Radiographic and clinical outcomes following single-level anterior cervical discectomy and allograft fusion without plate placement or cervical collar

Restricted access


Although the clinical outcomes following anterior cervical discectomy and fusion (ACDF) surgery are generally good, 2 major complications are graft migration and nonunion. These complications have led some to advocate rigid internal fixation and/or cervical immobilization postoperatively. This paper examines a single-surgeon experience with single-level ACDF without use of plates or hard collars in patients with degenerative spondylosis in whom allograft was used as the fusion material.


The authors conducted a retrospective review of a prospective database of (Cloward-type) ACDF operations performed by the senior author (J.A.J.) between July 1996 and June 2005. Radiographic follow-up included static and flexion/extension radiographs obtained to assess fusion, focal and segmental kyphosis, and change in disc space height. At most recent follow-up, the patients' condition was evaluated by an independent physician examiner. The Odom criteria and Neck Disability Index (NDI) were used to assess outcome.


One hundred seventy patients underwent single-level ACDF for degenerative pathology during the study period. Their most common presenting symptoms were pain, weakness, and radiculopathy; 88% of patients noted ≥ 2 neurological complaints. The mean hospital stay was 1.76 days (range 0–36 days), and 3 patients (2%) had major immediate postoperative complications requiring reoperation. The mean duration of follow-up was 22 months (range 12–124 months). Radiographic evidence of fusion was present in 160 patients (94%). Seven patients (4%) showed radiographic evidence of pseudarthrosis, and graft migration was seen in 3 patients (2%). All patients had increases in focal kyphosis at the operated level on postoperative radiographs (mean −7.4°), although segmental alignment was preserved in 133 patients (78%). Mean change in disc space height was 36.5% (range 28–53%). At most recent clinical follow-up, 122 patients (72%) had no complaints referable to cervical disease and were able to carry out their activities of daily living without impairment. The mean postoperative NDI score was 3.2 (median 3, range 0–31).


Single-level ACDF without intraoperative plate placement or the use of a postoperative collar is an effective treatment for cervical spondylosis. Although there is evidence of focal kyphosis and loss of disc space height, radiographic evidence of fusion is comparable to that attained with plate fixation, and the rate of clinical improvement is high.

Abbreviations used in this paper: ACDF = anterior cervical discectomy and fusion; NDI = Neck Disability Index; PLL = posterior longitudinal ligament; SD = standard deviation; VB = vertebral body.

Article Information

Address correspondence to: Jay Jagannathan, M.D., Department of Neurological Surgery, University of Virginia Health System, Box 800212, Charlottesville, Virginia 22908. email:

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Illustration showing the Jane modification to the Cloward technique. In patients without recurrent laryngeal nerve damage or prior surgery, a left-sided transverse skin incision is used (A). Following the dissection through the cervical musculature, the disc space is identified and the level is confirmed using an intraoperative radiograph. The disc space is then drilled using a Cloward drill (B), and a distraction apparatus that fits into the uncovertebral joint is placed to allow lordosis of the spine (C). Thorough decompression is then performed by removing all central disc material and endplate osteophyte to the extent of the PLL and uncovertebral joints (D). The PLL is also excised to achieve complete decompression and to be certain that no disc fragments are retained. We favor performing wide foraminotomies bilaterally, with a wider decompression on the side with pain (E). A Cloward interbody graft is then inserted into the disc space (F).

  • View in gallery

    Upright anteroposterior (left) and lateral (right) radiographs obtained 2 years after C5–6 ACDF in a 41-year-old man with degenerative spondylosis demonstrating solid fusion (white arrow).

  • View in gallery

    Radiographs showing measurements obtained 24 months after a C6–7 ACDF. A: Focal alignment was defined by the angle formed by lines drawn at the superior margin of the superior VB defining the disc space and the inferior margin of the inferior body on a lateral radiograph obtained with the patient standing. B: The Cobb angles from C-2 to C-7 were also determined. Angles were measured using quantitative measurement analysis software, which uses extrapolative algorithms to calculate the intersecting angle between 2 lines drawn by the investigator. C: Changes in disc space height were determined using pre- and postoperative lateral radiographs. The posterior height of the body of C-3 (a reference) and the height of the operated disc space were measured. The initial disc height ratio (Ri) represented the ratio between the operated disc space and the height of the C-3 VB on the lateral cervical radiograph obtained on the 1st postoperative day. Final disc height ratio (Rf) was the ratio between the operated disc space and the C-3 VB at most recent follow-up. The narrowing rate was defined as the ([Ri − Rf]/Ri) × 100.

