TITANIUM MESH CAGES FOR CERVICAL SPINE STABILIZATION

AFTER CORPECTOMY. A CLINICAL AND RADIOLOGICAL STUDY

Pradeep K. Narotam, MBChB, MMED, FCS (SA), FRCSC1

Sarah M. Pauley, MS1

Gregory J. McGinn, MD, FRCRC2

1
Division of Neurosurgery, Creighton University Medical
2
Center, Omaha, Nebraska and Department of Neuroradiology, St.

Boniface Hospital, Winnipeg, Canada

Corresponding Author:

Pradeep K. Narotam, MD

Division of Neurosurgery

Creighton University Medical Center

601 North 30th street, #3705, Omaha, NE 68131

Phone 402-2804119 FAX 402-

2804478

mailto:narotam@creighton.edu

Running Head

Titanium Mesh Cages for cervical corpectomy

Keywords:

Titanium mesh cage, cervical spine reconstruction, corpectomy,

vertebrectomy, spinal fusion, cervical myelopathy

Manuscript Number #13221

1
ABSTRACT

Object: Spinal Reconstruction after anterior cervical

decompression has involved tricortical iliac crest bone or

fibular strut grafts, not without significant morbidity. This

study evaluates titanium mesh cages (TMC) for stability and

fusion following anterior cervical corpectomy.

Methods: Thirty-seven patients were prospectively evaluated over

4-years. Majority had presented with spinal cord compression

(97%) from cervical spondylosis (87%). The TMC was filled with

iliac crest bone chips or Surgibone and stabilized with anterior

plating. The change in settling ratio (SR), coronal (CA) and

sagittal angles (SA), and sagittal displacement (SD) at 3, 6, &

12 months from surgery was determined using the immediate post

operative radiograph as baseline. Flexion/extension X-rays and C

T scans (taken at 1 year) evaluated stability, fusion & bone

growth within the TMC.

Conclusions: Complications such as settling, telescoping,

migration and pseudo-arthrosis were not observed. Stability was

achieved in all patients on dynamic radiographs. TMC related

Complications were 2.7%(TMC mal-placement 1 patient), surgery-

related 10.8% and graft-related 21%. Evidence of growth of bone

2
into the TMC was seen in 16/17 patients (95%) at CT scan. A mean

settling of 4.46% of cage height at 3 months (n=31, p=0.066),

3.89% at 6 months (n=28, p=0.028) and 4.35% at 1 year (n=27,

p=0.958) were observed. The mean SD changed by 3.9%. (n=23,

p=0.730). The mean CA and SA changed 2.89 (n=30, p=0.498) and

2.09 (n=29, p=0.001) at 1 year respectively or at last follow-up

from baseline. No significant differences in the radiological

indices were seen for multilevel vertebrectomy vs. single

vertebrectomy (p=0.221), smoking or age.

Titanium mesh cages, in combination with anterior plating, are a

safe & effective method of vertebral replacement in the cervical

spine.

Keywords: titanium mesh cage, cervical spine reconstruction,

corpectomy, vertebrectomy, spinal fusion, cervical myelopathy

3
INTRODUCTION

Extensive anterior cervical surgery has become more prevalent,

involving channel corpectomy or multi-level diskectomy, creating

a challenge for the stable reconstruction of the spine.

3,6,14,16,18,19,23,28,29,33,38,42,43
Current practice for bone grafting utilizes

iliac crest auto graft, allograft or fibular strut graft. Tri-

cortical iliac crest auto-graft is prone to graft resorption and

subsidence with pseudo-arthrosis rates of as high as 31%,

resulting in construct failure. Fibular strut grafting exhibits

high rates of pseudo-arthrosis, 27% for autograft and 41% for

allograft, often complicated by graft collapse, telescoping,

extrusion or host rejection while for multilevel diskectomy

pseudo-arthrosis rates from 7-42% have been reported.

1,6,16,18,23,30,33,36,38,41-43
Although anterior plating may eliminate some of

the complications, hardware or construct failure often occurs in

situations of failed fusion.14

The titanium mesh cage (TMC), a recent development in vertebral

prosthesis, offers the greatest biomechanical resistance to axial

7,10-12,24,26,27,32
loading. More recently, stability rates of 97% to

100% following corpectomy and ACD have been reported with the use
7,24,27
of TMC. Conjecture over possible complications such as

erosion of adjacent end plates, settling, telescoping, stress

4
shielding and the presence of a solid fusion within the TMC are
22,27
still being raised. This study examines the efficacy of

titanium mesh cages for stability & fusion following cervical

corpectomy for degenerative, traumatic and neoplastic disorders.

