ACDF Failure: Next Step — Anterior Revision or Posterior Fusion?

Anterior cervical discectomy and fusion (ACDF) is one way to treat an unstable cervical spine. The operation is done from the front (anterior) of the neck to avoid the spinal cord and nerves. The disc is removed and bone graft, plate, or cage is used to fuse the spine at that level.

In about six percent of the cases, the fusion doesn’t work. If movement remains at the level of the fusion it’s called a pseudoarthrosis which means a “false joint.” The spine is unstable and may cause problems for the patient. What’s the next step?

In this study surgeons compared two operations for this problem. The first was a repeat anterior (revision) surgery. The pseudoarthrosis is removed. Bone graft taken from the patient and metal plates are used to re-fuse the spine. The second was a posterior (from the back) fusion using wires, plates, or a screw-rod system.

Both of these operations have good and bad points. The anterior revision must cut through the old scar tissue. There’s a risk of injuring nerves and blood vessels. The esophagus and trachea are also at risk. Posterior fusion requires a longer hospital stay. There’s also more blood loss during the posterior fusion operation.

The overall advantage of the posterior fusion is a lower second revision surgery rate. Almost half of the anterior revision group still had a nonuninon. The fusion failed and another operation was needed. Posterior fusion with its high fusion rate (98 percent) and low failure rate (two percent) may be the best way to treat ACDF nonunion.