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Should We Re-Instrument the Originally Fused Level in ACDF Revision for Adjacent Segment Disease?: A Quality Outcomes
James F Bathon1,2, Omar Zakieh1, Claudia Davidson3
1Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN.
Study Design:
Retrospective cohort.
Objective:
To investigate differences in perioperative variables, patient-reported outcomes measures (PROMs), and reoperation rates between revision involving re-instrumentation of the originally fused level versus fusion of the adjacent segment alone in revision ACDF patients.
Summary Of Background Data:
Adjacent segment disease (ASD) continues to be a significant issue for patients undergoing anterior cervical discectomy and fusion (ACDF) surgery. Re-instrumenting the originally fused segment provides greater biomechanical stability. However, there remains a paucity of research investigating the differences in outcomes between patients undergoing re-instrumentation of the originally fused level vs. only the adjacent segment level.
Methods:
Patients who underwent single-level, adjacent segment revision ACDF were identified from the Quality Outcome Database. The primary exposure was re-instrumentation of the original segment. Patient characteristics were compared. Outcomes were perioperative variables, 3- and 12-month reoperation, and 3-, 12-, and 24-month PROMs, including numeric rating scale for neck and arm pain, neck disability index, EuroQol 5 Dimensions, and modified Japanese Orthopaedic Association scores. Multivariable regression models were fitted for each outcome.
Results:
Of the 767 patients undergoing revision ACDF, 25.0% had re-instrumentation. On analysis, patients with re-instrumentation had greater blood loss (60.7±11.6 vs. 40.9±10.8 mL, P<0.001), operative time (123.8±8.0 vs. 93.8±7.4 mins, P<0.001), and hospital length of stay (1.63±0.35 vs. 1.30±0.26 days, P=0.004) than patients with single-level fusion alone. There was no difference in neck and arm pain, NDI, and mJOA PROMs at 3-, 12- and 24-months between groups (P>0.05). Further, there was no difference in reoperation rates at 3- (4.3% vs. 3.2%, P=0.154) and 12-months (5.7% vs. 4.5%, P=0.194).
Conclusions:
Given comparable PROMs and reoperation rates, when clinically feasible, surgeons may consider avoiding re-instrumentation of the original ACDF fusion, opting for a more conservative single-level revision to minimize the negative risks/complications associated with increased perioperative blood loss, operative time, and length of stay.
