Clinical study| Volume 75, P19-24, May 2020

Download started.


Is it necessary to place screws in the intervening vertebrae in two-level anterior cervical discectomy with fusion and plating?

Published:April 01, 2020DOI:


      • The clinical efficacy of the two methods of screw placement was similar.
      • The incidence of complications was the same for two methods of screw placement.
      • ACDF (middle vertebra without screw) had shorter screw placement time and less implant cost.



      The clinical outcomes, radiological parameters, complication rate and the cost of implants in two-level ACDF with and without screws in the intervening segment were compared.


      A retrospective study of 68 patients who underwent 2-level ACDF from January 2014 to June 2016 was performed. The patients were divided into two groups: ACDF with screws in the intervening vertebra and those without screws in the intervening vertebra. Perioperative factors, clinical outcomes, postoperative complications, radiological parameters, and cost of the implants were evaluated in both groups.


      No statistical differences in clinical outcomes, operative blood loss, hospital stay, restoration of cervical lordosis or segment height, postoperative complications, and fusion rate were found between the ACDF (middle vertebra with screw) and ACDF (middle vertebra without screw) groups (P > 0.05). But the operative time of added screw placement and cost of implants in the ACDF (middle vertebra without screw) group were significantly less than the ACDF (middle vertebra with screw) group (P < 0.05).


