Perioperative and swallowing outcomes in patients undergoing 4- and 5-level anterior cervical discectomy and fusion

Abstract

OBJECTIVE Anterior cervical discectomy and fusion (ACDF) is a common and robust procedure performed on the cervical spine. Literature on ACDF for 4 or more segments is sparse. Increasing the number of operative levels increases surgical complexity, tissue retraction, and risks of complications, particularly dysphagia. The overall risks of these complications and rates of dysphagia are not well studied for surgery on 4 or more segments. In this study, the authors evaluated their institution’s perioperative experience with 4- and 5-level ACDFs. METHODS The authors retrospectively reviewed patients who underwent 4- or 5-level ACDF at their institution over a 6-year period (May 2013–May 2019). Patient demographics, perioperative complications, readmission rates, and swallowing outcomes were recorded. Outcomes were analyzed with a multivariate linear regression. RESULTS A total of 174 patients were included (167 had 4-level and 7 had 5-level ACDFs). The average age was 60.6 years, and 54.0% of patients (n = 94) were men. A corpectomy was performed in 12.6% of patients (n = 22). After surgery, 56.9% of patients (n = 99) experienced dysphagia. The percentage of patients with dysphagia decreased to 22.8% (37/162) at 30 days, 12.9% (17/132) at 90 days, and 6.3% (5/79) and 2.8% (1/36) at 1 and 2 years, respectively. Dysphagia was more likely at 90 days postoperatively in patients with gastroesophageal reflux (OR 4.4 [95% CI 1.5–12.8], p = 0.008), and the mean (± SD) lordosis change was greater in patients with dysphagia than those without at 90 days (19.8° ± 13.3° vs 9.1° ± 10.2°, p = 0.003). Dysphagia occurrence did not differ with operative implants, including graft and interbody type. The mean length of time to solid food intake was 2.4 ± 2.1 days. Patients treated with dexamethasone were more likely to achieve solid food intake prior to discharge (OR 4.0 [95% CI 1.5–10.6], p = 0.004). Postsurgery, 5.2% of patients (n = 9) required a feeding tube due to severe approach-related dysphagia. Other perioperative complication rates were uniformly low. Overall, 8.6% of patients (n = 15) returned to the emergency department within 30 days and 2.9% (n = 5) required readmission, whereas 1.1% (n = 2) required unplanned return to surgery within 30 days. CONCLUSIONS This is the largest series of patients undergoing 4- and 5-level ACDFs reported to date. This procedure was performed safely with minimal intraoperative complications. More than half of the patients experienced in-hospital dysphagia, which increased their overall length of stay, but dysphagia decreased over time.

Comparison of Fusion versus Nonunion After 4-Level and 5-Level Anterior Cervical Diskectomy and Fusion With Anterior Plate Fixation

“…In fact, the largest study recently published on 4level and 5-level ACDF focuses on the complication and swallowing outcomes. 14 In addition, the small number of reports with varying results may not reflect the true nonunion rate because of the disparities in study methodologies, small patient cohorts, and .017 b C2-3 vs C3-4 vs C4-5 vs C5-6 vs C6-7 vs C7-T1, n (% of subsident level) 0 (0.0) vs 2 (16.7) vs 1 (8.3) different definitions of nonunion as echoed in the meta-analysis by Shriver et al 19 Therefore, this work seeks to provide a robust analysis of nonunion after 4 to 5-level ACDF by comparing the demographic and surgical differences between the nonunion and fusion groups. Both groups displayed comparable baseline characteristics except that significantly higher proportion of the nonunion patients presented with weakness.…”

“…[11][12][13] The largest series on 4 to 5-level ACDF focused specifically on swallowing outcomes. 14 There are little data on nonunion rates in 4 to 5-level ACDFs. Therefore, this study analyzes factors predicting nonunion after 4 to 5-level ACDF by comparing patients who achieved fusion with those who failed to achieve fusion at 1 or multiple levels.…”

Multilevel cervical disc arthroplasty: a review of optimal surgical management and future directions

“…didates for CDA. [45][46][47] Due to arthrodesis-related consequences, 22,39,[48][49][50][51] multilevel CDA is particularly appealing for young patients with multilevel cervical spondylotic myelopathy caused by disc-related problems or congenital stenosis. Chang et al 1 reported a retrospective series of 37 patients younger than 50 years with cervical myelopathy who were treated with either hybrid CDA-ACDF (2-level CDA plus 1-level ACDF, 20 patients) or 3-level ACDF (17 patients).…”

Biomechanics of a novel artificial cervical vertebra from an in vivo caprine cervical spine non-fusion model

“…ACCF allows direct removal of the compression to the spinal cord and provides the cervical spine with a stable biomechanical environment via anterior arthrodesis at the operative levels. Although ACCF has been reported to exhibit good neurologic recovery [ 9 ], and restoration of cervical alignment in patients with CSM, the long-segment solid fusion inevitably sacrifices partial motor function of the cervical spine. The loss of motion at the operative levels can lead to an increased range of motion (ROM) of the adjacent intervertebral space [ 10 , 11 ], which can possibly lead to adjacent segment disease and resulting in CSM in those patients [ [12] , [13] , [14] ].…”