Anterior cervical discectomy: to graft or not to graft?

Abstract

The debate regarding whether to perform an interbody fusion after anterior cervical discectomy (ACD) has been going on for the last 50 years. Several prospective randomized clinical trials have been performed to evaluate the clinical outcome following anterior cervical discectomy with and without interbody fusion. None of these studies show a significant difference between the two techniques in terms of relief of arm pain or neck pain. The operative time, in-hospital stay and time for return to work seem to be slightly longer following anterior cervical discectomy with interbody grafting (ACDF) compared to ACD alone. However a temporary increase in postoperative axial pain seems to be a common complication following ACD. There is also no difference in the clinical outcomes between ACD and ACDF with plating and ACDF with interbody spacers. However, if a fusion procedure is undertaken, the use of interbody spacers does have the advantage of avoiding donor site complications. There is also some evidence to suggest that plate fixation can lead to increased fusion rates. There is a significant risk of a degree of segmental kyphosis following ACD. These radiological features, however, do not correlate with the clinical outcome. Radiological and clinical studies fail to show a significant difference in recurrence of foraminal narrowing or the rates of reoperation following ACD or ACDF. The available body of evidence suggests that the addition of a fusion procedure following anterior cervical decompression may give improved radiological results but does not necessarily result in improved clinical outcomes.

Iliac crest autograft versus alternative constructs for anterior cervical spine surgery: Pros, cons, and costs

“…[27] They observed that even in the multiple randomized prospective trials comparing ACF with ACDF, there was “no significant difference” in the relief of arm or neck pain. Differences included for the ADF patients, “…a temporary increase in postoperative axial neck pain”, while the ACDF patients required longer operative times, prolonged lengths of stay, and more time to return to work.…”

Single Level Anterior Cervical Discectomy without Fusion: An Outcome Analysis

“…Data on the long-term clinical, functional, and radiologic outcomes following these techniques have been reported proposing equally good results in comparison with the [1][2][3][4][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] fusion techniques.…”

“…On the other hand, the clinical results of ACD are reported to be favorable by numerous studies, which introduce this technique a safe and valuable alternative for the "fusion" [1][2][3][4][11][12][13][14][15][16][17][18][19][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]37 operations with less complication for the patient. However, still the issue of whether to perform fusion or not after anterior cervical discectomy remains controversial, and many comparative prospective clinical studies comparing the outcome of ACD alone with ACDF have failed to prove the superiority of either 1,4,11,12,14,17,18,[21][22][23][24]26,29,34,35 technique. Table 7 shows the variations in the design of the available studies for this narrative review comparing ACD and ACDF and Table 8...…”

“…When the length of follow-up extends to the longer periods of time, the type of surgery will have less 12,17,19,23,24,27,29,32,37,38 effect on pain and function of the patients. Furthermore, "immediate" postoperative pain (on the day after the surgery) is reported to be less in ACD group in 4,14 comparison with the ACDF cases.…”

Anterior Cervical Discectomy - An Overview of Technique and Developments for the Future

“…However, a correlation with a clinical effect has never been established. 17 The most common complications of CAD are hoarseness and dysphagia. A lesion of the recurrent laryngeal nerve can lead to dysfunction.…”