title: Long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion.
abstract: OBJECTIVE The purpose of this study was to report the long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion (ACDF). METHODS A retrospective review of all adult neurosurgical patients undergoing elective ACDF for degenerative disease at a single institution between 1996 and 2013 was performed. Patients who underwent first-time 3- or 4-level ACDF were included; patients with previous cervical spine surgery, those undergoing anterior/posterior approaches, and those with corpectomy were excluded. Outcome measures included perioperative complication rates, fusion rates, need for revision surgery, Nurick Scores, Odom's criteria, symptom resolution, neck visual analog scale (VAS) pain score, and persistent narcotics usage. RESULTS Seventy-one patients who underwent 3-level ACDF and 26 patients who underwent 4-level ACDF were identified and followed for an average of 7.6 ± 4.2 years. There was 1 case (3.9%) of deep wound infection in the 4-level group and 1 case in the 3-level group (1.4%; p = 0.454). Postoperatively, 31% of patients in the 4-level group complained of dysphagia, compared with 12.7% in the 3-level group (p = 0.038). The fusion rate was 84.6% after 4-level ACDF and 94.4% after 3-level ACDF (p = 0.122). At last follow-up, a significantly higher proportion of patients in the 4-level group continued to have axial neck pain (53.8%) than in the 3-level group (31%; p = 0.039); the daily oral morphine equivalent dose was significantly higher in the 4-level group (143 ± 97 mg/day) than in the 3-level group (25 ± 10 mg/day; p = 0.030). Outcomes based on Odom's criteria were also different between cohorts (p = 0.044), with a significantly lower proportion of patients in the 4-level ACDF group experiencing an excellent/good outcome. CONCLUSIONS In this study, patients who underwent 4-level ACDF had significantly higher rates of dysphagia, postoperative neck pain, and postoperative narcotic usage when compared with patients who underwent 3-level ACDF. Pseudarthrosis and deep wound infection rates were also higher in the 4-level group, although this did not reach statistical significance. Additionally, a smaller proportion of patients achieved a good/excellent outcome in the 4-level group than in the 3-level group. These findings suggest a significant increase of perioperative morbidity and worsened outcomes for patients who undergo 4- versus 3-level ACDF.
authors.affiliation: The Spinal Column Biomechanics and Surgical Outcomes Laboratory and.|Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;
authors.forename: Rafael
authors.initials: R
authors.lastname: De la Garza-Ramos
authors.affiliation: The Spinal Column Biomechanics and Surgical Outcomes Laboratory and.|Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;
authors.forename: Risheng
authors.initials: R
authors.lastname: Xu
authors.affiliation: The Spinal Column Biomechanics and Surgical Outcomes Laboratory and.|Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;
authors.forename: Seba
authors.initials: S
authors.lastname: Ramhmdani
authors.affiliation: The Spinal Column Biomechanics and Surgical Outcomes Laboratory and.|Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;
authors.forename: Thomas
authors.initials: T
authors.lastname: Kosztowski
authors.affiliation: Department of Neurosurgery, Mayo Clinic College of Medicine, Rochester, Minnesota; and.
authors.forename: Mohamad
authors.initials: M
authors.lastname: Bydon
authors.affiliation: The Spinal Column Biomechanics and Surgical Outcomes Laboratory and.|Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Sciubba
authors.affiliation: The Spinal Column Biomechanics and Surgical Outcomes Laboratory and.|Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Wolinsky
authors.affiliation: The Spinal Column Biomechanics and Surgical Outcomes Laboratory and.|Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;
authors.forename: Timothy F
authors.initials: TF
authors.lastname: Witham
authors.affiliation: Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
authors.forename: Ziya L
authors.initials: ZL
authors.lastname: Gokaslan
authors.affiliation: The Spinal Column Biomechanics and Surgical Outcomes Laboratory and.|Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;
authors.forename: Ali
authors.initials: A
authors.lastname: Bydon
mesh_terms: D002574:Cervical Vertebrae / Q000601:surgery*; D017586:Diskectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D055959:Intervertebral Disc Degeneration / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D019547:Neck Pain / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000453:epidemiology; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome
keywords: 3-level; 4-level; ACDF; ACDF = anterior cervical discectomy and fusion; ASD = adjacent-segment disease; anterior cervical discectomy and fusion; cervical spine; fusion; outcomes