  • View in gallery

    Graph depicting length of hospital stay following single-level ACDF.

  • View in gallery

    Postoperative lateral radiograph obtained in a 71-year-old man who experienced progressive weakness and cervical instability postoperatively. This patient had undergone ACDF but had persistent symptoms, requiring multilevel cervical laminectomies (arrows), which were performed at another institution. Approximately 24 months after the laminectomies were performed, the patient presented again at our institution with evidence of instability and required posterior and anterior fixation.


  • 1

    Abd-Alrahman NDokmak ASAbou-Madawi A: Anterior cervical discectomy (ACD) versus anterior cervical fusion (ACF), clinical and radiological outcome study. Acta Neurochir (Wien) 141:108910921999

  • 2

    Aebi MZuber KMarchesi D: Treatment of cervical spine injuries with anterior plating. Indications, techniques, and results. Spine 16:3 SupplS38S451991

  • 3

    Bailey RWBadgley CE: Stabilization of the cervical spine by anterior fusion. J Bone Joint Surg Am 42:5655941960

  • 4

    Bazaz RLee MJYoo JU: Incidence of dysphagia after anterior cervical spine surgery: a prospective study. Spine 27:245324582002

  • 5

    Bishop RCMoore KAHadley MN: Anterior cervical interbody fusion using autogeneic and allogeneic bone graft substrate: a prospective comparative analysis. J Neurosurg 85:2062101996

  • 6

    Böhler JGaudernak T: Anterior plate stabilization for fracture-dislocations of the lower cervical spine. J Trauma 20:2032051980

  • 7

    Brown JAHavel PEbraheim NGreenblatt SHJackson WT: Cervical stabilization by plate and bone fusion. Spine 13:2362401988

  • 8

    Cauthen JCKinard REVogler JBJackson DEDePaz OBHunter OL: Outcome analysis of noninstrumented anterior cervical discectomy and interbody fusion in 348 patients. Spine 23:1881921998

  • 9

    Cloward RB: The anterior approach for removal of ruptured cervical disks. J Neurosurg 15:6026171958

  • 10

    Connolly ESSeymour RJAdams JE: Clinical evaluation of anterior cervical fusion for degenerative cervical disc disease. J Neurosurg 23:4314371965

  • 11

    Connolly PJEsses SIKostuik JP: Anterior cervical fusion: outcome analysis of patients fused with and without anterior cervical plates. J Spinal Disord 9:2022061996

  • 12

    Dowd GCWirth FP: Anterior cervical discectomy: is fusion necessary?. J Neurosurg 90:8121999

  • 13

    Fountas KNKapsalaki EZMachinis TRobinson JS: Extrusion of a screw into the gastrointestinal tract after anterior cervical spine plating. J Spinal Disord Tech 19:1992032006

  • 14

    Gassman JSeligson D: The anterior cervical plate. Spine 8:7007071983

  • 15

    Goldberg EJSingh KVan UGarretson RAn HS: Comparing outcomes of anterior cervical discectomy and fusion in work-man's versus non-workman's compensation population. Spine J 2:4084142002

  • 16

    Graham JJ: Complications of cervical spine surgery. A five-year report on a survey of the membership of the Cervical Spine Research Society by the Morbidity and Mortality Committee. Spine 14:104610501989

  • 17

    Gregorius FKEstrin TCrandall PH: Cervical spondylotic radiculopathy and myelopathy. A long-term follow-up study. Arch Neurol 33:6186251976

  • 18

    Heidecke VRainov NGBurkert W: Anterior cervical fusion with the Orion locking plate system. Spine 23:179618031998

  • 19

    Hilibrand ASYoo JUCarlson GDBohlman HH: The success of anterior cervical arthrodesis adjacent to a previous fusion. Spine 22:157415791997

