Revision rates and complication incidence in single- and multilevel anterior cervical discectomy and fusion procedures: an administrative database study

Background context: The natural history of cervical degenerative disease with operative management has not been well described. Even with symptomatic and radiographic evidence of multilevel cervical disease, it is unclear whether single- or multilevel anterior cervical discectomy and fusion (ACDF) procedures produce superior long-term outcomes.

Purpose: To describe national trends in revision rates, complications, and readmission for patients undergoing single and multilevel ACDF.

Study design: Administrative database study.

Patient sample: Between 2006 and 2010, 92,867 patients were recorded for ACDF procedures in the Thomson Reuters MarketScan database. Restricting to patients with >24 months follow-up, 28,777 patients fulfilled our inclusion criteria, of which 12,744 (44%) underwent single-level and 16,033 (56%) underwent multilevel ACDFs.

Outcome measures: Revision rates and postoperative complications.

Methods: We used the MarketScan database from 2006 to 2010 to select ACDF procedures based on Current Procedural Terminology coding at inpatient visit. Outcome measures were ascertained using either International Classification of Disease version 9 or Current Procedural Terminology coding.

Results: Perioperative complications were more common in multilevel procedures (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.6; p<.0001). Single-level ACDF patients had higher rates of postoperative cervical epidural steroid injections (OR, 0.88; 95% CI, 0.8-1.0; p=.01). Within 30 days after index procedure, the multilevel ACDF cohort was 1.6 times more likely to have undergone revision (OR, 1.6; 95% CI, 1.1-2.4; p=.02). At 2 years follow-up, revision rates were 9.13% in the single-level ACDF cohort and 10.7% for multilevel ACDFs (OR, 1.2; 95% CI, 1.1-1.3; p<.0001). In a multivariate analysis at 2 years follow-up, patients from the multilevel cohort were more likely to have received a surgical revision (OR, 1.1; 95% CI, 1.0-1.2; p=.001), to be readmitted into the hospital for any cause (OR, 1.2; 95% CI, 1.1-1.4; p=.007), and to have suffered complications (OR, 1.3; 95% CI, 1.1-1.5; p=.0003).

Conclusions: In this study, we report rates of adverse events and the need for revision surgery in patients undergoing single versus multilevel ACDFs. Increasing number of levels fused at the time of index surgery correlated with increased rate of reoperations. Multilevel ACDF patients requiring additional surgery more often underwent more extensive revision surgeries.