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

Abstract

Background: Multilevel cervical pathology can often be addressed via anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF). While posterior procedures may be technically easier for four-level pathology, there are advantages and disadvantages to both approaches that make it of interest to compare outcomes. The purpose was to compare perioperative adverse events and long-term cervical reoperation rates of four-level ACDF and PCF.

Methods: The 2010 to Q1 2020 PearlDiver MSpine database was queried. Patients undergoing isolated elective four-level ACDF or PCF were identified (excluding cases performed for trauma, neoplasm, and/or infections) and 1:1 matched based on age, sex, and comorbidities. Ninety-day adverse events were compared with univariate and multivariate analyses. Five-year incidences of subsequent cervical reoperations were also compared.

Results: A total of 3,714 patients 1:1 matched for four-level ACDF and PCF performed for degenerative pathologies were identified (1,857 for each of the study groups). On multivariate analysis controlling for age, sex, and comorbidities, PCF was found to have significantly greater odds ratios (OR) for any (OR 2.12), serious (OR 2.31), and minor (OR 1.95) adverse events, as well as for length of stay ≥3 days (OR 1.76), p<0.001 for each. However, PCF had nearly three times lower odds of dysphagia compared to ACDF (OR 0.36, p<0.001). At five years, four-level ACDF cases were found to have significantly higher reoperation rates compared to four-level PCF cases (26.3% vs 18.3%, p<0.001).

Conclusion: In evaluating four-level cervical cases, compared to anterior approach cases, posterior approach procedures were associated with approximately double the odds of any, serious, and minor adverse events, but around one third the rate of dysphagia and two thirds the rate of five-year reoperations. While the pathology may dictate surgical approach, this data suggests that the choice between four-level anterior versus posterior approach becomes a balance of risks/benefit considerations.

Keywords: ACDF, anterior cervical discectomy and fusion; Big data; CI, confidence interval; CPT, Current Procedural Terminology; Cervical myelopathy; Dysphagia; ECI, Elixhauser Comorbidity Index; ICD, International Classification of Disease; LOS, length of stay; Multi-level cervical fusion; OR, odds ratio; PCF, posterior cervical fusion; Radiculopathy; SD, standard deviation; Spinal arthrodesis; Stenosis.

Fig. 1

Forest plot of 90-day complications and length of stay adjusted odds ratios for posterior cervical fusion (PCF), with anterior cervical discectomy and fusion (ACDF) as the reference population. Select serious and minor adverse events shown.

Fig. 2

Five-year Kaplan-Meier survival plot of cervical reoperations for anterior cervical discectomy and fusion (ACDF) and posterior cervical fusion (PCF) that were actively covered under their insurance plan for up to five years. Log-rank test, p < 0.001. Pie charts demonstrate the type of subsequent cervical reoperation – anterior (A), posterior (P), or both (A/P).