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Published on: July 25, 2025
Three- and Four-Level ACDF without Posterior Fusion: A Viable Treatment for Multilevel Cervical Disease
David Cowan1, Aubrie M Sowa1, Stephen R Barchick1
1Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Lane Atlanta, GA, USA 30329.
Summary
Pseudarthrosis, a complication of anterior cervical discectomy and fusion (ACDF), occurred in 13.6% of multilevel procedures. Recombinant human bone morphogenetic protein-2 (rhBMP-2) reduced pseudarthrosis risk, especially in smokers, but increased complication rates.
Area of Science:
- Spine surgery
- Orthopedics
- Neurosurgery
Background:
- Pseudarthrosis is a known complication of multi-level anterior cervical discectomy and fusion (ACDF).
- Limited data exist on pseudarthrosis incidence and risk factors in modern multi-level ACDF procedures.
Purpose of the Study:
- To determine the incidence of pseudarthrosis after three- or four-level ACDF without posterior fixation.
- To identify risk factors for pseudarthrosis.
- To evaluate the role of low-dose recombinant human bone morphogenetic protein-2 (rhBMP-2) in promoting fusion.
Main Methods:
- Retrospective, single-center observational cohort study.
- Included 206 adult patients undergoing three- or four-level ACDF with anterior plating (2011-2024).
- Assessed pseudarthrosis using dynamic and static radiographs/CT; primary outcome was fusion at one year.
Main Results:
- Pseudarthrosis occurred in 13.6% of patients (6.3% symptomatic).
- Smoking history was associated with higher pseudarthrosis rates (23.3% vs. 6.7%).
- rhBMP-2 use was associated with lower pseudarthrosis (13.6% vs. 28.6%) and reduced risk in smokers (14.0% vs. 36.1%), but increased overall complications (OR=2.70).
Conclusions:
- Three- and four-level ACDF without posterior fusion showed lower nonunion rates than historic controls.
- rhBMP-2 use was associated with significantly lower odds of pseudarthrosis (OR=0.15).
- Smoking is a risk factor, potentially mitigated by rhBMP-2; selective biologic augmentation is supported for high-risk patients.