review Boards: 1.Professor Dr. Md. Abul Hasnat, Department of Endocrinology, BSMMU. 2.Professor Dr. Md. Shamim Hossen, Department of Pulmonology, BSMMU. Consent: The author gives the permission to participate and publish the journal. Competing interests It is not a matter of conflict. Any financial benefit not taken from anywhere. Authors' contributions A.Md. Anowarul Islam (corresponding author) B. Wayez Mahbub C.Suvradev Saha D. Afia Ibnat Islam A.B wrote manuscript C. D. made charts and stastistical analysis A supervised and conducted the study all reviewed the manuscript Funding All the expences was carried by the personal fund. Availability of data and materials All the data were compiled and sorted properly and the quantitative data was analyzed statistically by using Statistical Package for Social Science (SPSS-26). Quantitative data was expressed as mean±standard deviation and analyzed by paired t-test. Qualitative data was expressed as frequency and percentage and analyzed by chi-square test, p<0.05 was considered as the level of significance(95% confidence interval). References Boogaarts, H.D. and Bartels, R.H., 2015. Prevalence of cervical spondylotic myelopathy. European Spine Journal , 24 (2), pp.139-141. Dillin WH. Clinical syndromes in cervical myelopathy. In: The Spine. 5th ed. Philadelphia: W.B. Saunders; 2006: 775-88. Baron EM, Young WF. Cervical spondylotic myelopathy: a brief review of its pathophysiology, clinical course and diagnosis. Neurosurgery. 2007; 60(1 Suppl 1): S35-S41. Abbed KM, Coumans JV. Cervical radiculopathy: pathophysiology, presentation and clinical evaluation. Neurosurgery. 2007; 60(Suppl 1): S28-S34 Shiban, E., Gapon, K., Wostrack, M., Meyer, B. and Lehmberg, J., 2016. Clinical and radiological outcome after anterior cervical discectomy and fusion with stand-alone empty polyetheretherketone (PEEK) cages. Acta neurochirurgica , 158 (2), pp.349-355. Yang JJ, Yu CH, Chang BS, Yeom JS, Lee JH, Lee CK. Subsidence and nonunion after anterior cervical interbody fusion using a stand-alone polyetheretherketone (PEEK) cage. Clin Orthop Surg. 2011; 3: 16-23. Chou Y.C., Chen D.C., Hsieh W.A., Chen W.F., Yen P.S., Harnod T., Chiou T.L., Chang Y.L., Su C.F., Lin S.Z. And Chen S.Y.: Efficacy of anterior cervical fusion: Comparison of titanium cages, polyethere-therketone (PEEK) cages and autogenous bone grafts. J. Clin. Neurosci., 15: 1240-1245, 2008. Islam MA, Hossain MA , Iqbal AA , Parvez MQ , Ahsanuzzaman M and Ahammed S. Anterior cervical discectomy and fusion with polyetherether ketone cages in the management of single and double level cervical spondylotic myelopathy-our experiences of 80 cases. KYAMC Journal. 2018; 9(1):32-34 Yang, J.J., Yu, C.H., Chang, B.S., Yeom, J.S., Lee, J.H. and Lee, C.K., 2011. Subsidence and nonunion after anterior cervical interbody fusion using a stand-alone polyetheretherketone (PEEK) cage. Clinics in Orthopedic Surgery , 3 (1), Moon, H.J., Kim, J.H., Kim, J.H., Kwon, T.H., Chung, H.S. and Park, Y.K., 2011. The effects of anterior cervical discectomy and fusion with stand-alone cages at two contiguous levels on cervical alignment and outcomes. Acta neurochirurgica , 153 (3), pp.559-565. Kwon, W.K., Kim, P.S., Ahn, S.Y., Song, J.Y., Kim, J.H., Park, Y.K., Kwon, T.H. and Moon, H.J., 2017. Analysis of associating factors with C2-7 sagittal vertical axis after two-level anterior cervical fusion: comparison between plate augmentation and stand-alone cages. Spine , 42 (5), pp.318-325. Kelsey, J.L., Githens, P.B., Walter, S.D., Southwick, W.O., Weil, U., Holford, T.R., Ostfeld, A.M., Calogero, J.A., O'connor, T. and White 3rd, A.A., 1984. An epidemiological study of acute prolapsed cervical intervertebral disc. The Journal of bone and joint surgery. American volume , 66 (6), pp.907-914 Shiban, E., Gapon, K., Wostrack, M., Meyer, B. and Lehmberg, J., 2016. Clinical and radiological outcome after anterior cervical discectomy and fusion with stand-alone empty polyetheretherketone (PEEK) cages. Acta neurochirurgica , 158 (2), pp.349-355. Topuz, K., Colak, A., Kaya, S., Şimşek, H., Kutlay, M., Demircan, M.N. and Velioğlu, M., 2009. Two-level contiguous cervical disc disease treated with peek cages packed with demineralized bone matrix: results of 3-year follow-up. European Spine Journal , 18 (2), pp.238-243. Choi, M.K., Kim, S.B., Park, C.K. and Kim, S.M., 2016. Comparison of the clinical and radiologic outcomes obtained with single-versus two-level anterior cervical decompression and fusion using stand-alone PEEK cages filled with allograft. Acta neurochirurgica , 158 (3), pp.481-487 Islam, M.A., Shohidullah, M., Mahbub, W. and Chowdhury, A.Z., Evaluation of Result of Anterior Cervical Discectomy and Fusion by Standalone PEEK cage in cervical Spondylotic Myeloradiculopathy. Wang, H.R., Li, X.L., Dong, J., Yuan, F.L. and Zhou, J., 2013. Skip-level anterior cervical discectomy and fusion with self-locking stand-alone PEEK cages for the treatment of 2 noncontiguous levels of cervical spondylosis. Clinical Spine Surgery , 26 (7), pp.E286-E292. Liao, J.C., Niu, C.C., Chen, W.J. and Chen, L.H., 2008. Polyetheretherketone (PEEK) cage filled with cancellous allograft in anterior cervical discectomy and fusion. International orthopaedics , 32 (5), pp.643-648. Choi, M.K., Kim, S.B., Park, C.K. and Kim, S.M., 2016. Comparison of the clinical and radiologic outcomes obtained with single-versus two-level anterior cervical decompression and fusion using stand-alone PEEK cages filled with allograft. Acta neurochirurgica , 158 (3), pp.481-487. Niu, C.C., Liao, J.C., Chen, W.J. and Chen, L.H., 2010. Outcomes of interbody fusion cages used in 1 and 2-levels anterior cervical discectomy and fusion: titanium cages versus polyetheretherketone (PEEK) cages. Clinical Spine Surgery , 23 (5), pp.310-316. