A Comparison Of The Bridge-Type Roi-c Interbody Fusion Cage System And Titanium Mesh Graft With Titanium Plate Fixation In 2-Level Anterior Cervical Discectomy And Fusion With Plating And Cage System: A Retrospective Study

A Comparison Of The Bridge-Type Roi-c Interbody Fusion Cage System And Titanium Mesh Graft With Titanium Plate Fixation In 2-Level Anterior Cervical Discectomy And Fusion With Plating And Cage System: A Retrospective Study | 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 A Comparison Of The Bridge-Type Roi-c Interbody Fusion Cage System And Titanium Mesh Graft With Titanium Plate Fixation In 2-Level Anterior Cervical Discectomy And Fusion With Plating And Cage System: A Retrospective Study Shuangjun He, Zhangzhe Zhou, Xiaofeng Shao, Changhao Zhang, Xinfeng Zhou, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-41918/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 explore the clinical efficacy and radioactive results of the bridge-type ROI-C interbody fusion cage (ROI-C) and anterior cervical discectomy and fusion with plating and cage system (ACDF) for cervical spondylopathy. Methods : From January 2014 to January 2018, 45 patients undergoing ACDF were retrospectively analyzed, including 24 cases of ROI-C (group A) and 21 cases of ACDF (group B). The operation time, blood loss, Neck Disability Index (NDI), Japanese Orthopaedic Association score (JOA), postoperative complications, imaging results including cervical Cobb angle and fusion were compared between groups. Results : All patients were successfully treated with surgery, and no cerebrospinal fluid leakage, esophageal fistula, or hoarseness occurred after surgery. The operation time and blood loss in group A were lower than those in group B (P<0.05). During the follow-up period, JOA score increased and NDI score decreased after operation (P0.05). The incidence of dysphagia in group A was lower than that in group B at 1 month and 3 months after operation (P0.05). In group A, the fusion rate was 83.3% 3 months after surgery and 100% at the last follow-up. The rate of adjacent level ossification development was 12.5%. In group B, the fusion rate was 85.7% 3 months after surgery and 100% at the last follow-up. The rate of adjacent level ossification development was 23.8%. Conclusion : Both ROI-C and ACDF can achieve satisfactory results, but ROI-C has shorter operation time, less bleeding and lower incidence of dysphagia in the short term. Orthopedics ACDF ROI-C cervical spondylosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Cervical spondylosis is a common clinical degenerative disease. With the change of people's lifestyles, the incidence of cervical spondylosis increases year by year [ 1 ] . Spinal cord dysfunction caused by cervical spondylosis seriously affects the quality of life of patients [ 2 ] . With the continuous improvement of medical technology and medical equipment, surgical treatment methods for cervical spondylopathy are becoming more and more diverse, including anterior discectomy and fusion internal fixation and posterior laminectomy or plastic surgery. Anterior cervical surgery is accepted by more and more patients due to its small trauma, fast recovery and definite curative effect [ 3 , 4 ] . ACDF is often used in the operation of 2-level cervical spondylosis. This operation has been proved to be an effective treatment method, but there are still some complications. It was reported that the complications are common such as dysphagia, esophageal injury, bone nonunion, screw loosening and plate displacement [ 5 , 6 ] . Therefore, how to reduce postoperative complications on the premise of adequate decompression, firm fixation and bone graft fusion has been an important research direction in the treatment of cervical spondylosis. ROI-C, a new surgery, that is composed of PEEK box and two self-locking clips has been successfully applied in clinical practice, which provide a stable biomechanical environment and avoid the implant contact with the anterior vertebral soft tissue. In this study, 45 patients with cervical spondylosis were retrospectively analyzed. We compared the curative effect and complications of patients with cervical spondylosis treated with the bridge-type ROI-C interbody fusion cage system and titanium mesh graft with titanium plate fixation. Materials And Methods General information From January 2014 to January 2018, there were 24 patients in ROI-C group (group A), including 9 males and 15 females, aged 51-71 (60.59 ± 8.21) years old; 21 patients in ACDF group (group B), including 8 males and 13 females, aged 52-70 (60.15 ± 7.52) years old. The inclusion criteria were as follows: (1) cervical spondylosis showed corresponding symptoms, such as neck and shoulder pain, numbness, limb weakness, walking instability, cotton feeling and other symptoms; (2) cervical X-ray film, computed tomography (CT) or magnetic resonance imaging (MRI) showed compression of adjacent 2-level spinal cord or nerve root. Exclusion criteria included: (1) developmental stenosis and ossification of the posterior longitudinal ligament; (2) previous cervical surgery, tumor or any serious disease history; (3) cervical fracture dislocation or severe cervical instability. Surgical procedures All operations were performed by two experienced surgeons in the same treatment group. The patients were administered general anesthesia and were placed in the supine position. In the group A, trial spacers were used to determine the appropriate size of the anchored intervertebral fusion cage. After implantation of the cage, two cervical anchoring clips were placed into the lower and upper vertebrae through the anterior part of the cage to ensure primary stabilization by self-locking function of the anchoring clips. In the group B, the appropriate size for the cage was determined by intraoperative evaluation using a trial cage。Self-tapping screws were used to fix the anterior cervical plate. Clinical evaluation Record the operation time, the bleeding during the operation, and observe the postoperative complications, including the incidence of dysphagia, the duration of symptoms and whether they are disappeared. JOA score [7] and NDI score [8] were used to evaluate the clinical outcomes before and after surgery. The effect of operation was determined by Odom's score [9] , and its grades were as follows: excellent, symptoms and signs disappeared after operation; good, most symptoms and signs were relieved and normal function was restored; generally, symptoms and signs were partially improved, but could not operate normally; poor, symptoms and signs were basically the same as before operation. According to the Bazaz score [10] , the degree of dysphagia was divided into four grades: none, no dysphagia; mild, almost no dysphagia; moderate, occasional dysphagia; severe, severe dysphagia. Radioactivity evaluation The imaging data included preoperative and postoperative imaging examination. If all the following conditions are satisfied, it is considered that radiologic fusion is achieved: a) The displacement of adjacent vertebrae < 2° in flexion and extension of neck; b) height of the intervertebral space was unchanged; c) no transparent line was seen between the grafted bone and the upper and lower endplates of vertebral body. The evaluation criteria of adjacent level ossification development (ALOD) were as follows: grade 0 (no ALOD formation), grade 1 (ALOD extends across less than 50 % of the disc space), grade 2 (ALOD extends greater than or equal to 50 % of the disc space), and grade 3 (complete bridging of the adjacent discspace). The cobb angle is measured in the sagittal position of the cervical spine, which is formed between the perpendicular line of the inferior end plate of the C2 and C7 