The ability to maintain the spinal integrity was determined by

developing radiological indices (RI) to determine changes in

coronal & sagittal angle, sagittal displacement, settling, while

CT scans were reviewed for evidence of bony fusion.

CLINICAL MATERIALS AND METHODS

Patient Population

A prospective study evaluated 37 patients over a four-year period

(from January 1996 to December 1999). The following clinical data

was captured: age, pathology, neurological syndrome, type of

surgery, site and extent of surgery (single or double

vertebrectomy), type of bone graft, type of plate and

neurological outcome. Other variables evaluated were smoking

history, injury on duty (WCB), psychiatric/psychological history

and review of medical history. Patients underwent anterior

cervical channel corpectomy and decompression using standard

techniques.1. Adjacent vertebral end plates & osteophytes were

removed using a 5mm burr on a high-speed drill. The TMC (Harm’s

cage)2 was filled with iliac crest bone chips or with xenograft

1
A sandbag was placed beneath the neck to maintain lordosis
2
Harm’s cage manufactured by Depuy-Acromed, Raynham, MA
5
bone. While TMC end caps were not used, fixed anterior locking

plates (Orion)3 were used in all patients. Closed suction wound

drains were used for 24 hours in all patients. Patients were

instructed to wear a hard collar for 8-12 weeks during

ambulation. Surgical complications and morbidity that were

monitored for included: neurosurgical wound infection, incidental

durotomy, visceral injury, dysphonia, dysphagia, respiratory

difficulties, neurological deterioration, graft site

complications i.e. pain infection, numbness, etc.

Radiographic Evaluation

The following potential hardware complications were monitored:

cage migration, dislodgement, telescoping, instability; plate

dislodgement, screw complications, etc on serial radiographs

performed at 24 to 48 hours (PO), 3-months, 6-months, and 1-year

post surgery while dynamic flexion/extension radiographs

evaluated stability. Axial CT scan were taken at 1 year to

evaluate the pattern of the bony fusion with the cage. Sagittal

reconstruction from axial images was also performed.

The radiographic indices (RI) were determined as follows. The

settling ratio (SR), a measurement of the invagination of the

cage into the vertebrae, was calculated depending on radiograph

3
Orion plate – manufactured by Medtronic Sofamor-Danek, Memphis, TN
6
quality as (Plan-A), the ratio of the height of the cage (CG) and

the distance between the superior end plate of the superior

vertebra and the inferior end plate of the inferior vertebra (AB)

or (Plan-B), as the ratio of the height of the cage (BC) and the

distance between the superior end plate of the superior vertebra

and the base of the cage (AB). (Figures 1a & b) Sagittal

displacement (SD) was determined by dividing the distance between

the posterior margin of the cage to the posterior spinal line

(FE) by the width of the cage (FD). The percentage change from

baseline was computed, using the patients as their own controls

and the height of the cage as a constant, thereby discounting

magnification differences between serial radiographs.

The coronal angle (CA) was subtended by the left margin of the

cage and the spinous processes line of the adjacent vertebrae on

the A-P radiograph (Figure 2) The sagittal angle (SA) was

subtended by the posterior edge of the cage and the posterior

spinal line on the lateral radiographs. (Figure 1b) A 5-9

degree difference was determined as mild change while > 10

degrees was considered radiologically significant.

The radiological indices were compared serially PO radiographs

(as baseline) to those taken at three, 6 & 12 months or at last

follow-up.

7
Statistical Analysis

The mean and standard deviation for the changes in the CA, SA,

SD, & SR from the immediate post-operative radiograph (baseline)

was computed and analyzed using the t-tests for correlated

samples. The effect of age, smoking, and the number of vertebral

bodies removed were analyzed using the t-tests for independent

samples. Post-hoc analysis was performed after exclusion of

outliers.

RESULTS

Clinical and Demographic Data

The majority of patients were under 60 years of age, 16% were

older than 60. There were 24 men and 13 women. Patients presented

primarily with spinal cord compression (89%) i.e. myelopathy

(43%), Myelo-radiculopathy (43%), radiculopathy (11%); and one

patient presented with Brown Sequard Syndrome. Cervical

spondylosis accounted for 85% of patients while 5% had tumors.

