Clinical study| Volume 62, P142-146, April 2019

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Fusion rate following three- and four-level ACDF using allograft and segmental instrumentation: A radiographic study

Published:January 25, 2019DOI:


      • Pseudarthrosis rates of extended anterior cervical fusion (3- and 4-level) are under-reported.
      • The minority of radiographic pseudarthrosis are clinically symptomatic.
      • Pseudarthrosis rates are higher in 4-level than 3-level ACDF.


      Cervical spine degenerative pathologies remain one of the most common spinal conditions treated by spine surgeons worldwide. Surgery is recommended in all patients with symptomatic cervical spinal stenosis with either moderate to severe myelopathy, degeneration, or refractory radiculopathy. As the number of levels increases the potential for complications associated with anterior surgery can be significant, especially dysphagia and pseudarthrosis. The objective of this study was to analyze the fusion rate following three- or more level anterior cervical discectomy and fusion (ACDF). A retrospective review was performed analyzing patients who underwent three or more level ACDF. Fusion was evaluated using post-operative dynamic upright radiographs Relevant post-operative complications especially dysphagia requiring dietary modifications or placement of feeding tube was also noted. A total of 72 patients were included in the study. Of the 232 levels fused, pseudarthrosis occurred at 47 (14%) levels. Overall 45.8% of patients (33/72) had a pseudarthrosis. The incidence of pseudarthrosis was higher in patients with 4 level ACDF as compared to those with 3 level ACDF [56% (9/16) versus 42% (24/56)]. At last follow up, the number of patients that were symptomatic from their pseudarthrosis and required posterior spinal instrumentation was 8/72 (11.1%). Fusion rates in a large cohort of patients with three- and four-level ACDF performed utilizing allograft and segmental instrumentation is reported. The study demonstrates that 3–4 level, stand-alone anterior cervical arthrodeses result in at least one level of pseudarthrosis in almost half of patients, especially at the caudal level of the construct.
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        • Barsa P.
        • Suchomel P.
        • Buchvald P.
        • Kolárová E.
        • Svobodník A.
        Multiple-level instrumented anterior cervical fusion: a risk factor for pseudoarthrosis? A prospective study with a minimum of 3-year follow-up.
        Acta Chir Orthop Traumatol Cech. 2004; 71: 137-141
        • Bucciero A.
        • Zorzi T.
        • Piscopo G.A.
        Peek cage-assisted anterior cervical discectomy and fusion at four levels: clinical and radiographic results.
        J Neurosurg Sci. 2008; 52: 37-40
        • Chen Y.
        • Wang X.
        • Lu X.
        • Yang L.
        • Yang H.
        • Yuan W.
        • et al.
        Comparison of titanium and polyetheretherketone (PEEK) cages in the surgical treatment of multilevel cervical spondylotic myelopathy: a prospective, randomized, control study with over 7-year follow-up.
        Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2013; 22: 1539-1546
        • Epstein N.E.
        Iliac crest autograft versus alternative constructs for anterior cervical spine surgery: Pros, cons, and costs.
        Surg Neurol Int. 2012; 3: S143-156
        • Fehlings M.G.
        • Tetreault L.
        • Nater A.
        • Choma T.
        • Harrop J.
        • Mroz T.
        • et al.
        The aging of the global population: the changing epidemiology of disease and spinal disorders.
        Neurosurgery. 2015; 77: S1-5
        • Furlan J.C.
        • Kalsi-Ryan S.
        • Kailaya-Vasan A.
        • Massicotte E.M.
        • Fehlings M.G.
        Functional and clinical outcomes following surgical treatment in patients with cervical spondylotic myelopathy: a prospective study of 81 cases.