vertebral body. Statistical treatment. All statistical analyses were performed using SPSS 19.0 software (SPSS Inc., Chicago, USA). Student t test was used to analyze the clinical and radiological outcomes among both groups. Chi square test was used to assess rate of dysphagia, ALOD and fusion. All P < 0.05 values were considered statistically significant. Results Clinical evaluation All patients were successfully treated with surgery, and no cerebrospinal fluid leakage, esophageal fistula, or hoarseness occurred after surgery. The 45 patients were divided into 2 groups: Group A (24 patients), who underwent fusion using ROI-C ( Figs. 1 and 2 ) ; and Group B (21 patients), who underwent fusion using ACDF ( Figs. 3 and 4 ) . In group A, the patient was 60.59 ± 8.21 years old, the follow-up time was 25.6 ± 3.3 months, the operation time was 101 ± 22 min and blood loss was 150 ± 46 ml ( Table 1 ) . JOA score increased from preoperative 9.6 ± 1.7 to postoperative 13.8 ± 2.2, and finally maintained at 14.5 ± 1.5. NDI score decreased from preoperative 32.1 ± 7.9 to postoperative 15.9 ± 4.7, and finally maintained at 13.7 ± 4.6 ( Table 2 ) . One month after surgery, 3 patients had complications of dysphagia, but the symptom soon disappeared ( Table 3 ) . In group B, the patient was 60.15 ± 7.52 years old, the follow-up time was 26.1 ± 3.5 months, the operation time was 118 ± 29 min and blood loss was 185 ± 58 ml ( Table 1 ) . JOA score increased from preoperative 9.4 ± 1.5 to postoperative 14.1 ± 1.6, and finally maintained at 14.6 ± 1.8. NDI score decreased from preoperative 30.5 ± 8.6 to postoperative 15.1 ± 4.9, and finally maintained at 13.1 ± 4.4 ( Table 2 ) . One month after the operation, 8 patients had dysphagia complications, of which 4 patients disappeared at 3 months after operation, and one patient still had dysphagia at the last follow-up ( Table 3 ) . The operation time and blood loss in group A were lower than those in group B (P < 0.05). During the follow-up period, JOA score increased and NDI score decreased after operation (P 0.05). The incidence of dysphagia in group A was lower than that in group B at 1 month and 3 months after operation (P 0.05). Table 1 General information Group A Group B P value Number 24 21 Gender Male 9 8 Female 15 13 Age (year) 60.59 ± 8.21 60.15 ± 7.52 0.853 Follow-up (months) 25.6 ± 3.3 26.1 ± 3.5 0.625 Operation time (minute) 101 ± 22 118 ± 29 0.031 Blood loss (ml) 150 ± 46 185 ± 58 0.029 P value is given for comparison between group A and group B P < 0.05, statistically significant. Table 2 Clinical and radiologic data evaluated before surgery and during follow-up (mean ± SD) Group A Group B P value JOA scores Preoperatvie 9.6 ± 1.7 a 9.4 ± 1.5 a 0.680 Postoperative 1 month 13.8 ± 2.2 b 14.1 ± 1.6 b 0.608 Last follow-up 14.5 ± 1.5 b 14.6 ± 1.8 b 0.840 NDI scores Preoperatvie 32.1 ± 7.9 a 30.5 ± 8.6 a 0.519 Postoperative 1 month 15.9 ± 4.7 b 15.1 ± 4.9 b 0.579 Last follow-up 13.7 ± 4.6 b 13.1 ± 4.4 b 0.658 JOA Japanese Orthopedic Association, NDI Neck Disability Index a P value is given for comparison between group A and group B b P < 0.05 comparing with preoperative value Table 3 Incidence of dysphagia. Group A Group B P value Dysphagia 12.5% (3/24) 38.1% (8/21) 0.046 One month postoperatively 0% (0/24) 19% (4/21) 0.025 Final follow-up 0% (0/24) 4.8% (1/21) 0.280 P value is given for comparison between group A and group B P < 0.05, statistically significant. Radioactivity evaluation In group A, cobb angle increased from preoperative 13.5 ± 10.3 to postoperative 18.9 ± 9.4, and finally maintained at 17.9 ± 9.8. The fusion rate was 83.3% 3 months after surgery and 100% at the last follow-up. The rate of adjacent level ossification development was 12.5%. In group B, cobb angle increased from preoperative 12.5 ± 9.4 to postoperative 17.5 ± 10.4, and finally maintained at 17.1 ± 10.6. The fusion rate was 85.7% 3 months after surgery and 100% at the last follow-up. The rate of adjacent level ossification development was 23.8% (Table 4 ). Table 4 The mean outcomes of radiological parameters measured before operation and during follow-up(mean ± SD) Group A Group B P value Cervical lordosis Preoperatvie 13.5 ± 10.3 a 12.5 ± 9.4 a 0.737 Postoperative 1 month 18.9 ± 9.4 b 17.5 ± 10.4 b 0.638 Last follow-up 17.9 ± 9.8 b 17.1 ± 10.6 b 0.794 Fusion rate Postoperative 3 month 83.3% (20/24) 85.7% (18/21) 0.826 Final fusion 100% 100% Adjacent segment degeneration 12.5% (3/24) 23.8%(5/21) 0.322 a P value is given for comparison between group A and group B b P < 0.05 comparing with preoperative value Discussion After conservative treatment was ineffective, surgical intervention became the first choice [ 11 ] . ACDF is the standard surgery for the treatment of cervical degenerative disc disease, which can restore the physiological radian of cervical vertebra to the maximum extent, have high intervertebral fusion rate, maintain the stability of cervical spine, and have remarkable surgical effect [ 12 ] . In our study, the postoperative cervical cobb angle of the two surgery was significantly bigger than the preoperative cervical cobb angle, which indicated that both surgery can correct cervical kyphosis. Therefore, the fusion and biomechanical stability of ROI-C are equal to those of ACDF, and satisfactory surgical results of both surgery have been achieved [ 13 ] . The results of this study showed that JOA score and NDI score of both groups were improved, and good operation effect was maintained during the follow-up period, which demonstrated that the two surgery can relieve spinal cord and nerve compression, and improve the quality of life of patients. This study found that the ROI-C has the following advantages: 1. The operation wound is smaller and less bleeding. Although ROI-C surgery can’t reduce skin incision, it is not necessary to consider the placement of plate fixation and extensive exposure of adjacent vertebral body, only need to expose the target intervertebral space, which is convenient for operation. 2. The operation time is relatively short and the operation is simple. In group A, the cage was directly fixed with self-locking clip, which could save operation time. 3. The incidence of dysphagia was reduced after operation. At present, dysphagia is a common complication after ACDF, whose mechanism has not been explained clearly [ 14 , 15 ] . It may be related to the following factors: 1. During anesthesia, the stimulation of pharynx and trachea may cause dysphagia. Some scholars suggest that atomization after operation can partly relieve dysphagia symptoms. Dysphagia caused by this reason can be recovered within one month. 2. Postoperative soft tissue adhesion may lead to dysphagia. In order to expose the target position, the soft tissue in front of the vertebral body needs to be stripped. In group A, only the intervertebral space needs to be exposed to facilitate the operation, while in group B, the plate fixation is placed in front of the vertebral body, resulting in a wider range of exposure and more bleeding, which increased the possibility of postoperative adhesion. 