Four-level ACDF surgical series 2000–2022: a systematic review of clinical and radiological outcomes and complications

Figures & data

Table 1. Characteristics of included studies and samples.

Reference	Year	Country	Type of study	Time range	Surgery performance	Number of patients	Gender male/ female	Age
Wang et al. ^10	2018	China	Retrospective	2012–2014	Single surgeon	26	12/14	55.3 ± 10.1
Joo et al.^11	2022	USA	Retrospective (Database analysis)	2010–2020	n/a	1857	893/964	61.3
Wang et al.^12	2016	China	Retrospective	2007–2010	Single surgeon	32	19/13	55.3
Charalampidis et al.^13	2022	Canada	Retrospective	2005–2019	Two surgeons	33	15/13	58.5
Soliman et al.^14	2021	India	Retrospective	n/d	Single surgeon	41	27/14	40–68
Alhashash et al.^15	2022	Germany	Retrospective	2008–2016	n/d	130	78/52	60.5 ± 10.54
Kim et al.^8	2019	USA	Retrospective	2004–2016	Single surgeon	51	30/21	58.7 ± 10.15
Li et al.^16	2015	China	Retrospective	2008–2011	Single surgeon	27	18/9	57.3
Lin et al.^17	2013	China	Retrospective	2002–2010	Multiple surgeons	27	19/8	52.2
Shousha et al.^18	2012	Egypt	Retrospective	2006–2008	Single surgeon	34	17/18	63.9
Li et al.^19^,^20^,a	2017	China	Retrospective	2006–2014	Single surgeon	31	21/10	54.9 ± 8.1
Chen et al.^21	2019	China	Retrospective	n/d	Single surgeon	80	60/20	55.4 ± 10.9
Kreitz et al.^22	2018	USA	Retrospective	2010–2014	n/d	25	16/9	57.5
White et al.^23	2023	USA	Retrospective	2013–2018	Multiple surgeons	63	31/32	62

^atwo studies with same sample; n/a: not available; n/d: not defined.

Figure 1. PRISMA flow chart.

Figure 2. Overview of key characteristics in the included studies, specifically addressing (a) temporal distribution, (b) geographical distribution, (c) surgery performance, and d) spanning period. n/a: not available; n/d: not defined.

Figure 3. Preoperative patients’ characteristics related to myelopathy and radiculopathy (a), and levels related to performed 4L ACDF (b). n/a: not available;

Table 2. Data related to four – level anterior cervical discectomy and fusion (4L ACDF) surgery, complications, follow-up period, clinical outcome, and fusion rate.

