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1. Dr. Corenman, at what intervals do you order post-ACDF X-rays to monitor fusion?
2. I imagine the next answer takes the form of a bell-shaped curve: at what point is fusion usually apparent?
3. How significant is apparent, beginning fusion on an X-ray in your decision to allow the patient to return to increased activities?
4. At what point is it generally understood that no fusion is going to happen?
I have told many people about this site. My gratitude continues.
My interval of ordering X-rays depends upon the type of fusion graft requested by the patient. I offer the patient their own bone (autograft) or donor bone (allograft). I always use iliac crest bone graft as it has the best structural integrity with the greatest surface area of biological activity.
I sometimes post-operatively follow patients that have had surgery elsewhere. There are surgeons that use PEEK cages (plastic) as spacers and some that use fibular allograft so I will delineate the algorithm for all of these.
For autograft iliac crest patients, I obtain X-rays at six weeks and three months post-operatively. Almost all are healed by six weeks and three months confirms the healing. If there is a radiolucent line that still is apparent at three months, an X-ray at six months is required.
For allograft iliac crest where I have performed the operation, again X-rays at six weeks, three month and then six months to confirm fusion (there is a higher non-fusion rate with allograft that needs to be followed).
For PEEK cages and fibular allograft, I follow these cases out for at least one year with X-rays. Unfortunately, since the PEEK cage is biologically inactive, there will always be a “line” at the interface between the vertebral body bone and the cage. The fusion occurs inside the cage and is difficult to visualize without a CT scan. What I look for is evidence of non-fusion such as haloing of the cage against the bone, loosening/fracture of the screws or motion of the segment on flexion-extension x-ray. This is also the algorithm I use for fibular allograft as this thick cortical structure does not incorporate well into native bone. I have seen radiolucent lines three years out from the use of this graft material in spite of a solid fusion.
Even with non-fusion, there is a small chance that with time, the fusion might “take”. If the graft fractures/collapses or the graft recesses into the vertebral body as the PEEK cages are prone to do, there might come a point that with settling the construct becomes stable and fusion might occur. This is why there are some fixation plates on the market that have a sliding channel for the fixation screws to compensate for this collapse.
If the level has obvious fracture, graft collapse or erosion, the hardware is loose and there is motion on flexion/extension X-rays, a CT scan is used to confirm the pseudoarthrosis (non-fusion). If the level is painful or unstable, revision surgery is called for. This might take the form of a posterior fusion or a revision anterior fusion.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.Remarkable stuff. My surgeon’s unenthusiastic view of X-rays is coming into focus.
Stryker views the matter differently, it seems. Their website says “PEEK material provides good radiolucency for post-op visualization.”
One study notes, “The use of a PEEK cage is becoming popular because of better elasticity and radiolucency.”
In a discussion of Stryker’s performance in the market from 2007, it is noted, “The advantage of PEEK is that it is radiolucent, which allows the surgeon to better examine the progression of bone growth after a spine fusion is performed.”
Of course, “good” and “better” are relative terms.
It seems a little nutty to make an ACDF device that obscures (to any degree) the documenting of the very process (fusion) it is intended to produce. Perhaps there is a trade-off of the strength of the cage relative to its radiolucency.
And it makes sense that nothing can surpass an auto- or allograft for post-op fusion assessment, as there, nothing at all obscures the X-ray.
I agree with Stryker that radiolucent cages allow post-operative visualization of fusion- in the lumbar spine- but in the cervical spine, there is so little surface area for fusion that any waste of surface area reduces the opportunity for fusion,
The other problem is that the amount of space in the center of the peek cage is so small that fusion bone is not easily visualized. Again, the edge of the PEEK cage will not fuse with the edge of the vertebra so a continuous visual line will persist even in the place of solid fusion.
The ease and speed of placing the PEEK cage is valuable to a number of surgeons but there is some cost to it.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books. -
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