Cervical disc herniation and cervical spondylosis surgically treated by Cloward procedure: a 10-year-minimum follow-up study
© The Author(s) 2010
Received: 19 April 2010
Accepted: 26 April 2010
Published: 9 June 2010
Cervical degenerative pathology produces pain and disability, and if conservative treatment fails, surgery is indicated. The aim of this study was to determined whether anterior decompression and interbody fusion according to Cloward is effective for treating segmental cervical degenerative pathology and whether the results are durable after a 10-year-minimum follow-up.
Materials and methods
Fifty-one patients affected by single-level cervical degenerative pathology between C4 and C7 were surgically treated by the Cloward procedure. Clinical evaluation was rated using the Neck Disability Index (NDI) and the visual analog scale (VAS). At last follow-up, the outcomes were rated according to Odom’s criteria. On radiographs, the sagittal segmental alignment (SSA) of the affected level and the sagittal alignment of the cervical spine (SACS) were measured.
Average NDI was 34 preoperatively and 11 at last follow-up. Average VAS was 7 preoperatively and 1 at last follow-up. According to Odom’s criteria, the outcome was considered excellent in 18 cases, good in 22, and fair in 11. Average SSA was 0.5 ± 2.1 preoperatively, 1.8 ± 3.8 at 6 months, and 1.8 ± 5.7 at last follow-up. Average SACS was 16.5 ± 4.0 preoperatively, 20.9 ± 5.8 at 6 months, and 19.9 ± 6.4 at last follow-up. Degenerative changes at the adjacent levels were observed in 18 patients (35.3%).
The Cloward procedure proved to be a suitable and effective technique for treating segmental cervical degenerative pathology, allowing good clinical and radiographic outcomes even at a long-term follow-up.
KeywordsCervical spondylosis Cervical disc herniation Single level Surgical treatment Cloward procedure Long-term follow-up
Cervical disc herniation and cervical spondylosis are common causes of acquired disability in patients over 50 years . These two clinical pathologies can lead to different conditions ranging from axial neck pain to cervical radiculopathy and cervical myelopathy. In most patients, conservative treatment is sufficient to address symptoms . Surgery is indicated if conservative treatment fails, leaving intractable pain, worsening radiculopathy, and myelopathy [3–5].
The main aim of surgical intervention is decompression, and historically, it has been attempted by either an anterior or posterior route with or without associated fusion [2, 3, 6–12]. Cervical decompression via an anterior approach associated with an interbody fusion is widely used and is the surgery of choice for neural compressions by the anterior structures in both single- and double-level surgeries [2, 9, 11, 13–17]. Anterior approach to cervical spine degeneration, first described by Robinson and Smith  and Cloward [19–21], has been widely used by many surgeons, with satisfactory short-term results [2, 9, 11, 13–17]. Despite the good clinical outcomes, some authors reported degenerative changes at disc spaces adjacent to the fused segment and lower clinical outcomes at long-term follow-up [22–24].
The aim of this study was to report clinical and radiological results of 51 patients operated on with discectomy and one-level anterior cervical fusion according to the Cloward procedure, with a minimum 10-year follow-up. We determined whether this procedure is effective for treating cervical disc herniation and cervical spondylosis in terms of postoperative recovery of the cervical sagittal alignment and symptoms relief. We also analyzed whether the clinical and radiographic results were durable after a 10-year-minimum follow-up.
Materials and methods
All preoperative symptoms relieved; abnormal findings improved
Minimal persistence of preoperative symptoms; abnormal findings unchanged or improved
Definite relief of some preoperative symptoms; other symptoms unchanged or slightly improved
Symptoms and signs unchanged or exacerbated
On lateral radiographs, cervical spine alignment was evaluated by SSA and SACS, and preoperative and postoperative data were compared. Moreover, the presence of degenerative changes at the levels adjacent to the fusion was evaluated according to Kellgreen and Lawrence . The study conforms to the Declaration of Helsinki and was approved by the ethical review board. Patients provided informed consent for enrollment.
When conservative treatment for cervical disc herniation and cervical spondylosis fails, surgical treatment is indicated, and anterior decompression and fusion are considered as the treatment of choice [11, 13, 14, 17, 30–32]. The Cloward procedure proved to be a suitable and effective technique for treating segmental cervical degenerative pathology. In this series, with the use of carefully conducted Cloward procedure, improvement in sagittal alignment of the cervical spine with recovery of physiologic lordosis was obtained. In these patients, recovery of sagittal alignment was consistent with favorable clinical and radiographic outcomes at long-term follow-up. In fact, comparison between preoperative and follow-up SSA and SACS angles demonstrated the effectiveness of the Cloward procedure in correcting cervical sagittal misalignment when degenerative changes produce cervical spine straightening or cervical kyphosis. Moreover, no significant changes in SSA and SACS angles were observed between postoperative values and those measured at follow-up, suggesting that the correction obtained with surgery was maintained, even on long-term follow-up. Interestingly, no significant reabsorption or collapse of the bone graft occurred in the postoperative period. Radiographic evidence of degenerative changes at the levels adjacent to a previous fusion represent a frequent finding, even at long-term follow-up. However, it should be considered that disc degeneration represents the natural history of the aging cervical spine; therefore, it is not possible to explore the role of fusion in promoting this process. Most probably, in patients with preoperative evident adjacent disc degeneration, fusion increases degeneration rate; this occurs less frequently in patients with preoperatively intact discs, as in our study population. This has also been demonstrated in patients undergoing cervical spine arthroplasty surgery . Moreover, even in patients with evident radiological adjacent disc degeneration, clinical symptoms remain scant and most often resolve conservatively. This result is in accordance with previous findings . Finally, proper restoration of cervical alignment through a careful surgical technique and close decompression of the neural structures cannot be overemphasized .
In conclusion, spinal decompression and anatomic correction of cervical alignment, obtained with this technique, achieved resolution or significant improvement of clinical symptoms in most patients and allowed better exploitation of cervical spine residual function, counterbalancing the potential limitations imposed by the fused level.
Conflict of interest
This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
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