3.The incidence of dysphagia will be increased by using anterior cervical plate [ 16 ] . A large number of clinical studies have shown that after plate fixation is fixed, the plate will protrude from the surface of cervical body, which cause slight compression on the esophagus [ 17 , 18 ] . Some scholars reported that the use of thinner plate fixation will reduce the incidence of dysphagia [ 19 ] . Previous studies have also shown that the use of zero-profile anchored spacer can significantly reduce the incidence of dysphagia. In this study, we found that the ROI-C was completely implanted in the intervertebral space, and there was no compression on the esophagus. The incidence of dysphagia in group A was lower than that in group B. the difference was statistically significant at one month and three months after operation, which indicated that the use of ROI-C can reduce the incidence of early dysphagia. The effect of ACDF depends on the degree of decompression, the recovery of cervical lordosis and the stability of fusion. Anterior plate fixation is often used in ACDF to improve the speed of interbody fusion and enhance the stability of cage. Only after bone fusion can kyphosis and spinal canal stenosis be effectively prevented, so as to prevent compression of spinal cord and nerve root [ 20 ] . Wang et al. [ 21] and Grasso et al. [ 22] reported a fusion rate of 100% in patients with ROI-C who were followed up for 2 years. Hofstetter et al. [ 12] reported that the fusion rate of ROI-C was 95.2% after an average follow-up of 13.9 months. Our results show that the two groups have achieved satisfactory results of bone fusion, and there is no significant difference between the two methods. So far, the mechanism of adjacent joint degeneration is not clear. It is not only related to the natural degradation of adjacent joints, but also to the increase of adjacent upper and lower joint activities caused by abnormal fusion [ 23 , 24 ] . Lee et al. [ 25 ] believe that the use of short plates with oblique screw tracks can significantly reduce the incidence and severity of ALOD. Many studies have shown that the shorter the plate length, the lower the incidence of ossification of the adjacent vertebral body, which may be related to the separation of the soft tissue in front of the vertebral body [ 26 , 27 ] . In group A, 3 patients had adjacent vertebral degeneration, and 5 patients in group B had adjacent vertebral degeneration. In the last follow-up, no patient needed surgical intervention. In the future, we will continue to investigate and further evaluate whether the bridge-type ROI-C interbody fusion cage can help reduce the incidence of adjacent vertebral degeneration and the need for reoperation. Of course, this study also has some limitations: first of all, this study is a retrospective study, and the level of evidence is limited. Secondly, there may be measurement errors. In order to minimize these errors, three orthopedic surgeons measured the X-ray data separately. Finally, the number of cases in this study is small and the follow-up time is short, which may lead to selective bias. In the future, robust randomized multi-center prospective studies with long-term follow-up are needed to confirm these findings. Conclusion Both ROI-C and ACDF can achieve satisfactory results, but ROI-C has shorter operation time, less bleeding and lower incidence of dysphagia in the short term. Abbreviations ROI-C: the bridge-type ROI-C interbody fusion cage; ACDF: anterior cervical discectomy and fusion with plating and cage system; JOA: Japanese Orthopaedic Association score; NDI: Neck Disability Index; ALOD: adjacent level ossification development; MRI: magnetic resonance imaging; CT: computed tomography Declarations Funding This work was supported by the National Nature Science Foundation of China (grant no. 81802682) and the Natural Science Foundation of Jiangsu Province (grant no. BK20180199). Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Authors’ contributions All authors made substantive intellectual contributions to this study to qualify as authors. QZ, WY and CK contributed to study design, acquisition of data, analysis of data, and interpretation of results. ZC and ZX contributed to study coordination. SX, ZC and WS contributed to statistical analysis. HS and ZZcontributed to manuscript preparation. All authors read and approved the final manuscript. Ethics approval and consent to participate This study was approved by the Institutional Ethics Committee of Soochow University. Written informed consent was obtained from all participants. Competing interests The authors declare that they have no competing interests. Consent for publication Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Acknowledgements Thanks to the support from the First Affiliated Hospital of Soochow University. References Boogaarts HD, Bartels RH. Prevalence of cervical spondylotic myelopathy. Eur Spine J. 2015;24 Suppl 2: 139-141. Matsunaga S, Komiya S, Toyama Y. Risk factors for development of myelopathy in patients with cervical spondylotic cord compression. Eur Spine J. 2015;24 Suppl 2:142-149. De la Garza-Ramos R, Xu R, Ramhmdani S, et al. Long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion. J Neurosurg Spine. 2016;24(6): 885-891. Epstein NE, Hollingsworth R. Diagnosis and management of traumatic cervical central spinal cord injury: A review. Surg Neurol Int. 2015;6(Suppl 4): S140-153. Arnold PM, Anderson KK, Selim A, et al. Heterotopic ossification following single-level anterior cervical discectomy and fusion: results from the prospective, multicenter, historically controlled trial comparing allograft to an optimized dose of rhBMP-2. J Neurosurg Spine. 2016;25(3):292-302. Lee CH, Lee J, Kang JD, et al. Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: a meta-analysis of clinical and radiological outcomes. J Neurosurg Spine. 2015;22(6):589-595. Yonenobu K, Abumi K, Nagata K, Taketomi E, Ueyama K. Interobserver and intraobserver reliability of the Japanese orthopaedic association scoring system for evaluation of cervical compression myelopathy. Spine. 2001;26(17):1890–1894. Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther. 1991;14(7):409–415. Odom GL, Finney W, Woodhall B. Cervical disk lesions. J Am Med Assoc ,1958;166(1):23–28. Bazaz R, Lee MJ, Yoo JU. Incidence of dysphagia after anterior cervical spine surgery: a prospective study. Spine. 2002;27(22):2453–2458. Li J, Zheng Q, Guo X et al. Anterior surgical options for the treatment of cervical spondylotic myelopathy in a long-term follow-up study. Arch Orthop Trauma Surg. 2013; 133(6):745–751 Hofstetter CP, Kesavabhotla K, Boockvar JA. Zero-Profile Anchored Spacer Reduces Rate of Dysphagia Compared with ACDF with Anterior Plating. J Spinal Disord Tech. 2015;28(5): E284-290. Michael N Bucci , Dennis Oh , R Scott Cowan et al. The ROI-C Zero-Profile Anchored Spacer for Anterior Cervical Discectomy and Fusion: Biomechanical Profile and Clinical Outcomes. Med Devices (Auckl). 2017 Apr 18(10)61-69. Nguyen C, Sanchez K, Roren A, et al. Anatomical specificities of the degenerated cervical spine: a narrative review of clinical implications, with special focus on targeted spinal injections. Ann Phys Rehabil Med. 2016. Nakagawa H, Okazaki T, Saito K. Surgical Strategies in Management of Cervical Spondylotic Myelopathy. World Neurosurg. 2015;84(2): 220-221. Shin J S, Oh S H, Cho P G. Surgical outcome of a Zero-profile device comparing with stand-alone cage and anterior cervical plate with iliac bone graft in the anterior cervical discectomy and fusion [J]. Korean J Spine, 2017,11（3）: 169-177. Chung J Y, Kim S K, Jung S T, et al. Clinical adjacentsegment pathology after anterior cervical discectomy and fusion: results after a minimum of 10-year follow-up [J]. Spine J, 2014, 14（10）: 2290-2298. DOI: 10.1016/j.spine.2014.01.027. Chen Y, Chen H, Cao P, et al. Anterior cervical interbody fusion with the Zero-P spacer: mid-term results of two-level fusion. Eur Spine J. 2015;24(8): 1666-1672. Alimi M, Njoku I, Hofstetter C P, et al. Anterior cervical discectomy and fusion (ACDF): comparison between Zero Profile implants and anterior cervical plate and spacer [J]. Cureus, 2016, 8（4）: e573- e580. Kaiser MG, Haid RW Jr, Subach BR, Barnes B, Rodts GE Jr. Anterior cervical plating enhances arthrodesis after discectomy and fusion with cortical allograft. Neurosurgery. 