What are the next steps in managing a patient with a history of cervical spine surgery, current cervicalgia, and recent X-ray findings showing resecured inferior screws?

Management of Post-Cervical Fusion with Cervicalgia and Resecured Hardware

For a patient with prior C5-7 anterior cervical fusion presenting with cervicalgia and recent X-ray showing resecured inferior screws, the priority is clinical assessment for hardware-related complications followed by advanced imaging if symptoms persist, as hardware failure and pseudarthrosis are the most common causes of post-surgical neck pain requiring intervention. 1

Immediate Clinical Evaluation

Assess specifically for dysphagia, odynophagia, or new neurological symptoms, as these indicate potential hardware complications requiring urgent intervention 2, 3:

• Screw backout causing esophageal irritation or perforation occurs in approximately 4% of anterior cervical cases and is the most common reason for reoperation 2
• New or progressive radiculopathy or myelopathy suggests recurrent compression or instability 1, 4
• Severe dysphagia warrants immediate evaluation for hardware impingement on the esophagus 2, 3

Diagnostic Imaging Algorithm

Obtain CT imaging of the cervical spine as the next step to definitively assess hardware position, fracture healing, and potential pseudarthrosis 5, 6:

• CT remains the reference standard for evaluating bony fusion and hardware integrity 5, 6
• Plain radiographs alone are insufficient, as they miss critical details about screw purchase and bone quality 6
• Flexion-extension radiographs should be avoided in the acute phase (first 6-8 weeks) due to pain and muscle spasm limiting diagnostic utility, but may be considered if CT shows questionable fusion at the appropriate time point 5, 4

Add MRI if new neurological deficits develop or if CT shows pseudarthrosis, as MRI evaluates neural compression, disc pathology, and can differentiate scar from infection 4:

• MRI is indicated for new radicular symptoms not explained by hardware position 4
• However, do not rely solely on MRI soft tissue abnormalities to guide treatment, as MRI has high sensitivity but poor specificity and can lead to unnecessary interventions in 25% of patients 5, 6

Treatment Decision Framework

If Hardware is Intact and Fusion is Solid:

Conservative management with physical therapy and analgesics is appropriate 1:

• Axial neck pain without instability or neurological deficit can be managed non-operatively 1, 7
• Consider peripheral nerve field stimulation for refractory axial neck pain if conservative measures fail after 3-6 months 7

If Pseudarthrosis is Identified:

Evaluate whether the pseudarthrosis is symptomatic, as this determines surgical intervention 1:

• Symptomatic pseudarthrosis (persistent pain correlating with motion at the pseudarthrosis site) warrants revision surgery, as arthrodesis is associated with improved clinical outcomes 1
• Both anterior revision and posterior fusion have proven successful, though posterior approaches may achieve higher fusion rates (Class III evidence) 1, 8
• The choice between anterior revision versus posterior fusion depends on bone quality, number of levels involved, and sagittal alignment 1, 4

If Hardware Failure is Present:

Surgical revision is indicated for screw backout causing symptoms, complete screw pullout, or plate disruption 2:

• Screw backout causing dysphagia requires reoperation in approximately 4% of cases 2
• Complete loss of screw purchase necessitates revision with either anterior replating or posterior stabilization 1, 2

Critical Pitfalls to Avoid

Do not assume the "resecured" screws are functioning adequately without CT confirmation 5, 6:

• The radiology report notes screws were "resecured" but does not specify bone purchase quality or fusion status 5
• Baseline CT within the first week establishes reference for future comparison 5

Do not order routine MRI without specific neurological indications, as this leads to overtreatment based on incidental findings with unclear clinical significance 5, 6:

• MRI abnormalities are present in up to 25% of asymptomatic post-surgical patients 5

Obtain laboratory studies including ESR, CRP, and CBC to rule out infection before attributing symptoms solely to mechanical causes 4:

• Infection must be excluded in any patient with persistent post-operative pain 4

Evaluate sagittal alignment on lateral radiographs or CT, as kyphotic deformity can cause persistent pain and may require correction 1, 4:

• Progressive kyphosis is an indication for revision surgery 8, 4

Follow-Up Protocol

Serial CT imaging at 4-6 weeks and 8-12 weeks is necessary to confirm fusion progression 5, 6:

• Some injuries initially deemed stable demonstrate delayed instability requiring intervention 5, 6
• Solid bony union should be confirmed before discontinuing any external support 6