I have a 10‑month history of cervical spondylosis with radiculopathy most severe at C5‑C6, failed medication, physical therapy, and two epidural steroid injections; two neurosurgeons now recommend a two‑level anterior cervical discectomy and fusion (ACDF) at C4‑C5 and C5‑C6. How does adding the second level change the risks and benefits compared to a single‑level ACDF?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: February 21, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Two-Level ACDF at C4-C5 and C5-C6: Impact on Risks and Benefits

For your two-level ACDF at C4-C5 and C5-C6, the addition of anterior cervical plating (instrumentation) is strongly recommended, as it dramatically reduces pseudarthrosis risk from 4.8% to 0.7% and improves fusion rates from 72% to 91% in two-level constructs. 1

Key Differences: Two-Level vs Single-Level ACDF

Enhanced Fusion Success with Instrumentation

  • Anterior cervical plating is specifically recommended for two-level cervical disc degeneration to improve arm pain (Class II evidence, strength of recommendation C). 2
  • Plating provides greater stability in multilevel constructs, which is critical for achieving solid arthrodesis across two motion segments. 1
  • Without instrumentation, two-level fusions carry substantially higher pseudarthrosis rates (4.8%) compared to instrumented constructs (0.7%). 1

Clinical Outcomes Remain Excellent

  • Surgical outcomes for two-level ACDF demonstrate 80-90% success rates for arm pain relief, comparable to single-level procedures. 1
  • Motor function recovery occurs in 92.9% of patients, with long-term improvements maintained over 12 months. 1
  • Rapid relief of arm/neck pain, weakness, and sensory loss typically occurs within 3-4 months post-operatively. 1

Adjacent Segment Disease Considerations

  • Contrary to common assumptions, multilevel arthrodesis carries significantly lower risk of symptomatic adjacent-segment disease compared to single-level fusion (p<0.001). 3
  • The annual incidence of new symptomatic disease at adjacent levels is 2.9% per year, with 25.6% of patients developing adjacent-segment disease within 10 years after any anterior cervical arthrodesis. 3
  • Single-level arthrodesis involving C5 or C6 with preexisting radiographic degeneration at adjacent levels carries the greatest risk for future adjacent-segment disease. 3
  • This evidence supports the recommendation that all degenerated segments causing radiculopathy should be included in the initial fusion, which aligns with your surgeons' recommendation to address both C4-C5 and C5-C6. 3

Surgical Approach and Technical Considerations

Graft Selection

  • Allograft is an appropriate and evidence-based choice for two-level fusion, achieving 93.4% fusion rates at 24 months when combined with anterior plating. 1
  • Allograft eliminates the 20% rate of prolonged donor site pain associated with iliac crest autograft harvest, without compromising fusion outcomes. 1
  • Document your smoking status, as cigarette smoking diminishes fusion rates with allograft, though differences are not always statistically significant. 1

Instrumentation Benefits Beyond Fusion Rates

  • Anterior plating maintains cervical lordosis (Class II evidence, strength of recommendation C), which is particularly important in multilevel constructs. 2
  • Instrumentation provides immediate structural support and maintains disc height, critical for foraminal decompression at both levels. 1

Realistic Expectations and Outcomes

Pain Relief Timeline

  • ACDF provides more rapid reduction of neck and arm pain compared to continued conservative treatment (Class III evidence, strength of recommendation D). 2
  • Expect significant symptom improvement within 3-4 months, with 80-90% success rates for arm pain relief. 1, 4
  • At 12 months, surgical outcomes demonstrate sustained improvements in motor function, sensation, and pain control. 1

Functional Recovery

  • 90.9% functional improvement is reported following surgical intervention for cervical radiculopathy. 1
  • Strength improvements are maintained over 12 months but may not achieve 100% return to baseline. 1
  • Neck disability index (NDI) scores show significant improvement at 6 months post-operatively compared to conservative treatment. 4

Complication Profile

Overall Safety

  • The complication rate for ACDF is approximately 5%, with good or better outcomes in 99% of patients using Odom's criteria. 1
  • Two-level constructs with instrumentation do not demonstrate significantly higher complication rates compared to single-level procedures when properly executed. 1

