What is a multilevel Anterior Cervical Discectomy and Fusion (ACDF)?

Multilevel Anterior Cervical Discectomy and Fusion (ACDF)

A multilevel ACDF is a surgical procedure that involves the removal of multiple intervertebral discs and fusion of adjacent vertebrae across two or more levels of the cervical spine to treat cervical spondylotic myelopathy or other degenerative cervical spine conditions. 1

Definition and Procedure

• Multilevel ACDF refers to anterior cervical discectomy and fusion performed at two or more consecutive vertebral levels (e.g., C3-C4, C4-C5, C5-C6) 1
• The procedure involves removing the degenerated discs at multiple levels, decompressing the spinal cord and nerve roots, and fusing the vertebrae with bone grafts and often anterior plating 2
• Multilevel ACDF can range from two-level to five-level procedures, with four and five-level procedures being less common but still performed in appropriate cases 2, 3

Indications for Multilevel ACDF

• Multilevel cervical degenerative disc disease affecting multiple segments 4
• Cervical spondylotic myelopathy with compression at multiple disc levels 1
• Multilevel cervical stenosis causing neurological symptoms 3
• Patients with radiographic evidence of spinal cord compression at multiple consecutive cervical levels 3

Surgical Considerations

• For two or three-level ACDF, a standard transverse incision is typically used 2
• For four or five-level procedures, some surgeons may switch to a longitudinal incision along the sternocleidomastoid muscle border, though transverse incisions can still be used in select patients 2
• Anterior plating is commonly used in multilevel ACDF to provide additional stability and improve fusion rates 1
• Without anterior fixation, anterior cervical corpectomy with fusion (ACCF) may provide higher fusion rates than multilevel ACDF, but with higher graft failure rates 1

Outcomes and Considerations

• Multilevel ACDF has demonstrated good clinical outcomes with high fusion rates (approximately 95% for four-level procedures) 3
• Four-level ACDF has shown significant improvement in neurological symptoms with 88.3% of patients reporting improvement 3
• Compared to single-level procedures, multilevel ACDF (especially four-level) is associated with:
  • Higher rates of dysphagia (temporary in most cases) 5
  • Increased risk of prolonged hospital stay 5
  • Higher reoperation rates at 5 years (22.1% for four-level vs. 13.0% for one-level) 5

Complications and Risks

• Early postoperative dysphagia is common (18.3% in four-level ACDF), though most cases resolve with time 3
• Hardware failure can occur in multilevel constructs 3
• Residual neck pain and paresthesias may persist in some patients 3
• Adjacent segment degeneration is a potential long-term complication, though evidence regarding its increased risk in multilevel versus single-level procedures is mixed 2, 4

Comparison with Alternative Approaches

• Multilevel ACDF and anterior cervical corpectomy with fusion (ACCF) yield similar results for lesions at the disc level when anterior plating is used 1
• For multilevel cervical spine decompression, there is insufficient evidence to recommend ACDF over laminoplasty or laminectomy with arthrodesis in the short term 1
• However, laminectomy alone is associated with late deterioration compared to ACDF and other approaches 1
• Cervical disc replacement is being investigated as an alternative to multilevel ACDF, but evidence is still insufficient to draw strong conclusions 4

Practical Considerations

• Surgical approach (ACDF vs. alternative procedures) should be based on the location of compression (disc level vs. vertebral body), number of levels involved, and presence of kyphotic deformity 1
• When considering multilevel ACDF, especially for four or more levels, patients should be counseled about the higher risk of dysphagia, prolonged hospital stay, and potential reoperation compared to single-level procedures 5