        J Neurosurg Spine. 2011; 14: 348-355
        • Gercek E.
        • Arlet V.
        • Delisle J.
        • Marchesi D.
        Subsidence of stand-alone cervical cages in anterior interbody fusion: warning.
        Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2003; 12: 513-516
        • Hilibrand A.S.
        • Yoo J.U.
        • Carlson G.D.
        • Bohlman H.H.
        The success of anterior cervical arthrodesis adjacent to a previous fusion.
        Spine. 1997; 22: 1574-1579
        • Kasliwal M.K.
        • Corley J.A.
        • Traynelis V.C.
        Posterior cervical fusion using cervical interfacet spacers in patients with symptomatic cervical pseudarthrosis.
        Neurosurgery. 2015;
        • Lu D.C.
        • Tumialán L.M.
        • Chou D.
        Multilevel anterior cervical discectomy and fusion with and without rhBMP-2: a comparison of dysphagia rates and outcomes in 150 patients.
        J Neurosurg Spine. 2013; 18: 43-49
        • Mummaneni P.V.
        • Kaiser M.G.
        • Matz P.G.
        • Anderson P.A.
        • Groff M.W.
        • Heary R.F.
        • et al.
        Cervical surgical techniques for the treatment of cervical spondylotic myelopathy.
        J Neurosurg Spine. 2009; 11: 130-141
        • Pereira E.A.C.
        • Chari A.
        • Hempenstall J.
        • Leach J.C.D.
        • Chandran H.
        • Cadoux-Hudson T.A.D.
        Anterior cervical discectomy plus intervertebral polyetheretherketone cage fusion over three and four levels without plating is safe and effective long-term.
        J Clin Neurosci Off J Neurosurg Soc Australas. 2013; 20: 1250-1255
        • Phillips F.M.
        • Carlson G.
        • Emery S.E.
        • Bohlman H.H.
        Anterior cervical pseudarthrosis. Natural history and treatment.
        Spine. 1997; 22: 1585-1589
        • Roguski M.
        • Benzel E.C.
        • Curran J.N.
        • Magge S.N.
        • Bisson E.F.
        • Krishnaney A.A.
        • et al.
        Postoperative cervical sagittal imbalance negatively affects outcomes after surgery for cervical spondylotic myelopathy.
        Spine. 2014; 39: 2070-2077
        • Samartzis D.
        • Shen F.H.
        • Goldberg E.J.
        • An H.S.
        Is autograft the gold standard in achieving radiographic fusion in one-level anterior cervical discectomy and fusion with rigid anterior plate fixation?.
        Spine. 2005; 30: 1756-1761
        • Samartzis D.
        • Shen F.H.
        • Matthews D.K.
        • Yoon S.T.
        • Goldberg E.J.
        • An H.S.
        Comparison of allograft to autograft in multilevel anterior cervical discectomy and fusion with rigid plate fixation.
        Spine J Off J North Am Spine Soc. 2003; 3: 451-459
        • Sampath P.
        • Bendebba M.
        • Davis J.D.
        • Ducker T.B.
        Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review.
        Spine. 2000; 25: 670-676
        • Shriver M.F.
        • Lewis D.J.
        • Kshettry V.R.
        • Rosenbaum B.P.
        • Benzel E.C.
        • Mroz T.E.
        Pseudoarthrosis rates in anterior cervical discectomy and fusion: a meta-analysis.
        Spine J Off J North Am Spine Soc. 2015; 15: 2016-2027
        • Song K.-S.
        • Piyaskulkaew C.
        • Chuntarapas T.
        • Buchowski J.M.
        • Kim H.J.
        • Park M.S.
        • et al.
        Dynamic radiographic criteria for detecting pseudarthrosis following anterior cervical arthrodesis.
        J Bone Joint Surg Am. 2014; 96: 557-563
        • Wang J.C.
        • McDonough P.W.
        • Endow K.K.
        • Delamarter R.B.
        Increased fusion rates with cervical plating for two-level anterior cervical discectomy and fusion.
        Spine. 2000; 25: 41-45
        • Wang J.C.
        • McDonough P.W.
        • Kanim L.E.
        • Endow K.K.
        • Delamarter R.B.
        Increased fusion rates with cervical plating for three-level anterior cervical discectomy and fusion.
        Spine. 2001; 26: 643-646