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-2908735\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":198436037,\"identity\":\"2e5dae43-2807-4ece-9769-5769afed031e\",\"order_by\":0,\"name\":\"Md. Anowarul Islam\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYFACxgaGBzAGQwWQZmZuIKwlAa7lDEgLIyEtQJAA194G04sH6LYfbv6QULONQX52c9uDj/Nqo/nbgVp+VGzDqcXsTGKbRMKx2wwGdw62G87cdjx3xmHGBsaeM7dxazmQ2MaQwAbUIpHYJs277VhuA1ALM2MbHi3nHwId9u82g/wMoJa/c47lzieo5UZiA9B8oIIbQC2MDTW5Gwhredgmkdh3mwfolzbJnmMHcjcCtRzE65fz6Y8/fPh2W05+dvsziR81dbnzzh8++OBHBW4tMMDDIAGmD4PJAwTVgwFESx1xikfBKBgFo2BEAQDVwmNw5j6CEwAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Bangabandhu Sheikh Mujib Medical University\",\"correspondingAuthor\":true,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Md.\",\"middleName\":\"Anowarul\",\"lastName\":\"Islam\",\"suffix\":\"\"},{\"id\":198436038,\"identity\":\"21a93ce6-89b4-4b8a-a6c7-ee1ebc729f77\",\"order_by\":1,\"name\":\"Wayez Mahbub\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Bangabandhu Sheikh Mujib Medical University\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Wayez\",\"middleName\":\"\",\"lastName\":\"Mahbub\",\"suffix\":\"\"},{\"id\":198436039,\"identity\":\"1abab516-07db-4e9b-ae0b-8cf151f9f13a\",\"order_by\":2,\"name\":\"Suvradev Saha\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Bangabandhu Sheikh Mujib Medical University\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Suvradev\",\"middleName\":\"\",\"lastName\":\"Saha\",\"suffix\":\"\"},{\"id\":198436040,\"identity\":\"132d82df-85fb-4ca3-8b72-be5b5c20a704\",\"order_by\":3,\"name\":\"Afia Ibnat Islam\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Bangabandhu Sheikh Mujib Medical University\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Afia\",\"middleName\":\"Ibnat\",\"lastName\":\"Islam\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2023-05-08 16:59:15\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-2908735/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-2908735/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":36816502,\"identity\":\"c3d1be58-c98f-440d-bc2e-c473a36e6824\",\"added_by\":\"auto\",\"created_at\":\"2023-05-11 14:07:18\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":382239,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePer-operative picture showing double level stand-alone cages.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-2908735/v1/51b02a4997bc7d24492a8854.png\"},{\"id\":36818105,\"identity\":\"84b76ce7-9578-4e76-9ed0-7b6f34216748\",\"added_by\":\"auto\",\"created_at\":\"2023-05-11 14:15:18\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":578002,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eX-ray cervical spine A-P and Lateral view showing Stand-alone PEEK cage at C5/6, C6/7 level\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-2908735/v1/57eb4bc8abc1e903b1926ad3.png\"},{\"id\":37286126,\"identity\":\"3c09884a-5fc6-4420-9fff-7936d1174465\",\"added_by\":\"auto\",\"created_at\":\"2023-05-21 08:52:20\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1219931,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-2908735/v1/e3938300-e0e9-445e-a613-f1baa8663093.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Evaluation of Results of Anterior Cervical Discectomy and Fusion by Stand- alone PEEK Cage for the Treatment of Double level Cervical Spondylotic Myelopathy\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eCervical spondylotic myelopathy (CSM) is a disorder of the spinal cord due to compression of the cord by degenerative disease depicted at radiological examinations [1]. Myelopathic or upper motor neuron lesion findings (e.g., hyper-reflexia and gait disturbance) are the typical manifestations of this disorder [2]. Patients may also present with radiculopathy due to degenerative process including bulging or tear of annulus, herniation of disc material into the canal causing pressure effect over the spinal cord and nerve roots [3]. Myelopathic hand signs, Grip release sign, Hoffman\\u0026rsquo;s sign, Romberg test along with gait disturbances (broad based and hesitant) are common in advanced conditions. Changes in the pattern of bladder and bowel dysfunction are also found in about 20% -50% of the patients [4]. Surgical procedures performed in cervical myelopathy are aimed at relieving spinal cord compression, as well as achieving stabilization. Anterior cervical discectomy and fusion (ACDF) is the established gold standard treatment for degenerative cervical spine disease both for radiculopathy and for myelopathy [5]. Interbody fusion rate is about 92% by ACDF [6]. Various techniques for performing ACDF depending on surgeon preference are available. Cervical cages of different materials have been used like titanium, PEEK cage and carbon fiber [7]. ACDF with PEEK cage provides good functional outcome and fusion rate following surgery [8]. ACDF by stand-alone PEEK cage provides immediate load bearing support to the anterior column and may facilitate fusion and also has the advantage of mitigating the complications associated with anterior plating [9]. The aim of this study is to evaluate the results of ACDF by Stand-alone PEEK cage for the treatment of double level cervical spondylotic myelopathy.