2002;50:229–236. Wang Z, Jiang W, Li X, et al. The application of zero-profile anchored spacer in anterior cervical discectomy and fusion. Eur Spine J. 2015;24: 148–154. Grasso G, Giambartino F, Tomasello G, Iacopino G. Anterior cervical discectomy and fusion with ROI-C PEEK cage: cervical alignment and patient outcomes. Eur Spine J. 2014;23(Suppl 6): S650–S657. Goodwin CR, Desai A, Khattab MH, et al. Cervical Fusion for Absent Pedicle Syndrome Manifesting with Myelopathy. World Neurosurg. 2016;86: 515. e17-22. He L, Qian Y, Jin YJ, et al. [The clinical value of end plate rings in preventing subsidence of titanium cage in anterior cervical corpectomy and fusion surgery]. Zhongguo Gu Shang. 2014;27(9): 738-744. Lee DH, Lee JS, Yi JS et al. Anterior cervical plating technique to prevent adjacent-level ossification development. Spine J.2013;13(7):823–829 Park JB, Cho YS, Riew KD et al. Development of adjacent- level ossification in patients with an anterior cervical plate. J Bone Joint Surg Am 2005; 87:558–563 Ishihara H, Kanamori M, Kawaguchi Y et al. Adjacent segment disease after anterior cervical interbody fusion. Spine J;2004; 4(6):624–628 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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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-41918","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":816229,"identity":"c152e284-e7d6-442e-8d00-fac680c8e2ef","order_by":0,"name":"Shuangjun He","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shuangjun","middleName":"","lastName":"He","suffix":""},{"id":816230,"identity":"40a66c4c-620c-4944-9e80-94d409c7a745","order_by":1,"name":"Zhangzhe Zhou","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhangzhe","middleName":"","lastName":"Zhou","suffix":""},{"id":816231,"identity":"cdc344ab-a3c9-490c-8d0b-d37f095bce58","order_by":2,"name":"Xiaofeng Shao","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaofeng","middleName":"","lastName":"Shao","suffix":""},{"id":816232,"identity":"fc722f3a-6964-4937-a63c-bc36560f5aa3","order_by":3,"name":"Changhao Zhang","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Changhao","middleName":"","lastName":"Zhang","suffix":""},{"id":816233,"identity":"b43355a5-2c71-4468-a3b4-bfc4a5159b61","order_by":4,"name":"Xinfeng Zhou","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xinfeng","middleName":"","lastName":"Zhou","suffix":""},{"id":816234,"identity":"1594e091-c827-49b1-a41e-e92954f5872e","order_by":5,"name":"Shuhua Wu","email":"","orcid":"","institution":"The people's hospital of danyang","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shuhua","middleName":"","lastName":"Wu","suffix":""},{"id":816235,"identity":"27565d86-6199-40b0-9dad-e22632885720","order_by":6,"name":"Kangwu Chen","email":"","orcid":"","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kangwu","middleName":"","lastName":"Chen","suffix":""},{"id":816236,"identity":"d571b641-eef6-4949-a31d-479e40b1e533","order_by":7,"name":"Yaowei Wang","email":"","orcid":"","institution":"The people's hospital of danyang","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yaowei","middleName":"","lastName":"Wang","suffix":""},{"id":816237,"identity":"8cc27cc0-e48e-495b-8195-6b4b5986333e","order_by":8,"name":"Qian Zhonglai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYFAC5gYJMM3e2PjwA3FaGEFaDBgYeA43G0uQpkUivU2AhxgNfOcPNt74UPNHznzmwzYGCQY7Od0GAlokDxxstpxxzMBY5nZi24MChmRjswMEtBgcbGyT5m0wSJwhndhuIMFwIHEbQS2HGaFaJA+2SfAQpeUYTIsEI5FaJM8wgvxibCzBkwgMZAMi/MJ3/vBBYIjJyUmwH3/48EOFnRxBLQyoCgwIKcfUMgpGwSgYBaMACwAA5GdBjasoWOYAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-0737-9696","institution":"First Affiliated Hospital of Soochow University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Qian","middleName":"","lastName":"Zhonglai","suffix":""}],"badges":[],"createdAt":"2020-07-13 15:04:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-41918/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-41918/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":1566886,"identity":"83a484bc-f7ab-4b08-a95d-6c7efcb14d2a","added_by":"auto","created_at":"2020-07-15 16:01:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":245978,"visible":true,"origin":"","legend":"A 65-year-old woman with cervical spondylosis was admitted to our hospital due to numbness and weakness of both upper limbs: (a) Preoperative CT showed cervical degeneration, loss of physiological radian and hyperosteogeny; (b) Preoperative MRI indicated C3-C4 and C4-C5 cervical disc herniation and spinal cord compression; (c) Postoperative MRI noted that the spinal cord compression and the symptoms were relieved.","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-41918/v1/Figure1.jpg"},{"id":1566887,"identity":"843fc458-dec3-46fa-a3b1-fa1460b8d157","added_by":"auto","created_at":"2020-07-15 16:01:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":246938,"visible":true,"origin":"","legend":"(a, b) Three days after operation, X-ray showed that C3-C4 and C4-C5 cervical discectomy and the positions of bridge-type ROI-C interbody fusion cages were good; (c, d) One year after operation, X-ray showed that C3-C4 and C4-C5 cervical fusion and the positions of bridge-type ROI-C interbody fusion cages were good.","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-41918/v1/Figure2.jpg"},{"id":1566888,"identity":"9cbae334-e20f-4f21-b715-d09cb38f0050","added_by":"auto","created_at":"2020-07-15 16:01:01","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":264106,"visible":true,"origin":"","legend":"(a, b) Preoperative X-ray showed the disappearance of cervical vertebrae radian and hyperosteogeny; (c) Preoperative CT scan showed the disappearance of cervical vertebrae radian and the change of intervertebral space; (d) Preoperative MRI showed C4-C5 and C5-C6 cervical disc herniation and spinal cord compression.","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-41918/v1/Figure3.jpg"},{"id":1566889,"identity":"868ab043-28ab-4e02-984b-8a7938bb7d06","added_by":"auto","created_at":"2020-07-15 16:01:01","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":310395,"visible":true,"origin":"","legend":"(a, b) Three days after operation, X-ray showed that C4-C5 and C5-C6 cervical discectomy and the positions of titanium mesh and plate were good. (c, d) One year after operation, X-ray showed that C4-C5 and C5-C6 cervical fusion and the positions of titanium mesh and plate were good.","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-41918/v1/Figure4.jpg"},{"id":13551629,"identity":"f7ddfc1b-ef56-4b4d-abf3-6565c9bb228c","added_by":"auto","created_at":"2021-09-17 02:29:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":646808,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-41918/v1/1b464aea-63bb-4bc7-93e1-b4b3b407bcd5.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eA Comparison Of The Bridge-Type Roi-c Interbody Fusion Cage System And Titanium Mesh Graft With Titanium Plate Fixation In 2-Level Anterior Cervical Discectomy And Fusion With Plating And Cage System: A Retrospective Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eCervical spondylosis is a common clinical degenerative disease. With the change of people's lifestyles, the incidence of cervical spondylosis increases year by year \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Spinal cord dysfunction caused by cervical spondylosis seriously affects the quality of life of patients \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. With the continuous improvement of medical technology and medical equipment, surgical treatment methods for cervical spondylopathy are becoming more and more diverse, including anterior discectomy and fusion internal fixation and posterior laminectomy or plastic surgery. Anterior cervical surgery is accepted by more and more patients due to its small trauma, fast recovery and definite curative effect \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. ACDF is often used in the operation of 2-level cervical spondylosis. This operation has been proved to be an effective treatment method, but there are still some complications. It was reported that the complications are common such as dysphagia, esophageal injury, bone nonunion, screw loosening and plate displacement \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Therefore, how to reduce postoperative complications on the premise of adequate decompression, firm fixation and bone graft fusion has been an important research direction in the treatment of cervical spondylosis.