Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Mar 24:10:100115.
doi: 10.1016/j.xnsj.2022.100115. eCollection 2022 Jun.

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

Peter Y Joo  1 , Rahul H Jayaram  1 , William M McLaughlin  1 , Bijan Ameri  1 , Alexander J Kammien  1 , Paul M Arnold  2 , Jonathan N Grauer  1
Affiliations

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

Peter Y Joo et al. N Am Spine Soc J. .

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.

PubMed Disclaimer

Conflict of interest statement

One or more authors declare potential competing financial interests or personal relationships as specified on required ICMJE Disclosure Forms.

Figures

Fig 1:
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:
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).
See this image and copyright information in PMC

References

    1. Kato S, Fehlings M. Degenerative cervical myelopathy. Curr Rev Musculoskelet Med. 2016;9(3):263–271. - PMC - PubMed
    1. Xiao SW, Jiang H, Yang LJ, Xiao ZM. Anterior cervical discectomy versus corpectomy for multilevel cervical spondylotic myelopathy: a meta-analysis. Eur Spine J. 2015;24(1):31–39. - PubMed
    1. Neifert SN, Martini ML, Yuk F, et al. Predicting trends in cervical spinal surgery in the United States from 2020 to 2040. World Neurosurg. 2020;141:e175–ee81. - PubMed
    1. Yang X, Gharooni AA, Dhillon RS, et al. The relative merits of posterior surgical treatments for multi-level degenerative cervical myelopathy remain uncertain: findings from a systematic review. J Clin Med. 2021;10(16) - PMC - PubMed
    1. Hirabayashi K, Bohlman HH. Multilevel cervical spondylosis. Laminoplasty versus anterior decompression. Spine (Phila Pa 1976) 1995;20(15):1732–1734. - PubMed

LinkOut - more resources