A single-center retrospective analysis of 3- or 4-level anterior cervical discectomy and fusion: surgical outcomes in 66 patients

Abstract

OBJECTIVEAnterior cervical discectomy and fusion (ACDF) is a safe and effective intervention to treat cervical spine pathology. Although these were originally performed as single-level procedures, multilevel ACDF has been performed for patients with extensive degenerative disc disease. To date, there is a paucity of data regarding outcomes related to ACDFs of 3 or more levels. The purpose of this study was to compare surgical outcomes of 3- and 4-level ACDF procedures.METHODSThe authors performed a retrospective chart review of patients who underwent 3- and 4-level ACDF at the University of Virginia Health System between January 2010 and December 2017. In patients meeting the inclusion/exclusion criteria, demographics, fusion rates, time to fusion, and reoperation rates were evaluated. Fusion was determined by < 1 mm of change in interspinous distance between individual fused vertebrae on lateral flexion/extension radiographs and lack of radiolucency between the grafts and vertebral bodies. Any procedure requiring a surgical revision was considered a failure.RESULTSSixty-six patients (47 with 3-level and 19 with 4-level ACDFs) met the inclusion/exclusion criteria of having at least one lateral flexion/extension radiograph series ≥ 12 months after surgery. Seventy percent of 3-level patients and 68% of 4-level patients had ≥ 24 months of follow-up. Ninety-four percent of 3-level patients and 100% of 4-level patients achieved radiographic fusion for at least 1 surgical level. Eighty-eight percent and 82% of 3- and 4-level patients achieved fusion at C3–4; 85% and 89% of 3- and 4-level patients achieved fusion at C4–5; 68% and 89% of 3- and 4-level patients achieved fusion at C5–6; 44% and 42% of 3- and 4-level patients achieved fusion at C6–7; and no patients achieved fusion at C7–T1. Time to fusion was not significantly different between levels. Revision was required in 6.4% of patients with 3-level and in 16% of patients with 4-level ACDF. The mean time to revision was 46.2 and 45.4 months for 3- and 4-level ACDF, respectively. The most common reason for revision was worsening of initial symptoms.CONCLUSIONSThe authors’ experience with long-segment anterior cervical fusions shows their fusion rates exceeding most of the reported fusion rates for similar procedures in the literature, with rates similar to those reported for short-segment ACDFs. Three-level and 4-level ACDF procedures are viable options for cervical spine pathology, and the authors’ analysis demonstrates an equivalent rate of fusion and time to fusion between 3- and 4-level surgeries.

Four-level anterior versus posterior cervical fusions: Perioperative outcomes and five-year reoperation rates

“…For ACDF, fewer level cases are the most common [12] , but four-level cases account for approximately 2.4% of such cases [12] . Regarding treatment for multi-level cervical pathology, four-level ACDF and PCF have been compared with small sample sizes studies [ 8 , 10 , [13] , [14] , [15] ]. Zhai et al evaluated 19 patients that underwent four-level ACDF and 25 that underwent four-level PCF and found similar clinical and radiographical outcomes, though the small sample size limited their ability to control for confounders and obtain adequate power for outcome comparison [10] .…”

Pseudarthrosis of the Cervical Spine

“…In 71 patients undergoing 3-level ACDF and 26 patients with 4-level ACDF, fusion rates were 94.4% and 84.6%, respectively, with an average follow-up of 7.6 years. 28 McClure et al 29 studied patients undergoing 3-level and 4-level ACDFs and found significantly lower fusions rates at more caudal levels, and fusion rates were similar between the 3-level and 4-level groups. However, revision rates were required in 6.4% of 3-level patients and 16.0% of patients undergoing 4-level surgery, emphasizing the increased risk of suboptimal outcomes in 4-level operations.…”

Risk Factors for Dysphagia After Anterior Cervical Discectomy and Fusion With the Zero-P Implant System: a Retrospective Study With Minimum of 2 Years Follow-up

“…Exclusion criteria: (1) Preoperative dysphagia; (2) A history of other disorders that may trigger symptoms of dysphagia, such as craniocerebral trauma or cerebral infarction; (3) Received revision surgery; (4) Combined with cervical deformity, tumor, severe osteoporosis, ankylosing spondylitis and rheumatoid arthritis; (5) Incomplete imaging data; (6) loss of follow-up or follow-up was less than 1 year; (7) Received hybrid surgery.…”

“…Anterior cervical discectomy and fusion (ACDF) is the gold standard for the treatment of cervical spondylosis. [1][2][3][4] Anterior cage-plate construct is commonly used in ACDF in order to enhance segmental stability improve cervical sagittal alignment, reduce graft extrusion and subsidence, and increase fusion rates. These techniques have their own bene ts as well as potential drawbacks and adverse effects.…”