\u003c/p\u003e \u003cp\u003eROI-C, a new surgery, that is composed of PEEK box and two self-locking clips has been successfully applied in clinical practice, which provide a stable biomechanical environment and avoid the implant contact with the anterior vertebral soft tissue. In this study, 45 patients with cervical spondylosis were retrospectively analyzed. We compared the curative effect and complications of patients with cervical spondylosis treated with the bridge-type ROI-C interbody fusion cage system and titanium mesh graft with titanium plate fixation.\u003c/p\u003e "},{"header":"Materials And Methods","content":"\u003cp\u003e\u003cstrong\u003eGeneral information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom January 2014 to January 2018, there were 24 patients in ROI-C group (group A), including 9 males and 15 females, aged 51-71 (60.59 \u0026plusmn; 8.21) years old; 21 patients in ACDF group (group B), including 8 males and 13 females, aged 52-70 (60.15 \u0026plusmn; 7.52) years old. The inclusion criteria were as follows: (1) cervical spondylosis showed corresponding symptoms, such as neck and shoulder pain, numbness, limb weakness, walking instability, cotton feeling and other symptoms; (2) cervical X-ray film, computed tomography (CT) or magnetic resonance imaging (MRI) showed compression of adjacent 2-level spinal cord or nerve root. Exclusion criteria included: (1) developmental stenosis and ossification of the posterior longitudinal ligament; (2) previous cervical surgery, tumor or any serious disease history; (3) cervical fracture dislocation or severe cervical instability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll operations were performed by two experienced surgeons in the same treatment group. The patients were administered general anesthesia and were placed in the supine position. In the group A, trial spacers were used to determine the appropriate size of the anchored intervertebral fusion cage. After implantation of the cage, two cervical anchoring clips were placed into the lower and upper vertebrae through the anterior part of the cage to ensure primary stabilization by self-locking function of the anchoring clips. In the group B, the appropriate size for the cage was determined by intraoperative evaluation using a trial cage。Self-tapping screws were used to fix the anterior cervical plate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRecord the operation time, the bleeding during the operation, and observe the postoperative complications, including the incidence of dysphagia, the duration of symptoms and whether they are disappeared. JOA score \u003csup\u003e[7]\u003c/sup\u003e and NDI score \u003csup\u003e[8]\u003c/sup\u003e were used to evaluate the clinical outcomes before and after surgery. The effect of operation was determined by Odom's score \u003csup\u003e[9]\u003c/sup\u003e, and its grades were as follows: excellent, symptoms and signs disappeared after operation; good, most symptoms and signs were relieved and normal function was restored; generally, symptoms and signs were partially improved, but could not operate normally; poor, symptoms and signs were basically the same as before operation. According to the Bazaz score \u003csup\u003e[10]\u003c/sup\u003e, the degree of dysphagia was divided into four grades: none, no dysphagia; mild, almost no dysphagia; moderate, occasional dysphagia; severe, severe dysphagia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRadioactivity evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe imaging data included preoperative and postoperative imaging examination. If all the following conditions are satisfied, it is considered that radiologic fusion is achieved: a) The displacement of adjacent vertebrae \u0026lt; 2\u0026deg; in flexion and extension of neck; b) height of the intervertebral space was unchanged; c) no transparent line was seen between the grafted bone and the upper and lower endplates of vertebral body. The evaluation criteria of adjacent level ossification development (ALOD) were as follows: grade 0 (no ALOD formation), grade 1 (ALOD extends across less than 50 % of the disc space), grade 2 (ALOD extends greater than or equal to 50 % of the disc space), and grade 3 (complete bridging of the adjacent discspace). The cobb angle is measured in the sagittal position of the cervical spine, which is formed between the perpendicular line of the inferior end plate of the C2 and C7 vertebral body.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical treatment.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using SPSS 19.0 software (SPSS Inc., Chicago, USA). Student t test was used to analyze the clinical and radiological outcomes among both groups. Chi square test was used to assess rate of dysphagia, ALOD and fusion. All P \u0026lt; 0.05 values were considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eClinical evaluation\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAll patients were successfully treated with surgery, and no cerebrospinal fluid leakage, esophageal fistula, or hoarseness occurred after surgery. The 45 patients were divided into 2 groups: Group A (24 patients), who underwent fusion using ROI-C \u003cb\u003e(\u003c/b\u003eFigs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e; and Group B (21 patients), who underwent fusion using ACDF \u003cb\u003e(\u003c/b\u003eFigs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. In group A, the patient was 60.59\u0026thinsp;\u0026plusmn;\u0026thinsp;8.21\u0026nbsp;years old, the follow-up time was 25.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3 months, the operation time was 101\u0026thinsp;\u0026plusmn;\u0026thinsp;22\u0026nbsp;min and blood loss was 150\u0026thinsp;\u0026plusmn;\u0026thinsp;46\u0026nbsp;ml \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. JOA score increased from preoperative 9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 to postoperative 13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2, and finally maintained at 14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5. NDI score decreased from preoperative 32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9 to postoperative 15.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7, and finally maintained at 13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. One month after surgery, 3 patients had complications of dysphagia, but the symptom soon disappeared \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. In group B, the patient was 60.15\u0026thinsp;\u0026plusmn;\u0026thinsp;7.52\u0026nbsp;years old, the follow-up time was 26.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5 months, the operation time was 118\u0026thinsp;\u0026plusmn;\u0026thinsp;29\u0026nbsp;min and blood loss was 185\u0026thinsp;\u0026plusmn;\u0026thinsp;58\u0026nbsp;ml \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. JOA score increased from preoperative 9.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 to postoperative 14.