Twenty-four patients underwent single vertebrectomy and 13

patients underwent double vertebrectomy. Iliac crest bone graft

had been harvested in 34/37 patients (91%) while xenografts

(Surgibone) were used in three patients. Ninety-five percent of

patients (n=35) showed neurological improvement. One patient did

not respond to spinal decompression and remained the same as pre-

operatively. (Table 1)

8
Surgery-related Complications

There were no neurosurgical wound infections, CSF leaks,

respiratory difficulties or visceral injury. There was only one

TMC related complication (2.7%): A patient had undergone a

double vertebrectomy (C4-C7) for a myeloradiculopathy from

degenerative spinal stenosis. Mal-placement of the TMC

,confirmed on X-Ray, was detected immediately postoperatively

after the patient experienced severe arm pain. The TMC was

surgically re-positioned. Complications related to anterior

cervical surgery occurred in 10.8% (n=4) of patients, which are

described as follows: One patient deteriorated (Brown-Sequard

syndrome) from a spinal epidural hematoma 4-hours after a double

vertebrectomy (C4-C7) and resection of the ossification of the

posterior longitudinal ligament (OPLL). Immediate re-operation

resulted in neurological recovery. One of the 16 patients who

underwent surgery involving the C7 level, developed dysphonia

(2.7%), which recovered by the 6-month follow-up visit.

Dysphagia was encountered in two patients, one of which persisted

at 3 months. Esophageal motility studies were negative and the

symptoms had resolved by the 1-year follow-up visit. Graft site

complications (21%) included pain (8.8%, n=3), superficial wound

infection (5.9%, n=2) and numbness (5.4%, n=2). (Table 1)

Stability & Fusion

9
Thirty-four sets of radiographs were obtained at the 3-month

visit and 31 sets at 6-months. Radiographs could be obtained in

only 30/37 patients (81%) at the 1-year mark. Six patients were

lost to follow-up or had re-located while one refused follow-up

after the 3-month visit. RI could not be performed in a further

3 patients. There were no instances of hardware failure e.g.

screw loosening, back out, radiographic lucencies, plate breakage

or plate pullout seen on radiographs or CT scan. Neither

telescoping nor subsidence of the cage occurred in any patient.

CT scans were obtained in 17 patients (46%). On serial axial

images, bone growth into the TMC could be seen in 16 patients

(95%). (Figures 3 & 4). Although an incomplete bone mass was

observed in one patient, evaluated on CT scan at 7 months,

flexion/extension radiographs revealed no instability, nor was

there hardware failure on subsequent radiographs.

Settling and Displacement

Twenty-nine patients (86%) had mild or insignificant changes in

the settling ratio. (Table 2) The TMC mean settling at 3 months

was 4.46% of cage height from the post-operative baseline (n=31,

p=0.066) while at 6 months from surgery, a 3.89% mean settling

was observed (n=28, p=0.028). At 1 year, the change in mean SR

was 4.35% (n=27, p=0.958). (Table 3) There were two patients

with SR of 10% (3mm) and 13% (4mm). The first patient, a 37-year

10
old male, presented with cervical myeloradiculopathy due to

spinal stenosis and OPLL, underwent a C6 vertebrectomy and TMC

reconstruction with anterior plating. Four years following

surgery radiographs revealed C5 vertebral erosion & degenerative

changes at the C4-5 junction. The second patient was a 57-year

old female with cervical myelopathy who underwent a C5

vertebrectomy and TMC fusion. She has developed adjacent stenosis

and degeneration at the C3-4 level. Hardware failure,

instability, TMC subsidence, telescoping were not seen on

flexion/extension radiographs in either patient. On post hoc

analysis, no significant differences in SR could be detected when

compared to baseline. In 64% of patients, a minimal change in SD

was seen while in 15%, >10% displacement was documented. (Table

2) The changes in sagittal displacement were not statistically

significant. (Table 3)

Coronal & Sagittal Angle

The majority of the patients (85%) exhibited minimal (< 5

degrees) or no change in the CA while in five patients mild

changes (5 to 9 degrees) were detected. (Table 2) No

significant differences in the change in mean CA from the

postoperative period to 3 months, 6 months or at 1-year was seen.

(n=30) (Table 3) In 31 patients, the SA changed less than 5

degrees. Only one patient had a change in the SA of >10 degrees

11
without clinical consequence. At one year, a statistically

significant mean change of 2.09 degrees (n=30, p=0.001) was

detected again, without clinical significance or impact.