\\u003c/p\\u003e\"},{\"header\":\"Materials and methods\",\"content\":\"\\u003cp\\u003eThis retrospective study was conducted in the spine unit of Orthopaedic Surgery department of Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka from January 2016 to December 2021. A total number of 50 patients with cervical spondylotic myeloradiculopathy with two level involvement confirmed by MRI were selected for the study who were failed to improve after conservative treatment. Patients having involvement of one level, infection, tumor or fracture of vertebra were excluded from the study. Patients were followed up at 3 months, 6 months, 12 months and finally at 24 months. Outcome was measured by using\\u0026nbsp;visual analogue score (VAS) for\\u0026nbsp;pain,\\u0026nbsp;Nurick Grading for neurological status, Bridwell criteria for radiological fusion\\u0026nbsp;\\u0026amp; finally overall improvement was evaluated by Modified Odom\\u0026acute;s\\u0026nbsp;criteria. All the data were compiled and sorted properly and the quantitative data was analyzed statistically by using Statistical Package for Social Science (SPSS-26). The results were expressed as percentage and mean \\u0026plusmn; SD and p\\u0026lt;0.001 was considered as the level of significance.\\u0026nbsp;Comparison of continuous variables was made with Student\\u0026rsquo;s t-tests. Comparison of categorical data was made with Chi-Square tests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSurgical procedure:\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePatient was positioned in supine. The Gardener-wells tong traction was applied. A sandbag was placed in between shoulder blades to extend the neck. Patient\\u0026rsquo;s head was rotated slightly to the opposite of the planned approach site. Transverse skin incisions were made over the targeted disc levels. The platysma muscle was identified and incised longitudinally. The esophagus was identified and retracted medially, while the sternocleidomastoid and underlying carotid sheath was retracted laterally. The pre-vertebral fascia was divided, and the longus colli musculature was further retracted. Intra-operative radiograph was obtained to confirm the appropriate cervical levels. The offending disc was removed with a rongeur. The entire disc, vertebral body endplates were decorticated. Stand-alone PEEK cages were inserted and fixed with screw in desired position after measuring with template.\\u003c/p\\u003e\\n\\u003cp\\u003ePosition was checked by fluoroscope. Hemostasis was ensured by gel foam and electrocautery. A drain tube was kept in situ. Platysma, subcutaneous layer and skin were closed in layers. Sterile dressing was applied over the wound and cervical collar was applied before extubation.\\u0026nbsp;Patients were encouraged to ambulate on the 5\\u003csup\\u003eth\\u003c/sup\\u003e post-operative day.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eMean patient age was 48.4 \\u0026plusmn; 6.49 years. Among them, 33 were men and 17 were women with a male: female ratio 2:1. Patient demographic characteristics are illustrated in Table I. C5-6, C6-7 were most commonly involved disc levels (56%), following in decreasing order C4/5, C5/6 (26%), C4/5, C6/5 (18%). All of the study patients had neck pain and motor weakness in upper and lower extremities. 44 patients (88%) had myelopathic signs and 42 patients (84%) had gait difficulty. Sensory changes in both extremities were seen in 33 patients (66%). Pre-operatively, mean VAS score of all patients was 7.13\\u0026plusmn;1.51 (5-10) whereas post-operatively VAS score was decreased significantly after 6 and 12 months of follow up 1.06\\u0026plusmn;0.88 and 0.47\\u0026plusmn;0.64 respectively. (p value \\u0026lt;0.001). Neurological outcome was assessed by Nurick grading system, where all patients were in grade I (80%), grade II (14%) \\u0026amp; grade III (6%) pre-operatively. Post-operatively at 3, 6, 9 and 12 months follow up, maximum patients were in grade 0 (80%, 86% and 92% respectively) with significant difference compared to pre-operative status (p value \\u0026lt;0.001). Radiological outcome was assessed by Bridwell fusion criteria, radiological fusion was found in majority of patients after 6 and 12 months follow up (80% and 92%, respectively) (p value \\u0026lt;0.001). Overall improvement was assessed by modified Odom\\u0026rsquo;s score, excellent improvement was seen in majority patients after 3, 6 and 12 months of post-operative follow up (70%, 80% and 86%, respectively) (p value \\u0026lt;0.001). Perioperative complications were seen in 10 (20%) patients wherein 4 (8%) patients had transient paraparesis, 3 (6%) patients had transient dysphagia, 3 (6%) patients had dural injury. Average postoperative hospital stay was 3\\u0026plusmn;1.2 days which was ranged 3-5 days.