Comparison of Clinical and Radiographic Outcomes After Standalone Versus Cage and Plate Constructs for Anterior Cervical Discectomy and Fusion

Abstract

Background: Anterior cervical discectomy and fusion (ACDF) has conventionally been performed using an allograft cage with a plate-and-screw construct. Recently, standalone cages have gained popularity due to theorized decreases in operative time and postoperative dysphagia. Few studies have compared these outcomes. Here, we directly compare the outcomes of plated versus standalone ACDF constructs.

Methods: A single-center retrospective review of patients undergoing ACDF after June 2011 with at least 6 months of follow up was conducted. Clinical outcomes were analyzed and compared between standalone and plated constructs. Multivariate regression analysis of the primary outcome, need for revision surgery, as well as several secondary outcomes, procedure duration, estimated blood loss (EBL), length of hospital stay, disposition, and incidence of dysphagia, hoarseness, or surgical site infection, was completed.

Results: A total of 321 patients underwent ACDF and met inclusion-exclusion criteria, with mean follow-up duration of 20 months. Forty-six (14.3%) patients received standalone constructs, while 275 (85.7%) received plated constructs. Fourteen (4.4%) total revisions were necessary, 4 in the standalone group and 10 in the plated group, yielding revision rates of 8.7% and 3.6%, respectively (P = .125). Mean EBL was 98 mL in the standalone group and 63 mL in the plated group (P = .001). Mean procedure duration was 147 minutes in the standalone group and 151 minutes in the plated group (P = .800). Mean hospital stay was 3.6 days in the standalone group and 2.5 days in the plated group (P = .270). There was no significant difference in incidence of dysphagia (P = .700) or hoarseness (P = .700).

Conclusions: Standalone ACDF demonstrates higher, but not statistically significant, revision rates than plate-and-screw constructs, without the hypothesized decreased incidence of dysphagia or hoarseness and without decreased procedure duration or EBL. Surgeons may consider limiting use of these constructs to cases of adjacent segment disease. Larger studies with longer follow up are necessary to make more definitive conclusions.

Level of evidence: 4.

Clinical relevance: This study will help spine surgeons decide between using standalone or cage-and-plate constructs for ACDF.

Keywords: anterior cervical discectomy and fusion; anterior plate; dysphagia; pseudarthrosis; standalone.

Figure

Case illustration. Preoperative lateral (A) extension and (B) flexion radiographs demonstrate dynamic spondylolisthesis at C4–5 and C7–T1. Preoperative magnetic resonance imaging with (C) sagittal and (D) axial cuts at C4–5 and (E) C7–T1 show disc herniations at those levels with moderate canal stenosis at C4–5 and severe canal stenosis at C7–T1. Postoperative (F) lateral and (G) anterior-posterior (AP) radiographs show placement of standalone constructs at C4–5 and C7–T1. Interval (H) lateral and (I) AP radiographs, as well as (J) sagittal and (K) axial computed tomography images 2 months later demonstrate hardware failure with anterior displacement of the C7–T1 standalone construct out of the disc space. Postrevision (L) lateral and (M) AP radiographs show implantation of a cage-and-plate construct at C7–T1.