Other variables

Thirteen patients had undergone multilevel vertebrectomy (3-level

fusions). (Figure 5) No settling occurred in six patients, while

in seven, settling ranged from only 2.3% to 7.9% of cage height

representing 1.3mm-4.7 mm. When compared to single vertebrectomy

(2-level fusions), no significant differences in changes in the

CA (p=0.944), SA (p=0.878), SR (p=0.221) or SD (p=0.352) was

detected. There were six elderly patients (>70). No increase in

settling was seen in four of these patients, while two patients

exhibited 3.9% and 5.1% settling compared favorably to the mean

settling ratio (3.9%).

Although xenograft filled TMCs were used in three patients, two

of whom had undergone multilevel decompression, stability was not

adversely affected in any of these patients. (The RI revealed no

significant changes in CA, SA, SD. The SR was 0%, not readable

in 1 patient and 6.7% in the other.) CT scans in all three

patients confirmed bony growth at 1 year. Patient age did not

significantly affect changes in the angles (p=0.44) or settling

(p=0.468). Although 32% were smokers or former smokers, the

12
radiological indices did not differ significantly when compared

to non-smokers.

DISCUSSION

Controversy in anterior cervical spine surgery still exists in a

variety of areas inter-alia: the role of multi-level-discectomy

vs. channel corpectomy, the role of expansive laminoplasty or

laminectomy, types of fusion devices, role of various grafting

38
materials, role of anterior plates, type of plates etc. We

prefer channel corpectomy when performing extensive anterior

cervical decompression. Surgeons employ a variety of methods to

provide anterior column support following cervical channel

corpectomy, most commonly a tri-cortical iliac crest graft. The

vertebral bodies have been vulnerable to erosion of the endplates

16,28,30,38,43
and telescoping with fibular strut grafts. We believe

that the TMC-plate construct represents a suitable alternative.

Recent studies have shown that they have excellent stability

rates when compared to the traditional tri-cortical iliac crest

grafts or fibular grafts since they present immediate

immobilization and a larger healing surface when packed with

7,27
cancellous bone. Disadvantages include cost, difficulty in

assessing fusion on plain radiographs, difficulty in performing

revisions, stress shielding which may affect fusion, and the

potential for soft tissue injury.32

13
In the preparation for cage insertion, it has been postulated the

preservation of the end-plates would prevent potential

telescoping of the graft. On the other hand, end plate removal

allows for osteophyte resection, easier decompression and bone-

on-bone interface for fusion. End caps, designed to prevent

telescoping, increases the maximum load bearing ability of the

cage but does not affect the stiffness of the construct. They

may interfere with the bone-on-bone interface or the transference

20,24
of stress lines, which is needed for fusion, through the TMC.

We believe better early stabilization could be achieved by biting

of the cage ends into the adjacent vertebral bodies. No

complications, i.e. graft subsidence or telescoping, resulted

from this practice.

Although some debate still exists over the use of anterior plates

following ACD and fusion, a plate may become more important in

more extensive surgery, i.e. multi-level ACD and corpectomy where

it increases the stiffness and immediate stability of the

construct. Plates may also prevent potential complications such

2,13,14
as graft extrusion, subsidence and soft tissue injury. The

plate/TMC construct results in the strongest and stiffest

construct preventing flexion and extension, rotation, and

14
parallelogram effect, which have been supported by biomechanical
24,37
evidence. This raised the question of further stress

shielding and its potential detrimental effect on fusion.

In this study, all patients underwent fixed anterior plate

stabilization to supplement the cage. This could have

contributed to the over-all low settling ratio, the absence of

subsidence or early hardware failure. Indeed, Wilke et al in

2000 have shown that stand-alone cages were susceptible to

37,44
subsidence resulting from excessive movement. The risk of

advancing adjacent level disease has been raised due to increased

construct stiffness and intra-discal pressures at adjacent levels

of stabilization.9 Two of our patients with the higher settling

ratios, developed progression of their pre-existing disease over

a 3-year period from the initial surgery. The stiff TMC-plate

construct may have been a contributing factor. On cost analysis,

performed by Castro Jr. et al, no difference between tri-cortical

iliac crest graft/plate vs. TMC/local autograft/plate was seen.

5
Although in this study, ICBG chips were harvested in 90% of our

patients, we have modified our technique to use local

vertebrectomy bone since 2000.

