Three-level ACDF versus 3-level laminectomy and fusion: are there differences in outcomes? An analysis of the Quality Outcomes Database cervical spondylotic myelopathy cohort

Author:

Ambati Vardhaan S.1,Macki Mohamed1,Chan Andrew K.2,Michalopoulos Giorgos D.3,Le Vivian P.12,Jamieson Alysha B.1,Chou Dean2,Shaffrey Christopher I.4,Gottfried Oren N.4,Bisson Erica F.5,Asher Anthony L.6,Coric Domagoj6,Potts Eric A.7,Foley Kevin T.8,Wang Michael Y.9,Fu Kai-Ming10,Virk Michael S.10,Knightly John J.11,Meyer Scott11,Park Paul8,Upadhyaya Cheerag12,Shaffrey Mark E.13,Buchholz Avery L.13,Tumialán Luis M.14,Turner Jay D.14,Sherrod Brandon A.5,Haid Regis W.15,Bydon Mohamad3,Mummaneni Praveen V.1

Affiliation:

1. Department of Neurological Surgery, University of California, San Francisco, California;

2. Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York;

3. Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota;

4. Department of Neurosurgery, Duke University, Durham, North Carolina;

5. Department of Neurological Surgery, University of Utah, Salt Lake City, Utah;

6. Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;

7. Goodman Campbell Brain and Spine, Indianapolis, Indiana;

8. Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee;

9. Department of Neurological Surgery, University of Miami, Florida;

10. Department of Neurosurgery, Weill Cornell Medical Center, New York, New York;

11. Atlantic Neurosurgical Specialists, Morristown, New Jersey;

12. Marion Bloch Neuroscience Institute, Saint Luke’s Health System, Kansas City, Missouri;

13. Department of Neurosurgery, University of Virginia, Charlottesville, Virginia;

14. Barrow Neurological Institute, Phoenix, Arizona; and

15. Atlanta Brain and Spine Care, Atlanta, Georgia

Abstract

OBJECTIVE The authors sought to compare 3-level anterior with posterior fusion surgical procedures for the treatment of multilevel cervical spondylotic myelopathy (CSM). METHODS The authors analyzed prospective data from the 14 highest enrolling sites of the Quality Outcomes Database CSM module. They compared 3-level anterior cervical discectomy and fusion (ACDF) and posterior cervical laminectomy and fusion (PCF) surgical procedures, excluding surgical procedures crossing the cervicothoracic junction. Rates of reaching the minimal clinically important difference (MCID) in patient-reported outcomes (PROs) were compared at 24 months postoperatively. Multivariable analyses adjusted for potential confounders elucidated in univariable analysis. RESULTS Overall, 199 patients met the inclusion criteria: 123 ACDF (61.8%) and 76 PCF (38.2%) patients. The 24-month follow-up rates were similar (ACDF 90.2% vs PCF 92.1%, p = 0.67). Preoperatively, ACDF patients were younger (60.8 ± 10.2 vs 65.0 ± 10.3 years, p < 0.01), and greater proportions were privately insured (56.1% vs 36.8%, p = 0.02), actively employed (39.8% vs 22.8%, p = 0.04), and independently ambulatory (14.6% vs 31.6%, p < 0.01). Otherwise, the cohorts had equivalent baseline modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), numeric rating scale (NRS)–arm pain, NRS–neck pain, and EQ-5D scores (p > 0.05). ACDF patients had reduced hospitalization length (1.6 vs 3.9 days, p < 0.01) and a greater proportion had nonroutine discharge (7.3% vs 22.8%, p < 0.01), but they had a higher rate of postoperative dysphagia (13.5% vs 3.5%, p = 0.049). Compared with baseline values, both groups demonstrated improvements in all outcomes at 24 months (p < 0.05). In multivariable analyses, after controlling for age, insurance payor, employment status, ambulation status, and other potential clinically relevant confounders, ACDF was associated with a greater proportion of patients with maximum satisfaction on the North American Spine Society Patient Satisfaction Index (NASS) (NASS score of 1) at 24 months (69.4% vs 53.7%, OR 2.44, 95% CI 1.17–5.09, adjusted p = 0.02). Otherwise, the cohorts shared similar 24-month outcomes in terms of reaching the MCID for mJOA, NDI, NRS–arm pain, NRS–neck pain, and EQ-5D score (adjusted p > 0.05). There were no differences in the 3-month readmission (ACDF 4.1% vs PCF 3.9%, p = 0.97) and 24-month reoperation (ACDF 13.5% vs PCF 18.6%, p = 0.36) rates. CONCLUSIONS In a cohort limited to 3-level fusion surgical procedures, ACDF was associated with reduced blood loss, shorter hospitalization length, and higher routine home discharge rates; however, PCF resulted in lower rates of postoperative dysphagia. The procedures yielded comparably significant improvements in functional status (mJOA score), neck and arm pain, neck pain–related disability, and quality of life at 3, 12, and 24 months. ACDF patients had significantly higher odds of maximum satisfaction (NASS score 1). Given comparable outcomes, patients should be counseled on each approach’s complication profile to aid in surgical decision-making.

Publisher

Journal of Neurosurgery Publishing Group (JNSPG)

Subject

Neurology (clinical),General Medicine,Surgery

Reference39 articles.

1. Degenerative cervical myelopathy - update and future directions;Badhiwala JH,2020

2. Degenerative cervical myelopathy: epidemiology, genetics, and pathogenesis;Nouri A,2015

3. Myelopathy;Oyinkan Marquis B,2016

4. National trends in spinal fusion for cervical spondylotic myelopathy;Lad SP,2009

5. The natural history of degenerative cervical myelopathy;Badhiwala JH,2018

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