32,000 Patient Study Tracks ACDF Revision Rates

A new Yale University study using the PearlDiver MSpine database of 31,952 cervical spine surgery patients collected 5-year revision statistics for single-level anterior cervical discectomy and fusion cases.

The full study, “Single-level Anterior Cervical Discectomy and Fusion Results in Lower Five-year Revisions than Posterior Cervical Foraminotomy in a Large National Cohort,” appears in the September 15, 2023, edition of Spine.

While there have been numerous retrospective cohorts, randomized control studies, and meta-analyses comparing single-level anterior cervical discectomy and fusion (ACDF) to posterior cervical foraminotomy (PCF), the Yale School of Medicine team wanted to assemble a more statistically significant data set to better understand ACDF outcomes.

Lead author Rahul Jayaram, B.S., a medical student at Yale, told OTW, “Cervical radiculopathy is a common issue for which there are different potential surgical approaches. While there is some literature about the outcomes of these different approaches, prior studies have had defined limitations and have reported conflicting conclusions.”

“We believed we could approach this topic with large data tools that we had available to add to the literature on this topic.”

“Prior literature has been mixed regarding postoperative outcomes and revision surgery rates for anterior cervical discectomy and fusion ACDF and PCF, with some studies maintaining no difference while others demonstrating higher revision rate for posterior cervical foraminotomy (PCF).”

“There have been prior retrospective cohort studies, randomized control studies, and meta-analyses conducted that looked into the risks of anterior versus posterior approaches for cervical procedures, however, these studies are often limited by sample size and lack of adequate follow-up.”

“The larger patient numbers in our current analysis of a large national administrative database affords greater statistical power to further examine this question. Of course, this is balanced by limitation of administrative database studies and lack of patient reported outcomes.”

Using the Q1 2010 to Q3 2020 PearlDiver MSpine national database, the researchers looked at 31,953 patients who underwent either single-level ACDF (n=29,958) or posterior cervical foraminotomy (PCF) (n=1995).

They found that PCF was associated with significantly greater odds of aggregated serious adverse events, wound dehiscence, surgical site infection, and pulmonary embolism. On the other hand, they determined that PCF was associated with significantly lower odds of readmission, dysphagia, and pneumonia.

At five years, PCF cases had a significantly higher cumulative revision rate compared with ACDF cases (19.0% vs. 14.8%).

“The cumulative rate of revision surgery was significantly higher in PCF than in ACDF,” stated Jayaram to OTW. “When subsequent surgery was performed following either ACDF or PCF, posterior procedures were most common in both settings.”

Jayaram added, “Given the conflicting prior literature, it is likely that the statistical power of our large patient cohort allowed us to identify this observed difference in cumulative revision rates. It can be noted that the Kaplan-Meier curves in this study increasingly separated over time, highlighting the importance of sufficient follow-up time to determine differences between these procedures.”

“While the exact mechanism as to why the posterior approach is associated with higher cumulative incidence could not be defined, there are several potential mechanisms. With posterior approaches, it could be that there is less complete decompression of the neural elements, or it may be that the levels addressed are more likely to settle over time.”

“In cases where anterior or posterior approaches are possible for cervical radiculopathy, the relative incidence of different adverse events should be considered. This should also be put in the context of possible revision procedures over time.”