15
In this study, the majority of patients exhibited neurological

improvement. The development of an epidural hematoma in one

patient, which probably resulted from traction on the epidural

veins during resection of the adherent OPLL, was suspected by the

onset of new symptoms. The immediate evacuation of the hematoma

resulted in neurological improvement to baseline. These are rare

but recognized complications occurring in 0.1% of spinal

surgeries and up to 0.3% following cervical procedures but can

have devastating consequences if not detected early and

4,35
immediately treated within a 4-hour window of symptom onset.

Only one TMC-related complication (one of our early cases) i.e.

mal-position, was directly related to surgical technique. Since

then, intra-operative fluoroscopy is routinely performed to

validate hardware placement and we have not encountered this

complication again.

The other surgery-related complications are similar to several

reported series pertaining to extensive anterior cervical

surgery. The recurrent laryngeal nerve neuropraxia (2.7%) and

dysphagia (5.4%) are usually temporary and self-limiting with

2,8,17,28
conservative therapy. However, Frempong-Boadu, et al have

demonstrated that a significant proportion of asymptomatic

patients (48%) undergoing anterior cervical surgery have

radiographic evidence of swallowing dysfunction, while post-

16
operatively, 67% have radiographic abnormalities. Although 50%

can have post-operative dysphagia, it persists in only 12.5% at 1

year. Multi-level surgery may often be related to increased soft

tissue swelling which is thought to be the main contributing

factor, while the use of hardware, especially plates have not

17
been implicated. Our graft site complications of 21% are again

well within published range of 20-30%.15,16,21,28,31,32,34,36,41

The inability of plain radiographs to evaluate bone growth within

the TMC due to the metallic artifact, has been touted as a

drawback against these devices. Eck et al, in 2000, found that

fusion could only be assessed in 86% of patients with cages using

plain radiographs and indirect evidence of fusion has previously

12,32
been presumed based on radiographic stability. We attempted

to determine bony growth within the TMC on CT Scan. Although

only 17 of the 37 patients had CT scans performed, 95% of these

showed hyper-dense areas on the axial slices, suggestive of bone

growth occurring within the TMC. Sagittal reconstruction using

axial images were still unable to fully resolve the TMC-vertebral

interface with sufficient clarity due to artifact from the TMC or

the screws securing the plate. Multi-slice CT with subtraction

may offer a better solution to evaluate this region.

17
In this study, histological confirmation of contiguous new bone

formation and modeling was not available. Recently, Akamaru, et

al has been able to examine at autopsy, bone growth through a TMC

in a patient who had undergone TMC reconstruction with posterior

fixation after a spondylectomy. They were able to demonstrate

solid fusion on both gross examination and histology. Consecutive

trabecular cancellous bone was seen at the TMC end-plate

junctions and bony re-modeling within the cage.1 Histological

studies from both retrieved TMC and biopsy form in-situ TMC have

confirmed that active bone growth and remodeling, in response to

stress lines, occurs within the cages.1,25,39,40 This supports the

view that the theoretical risks of stress shielding with a rigid

TMC-plate construct may not seriously affect the ability to

produce a stable fusion.

Notwithstanding these controversial issues, this study focuses

primarily on serial radiographic measurements to determine TMC-

plate stability over time and evidence of bony growth using CT

scan. Graft subsidence, described as loss of height of greater

than 2 mm, can present a significant problem following non-

instrumented anterior cervical diskectomy (ACD) and occurs in 16-

30% of patients especially with allograft fusions. Graft

collapse, defined as 30% of height loss, can occur in 36% of

18
 3,30
patients. In the majority of the patients (96%) undergoing ACD

both single level and multi-level surgery as reported by Tye et

al, measurable graft subsidence was detected, while hardware

migration occurred in 20% probably due to failure of the graft to

41
provide adequate load bearing support.

TMC, on the other hand, have shown remarkable resistance to axial

7,10-12,24,26,27,32
loading. In 1999, Majd et al, reported on a 97%

stability rate in their experience with TMC in 34 patients

27
undergoing channel corpectomy with 12% complication rate. More

recently, Das et al were able to achieve 100% stability in their

patients with TMC using standard definitions of fusion i.e.

absence of hardware failure or graft lucencies, albeit majority

7
of their patients underwent single level ACD. Similarly, we

report a 100% stability rate at 1 year following channel

corpectomy, without pseudo-arthrosis or hardware failures while

maintaining a low 2.7% complication rate and excellent

neurological outcome in 95% of patients.