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6, and finally maintained at 14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8. NDI score decreased from preoperative 30.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 to postoperative 15.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9, and finally maintained at 13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4 \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. One month after the operation, 8 patients had dysphagia complications, of which 4 patients disappeared at 3\u0026nbsp;months after operation, and one patient still had dysphagia at the last follow-up \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The operation time and blood loss in group A were lower than those in group B (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). During the follow-up period, JOA score increased and NDI score decreased after operation (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but there was no significant difference between the groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The incidence of dysphagia in group A was lower than that in group B at 1\u0026nbsp;month and 3\u0026nbsp;months after operation (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but the final follow-up results showed that there was no significant difference in the incidence of dysphagia between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral information\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.59\u0026thinsp;\u0026plusmn;\u0026thinsp;8.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.15\u0026thinsp;\u0026plusmn;\u0026thinsp;7.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.853\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (minute)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101\u0026thinsp;\u0026plusmn;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118\u0026thinsp;\u0026plusmn;\u0026thinsp;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150\u0026thinsp;\u0026plusmn;\u0026thinsp;46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e185\u0026thinsp;\u0026plusmn;\u0026thinsp;58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eP\u003c/em\u003e value is given for comparison between group A and group B\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical and radiologic data evaluated before surgery and during follow-up (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJOA scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatvie\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.680\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNDI scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatvie\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.519\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.579\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.658\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eJOA\u003c/em\u003e Japanese Orthopedic Association, \u003cem\u003eNDI\u003c/em\u003e Neck Disability Index\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e P value is given for comparison between group A and group B\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 comparing with preoperative value\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIncidence of dysphagia.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDysphagia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.5% (3/24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.1% (8/21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne month postoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0% (0/24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19% (4/21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0% (0/24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8% (1/21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eP\u003c/em\u003e value is given for comparison between group A and group B\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eRadioactivity evaluation\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eIn group A, cobb angle increased from preoperative 13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3 to postoperative 18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4, and finally maintained at 17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8. The fusion rate was 83.3% 3 months after surgery and 100% at the last follow-up. The rate of adjacent level ossification development was 12.5%. In group B, cobb angle increased from preoperative 12.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4 to postoperative 17.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4, and finally maintained at 17.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6. The fusion rate was 85.7% 3 months after surgery and 100% at the last follow-up. The rate of adjacent level ossification development was 23.8% (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe mean outcomes of radiological parameters measured before operation and during follow-up(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical lordosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperatvie\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.737\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.794\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFusion rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 3 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.3% (20/24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.7% (18/21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal\u0026nbsp;fusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjacent segment degeneration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.5% (3/24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8%(5/21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.322\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e P value is given for comparison between group A and group B\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 comparing with preoperative value\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eAfter conservative treatment was ineffective, surgical intervention became the first choice \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. ACDF is the standard surgery for the treatment of cervical degenerative disc disease, which can restore the physiological radian of cervical vertebra to the maximum extent, have high intervertebral fusion rate, maintain the stability of cervical spine, and have remarkable surgical effect \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. In our study, the postoperative cervical cobb angle of the two surgery was significantly bigger than the preoperative cervical cobb angle, which indicated that both surgery can correct cervical kyphosis. Therefore, the fusion and biomechanical stability of ROI-C are equal to those of ACDF, and satisfactory surgical results of both surgery have been achieved \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. The results of this study showed that JOA score and NDI score of both groups were improved, and good operation effect was maintained during the follow-up period, which demonstrated that the two surgery can relieve spinal cord and nerve compression, and improve the quality of life of patients.\u003c/p\u003e \u003cp\u003eThis study found that the ROI-C has the following advantages: 1. The operation wound is smaller and less bleeding. Although ROI-C surgery can\u0026rsquo;t reduce skin incision, it is not necessary to consider the placement of plate fixation and extensive exposure of adjacent vertebral body, only need to expose the target intervertebral space, which is convenient for operation. 