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A systematic review of the use of expandable cages in the cervical spine

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Abstract

Expandable vertebral body replacement cages (VBRs) have been widely used for reconstruction of the thoracolumbar spine following corpectomy. However, their use in the cervical spine is less common, and currently, no expandable cages on the market are cleared or approved by the US Food and Drug Administration for use in the cervical spine. The objective of this study was to perform a systematic review on the use of expandable cages in the treatment of cervical spine pathology with a focus on fusion rates, deformity correction, complications, and indications. A comprehensive Medline search was performed, and 24 applicable articles were identified and included in this review. The advantages of expandable cages include greater ease of implantation with less risk of damage to the end plate, less intraoperative manipulation of the device, and potentially greater control over lordosis. They may be particularly advantageous in cases with poor bone quality, such as patients with osteoporosis or metastatic tumors that have been radiated. However, there is a potential risk of overdistraction, which is increased in the cervical spine, their minimum height limits their use in cases with collapsed vertebra, and the amount of hardware in the expansion mechanism may limit the surface area available for fusion. The use of expandable VBRs are a valuable tool in the armamentarium for reconstruction of the anterior column of the cervical spine with an acceptable safety profile. Although expandable cervical cages are clearly beneficial in certain clinical situations, widespread use following all corpectomies is not justified due to their significantly greater cost compared to structural bone grafts or non-expandable VBRs, which can be utilized to achieve similar clinical outcomes.

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Compliance with ethical standards

**This manuscript reflects the views of the authors and should not be construed to represent FDA’s views or policies.

Conflict of interest

Benjamin Elder has no conflict of interest.

Sheng-Fu Lo has no conflict of interest.

Thomas Kosztowski has no conflict of interest.

C. Rory Goodwin has no conflict of interest.

Timothy F. Witham receives research support from Eli Lilly & Co, The Johns Hopkins Neurological Pain Research Institute, and the Gordon and Marilyn Macklin Foundation.

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  1. Department of Neurosurgery, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, USA, 21287

    Benjamin D. Elder, Sheng-Fu Lo, Thomas A. Kosztowski, C. Rory Goodwin, Ioan A Lina, John E. Locke & Timothy F. Witham

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  1. Benjamin D. Elder
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  2. Sheng-Fu Lo
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Ziya L. Gokaslan, Baltimore, USA

In the article entitled "A systematic review of the use of expandable cages in the cervical spine," the authors present their findings after a systematic review of the literature on the use of expandable cages in cervical spine surgery, evaluating fusion rates, deformity correction, complications, and indications. The authors performed a Medline search and identified 24 relevant studies, of which 20 presented clinically relevant data. The studies included several expandable vertebral body replacements (VBRs), which are detailed. The 333 identified patients either had an additional anterior plate placed or posterior fixation, or both (two patients had stand-alone VBR only). The most common indication was degenerative spondylosis, in addition to trauma, osteomyelitis, tumor, deformity, and OPLL, with levels specified as one-level VBR in 130 patients, two levels in 86 patients, three levels in 19 patients, and four levels in 3 patients. At a follow up of 9–41 months, fusion rates ranged from 79 to 100 % and nine studies reported improvement in cervical lordosis of 4°–22°. Adverse events included subsidence in 0–43 % of cases, with other complications including vertebral body fractures, transient C5 palsy, dysphagia, durotomy, and esophageal injury. The authors conclude that expandable VBRs are a valuable option for reconstruction of the cervical anterior column, with an acceptable safety profile. Limitations of the study include the retrospective nature of the studies and lack of comparison cohorts. Only one study included comparison of cohorts with expandable VBR to other fixed reconstruction methods.

The authors are to be commended for providing a systematic review of the use of expandable VBRs in cervical spine surgery as an alternative to other methods such as autograft, allograft, and fixed cage use. They provide a larger cohort of patients for reporting of outcomes such as fusion rate, deformity correction, and complications associated with expandable VBRs, which can help further delineate their use in clinical practice. The use of expandable cages for anterior cervical reconstruction may become a good option for particular indications, such as patients undergoing surgery for tumor (where concerns for long-term fusion are less given lifespan) and deformity where further lordosis gained by expandable cages can be advantageous, though direct comparisons to fixed replacements are needed.

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Elder, B.D., Lo, SF., Kosztowski, T.A. et al. A systematic review of the use of expandable cages in the cervical spine. Neurosurg Rev 39, 1–11 (2016). https://doi.org/10.1007/s10143-015-0649-8

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