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1:\\u003c/strong\\u003e \\u003cstrong\\u003eDemographic characteristics of patients (n=50)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePatient characteristics\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSex:\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; Male\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e33(66%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; Female\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e17(34%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAge (years):\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e48.4\\u0026plusmn;6.49\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eLevel of disc space involvement:\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; C4/5, C5/6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e13(26%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; C5/6, C6/7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e28(56%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; C4/5, C6/7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e9(18%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eOccupation:\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; Service holder\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e13(26%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; Day labourer\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e15(30%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; Housewife\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e5(10%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; Farmer\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e10(20%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; Businessman\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e7(14%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"54.36046511627907%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eClinical presentation:\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;Neck pain\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;Motor weakness in upper \\u0026nbsp; \\u0026nbsp; and lower extremities\\u003c/p\\u003e\\n \\u003cp\\u003eMyelopathic Signs\\u003c/p\\u003e\\n \\u003cp\\u003eGait difficulty\\u003c/p\\u003e\\n \\u003cp\\u003eSensory disturbance in upper and lower extremities\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"45.63953488372093%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e50(100%)\\u003c/p\\u003e\\n \\u003cp\\u003e50(100%)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e44(88%)\\u003c/p\\u003e\\n \\u003cp\\u003e42(84%)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e33(66%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003cstrong\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable II: Mean VAS score in all patients at different time points (n=50)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTime point\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMean\\u0026nbsp;\\u003c/strong\\u003e\\u0026plusmn; \\u003cstrong\\u003eSD\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRange (Minimum-Maximum)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eP value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePre-operative\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e7.13 \\u0026plusmn; 1.51\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e5-10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 1 month\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e2.87 \\u0026plusmn; 0.52\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e2-4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 3 months\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e1.53 \\u0026plusmn; 1.06\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0-3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 6 months\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e1.06 \\u0026plusmn; 0.88\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0-3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 12 months\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0.47 \\u0026plusmn; 0.64\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0-2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"25%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable III: Comparison of Nurick grading at different time points (n=50)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNurick grading\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePre-operative\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 1 month\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 3 months\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 6 months\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 12 months\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGrade 0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e20 (40)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e40 (80)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e43 (86)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e46(92)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGrade I\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e40 (80)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e23 (46)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e10 (20)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e7 (14)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e3 (6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGrade II\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e7 (14)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e7 (14)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e3 (6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGrade III\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e3 (6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGrade IV\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGrade V\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ep value\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026gt;0.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable IV: Assessment according to Bridwell fusion criteria (n=50)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eBridwell grade\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 3 months\\u003c/p\\u003e\\n \\u003cp\\u003en (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 6 months\\u003c/p\\u003e\\n \\u003cp\\u003en (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 12 months\\u003c/p\\u003e\\n \\u003cp\\u003en (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ep value\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGrade I\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e40 (80)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e46 (92)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGrade II\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e40 (80)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e7 (14)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e3 (6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGrade III\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e10 (20)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e3 (6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGrade IV\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable V: Assessment according to modified Odom\\u0026rsquo;s criteria (n=50)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eStatus\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 1 month n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 3 months n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 6 months n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAfter 12 months n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ep value\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eExcellent\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e30 (60)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e35 (70)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e40 (80)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e43 (86)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eGood\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e13 (26)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e6 (12)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e6 (12)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e3 (6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eFair\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e6 (12)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e6 (12)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e3 (6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e3 (6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePoor\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"16.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eIn this study, average age of all patient was 48.4 \\u0026plusmn; 6.49 years (ranging from 35-62 year) with majority belonged to 50-59 years of age (53.3%). Almost similar result was found by Moon et al. (2010) [10]. In this study, most of the patients were male (66%) with a male to female ratio was 2:1. \\u0026nbsp;Kim also found male to female ratio of 2:1 in their study (Kim et al. 2017) [11]. In present study, maximum patients were day labourer (30%) who have to carry heavy objects that may contribute to cervical disc prolapse which was also suggested by Kelsey et al. (1984) [12]. All of the study patients had neck pain and motor weakness in upper and lower extremities. 44 patients (88%) had myelopathic signs and 42 patients (84%) had gait difficulty. Sensory changes in both extremities were seen in 33 patients (66%). These are nearer to the study of Shiban et al. (2015) [13]. C5-6, C6-7 were most commonly involved disc levels (56%), following in decreasing order C4/5, C5/6 (26%), C4/5, C6/5 (18%). Quite similar result was observed by Moon et al. (2010) [10] and Topuz et al. (2009) [14] in two different studies.