Background: Anterior cervical discectomy and fusion (ACDF) for cervical degenerative disease is an accepted treatment for symptomatic cervical radiculopathy and myelopathy. One-and two-level fusions are much more common and more widely studied. Outcomes and revision rates for three-and four-level ACDF have not been well described. The purpose of this study is to report on clinical outcomes and revision rates following multilevel ACDF. Methods: Patients who underwent three-or four-level anterior cervical discectomy with plate fixation between 2006 and 2011 from a single-center multi-surgeon practice for symptomatic cervical degenerative disease were identified. Improvements in neck disability index (NDI), neck and arm pain scores two years after surgery and revision rates were analyzed. Results: Forty-six patients with a mean age of 55.9 years were included in the analysis. Twenty-one (46%) were male, 10 (22%) were smokers. Forty-one (89%) underwent three-level fusion and 5 (11%) underwent four-level fusion. NDI improved from 34.46 at baseline to 25.47 at 2 years. Neck pain improved from 7.04 at baseline to 3.95 and arm pain improved from 6.24 to 3.09 at 2 year follow up. Sixteen patients (35%) returned to surgery within 2 years with 11 of these patients (24%) returning for non-union. The average number of days to revision surgery was 750.6±570.3 days. Conclusions: Patients undergoing three-and four-level ACDF for multilevel cervical disease demonstrate substantial improvement in outcomes. However, the two-year revision rate is relatively high at 35% with the majority of these patients returning due to non-union.
The value of an intervention depends on efficacy, safety, and durability. Despite improvements in technique and clinical outcome, an 18% revision rate at 4 years postoperatively is not sustainable from either a clinical or an economic standpoint. This study establishes a benchmark for the critical effort that is needed to reduce the revision rate in adult spinal deformity surgery.
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