Common Pitfalls to Avoid

  • Ensure both C4-C5 and C5-C6 levels meet moderate-to-severe stenosis criteria on imaging, as performing fusion at a level with insufficient pathology is not supported by guidelines. 1
  • Verify clinical correlation between your symptoms and the imaging findings at both levels before proceeding. 1
  • Avoid premature surgery—confirm you have completed at least 6 weeks of comprehensive conservative therapy including physical therapy, anti-inflammatory medications, and activity modification. 1, 5

Why Two Levels Are Being Recommended

Evidence-Based Rationale

  • All degenerated segments causing radiculopathy or myelopathy should be included in an anterior cervical arthrodesis to minimize future adjacent-segment disease risk. 3
  • Your imaging likely demonstrates moderate-to-severe foraminal stenosis or disc degeneration at both C4-C5 and C5-C6 that correlates with your clinical presentation. 1
  • Addressing both levels simultaneously reduces the risk of requiring revision surgery for adjacent-segment disease, which affects more than one-fourth of patients within 10 years after single-level fusion. 3

Long-Term Perspective

  • More than two-thirds of patients who develop symptomatic adjacent-segment disease require additional operative procedures. 3
  • By addressing both pathological levels now, you reduce the likelihood of needing a second surgery in the future. 3

Comparison to Conservative Management

When Surgery Is Justified

  • You have failed 10 months of conservative treatment including medications, physical therapy, and two epidural steroid injections—this meets the minimum 6-week threshold for surgical consideration. 1, 5
  • While 75-90% of cervical radiculopathy patients improve with conservative treatment, you are in the 10-25% who require surgical intervention after failed non-operative management. 1, 5
  • Surgery provides more rapid pain relief compared to continued conservative treatment, though at 12 months outcomes may be comparable if conservative treatment were to eventually succeed. 1, 4

Surgical Advantages in Your Case

  • ACDF demonstrates superior outcomes in VAS pain scores and NDI scores compared to conservative treatment at all time points up to 12 months. 4
  • Rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss is a key advantage over continued conservative management. 1
  • Given your 10-month history of failed conservative treatment, further delay is unlikely to provide additional benefit. 1

References

1
Guideline

Cervical Radiculopathy Diagnosis and Treatment

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

5
Guideline

Initial Treatment for Degenerative Cervical Disc Height and Facet Arthropathy

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Related Questions

Is surgery, including Anterior Cervical Discectomy and Fusion (ACDF) or posterior laminectomy with spine fixation and bone autograft, medically indicated for a 62-year-old male with chronic neck pain, low back pain, and associated radiculopathy due to reversal of the upper cervical lordosis, disc herniation, and central stenosis?
Are procedures 63045 (Laminectomy with facetectomy) and 63048 (Remove spinal lamina add-on) medically necessary for a patient with radiculopathy due to cervical spondylosis?
What is the appropriate management for a patient with C5 radiculopathy and moderate foraminal stenosis on MRI, without myelopathy?
What is the initial management for cervical radiculopathy due to cervical spondylosis?
What is the best course of treatment for a patient with cervical spine pain and degenerative changes, including disc desiccation and marginal osteophytes, with a history of resolved leg neuropathy?
Which diagnosis best explains a woman with menorrhagia, headaches, brain fog, fatigue, low mean corpuscular hemoglobin concentration (MCHC) and leukopenia, and what work‑up and treatment should be pursued?
On a prescription, where should I document the medical necessity justification for prior authorization?
What are the difficulties in implementing a pharmacoinvasive strategy for ST‑segment elevation myocardial infarction (STEMI)?
What is the best acute management for an 80‑year‑old woman with metastatic cervical cancer and a colovaginal fistula, ECOG performance status 3, and ASA class 3?
How should acute otitis media be treated in children aged 6 months to 2 years, children older than 2 years, and adults, including first‑line antibiotics, dosing, duration, analgesia, observation criteria, second‑line options, and referral indications?
What is the standard immunosuppressive protocol—including induction agents, maintenance drugs and doses, therapeutic drug monitoring, and infection prophylaxis—for adult lung transplant recipients?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question