Furthermore, Das et al measured changes in kyphotic or lordotic

angle to detect subsidence but did not directly address the issue

of settling, telescoping, which if present can lead to

progressive instability, hardware failure and kyphotic

19
deformities, or; the presence of a continuous solid bony fusion
7
mass. In this study, while there was absent or negligible

settling in 74% of the patients analyzed, the overall mean change

in SR changed barely 3.9%-4.5% (1.5-3mm) of the cage length over

a 3 to 12 month period. Factors that can influence the SR are

inter alia external immobilization, advancing spondylotic changes

in the adjacent vertebra and true cage subsidence or telescoping.

In addition, the use of the fixed non-translational anterior

plate added significant rigidity to the construct and may have

prevented graft subsidence and settling. The significant

difference in SR at 6 months from surgery was probably related to

cage settling after removal of the hard collar. Secondly, The

significant difference in SR could be related to the two patients

with SR of 10 & 13% in whom advancing spondylosis in the superior

vertebral body could have artificially increased the SR. On

post-hoc analysis, no significant difference in the SR was seen

and there were no instances of cage subsidence or telescoping.

The TMC exhibited remarkable stability against movement when

measured in the coronal and sagittal planes in the majority of

patients (85%) with a mean change of <3 degrees. Although a

significant difference was seen in the sagittal angulations when

compared to baseline, this only represented 2.09 degrees and was

20
considered not clinical significant and not too dissimilar to the

changes in kyphotic or lordotic angle changes of 1-2 degrees

7
reported by Das et al.

Other factors such as advanced age, smoking, and use of xenograft

did not affect stability or fusion. Long constructs have raised

concern about incompleteness of fusion and subsidence.

16,23,30,41
Tye, et al, found a significant correlation with construct

length and graft subsidence following multi-level diskectomy and

plating.41 Despite the early success of Majd, et al with the

TMC/plate reconstruction in the cervical spine with a 12%

complication rate, they have raised concern about this construct

for multilevel (2 or more vertebrectomy) surgery where a 25%

complication rate for double vertebrectomy and 60% for those with

more levels have been reported.22 In contrast, in our study, we

did not find any differences in any of the radiological indices

when comparing single to double vertebrectomy.

TMC/plate complications have been attributed to failures at the

bone-implant interface and osteopenia, resulting in cage and then

22
plate failure. These results are in keeping with the

biomechanical evidence provided by Hasegawa, et al who found a

positive correlation between bone mineral density and interface

21
strength.20 Therefore, in the severely osteoporotic spine, the
20,22
stability of the construct can be adversely affected. In

this study we used age as a discriminating factor, however, the

question of osteoporosis could not be addressed.

Although this study has not been designed to compare tri-cortical

iliac crest grafts or fibular strut grafts with TMC-plate

construct in a randomized trial, our hardware related

complications are lower than historical reports on fibular strut

16,30
or even tri-cortical iliac crest grafts. We would concur with

others that the TMC exhibits excellent stability and is superior

as a long load-bearing construct and little if any, load

shielding effects to adversely affect fusion as evidenced by a

100% stability rate and 95% fusion on CT scan while graft

subsidence; settling and telescoping were not detected even with

multi-level surgeries.1,7,20,24,32,39,40

CONCLUSION

This study examines the behavior of TMC in combination with

anterior plating and ICBG autograft as primary anterior inter-

vertebral support following channel corpectomy. TMC migration,

non-union, stress shielding, inadequate fusion, and vertebral

erosion represent serious concerns with the use of TMC. In this

study, these complications were not evident using geometric

22
measurements (RI) on serial plain radiographs. We were able to

achieve 100% stability rates with TMC, complications of less than

3% and a mean settling ratio of 4.35% of cage length at 1 year.

Although caution has been raised in situations of multi-level

surgery or osteopenic bone, the TMC-plate construct has been safe

and effective as vertebral replacement in the cervical spine.

INVESTMENT/FINANCIAL DISCLOSURE

None of the authors has any financial interest in any of the

devices reported upon in this manuscript.

23
FIGURE LEGENDS

Figure 1 a

Lateral radiograph of a patient undergoing titanium-mesh-cage

stabilization following double vertebrectomy. (Plan A) Settling

ratio was determined by the ratio of the height of the cage (CG)

and the distance between the superior end plate of the superior

vertebra and the inferior end plate of the inferior vertebra

(AB). Sagittal displacement (SD) was determined by dividing the

distance between the posterior margin of the cage to the

posterior spinal line (FE) by the width of the cage (FD).

