Anterior approaches to fusion of the cervical spine: a metaanalysis of fusion rates

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Anterior cervical discectomy (ACD), ACD with interbody fusion (ACDF), ACDF with placement of an anterior plate system (ACDFP), corpectomy, and corpectomy with plate placement are used to fuse the cervical spine. The authors conducted a metaanalysis of studies published after 1990 in which fusion rates achieved with each procedure were reported for patients with degenerative disease at one, two, and three disc levels.


Twenty-one papers each included data on at least 25 patients. In each of the 21 studies the average clinical follow up was more than 12 months, and the results were evaluated according to radiographic evidence of fusion and delineated by the number of levels fused. Chi-square and Fisher exact tests were used for comparisons. The mean age of the patients was 46.7 years, 46.6% were female, and the mean follow-up period was 39.6 months. The studies included 2682 patients and the overall fusion rate was 89.5%. For single disc–level disease, fusion rates were 84.9% for ACD, 92.1% for ACDF, and 97.1% for ACDFP (p = 0.0002). For two disc–level disease, fusion rates were 79.9% for ACDF, 94.6% for ACDFP, 95.9% for corpectomy, and 92.9% for corpectomy with plate placement (p = 0.0001). For three disc–level disease, fusion rates were 65.0% for ACDF, 82.5% for ACDFP, 89.8% for corpectomy, and 96.2% for corpectomy with plate placement (p = 0.0001). The use of anterior plates significantly improved fusion for one-level (p < 0.0001), two-level (p < 0.0001), and three-level (p < 0.05) ACDF. There was no significant difference in fusion rates between two-level ACDF and corpectomy with plate placement.


The anticipated fusion rate is one of several factors that may guide surgical decision making. Anterior cervical decompression and fusion results in high fusion rates. The results of the authors' study show that regardless of the number of levels fused, the use of an anterior cervical plate system significantly increases the fusion rate. For two-disc–level disease, there was no significant difference between ACD with a plate system or corpectomy with a plate system. For three-disc–level disease, however, the evidence suggests that corpectomy with plate placement is associated with higher fusion rates than discectomy with plate placement.

Abbreviations used in this paper:ACD = anterior cervical discectomy; ACDF = ACD and fusion; ACDFP = ACDF and placement of an anterior plate system.

Article Information

Address reprint requests to: Roger Härtl, M.D., Department of Neurological Surgery, Cornell University–Weill Medical College, 525 East 68th Street, Box 99, New York, New York 10021. email:

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Bar graph illustrating fusion rates for surgical interventions involving single disc levels. Note that the fusion rate for ACD alone (without an interbody fusion graft or plate placement) was 84.9%.

  • View in gallery

    Bar graph illustrating fusion rates for surgical interventions involving two disc levels. There were no significant differences between ACDFP, corpectomy (CORP), and corpectomy with plate placement (CORPp) in pairwise comparisons.

  • View in gallery

    Bar graph illustrating fusion rates for surgical interventions involving three disc levels. Corpectomy with plate placement resulted in the highest total fusion rate (96.2%).



Agresti A: Categorical Data Analysis New YorkJohn Wiley & Sons1990


Agrillo UMastronardi LPuzzilli F: Anterior cervical fusion with carbon fiber cage containing coralline hydroxyapatite: preliminary observations in 45 consecutive cases of soft-disc herniation. J Neurosurg 96:3 Suppl2732762002


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


Balabhadra RSKim DHZhang HY: Anterior cervical fusion using dense cancellous allografts and dynamic plating. Neurosurgery 54:140514122004


Caspar WGeisler FHPitzen TJohnson TA: Anterior cervical plate stabilization in one- and two-level degenerative disease: overtreatment or benefit?. J Spinal Disord 11:1111998


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


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


Cloward RB: The anterior surgical approach to the cervical spine: the Cloward Procedure: past, present, and future. The presidential guest lecture, Cervical Spine Research Society. Spine 13:8238271988


Dowd GCWirth FP: Anterior cervical discectomy: is fusion necessary?. J Neurosurg 90:1 Suppl8121999


Edwards CC IIHeller JGMurakami H: Corpectomy versus laminoplasty for multilevel cervical myelopathy: an independent matched-cohort analysis. Spine 27:116811752002


Epstein NE: Anterior cervical dynamic ABC plating with single level corpectomy and fusion in forty-two patients. Spinal Cord 41:1531582003


Gore DRSepic SB: Anterior discectomy and fusion for painful cervical disc disease. A report of 50 patients with an average follow-up of 21 years. Spine 23:204720511998


Hacker RJCauthen JCGilbert TJGriffith SL: A prospective randomized multicenter clinical evaluation of an anterior cervical fusion cage. Spine 25:264626552000


Hilibrand ASFye MAEmery SEPalumbo MABohlman HH: Increased rate of arthrodesis with strut grafting after multilevel anterior cervical decompression. Spine 27:1461512002


Hwang SLHwang YFLieu ASLin CLKuo THSu YF: Outcome analyses of interbody titanium cage fusion used in the anterior discectomy for cervical degenerative disc disease. J Spinal Disord Tech 18:3263312005


Isomi TPanjabi MMWang JLVaccaro ARGarfin SRPatel T: Stabilizing potential of anterior cervical plates in multilevel corpectomies. Spine 24:221922231999


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


Majd MEVadhva MHolt RT: Anterior cervical reconstruction using titanium cages with anterior plating. Spine 24:160416101999


Martin GJ JrHaid RW JrMacMillan MRodts GE JrBerkman R: Anterior cervical discectomy with freeze-dried fibula allograft. Overview of 317 cases and literature review. Spine 24:8528591999


Nirala APHusain MVatsal DK: A retrospective study of multiple interbody grafting and long segment strut grafting following multilevel anterior cervical decompression. Br J Neurosurg 18:2272322004


Panjabi MMIsomi TWang JL: Loosening at the screw-vertebra junction in multilevel anterior cervical plate constructs. Spine 24:238323881999


Park MSAryan HEOzgur BMJandial RTaylor WR: Stabilization of anterior cervical spine with bioabsorbable polymer in one- and two-level fusions. Neurosurgery 54:6316352004


Porter RWCrawford NRChamberlain RHPark SCDetwiler PWApostolides PJ: Biomechanical analysis of multilevel cervical corpectomy and plate constructs. J Neurosurg 99:1 Suppl981032003


Rieger AHolz CMarx TSanchin LMenzel M: Vertebral autograft used as bone transplant for anterior cervical corpectomy: technical note. Neurosurgery 52:4494542003


Robinson RA: Anterior and posterior cervical spine fusions. Clin Orthop Relat Res 35:34621964


Savolainen SRinne JHernesniemi J: A prospective randomized study of anterior single-level cervical disc operations with long-term follow-up: surgical fusion is unnecessary. Neurosurgery 43:51551998


Sevki KMehmet TUfuk TAzmi HMercan SErkal B: Results of surgical treatment for degenerative cervical myelopathy: anterior cervical corpectomy and stabilization. Spine 29:249325002004


Singh KVaccaro ARKim JLorenz EPLim THAn HS: Enhancement of stability following anterior cervical corpectomy: a biomechanical study. Spine 29:8458492004


Vaccaro ARFalatyn SPScuderi GJEismont FJMcGuire RASingh K: Early failure of long segment anterior cervical plate fixation. J Spinal Disord 11:4104151998


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


Wirth FPDowd GCSanders HFWirth C: Cervical discectomy. A prospective analysis of three operative techniques. Surg Neurol 53:3403482000




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