2. The operation time is relatively short and the operation is simple. In group A, the cage was directly fixed with self-locking clip, which could save operation time. 3. The incidence of dysphagia was reduced after operation. At present, dysphagia is a common complication after ACDF, whose mechanism has not been explained clearly \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. It may be related to the following factors: 1. During anesthesia, the stimulation of pharynx and trachea may cause dysphagia. Some scholars suggest that atomization after operation can partly relieve dysphagia symptoms. Dysphagia caused by this reason can be recovered within one month. 2. Postoperative soft tissue adhesion may lead to dysphagia. In order to expose the target position, the soft tissue in front of the vertebral body needs to be stripped. In group A, only the intervertebral space needs to be exposed to facilitate the operation, while in group B, the plate fixation is placed in front of the vertebral body, resulting in a wider range of exposure and more bleeding, which increased the possibility of postoperative adhesion. 3.The incidence of dysphagia will be increased by using anterior cervical plate \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. A large number of clinical studies have shown that after plate fixation is fixed, the plate will protrude from the surface of cervical body, which cause slight compression on the esophagus \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Some scholars reported that the use of thinner plate fixation will reduce the incidence of dysphagia \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Previous studies have also shown that the use of zero-profile anchored spacer can significantly reduce the incidence of dysphagia. In this study, we found that the ROI-C was completely implanted in the intervertebral space, and there was no compression on the esophagus. The incidence of dysphagia in group A was lower than that in group B. the difference was statistically significant at one month and three months after operation, which indicated that the use of ROI-C can reduce the incidence of early dysphagia.\u003c/p\u003e \u003cp\u003eThe effect of ACDF depends on the degree of decompression, the recovery of cervical lordosis and the stability of fusion. Anterior plate fixation is often used in ACDF to improve the speed of interbody fusion and enhance the stability of cage. Only after bone fusion can kyphosis and spinal canal stenosis be effectively prevented, so as to prevent compression of spinal cord and nerve root \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Wang et al. \u003csup\u003e[ 21]\u003c/sup\u003e and Grasso et al. \u003csup\u003e[ 22]\u003c/sup\u003e reported a fusion rate of 100% in patients with ROI-C who were followed up for 2\u0026nbsp;years. Hofstetter et al. \u003csup\u003e[ 12]\u003c/sup\u003e reported that the fusion rate of ROI-C was 95.2% after an average follow-up of 13.9\u0026nbsp;months. Our results show that the two groups have achieved satisfactory results of bone fusion, and there is no significant difference between the two methods.\u003c/p\u003e \u003cp\u003eSo far, the mechanism of adjacent joint degeneration is not clear. It is not only related to the natural degradation of adjacent joints, but also to the increase of adjacent upper and lower joint activities caused by abnormal fusion \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Lee et al. \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e believe that the use of short plates with oblique screw tracks can significantly reduce the incidence and severity of ALOD. Many studies have shown that the shorter the plate length, the lower the incidence of ossification of the adjacent vertebral body, which may be related to the separation of the soft tissue in front of the vertebral body \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. In group A, 3 patients had adjacent vertebral degeneration, and 5 patients in group B had adjacent vertebral degeneration. In the last follow-up, no patient needed surgical intervention. In the future, we will continue to investigate and further evaluate whether the bridge-type ROI-C interbody fusion cage can help reduce the incidence of adjacent vertebral degeneration and the need for reoperation.\u003c/p\u003e \u003cp\u003eOf course, this study also has some limitations: first of all, this study is a retrospective study, and the level of evidence is limited. Secondly, there may be measurement errors. In order to minimize these errors, three orthopedic surgeons measured the X-ray data separately. Finally, the number of cases in this study is small and the follow-up time is short, which may lead to selective bias. In the future, robust randomized multi-center prospective studies with long-term follow-up are needed to confirm these findings.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eBoth ROI-C and ACDF can achieve satisfactory results, but ROI-C has shorter operation time, less bleeding and lower incidence of dysphagia in the short term.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eROI-C: \u003c/strong\u003ethe bridge-type ROI-C interbody fusion cage;\u003cstrong\u003e ACDF: \u003c/strong\u003eanterior cervical discectomy and fusion with plating and cage system; \u003cstrong\u003eJOA: \u003c/strong\u003eJapanese Orthopaedic Association score; \u003cstrong\u003eNDI: \u003c/strong\u003eNeck Disability Index; \u003cstrong\u003eALOD: \u003c/strong\u003eadjacent level ossification development; \u003cstrong\u003eMRI: \u003c/strong\u003emagnetic resonance imaging; \u003cstrong\u003eCT: \u003c/strong\u003ecomputed tomography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Nature Science Foundation of China (grant no. 81802682) and the Natural Science Foundation of Jiangsu Province\u0026nbsp;(grant no. BK20180199).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made substantive intellectual contributions to this study to qualify as authors. QZ, WY and CK contributed to study design, acquisition of data, analysis of data, and interpretation of results. ZC and ZX contributed to study coordination. SX, ZC and WS contributed to statistical analysis. HS and ZZcontributed to manuscript preparation. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Ethics Committee of Soochow University. Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThanks to the support from the First Affiliated Hospital of Soochow University.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBoogaarts HD, Bartels RH. Prevalence of cervical spondylotic myelopathy. Eur Spine J. 2015;24 Suppl 2: 139-141.\u003c/li\u003e\n\u003cli\u003eMatsunaga S, Komiya S, Toyama Y. Risk factors for development of myelopathy in patients with cervical spondylotic cord compression. Eur Spine J. 2015;24 Suppl 2:142-149.\u003c/li\u003e\n\u003cli\u003eDe la Garza-Ramos R, Xu R, Ramhmdani S, et al. Long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion. J Neurosurg Spine. 2016;24(6): 885-891.\u003c/li\u003e\n\u003cli\u003eEpstein NE, Hollingsworth R. Diagnosis and management of traumatic cervical central spinal cord injury: A review. Surg Neurol Int. 2015;6(Suppl 4): S140-153.\u003c/li\u003e\n\u003cli\u003eArnold PM, Anderson KK, Selim A, et al. Heterotopic ossification following single-level anterior cervical discectomy and fusion: results from the prospective, multicenter, historically controlled trial comparing allograft to an optimized dose of rhBMP-2. J Neurosurg Spine. 2016;25(3):292-302.\u003c/li\u003e\n\u003cli\u003eLee CH, Lee J, Kang JD, et al. Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: a meta-analysis of clinical and radiological outcomes. J Neurosurg Spine. 2015;22(6):589-595.\u003c/li\u003e\n\u003cli\u003eYonenobu K, Abumi K, Nagata K, Taketomi E, Ueyama K. Interobserver and intraobserver reliability of the Japanese orthopaedic association scoring system for evaluation of cervical compression myelopathy. Spine. 