Reference	Radiculopathy vs myelopathy	Levels	Type of cage	Complications	Follow up	Clinical outcome	Fusion and lordosis correction
Wang et al.^10	n/d	C3-7 (n = 26)	Standalone: filled with hydroxyapatite-collagen artificial bone (Bonegold®, Allgens, Beijing, China);	3 (11.5%) dysphagia	25.1 ± 7.3 m	JOA score increased from 10.1 ± 1.1 to 12.9 ± 1.2	6 (23 %) pseudoarthrosis; 6 (23%) cage subsidence;
Joo et al.^11	561/904	n/a	n/a	13 (0.7%) sepsis; 11 (0.6%) deep venous thrombosis; 34 (1.8%) acute kindey injury; 71 (3.8%) urinary tract infection; 46 (2.5%) pneumonia; 11 (0.6%) wounds; 28 (1.5 %) hematomas; 68 (8.7 %) dysphagia;	n/a	n/a	n/a
Wang et al.^12	11/21	C3-7 (n = 32)	PEEK cages with an anterior plate;	1 (3.1 %) hematoma; 6 (18.75%) dysphagia; 3 (9.38%) hoarseness 3 (9.38%) respiratory deficits; 1 (3.1 %) CSF leak;	5 y	VAS for neck and arm pain improved from 14.2–6.84 (p = .012); NDI improved from 31.62 to 12.17 (p<.01); JOA score improved from 10.1 to 13.9;	94% FR; 2 cage subsidence, 1 pseudoarthrosis
Charalampidis et al.^13	11/17	C3-7 (n = 28)	Allograft + titanium plate;	9 (32%) dysphagia; 4 (14%) hoarseness; 1 (3.6%) C5 palsy; 1 (3.6) C7 nerve root injury; 2 (7%) other; 4 (14%) surgery revisions;	12 m	NDI scores improved from 38 to 28 (p = .046); VAS for neck pain scores improved from 5.1 to 3 (p = .012);	4 (14%) pseudoarthrosis;
Soliman et al.^14	n/a	C3-C7 (n = 37) C4-T1 (n = 4)	Lordotic cornerstone bone graft, plate;	11 (26.8 %) dysphagia; 3 (7.3 %) dysphonia; 2 (4.8 %) hematomas; 1 (2.4 %) C5 palsy; 1 (2.4 %) VA injury; 1 (2.4 %) superficial infection 3 (7.3 %) adjacent segment disease-related revision;	12 m	Neck and arm VAS scores improved from 7.7 ± 1.4 to 3.5 ± 1.7 (p < .001); NDI score improved from 31 ± 8.2 to 19.3 ± 8.1;	87.5% FR;
Alhashash et al.^15	n/a	C3-7 (n = 165)	Titanium rectangular cage filled with iliac graft;	3 (2.3%) C5 palsy; 3 (2.3%) hematomas; 1 (0.8%) transient paraparesis – epidural hematoma; 2 (1.6%) revision with decompression of neuroforamen 1 (0.8%) hoarseness;	2 y	NDI improved from 39.4 ± 9.3 to 8.3 ± 6.6; VAS for neck pain improved from 8.4 ± 2.95 to 2.95 ± 1.5; VAS for arm pain improved from 7.8 ± 1.8 to 2.3 ± 2;	80.77% FR;
Kim et al.^8	0/4	C3-7 (n = 49) C4-T1 (n = 2)	Allograft + plate;	1 (2%) hematoma; 14 (27.5%) dysphagia;	2.7 ± 1.9 y	16 patients experienced improved neck pain; 4 patients showed improved myelopathy; 10 (21.7%) experienced improved weakness;	n/d
Li et al.^16	n/d	C3-7 (n = 27)	Interbody fusion cage with anterior dynamic cervical plates;	6 (2.2%) dysphagia; 6 (2.2%) hoarseness; 3 (3.3%) C5 palsy;	2 y	JOA score and NDI showed a 50% improvement;	Cobb angle increased C3–7 from 8.5 to 21 and C2–7 from 10.7 to 24.7;
Lin et al.^17	0/27	C3-7 (n = 27)	Autogenous iliac crest graft or a titanium mesh cage and plate;	2 (7%) dysphagia;	39.8 m	JOA score and Nurick grade improved from 9.6 ± 1.4 and 2.74 ± 0.45 to 13.9 ± 1.3 and 0.86 ± 0.38 postoperatively;	ROM no difference between the groups;
Shousha et al.^18	0/34	C3-7 (n = 34)	Titanium rectangular cage, no plate;	1 (2.9%) C5 palsy;	48.6 m	NDI improved from 40 ± 23.25 at presentation to 16.31 ± 15.09 at the final follow-up;	87.5% FR;
Li et al.^19^,^20^,a	5/15 (+11 mixed)	C3-7 (n = 25) C2-6 (n = 6)	PEEK cages and anterior cervical plate	3 (9.7 %) dysphagia; 2 (6.5 %) hoarseness; 2 (6.5 %) C5 palsy;	36.2 m	JOA score improved from 7.5 ± 1.9 to 14.3 ± 1.5; NDI score improved from 26.5 ± 3.0 to 13.1 ± 3.2;	90.3% FR;
Chen et al.^21	0/80	C3-7 (n = 80)	Autogenous bone + cervical locking plate;	9 (11.3%) dysphagia; 3 (3.8%) neck pain; 3 (3.8%) C5-palsy;	45.7 m	JOA score preoperative: 10.0 ± 4.1, postoperative: 13.3 ± 3.1; C2-C7 angle preoperative: 12.9 ± 12.3, postoperative: 22.3 ± 7.5;	100% FR;
Kreitz et al.^22	25/missing data	C3-7 (n = 18) C4-T1 (n = 2) C2-6 (n = 1)	Autogenous bone + anterior cervical plate;	6 (8%) revision surgery;	19 m	65% motoric deficit, postoperatively 83% full strength;	69% FR;
White et al.^23	47/51	C2-7 (n = 63)	PEEK + structural allograft;	1 (1.6%) revision surgery;	2.6 y	NDI improvement was 15.7 ± 4.5 (p < .01), with 25.8% improvement; SF-36 showed improvement of 5.8 ± 3.1 (18.1%) (p = 0.14).	41.3% FR;

n: frequency; y: year; m: month; FR: fusion rate; NDI: Neck Disability Index; SF-36: 36-item Short-Form Health Survey; JOA: Japanese Orthopaedic Association Score; n/a: not available; n/d: not defined.

^aTwo studies with same cohort.

Figure 4. Perioperative and postoperative complications. *: two studies with same cohort.

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