Stand-Alone Cage Versus Anterior Plating for 1-Level and 2-Level Anterior Cervical Discectomy and Fusion: A Randomized Controlled Trial.

Abstract

Prospective, randomized controlled trial. The aim was to compare perioperative and radiographic outcomes between stand-alone and anterior plated 1 and 2-level anterior cervical discectomy and fusion (ACDF). ACDF with interbody spacer and separate plate/screw construct (PLATE) may be associated with a higher incidence of postoperative dysphagia, increased operative time, and other complications. Therefore, some have opted to utilize an interbody cage with integrated screws and no plate (CAGE) with good results. Patients with 1-level to 2-level degenerative disease were prospectively enrolled and randomized into 1 of 2 treatment arms consisting of either PLATE or CAGE reconstruction. Patients were followed for a minimum of 1 year postoperatively. Primary endpoints included improvement on patient-reported outcome metrics, construct integrity, cervical alignment, successful arthrodesis, and subsequent revision surgeries. Forty-six patients were included: 12 with 1-level PLATE, 12 with 1-level CAGE, 12 with 2-level PLATE, and 10 with 2-level CAGE. For 1-level ACDF, PLATE patients reported worse swallow function on Swallowing Quality of Life Questionnaire at 6 weeks (P=0.050) and 6 months (P=0.042). Pseudarthrosis requiring revision was observed in one PLATE patient. For 2-level ACDF CAGE patients reported worse disability on neck disability index (P=0.037) at 6 weeks, as well as worse neck disability index (P=0.017) and visual analog scale neck (P=0.010) at 6 months. However, PLATE patients reported worse swallow function on Swallowing Quality of Life Questionnaire at 6 weeks (P=0.038). There were no differences in the rates of fusion, loss of disc height correction, subsidence, or in sagittal parameters between cohorts for both 1-level and 2-level ACDF. There was greater incidence of transient postoperative dysphagia in both single and 2-level PLATE cohorts. However, early postoperative outcomes were worse for 2-level CAGE in certain patient-reported metrics. This suggests that although anterior instrumentation may be associated with a higher likelihood of dysphagia, it may also lead to higher short-term stability and improved patient-reported outcomes for 2-level fusion.