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn this study, mean preoperative VAS score was 7.13\\u0026plusmn;1.51 (5-10) whereas post-operatively VAS score was decreased significantly after 1, 3, 6 and 12 months of follow up (2.87\\u0026plusmn;0.52, 1.53\\u0026plusmn;1.06, 1.06\\u0026plusmn;0.88 and 0.47\\u0026plusmn;0.64 respectively), which is statistically significant (P \\u0026lt;0.001). Similar result was observed by Choi et al. (2016) [15]. According to Nurick grading system at 12 months of post-operative follow up, 46 patients (92%) were in grade 0 level and 3 patient (6%) in grade I level. Islam et al. (2020) [16] reported 90.6% in grade 0 level and 6 patients (9.4%) in grade I level in follow up according to Nurick grading in a study on 64 patients. According to Bridwell fusion grading system, radiological fusion (grade I) was found in majority patients after 6 and 12 months of follow up (80% and 92% respectively) which is similar to the study of Wang et al. (2013) [17]. Overall improvement was assessed by modified Odom\\u0026rsquo;s score where postoperative outcome at 12 months follow-up demonstrated 86% patients had excellent outcome and 6% had good outcome. Almost similar result was found by Liao et al. (2008) [18]\\u003c/p\\u003e\\n\\u003cp\\u003ePerioperative complications were seen in 10 patients (20%). 4 patients (8%) developed transient paraparesis who all improved within 6 months. 3 patients (6%) had transient dysphagia which resolved within 2 weeks. 3 patients (6%) had dural injury which was treated per operatively by application of gel foam and no further leakage of CSF postoperatively. No patient developed surgical site infection. Choi et al. (2016) [19] found smilar results. Postoperative average hospital stay was 3 \\u0026plusmn; 1.2 days (range: 3-5 days) in this study which was comparable to Niu et al. (2010) [20].\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThe use of a stand-alone PEEK cage in a 2-level cervical interbody fusion achieves satisfactory improvements in both clinical outcomes and fusion. So it can be concluded that ACDF with standalone PEEK cage can be an ideal technique for the treatment of patients with double level cervical spondylotic myelopathy with excellent postoperative outcome and good fusion rate.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eDisclosure:\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIt is not a matter of conflict. Any financial benefit not taken from anywhere. \\u0026nbsp; Any part of this article previously has not been published or submitted any of the journal.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical Approval \\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn this study, keeping compliance with Helsinki Declaration for Medical Research Involving Human Subjects 1964, the nature and purpose of the study was informed in detail to all participants. Voluntary participation was encouraged. There was physical, psychological risk to the subjects. Informed and understood written consent was taken from every patient before enrollment. Privacy, anonymity and confidentiality of data information identifying any patient was maintained strictly. Each patient enjoyed every right to participate or refuse or even withdraw from the study at any point of time. Before starting this study ethical clearance was taken from Institutional Review Board (IRB) of BSMMU. Data taken from the participants was regarded as confidential and kept locked under investigator for purposeful use only. Due respect was given to all the subjects.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eThe ethical committee included the following members\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e1.Professor Dr. Md. Abu Zaffar Chowdhury, Department of Orthopaedic Surgery, BSMMU\\u003c/p\\u003e\\n\\u003cp\\u003e2.Professor Dr. Md. Shafiqul Alam, Department of Orthopaedic Surgery, BSMMU.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;It was reviewed by the Internal Review Boards:\\u003c/p\\u003e\\n\\u003cp\\u003e1.Professor Dr. Md. Abul Hasnat, Department of Endocrinology, BSMMU.\\u003c/p\\u003e\\n\\u003cp\\u003e2.Professor Dr. Md. Shamim Hossen, Department of Pulmonology, BSMMU.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe author gives the permission to participate and publish the journal.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u0026nbsp;\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIt is not a matter of conflict. Any financial benefit not taken from anywhere.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; contributions \\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA.Md. Anowarul Islam (corresponding author)\\u003c/p\\u003e\\n\\u003cp\\u003eB. Wayez Mahbub\\u003c/p\\u003e\\n\\u003cp\\u003eC.Suvradev Saha\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eD. Afia Ibnat Islam\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eA.B wrote manuscript C. D. made charts and stastistical analysis A supervised and conducted the study all reviewed the manuscript\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding \\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll the expences was carried by the personal fund.