      Two kinds of screw placement with ACDF were found to be similar in terms of clinical outcomes. However, ACDF (middle vertebra without screw) was found to be superior to ACDF (middle vertebra with screw) in terms of the screw placement time and cost of implants.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Clinical Neuroscience
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Luo J.
        • Cao K.
        • Huang S.
        • et al.
        Comparison of anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy.
        Eur Spine J. 2015; 24: 1621-1630
        • Zhu B.
        • Xu Y.
        • Liu X.
        • et al.
        Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy: a systemic review and meta-analysis.
        Eur Spine J. 2013; 22: 1583-1593
        • Perrini P.
        • Lorenzo N.D.
        Anterior cervical decompression and fusion with autologous bone graft.
        Cervical Spine. 2016; 13: 115-124
        • Zhao H.
        • Duan L.J.
        • Gao Y.S.
        • et al.
        What is the superior surgical strategy for bi-level cervical spondylosis-anterior cervical disc replacement or anterior cervical decompression and fusion?: a meta-analysis from 11 studies.
        Medicine. 2018; 97: 5-12
        • Herrmann A.M.
        • Geisler F.H.
        Geometric results of anterior cervical plate stabilization in degenerative disease.
        Spine. 2004; 29: 1226-1234
        • Wang J.C.
        • McDonough P.W.
        • Endow K.K.
        • et al.
        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.A.
        • 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
        • Tracy J.A.
        • Bartleson J.D.
        Cervical spondylotic myelopathy.
        Neurologist. 2010; 16: 176-187
        • Hillard V.H.
        • Apfelbaum R.I.
        Surgical management of cervical myelopathy: indications and techniques for multilevel cervical discectomy.
        Spine J. 2006; 6: 242-251
        • Stewart T.J.
        • Schlenk R.P.
        • Benzel E.C.
        Multiple level discectomy and fusion.
        Neurosurgery. 2007; 60: 143-148
        • Donk R.
        • Verbeek A.
        • Verhagen W.
        • et al.
        The qualification of outcome after cervical spine surgery by patients compared to the neck disability index.
        PLoS ONE. 2016; 11: 156-171
        • Min H.
        • Xiao H.J.
        • KyeongAh
        • et al.
        A comparison of the validity and reliability between a digital radiographic imaging system and manual method in measuring the Cobb angle.
        Scoliosis. 2013; 8: 1-2
        • Gstoettner M.
        • Sekyra K.
        • Walochnik N.
        • et al.
        Inter- and intraobserver reliability assessment of the Cobb angle: manual versus digital measurement tools.
        Eur Spine J. 2007; 16: 1587-1592
        • Epstein N.E.
        • Silvergleide R.S.
        Documenting fusion following anterior cervical surgery: a comparison of roentgenogram versus two-dimensional computed tomographic findings.
        J Spinal Disorders Techniques. 2003; 16: 243-247
        • Epstein N.E.
        • SilvergIeide R.S.
        • Black K.
        Computed tomography validating bony ingrowth into fibula strut allograft: a criterion for fusion.
        Spine. 2002; 2: 129-133
        • Wang J.C.
        • McDonough P.W.
        • Endow K.K.
        • Delamarter R.B.
        A comparison of fusion rates between single-level cervical corpectomy and two-level discectomy and fusion.
        J Spinal Disord. 2001; 14: 222-225
        • Tureyen K.
        Disc height loss after anterior cervical microdiscectomy with titanium intervertebral cage fusion.
        Acta Neurochir. 2003; 145: 569-570
        • Van Jonbergen H.P.
        • Spruit M.
        • Anderson P.G.
        • et al.
        Anterior cervical interbody fusion with a titanium box cage: early radiological assessment of fusion and subsidence.
        Spine. 2005; 5: 645-649
        • Montgomery D.M.
        • Brower R.S.
        Cervical spondylotic myelopathy. Clinical syndrome and natural history.
        Orthop Clin N AM. 1992; 23: 487-493
        • Ebersold M.J.
        • Pare M.C.
        • Quast L.M.
        Surgical treatment for cervical spondylitc myelopathy.
        Neurosurg. 1995; 82: 745-751
        • Karadimas S.K.
        • Gatzounis G.
        • Fehlings M.G.
        Pathobiology of cervical spondylotic myelopathy.
        Eur Spine J. 2015; 24: 132-138
        • Suen T.K.
        • Wong K.H.
        • Ho Y.F.
        The outcomes of anterior spinal fusion for cervical compressive myelopathy – a retrospective review.
        J Orthop. 2011; 15: 53-56
        • Mobbs R.J.
        • Rao P.
        • Chandmn N.K.
        Anterior cervical discectomy and fusion: analysis of surgical outcome with and without plating.
        Clin Neurosci. 2007; 14: 639-642
        • Zeng J.
        • Duan Y.
        • Yang Y.
        • et al.
        Anterior corpectomy and reconstruction using dynamic cervical plate and titanium mesh cage for cervical spondylotic myelopathy: a minimum 5-year follow-up study.
        Medicine. 2018; 97: 9724-9734
        • Bose B.
        Anterior cervical fusion using Caspar plating: analysis of results and review of the literature.
        Surg Neuro. 1998; 49: 25-31
        • Hwang S.L.
        • Lee K.S.
        • Su Y.F.
        • et al.
        Anterior corpectomy with iliac bone fusion or discectomy with interbody titanium cage fusion for multilevel cervical degenerated disc disease.
        J Spinal Disord Tech. 2007; 20: 565-570
        • Song K.J.
        • Lee K.B.
        • Song J.H.
        Efficacy of multilevel anterior cervical discectomy and fusion versus corpectomy and fusion for multilevel cervical spondylotic myelopathy: a minimum 5-year follow-up study.
        Eur Spine J. 2012; 21: 1551-1557
        • Dong F.
        • Shen C.
        • Jiang S.
        • et al.
        Measurement of volume-occupying rate of cervical spinal canal and its role in cervical spondylotic myelopathy.
        Eur Spine J. 2013; 22: 1152-1157
        • Peterson J.M.
        • Chlebek C.
        • Clough A.M.
        • et al.
        Stiffness matters: Part II – the effects of plate stiffness on load-sharing and the progression of fusion following ACDF in vivo.
        Spine. 2018; 43: 1069-1076
        • Akamaru
        • Tomoyuki
        • Kawahara
        • et al.
        The transmission of stress to grafted bone inside a titanium mesh cage used in anterior column reconstruction after total spondylectomy: a finite-element analysis.
        Spine. 2005; 30: 2783-2787
        • Ledet E.H.
        • Sanders G.P.
        • Dirisio D.J.
        • et al.
        Load-sharing through elastic micro-motion accelerates bone formation and interbody fusion.
        Spine J. 2018; 18: 1222-1230
        • Wu X.D.
        • Wang X.W.
        The effect of multilevel anterior cervical fusion on neck motion.
        Eur Spine J. 2012; 21: 1368-1373
        • Bolesta M.J.
        • Ii G.R.R.
        • Chrin A.M.
        One- and two-level anterior cervical discectomy and fusion: the effect of plate fixation.
        Spine J. 2002; 2: 197-203
        • Park D.H.
        • Ramakrishnan P.
        • Cho T.H.
        • et al.
        Effect of lower two-level anterior cervical fusion on the superior adjacent level.
        J Neurosurg-Spine. 2007; 7: 336-340
        • Liu Y.
        • Hou Y.
        • Yang L.
        • et al.
        Comparison of 3 reconstructive techniques in the surgical management of multilevel cervical spondylotic myelopathy.
        Spine. 2012; 37: 1450-1458
        • Yue W.M.
        • Brodner W.
        • Highland T.R.
        Long-term results after anterior cervical discectomy and fusion with allograft and plating: a 5-to 11-year radiologic and clinical follow-up study.
        Spine. 2005; 30: 2138-2144
        • Bithal P.K.
        • Prabhakar H.
        • Marda M.K.
        • Garg R.
        • Rath G.P.
        Effects of retractor application on cuff pressure and vocal cord function in patients undergoing anterior cervical discectomy and fusion.
        Indian J Anaesth. 2010; 54: 292