Figure 1 b

Settling ratio was alternatively computed (Plan B), as the ratio

of the height of the cage (BC) and the distance between the

superior end plate of the superior vertebra and the base of the

cage (AB). The sagittal angulation (SA) was subtended by the

posterior edge of the cage and the posterior spinal line.

Figure 2

A-P radiograph demonstrating the use of TMC and a fixed anterior

Orion plate. The coronal angulation (CA) was subtended by the

left margin of the TMC and the spinous process line.

Figure 3a,b,c

24
CT scans of a patient undergoing TMC-plate reconstruction

following double vertebrectomy at 1-year. A) axial slices at the

superior end of the cage demonstrating the cage vertebral

interface. Hyperdense areas are suggestive of bone growth. B)

axial slices at the middle of the cage demonstrating bone growth.

C) Inferior end of the cage demonstrates contiguous bone growth

into the TMC from the adjacent vertebra.

Figure 4

Sagittal reconstruction from axial CT slices attempting to show

bone growth within the TMC at 1-year following double channel

corpectomy and TMC reconstruction.

25
Table Legends

Table 1

Demographic, clinical data, details of surgery, complications and

outcome in 37 patients undergoing titanium mesh cage

reconstruction following channel corpectomy.

Table 2

Number of patients (n=34) undergoing changes in radiological

indices i.e. coronal angle (CA), sagittal angle (SA), sagittal

displacement (SD) and settling ratio (SR) following TMC

stabilization at the last follow-up.

Table 3

Summary of the mean changes in coronal angle (CA), sagittal angle

(SA), sagittal displacement (SD) and settling ratio (SR) from the

post-operative baseline radiograph to 1-year in the available and

readable films. Significant* change in settling was observed at

6 months.

26
REFERENCES

1. Akamaru T, Kawahara N, Tsuchiya H, et al: Healing of

autologous bone in a titanium mesh cage used in anterior

column reconstruction after total spondylectomy. Spine

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 TABLE ONE
AGE <60 21
61-70 10
>70 6
SMOKERS 12
SEX M 24
F 13
CLINICAL Radiculopathy 4
Myelopathy 16
Myelo-radiculopathy 16
Brown Sequard 1
PATHOLOGY Degenerative 31
Deg. + Trauma 2
Deg. + Instability 2
Tumor 2
SURGERY Single Vertebrectomy 24
Double Vertebrectomy 13
GRAFT Autograft 34
Xenograft 3
PLATES Anterior all
Osteosynthetic
NEUROLOGICAL Improved 35
OUTCOME No change 1
Worse 1
COMPLICATIONS Epidural hematoma 1
Dysphonia 1
Dysphagia 2
Graft site pain 3
Graft site infection 2
Graft related 2
numbness
STABILITY Dynamic X-Rays all
CT SCANS Performed 17
fusion in TMC 16
Incomplete fusion 1*
Mass

34
 Table Two
Overall Number of Percentage
Change Patients of Patients
CA None 3 9%

1-4 degrees 26 76%

5-9 degrees 5 15%
>10 degrees 0 0%
SA None 3 9%
1-4 degrees 25 74%
5-9 degrees 4 12%
>10 degrees 1 3%
Not readable 1 3%
SD Change None 7 20%
1-5% 7 20%
6-9% 8 24%
>10% 5 15%
Not readable 7 20%
SR Change None 20 59%
1-5% 5 15%
6-9% 4 12%
>10% 2 6%
Not readable 3 9%

35
 TABLE THREE
Number of Time Period Mean SD t-test Post Hoc

comparisons t-test
CA 34 PO-3M 2.29 2.24 P=0.742
31 PO-6M 2.21 2.23 P=0.175
Change 30 PO-1Yr 2.89 3.02 P=0.498
SA 33 PO-3M 2.29 3.34 P=0.257
30 PO-6M 2.33 2.32 P=0.373
Change 29 PO-1Yr 2.09 1.38 P=0.001*
SD Ratio 27 PO-3M 7.8% P=0.229
24 PO-6M 5.7% P=0.262
Change 23 PO-1Yr 3.9% P=0.730
SR 31 PO-3M 4.46% p=0.066 P=0.188
28 PO-6M 3.89% p=0.028* P=0.086
Change 27 PO-1Yr 4.35% p=0.958 0.532

36