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials \\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll the data were compiled and sorted properly and the quantitative data was analyzed statistically by using Statistical Package for Social Science (SPSS-26). Quantitative data was expressed as mean\\u0026plusmn;standard deviation and analyzed by paired t-test. Qualitative data was expressed as frequency and percentage and analyzed by chi-square test, p\\u0026lt;0.05 was considered as the level of significance(95% confidence interval). \\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eBoogaarts, H.D. and Bartels, R.H., 2015. Prevalence of cervical spondylotic myelopathy. \\u003cem\\u003eEuropean Spine Journal\\u003c/em\\u003e, \\u003cem\\u003e24\\u003c/em\\u003e(2), pp.139-141.\\u003c/li\\u003e\\n \\u003cli\\u003eDillin WH. Clinical syndromes in cervical myelopathy. In: The Spine. 5th ed. Philadelphia: W.B. Saunders; 2006: 775-88.\\u003c/li\\u003e\\n \\u003cli\\u003eBaron EM, Young WF. Cervical spondylotic myelopathy: a brief review of its pathophysiology, clinical course and diagnosis. Neurosurgery. 2007; 60(1 Suppl 1): S35-S41.\\u003c/li\\u003e\\n \\u003cli\\u003eAbbed KM, Coumans JV. Cervical radiculopathy: pathophysiology, presentation and clinical evaluation. Neurosurgery. 2007; 60(Suppl 1): S28-S34\\u003c/li\\u003e\\n \\u003cli\\u003eShiban, E., Gapon, K., Wostrack, M., Meyer, B. and Lehmberg, J., 2016. Clinical and radiological outcome after anterior cervical discectomy and fusion with stand-alone empty polyetheretherketone (PEEK) cages. \\u003cem\\u003eActa neurochirurgica\\u003c/em\\u003e, \\u003cem\\u003e158\\u003c/em\\u003e(2), pp.349-355.\\u003c/li\\u003e\\n \\u003cli\\u003eYang JJ, Yu CH, Chang BS, Yeom JS, Lee JH, Lee CK. Subsidence and nonunion after anterior cervical interbody fusion using a stand-alone polyetheretherketone (PEEK) cage. Clin Orthop Surg. 2011; 3: 16-23.\\u003c/li\\u003e\\n \\u003cli\\u003eChou Y.C., Chen D.C., Hsieh W.A., Chen W.F., Yen P.S., Harnod T., Chiou T.L., Chang Y.L., Su C.F., Lin S.Z. And Chen S.Y.: Efficacy of anterior cervical fusion: Comparison of titanium cages, polyethere-therketone (PEEK) cages and autogenous bone grafts. J. Clin. Neurosci., 15: 1240-1245, 2008.\\u003c/li\\u003e\\n \\u003cli\\u003eIslam MA, Hossain MA , Iqbal AA , Parvez MQ , Ahsanuzzaman M and Ahammed S. Anterior cervical discectomy and fusion with polyetherether ketone cages in the management of single and double level cervical spondylotic myelopathy-our experiences of 80 cases. KYAMC Journal. 2018; 9(1):32-34\\u003c/li\\u003e\\n \\u003cli\\u003eYang, J.J., Yu, C.H., Chang, B.S., Yeom, J.S., Lee, J.H. and Lee, C.K., 2011. Subsidence and nonunion after anterior cervical interbody fusion using a stand-alone polyetheretherketone (PEEK) cage. \\u003cem\\u003eClinics in Orthopedic Surgery\\u003c/em\\u003e, \\u003cem\\u003e3\\u003c/em\\u003e(1),\\u003c/li\\u003e\\n \\u003cli\\u003eMoon, H.J., Kim, J.H., Kim, J.H., Kwon, T.H., Chung, H.S. and Park, Y.K., 2011. The effects of anterior cervical discectomy and fusion with stand-alone cages at two contiguous levels on cervical alignment and outcomes. \\u003cem\\u003eActa neurochirurgica\\u003c/em\\u003e, \\u003cem\\u003e153\\u003c/em\\u003e(3), pp.559-565.\\u003c/li\\u003e\\n \\u003cli\\u003eKwon, W.K., Kim, P.S., Ahn, S.Y., Song, J.Y., Kim, J.H., Park, Y.K., Kwon, T.H. and Moon, H.J., 2017. Analysis of associating factors with C2-7 sagittal vertical axis after two-level anterior cervical fusion: comparison between plate augmentation and stand-alone cages. \\u003cem\\u003eSpine\\u003c/em\\u003e, \\u003cem\\u003e42\\u003c/em\\u003e(5), pp.318-325.\\u003c/li\\u003e\\n \\u003cli\\u003eKelsey, J.L., Githens, P.B., Walter, S.D., Southwick, W.O., Weil, U., Holford, T.R., Ostfeld, A.M., Calogero, J.A., O\\u0026apos;connor, T. and White 3rd, A.A., 1984. An epidemiological study of acute prolapsed cervical intervertebral disc. \\u003cem\\u003eThe Journal of bone and joint surgery. American volume\\u003c/em\\u003e, \\u003cem\\u003e66\\u003c/em\\u003e(6), pp.907-914\\u003c/li\\u003e\\n \\u003cli\\u003eShiban, E., Gapon, K., Wostrack, M., Meyer, B. and Lehmberg, J., 2016. Clinical and radiological outcome after anterior cervical discectomy and fusion with stand-alone empty polyetheretherketone (PEEK) cages. \\u003cem\\u003eActa neurochirurgica\\u003c/em\\u003e, \\u003cem\\u003e158\\u003c/em\\u003e(2), pp.349-355.\\u003c/li\\u003e\\n \\u003cli\\u003eTopuz, K., Colak, A., Kaya, S., Şimşek, H., Kutlay, M., Demircan, M.N. and Velioğlu, M., 2009. Two-level contiguous cervical disc disease treated with peek cages packed with demineralized bone matrix: results of 3-year follow-up. \\u003cem\\u003eEuropean Spine Journal\\u003c/em\\u003e, \\u003cem\\u003e18\\u003c/em\\u003e(2), pp.238-243.\\u003c/li\\u003e\\n \\u003cli\\u003eChoi, M.K., Kim, S.B., Park, C.K. and Kim, S.M., 2016. Comparison of the clinical and radiologic outcomes obtained with single-versus two-level anterior cervical decompression and fusion using stand-alone PEEK cages filled with allograft. \\u003cem\\u003eActa neurochirurgica\\u003c/em\\u003e, \\u003cem\\u003e158\\u003c/em\\u003e(3), pp.481-487\\u003c/li\\u003e\\n \\u003cli\\u003eIslam, M.A., Shohidullah, M., Mahbub, W. and Chowdhury, A.Z., Evaluation of Result of Anterior Cervical Discectomy and Fusion by Standalone PEEK cage in cervical Spondylotic Myeloradiculopathy.