Nationwide Study of Multilevel Cervical Fusion

This is the first nationwide study to look at the results of multilevel cervical spine (neck) fusion comparing an anterior approach to a posterior approach. Anterior refers to fusion from the front of the spine. Posterior is done from behind the spine.

Data from over 8500 patients with degenerative disease was included. Information entered into the patient database came from 1000 hospital across the United States. The researchers looked at variables such as age, gender, race, and the presence of comorbidities.

Comorbidities refer to other health problems the patient may have such as high blood pressure, diabetes, osteoporosis, and so on. They compared the number and type of complications after surgery between the two approaches. They also looked at cost, number of days in the hospital, and whether or not the patient was discharged home or to some other facility.

In all patients who were included, fusion was done at multiple levels of the cervical spine. Multiple levels means there were between four and eight vertebrae fused together.

They found that posterior fusions were done more often in larger, teaching hospitals. Patients were more likely to be older, Black men with many other health problems. Anterior fusion was more common in younger patients with fewer levels affected.

Posterior fusions were usually Medicare cases. Anterior fusions were usually performed in private hospitals and paid for by private sources. Complications were more likely to occur in posterior fusions. The problems that developed varied and included hematomas (pockets of blood), blood loss (enough to need a transfusion), and even death.

Sometimes there was a cerebrospinal fluid leak. Respiratory and cardiac complications were present in both surgical approaches but were more common in patients who had a posterior fusion. Difficulties swallowing called dysphagia was a more common effect with anterior fusion. Damage to the nerves in the front of the neck is a greater risk with anterior fusion and especially when multiple levels are involved.

Analyzing all the data more closely showed that older age and health status (more comorbidities) kept people in the hospital longer. This group was more likely to need critical care and were especially at risk for death.

Many patients in both groups could be routinely discharged to home. Some required additional services such as home health care. But almost half of the posterior fusion group had a nonroutine discharge. More money was spent for the posterior fusion group on what's called resource utilization (meaning added services such as longer hospitalizations and discharge to a nursing home or assisted living facility).

In summary, the impact of surgical approach for cervical spine fusion is significant. There is a greater level of complications with the posterior approach. Patients who need multilevel fusions seem to do better with the anterior surgical procedure. The authors advise that whenever possible, this method should be chosen over posterior procedures.

Reference: 

Mohammed F. Shamji, MD, MSc, et al. Impact of Surgical Approach on Complications and Resource Utilization of Cervical Spine Fusion: A Nationwide Perspective to the Surgical Treatment of Diffuse Cervical Spondylosis. In The Spine Journal. January 2009. Vol. 9. No. 1. Pp. 31-38.

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