  • 20

    Kaiser MGHaid RW JrSubach BRBarnes BRodts GE Jr: Anterior cervical plating enhances arthrodesis after discectomy and fusion with cortical allograft. Neurosurgery 50:2292382002

  • 21

    Katsuura AHukuda SSaruhashi YMori K: Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels. Eur Spine J 10:3203242001

  • 22

    Kostuik JPConnolly PJEsses SISuh P: Anterior cervical plate fixation with the titanium hollow screw plate system. Spine 18:127312781993

  • 23

    Kulkarni AGHee HT: Adjacent level discitis after anterior cervical discectomy and fusion (ACDF): a case report. Eur Spine J 15:5 Suppl5595632006

  • 24

    Lee MJBazaz RFurey CGYoo J: Influence of anterior cervical plate design on dysphagia: a 2-year prospective longitudinal follow-up study. J Spinal Disord Tech 18:4064092005

  • 25

    Lowery GLSwank MLMcDonough RF: Surgical revision for failed anterior cervical fusions. Articular pillar plating or anterior revision?. Spine 20:243624411995

  • 26

    Lunsford LDBissonette DJJannetta PJSheptak PEZorub DS: Anterior surgery for cervical disc disease. Part 1: Treatment of lateral cervical disc herniation in 253 cases. J Neurosurg 53:1111980

  • 27

    Murphy MGGado M: Anterior cervical discectomy without interbody bone graft. J Neurosurg 37:71741972

  • 28

    Peolsson AHedlund RVavruch L: Prediction of fusion and importance of radiological variables for the outcome of anterior cervical decompression and fusion. Eur Spine J 13:2292342004

  • 29

    Peolsson AHedlund RVavruch LOberg B: Predictive factors for the outcome of anterior cervical decompression and fusion. Eur Spine J 12:2742802003

  • 30

    Rosenørn JHansen EBRosenørn MA: Anterior cervical discectomy with and without fusion. A prospective study. J Neurosurg 59:2522551983

  • 31

    Samartzis DShen FHLyon CPhillips MGoldberg EJAn HS: Does rigid instrumentation increase the fusion rate in one-level anterior cervical discectomy and fusion?. Spine J 4:6366432004

  • 32

    Smith GWRobinson RA: The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and inter-body fusion. J Bone Joint Surg Am 40:6076241958

  • 33

    Taha JMZuccarello M: ORION anterior cervical plate system. Neurosurgery 38:6076101996

  • 34

    Türeyen K: Disc height loss after anterior cervical microdiscectomy with titanium intervertebral cage fusion. Acta Neurochir (Wien) 145:5655702003

  • 35

    Vernon HMior S: The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther 14:4094151991

  • 36

    Wang JCMcDonough PWEndow KKDelamarter RB: A comparison of fusion rates between single-level cervical corpectomy and two-level discectomy and fusion. J Spinal Disord 14:2222252001

  • 37

    Wang JCMcDonough PWEndow KKDelamarter RB: Increased fusion rates with cervical plating for two-level anterior cervical discectomy and fusion. Spine 25:41452000

  • 38

    Wang JCMcDonough PWEndow KKanim LEDelamarter RB: The effect of cervical plating on single-level anterior cervical discectomy and fusion. J Spinal Disord 12:4674711999

  • 39

    Wang JCMcDonough PWKanim LEEndow KKDelamarter RB: Increased fusion rates with cervical plating for three-level anterior cervical discectomy and fusion. Spine 26:6436472001

  • 40

    White AA IIIPanjabi MM: Biomechanical considerations in the surgical management of cervical spondylotic myelopathy. Spine 13:8568601988

  • 41

    Wiberg J: Effects of surgery on cervical spondylotic myelopathy. Acta Neurochir (Wien) 81:1131171986

  • 42

    Zdeblick TACooke MEWilson DKunz DNMcCabe R: Anterior cervical discectomy, fusion, and plating. A comparative animal study. Spine 18:197419831993

  • 43

    Zoëga BKärrholm JLind B: Outcome scores in degenerative cervical disc surgery. Eur Spine J 9:1371432000


Cited By



All Time Past Year Past 30 Days
Abstract Views 213 213 37
Full Text Views 100 100 8
PDF Downloads 100 100 8
EPUB Downloads 0 0 0


Google Scholar