\\u003c/li\\u003e\\n \\u003cli\\u003eWang, H.R., Li, X.L., Dong, J., Yuan, F.L. and Zhou, J., 2013. Skip-level anterior cervical discectomy and fusion with self-locking stand-alone PEEK cages for the treatment of 2 noncontiguous levels of cervical spondylosis. \\u003cem\\u003eClinical Spine Surgery\\u003c/em\\u003e, \\u003cem\\u003e26\\u003c/em\\u003e(7), pp.E286-E292.\\u003c/li\\u003e\\n \\u003cli\\u003eLiao, J.C., Niu, C.C., Chen, W.J. and Chen, L.H., 2008. Polyetheretherketone (PEEK) cage filled with cancellous allograft in anterior cervical discectomy and fusion. \\u003cem\\u003eInternational orthopaedics\\u003c/em\\u003e, \\u003cem\\u003e32\\u003c/em\\u003e(5), pp.643-648.\\u003c/li\\u003e\\n \\u003cli\\u003eChoi, M.K., Kim, S.B., Park, C.K. and Kim, S.M., 2016. Comparison of the clinical and radiologic outcomes obtained with single-versus two-level anterior cervical decompression and fusion using stand-alone PEEK cages filled with allograft. \\u003cem\\u003eActa neurochirurgica\\u003c/em\\u003e, \\u003cem\\u003e158\\u003c/em\\u003e(3), pp.481-487.\\u003c/li\\u003e\\n \\u003cli\\u003eNiu, C.C., Liao, J.C., Chen, W.J. and Chen, L.H., 2010. Outcomes of interbody fusion cages used in 1 and 2-levels anterior cervical discectomy and fusion: titanium cages versus polyetheretherketone (PEEK) cages. \\u003cem\\u003eClinical Spine Surgery\\u003c/em\\u003e, \\u003cem\\u003e23\\u003c/em\\u003e(5), pp.310-316.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-2908735/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-2908735/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eObjective:\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTo evaluate the results of Anterior Cervical Discectomy and Fusion by Stand-alone PEEK cage for the treatment of double level cervical spondylotic myelopathy.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eBackground:\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eCervical spondylotic myelopathy is a common cause of neck pain and radiating arm pain which develops when one or more of the intevertebral discs in the cervical spine start to degenerate. Anterior cervical discectomy and fusion (ACDF) is the gold standard treatment for degenerative cervical spine disease.Multiple techniques and modalities of fixation are used in ACDF, among them use of Stand-alone PEEK cage is standard one. To counteract the complications with the plating for ACDF, Stand-alone cage concept was constructed and favourable outcomes have been described with a low rate of dysphagia. Stand-alone PEEK cage provides immediate load bearing support to the anterior column and may facilitate fusion.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMaterials \\u0026amp; methods:\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThis retrospective study was conducted in the spine unit of Orthopaedic Surgery department of Bangabandhu Sheikh Mujib Medical University, Shahbag and other private hospitals in Dhaka, Bangladesh from January 2016 to December 2021. A total number of 50 patients with cervical spondylotic myelolopathy with two level involvement confirmed by MRI were selected for the study who were failed to improve after conservative treatment. Outcome was evaluated by usingvisual analog score (VAS), Modified Odom`s criteria, Nurick’s grading and fusion rate by Bridwell’s criteria.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eMean patient age was 48.4 ± 6.49 years. Male: female ratio 2:1. Pre-operatively, mean VAS score was 7.13±1.51 whereas post-operatively VAS score was decreased significantly to 0.47±0.64 after 12 months of follow up (p value \\u0026lt;0.001). Neurological outcome was assessed by Nurick grading system, where all patients were in grade I (80%), grade II (14%) \\u0026amp; grade III (6%) pre-operatively. Post-operatively at 12 months follow up, maximum patients (92%) were in grade 0 (p value \\u0026lt;0.001). Radiological fusion was assessed by Bridwell fusion criteria, fusion was found in 80% and 90% of patients after 6 and 12 months follow up. Overall improvement was assessed by modified Odom’s score; excellent improvement was seen in majority patients after 12 months of post-operative follow up (86%)\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion:\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eACDF by stand-alone PEEK cage is the best technique for the treatment of double level cervical spondylotic myelopathy with excellent functional outcome. This can be used with minimum risk as well excellent fusion rate.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Evaluation of Results of Anterior Cervical Discectomy and Fusion by Stand- alone PEEK Cage for the Treatment of Double level Cervical Spondylotic Myelopathy\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2023-05-11 14:07:13\",\"doi\":\"10.21203/rs.3.rs-2908735/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"edc31718-8fe5-4b42-9428-46d0d55365c1\",\"owner\":[],\"postedDate\":\"May 11th, 2023\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2023-05-21T08:44:13+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2023-05-11 14:07:13\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-2908735\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-2908735\",\"identity\":\"rs-2908735\",\"version\":[\"v1\"]},\"buildId\":\"GqpaHPwrfC8PjnIFayRh5\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}