Dana Saleh, Ahmad Zayd Alkadri, Vito Evola, Atef F Hulliel, Kiana J Yeganeh, Jay Kumar, Alexander Haas, Patrick Kim, Mohsen Rostami, Puya Alikhani
Four-level ACDF offers perioperative efficiency with shorter hospital length of stay but is associated with higher rates of dysphagia, hoarseness, and hardware failure compared to PCF. In contrast, PCF provides greater hardware durability. Approach selection should be individualized based on pathology location, sagittal goals, and patient risk profile. Prospective studies with functional outcomes are needed to optimize the management of four-level cervical reconstruction.
BACKGROUND: Four-level cervical fusion is uncommon for extensive degenerative cervical spondylotic myelopathy or multilevel stenosis, with anterior cervical discectomy and fusion (ACDF) and posterior cervical fusion (PCF) representing the primary approaches. Direct comparisons of four-level constructs are limited, particularly regarding perioperative outcomes, complications, hardware durability, and sagittal alignment.
METHODS: Retrospective review of 64 consecutive patients (34 ACDF, 30 PCF) undergoing primary four-level cervical fusion at a single institution (2011-2024) with a minimum 1-year follow-up (mean ~ 44 months). Groups were comparable in demographics, comorbidities, and primary diagnosis (96.9% stenosis ± myelopathy). Outcomes included perioperative metrics, complications, hardware failure, revision rates, and sagittal parameters.
RESULTS: ACDF demonstrated significantly longer operative time (285 vs. 200 min, P < 0.001) but shorter hospital length of stay (4.1 vs. 8.3 days, P = 0.04). Transient dysphagia was significantly more common after ACDF (44.1% vs. 6.6%, P < 0.001). Persistent dysphagia (>6 months: 11.7% vs. 0.0%, P = 0.11) and persistent hoarseness (8.8% vs. 3.3%, P = 0.61) showed no significant difference. Hardware failure was markedly higher in ACDF (32.4% vs. 3.3%, P = 0.003). C5 palsy rates were numerically lower in ACDF (5.8% vs. 20.0%, P = 0.13). Overall revision rates were comparable between groups (20.6% vs. 10.0%, P = 0.31). At final follow-up, the ACDF group had a significantly lower C2 slope compared with the PCF group 19.3° vs. 26.2°, P = 0.008), with a significant increase in T1-slope within the ACDF group (P = 0.006).
CONCLUSION: Four-level ACDF offers perioperative efficiency with shorter hospital length of stay but is associated with higher rates of dysphagia, hoarseness, and hardware failure compared to PCF. In contrast, PCF provides greater hardware durability. Approach selection should be individualized based on pathology location, sagittal goals, and patient risk profile. Prospective studies with functional outcomes are needed to optimize the management of four-level cervical reconstruction.