2001;26(17):1890\u0026ndash;1894.\u003c/li\u003e\n\u003cli\u003eVernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther. 1991;14(7):409\u0026ndash;415.\u003c/li\u003e\n\u003cli\u003eOdom GL, Finney W, Woodhall B. Cervical disk lesions. J Am Med Assoc ,1958;166(1):23\u0026ndash;28.\u003c/li\u003e\n\u003cli\u003eBazaz R, Lee MJ, Yoo JU. Incidence of dysphagia after anterior cervical spine surgery: a prospective study. Spine. 2002;27(22):2453\u0026ndash;2458.\u003c/li\u003e\n\u003cli\u003eLi J, Zheng Q, Guo X et al. Anterior surgical options for the treatment of cervical spondylotic myelopathy in a long-term follow-up study. Arch Orthop Trauma Surg. 2013; 133(6):745\u0026ndash;751\u003c/li\u003e\n\u003cli\u003eHofstetter CP, Kesavabhotla K, Boockvar JA. Zero-Profile Anchored Spacer Reduces Rate of Dysphagia Compared with ACDF with Anterior Plating. J Spinal Disord Tech. 2015;28(5): E284-290.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://pubmed.ncbi.nlm.nih.gov/?size=50\u0026amp;term=Bucci+MN\u0026amp;cauthor_id=28458586\"\u003eMichael N Bucci\u003c/a\u003e\u0026nbsp;,\u0026nbsp;\u003ca href=\"https://pubmed.ncbi.nlm.nih.gov/?size=50\u0026amp;term=Oh+D\u0026amp;cauthor_id=28458586\"\u003eDennis Oh\u003c/a\u003e\u0026nbsp;,\u0026nbsp;\u003ca href=\"https://pubmed.ncbi.nlm.nih.gov/?size=50\u0026amp;term=Cowan+RS\u0026amp;cauthor_id=28458586\"\u003eR Scott Cowan\u003c/a\u003e\u0026nbsp;et al. The ROI-C Zero-Profile Anchored Spacer for Anterior Cervical Discectomy and Fusion: Biomechanical Profile and Clinical Outcomes. Med Devices (Auckl).\u0026nbsp;2017 Apr 18(10)61-69.\u003c/li\u003e\n\u003cli\u003eNguyen C, Sanchez K, Roren A, et al. Anatomical specificities of the degenerated cervical spine: a narrative review of clinical implications, with special focus on targeted spinal injections. Ann Phys Rehabil Med. 2016.\u003c/li\u003e\n\u003cli\u003eNakagawa H, Okazaki T, Saito K. Surgical Strategies in Management of Cervical Spondylotic Myelopathy. World Neurosurg. 2015;84(2): 220-221.\u003c/li\u003e\n\u003cli\u003eShin J S, Oh S H, Cho P G. Surgical outcome of a Zero-profile device comparing with stand-alone cage and anterior cervical plate with iliac bone graft in the anterior cervical discectomy and fusion [J]. Korean J Spine, 2017,11（3）: 169-177.\u003c/li\u003e\n\u003cli\u003eChung J Y, Kim S K, Jung S T, et al. Clinical adjacentsegment pathology after anterior cervical discectomy and fusion: results after a minimum of 10-year follow-up [J]. Spine J, 2014, 14（10）: 2290-2298. DOI: 10.1016/j.spine.2014.01.027.\u003c/li\u003e\n\u003cli\u003eChen Y, Chen H, Cao P, et al. Anterior cervical interbody fusion with the Zero-P spacer: mid-term results of two-level fusion. Eur Spine J. 2015;24(8): 1666-1672.\u003c/li\u003e\n\u003cli\u003eAlimi M, Njoku I, Hofstetter C P, et al. Anterior cervical discectomy and fusion (ACDF): comparison between Zero Profile implants and anterior cervical plate and spacer [J]. Cureus, 2016, 8（4）: e573- e580.\u003c/li\u003e\n\u003cli\u003eKaiser MG, Haid RW Jr, Subach BR, Barnes B, Rodts GE Jr. Anterior cervical plating enhances arthrodesis after discectomy and fusion with cortical allograft. Neurosurgery. 2002;50:229\u0026ndash;236.\u003c/li\u003e\n\u003cli\u003eWang Z, Jiang W, Li X, et al. The application of zero-profile anchored spacer in anterior cervical discectomy and fusion. Eur Spine J. 2015;24: 148\u0026ndash;154.\u003c/li\u003e\n\u003cli\u003eGrasso G, Giambartino F, Tomasello G, Iacopino G. Anterior cervical discectomy and fusion with ROI-C PEEK cage: cervical alignment and patient outcomes. Eur Spine J. 2014;23(Suppl 6): S650\u0026ndash;S657.\u003c/li\u003e\n\u003cli\u003eGoodwin CR, Desai A, Khattab MH, et al. Cervical Fusion for Absent Pedicle Syndrome Manifesting with Myelopathy. World Neurosurg. 2016;86: 515. e17-22.\u003c/li\u003e\n\u003cli\u003eHe L, Qian Y, Jin YJ, et al. [The clinical value of end plate rings in preventing subsidence of titanium cage in anterior cervical corpectomy and fusion surgery]. Zhongguo Gu Shang. 2014;27(9): 738-744.\u003c/li\u003e\n\u003cli\u003eLee DH, Lee JS, Yi JS et al. Anterior cervical plating technique to prevent adjacent-level ossification development. Spine J.2013;13(7):823\u0026ndash;829\u003c/li\u003e\n\u003cli\u003ePark JB, Cho YS, Riew KD et al. Development of adjacent- level ossification in patients with an anterior cervical plate. J Bone Joint Surg Am 2005; 87:558\u0026ndash;563\u003c/li\u003e\n\u003cli\u003eIshihara H, Kanamori M, Kawaguchi Y et al. Adjacent segment disease after anterior cervical interbody fusion. Spine J;2004; 4(6):624\u0026ndash;628\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":"[email protected]","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":"ACDF, ROI-C, cervical spondylosis","lastPublishedDoi":"10.21203/rs.3.rs-41918/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-41918/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: To explore the clinical efficacy and radioactive results of the bridge-type ROI-C interbody fusion cage (ROI-C) and anterior cervical discectomy and fusion with plating and cage system (ACDF) for cervical spondylopathy.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: From January 2014 to January 2018, 45 patients undergoing ACDF were retrospectively analyzed, including 24 cases of ROI-C (group A) and 21 cases of ACDF (group B). The operation time, blood loss, Neck Disability Index (NDI), Japanese Orthopaedic Association score (JOA), postoperative complications, imaging results including cervical Cobb angle and fusion were compared between groups.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: All patients were successfully treated with surgery, and no cerebrospinal fluid leakage, esophageal fistula, or hoarseness occurred after surgery. The operation time and blood loss in group A were lower than those in group B (P\u0026lt;0.05). During the follow-up period, JOA score increased and NDI score decreased after operation (P\u0026lt;0.05), but there was no significant difference between the groups (P\u0026gt;0.05). The incidence of dysphagia in group A was lower than that in group B at 1 month and 3 months after operation (P\u0026lt;0.05), but the final follow-up results showed that there was no significant difference in the incidence of dysphagia between the two groups (P\u0026gt;0.05). In group A, the fusion rate was 83.3% 3 months after surgery and 100% at the last follow-up. The rate of adjacent level ossification development was 12.5%. In group B, the fusion rate was 85.7% 3 months after surgery and 100% at the last follow-up. The rate of adjacent level ossification development was 23.8%.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Both ROI-C and ACDF can achieve satisfactory results, but ROI-C has shorter operation time, less bleeding and lower incidence of dysphagia in the short term.\u003c/p\u003e","manuscriptTitle":"A Comparison Of The Bridge-Type Roi-c Interbody Fusion Cage System And Titanium Mesh Graft With Titanium Plate Fixation In 2-Level Anterior Cervical Discectomy And Fusion With Plating And Cage System: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-07-15 16:00:55","doi":"10.21203/rs.3.rs-41918/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"f09de2a1-7779-4264-b354-f1c29945c312","owner":[],"postedDate":"July 15th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":159759,"name":"Orthopedics"}],"tags":[],"updatedAt":"2020-07-22T15:47:53+00:00","versionOfRecord":[],"versionCreatedAt":"2020-07-15 16:00:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-41918","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-41918","identity":"rs-41918","version":["v1"]},"buildId":"CiT4i_kKBbxQbnFL0ufpk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}