Introduction: The literature on ACDF> 3 levels remains controversial. Combined anterior posterior cervical fusion leads to increased morbidity and loss of cervical mobility. We investigated fusion rate, incidence of dysphagia and patient satisfaction in 4-level ACDF in order to demonstrate that multi-level ACDF >3 levels is a reasonable option.

Methods: Radiographic and chart review were done for consecutive patients who underwent elective 4-level ACDF from 2006-2011. Fusion rate was evaluated for patients with postoperative cervical radiographs/CT at 6 months or more. We excluded patients with a planned staged anterior-posterior cervical fusion. Fusion is determined by neuroradiologists who evaluated post-operative standing radiographs and CT. The criteria are lucency around the hardware, absence of spinous process movement on flexion/extension films, and bone bridging.Patients completed a dysphagia and satisfaction survey by phone. Descriptive statistics were used.

Results: Ninety-three patients were included in the study. Eighty-two patientshad postoperative imaging at 6 months or more. There were a total of 328 interspaces; 316 interspaces were adequate for fusion evaluation. Ten interspaces either had failed fusion or indeterminate fusion status. Fusion rate per interspace is 96.8%. Seventy-seven patients had successful fusion. Fusion rate per patient is 93.9%. Patient satisfaction surveys were completed in 60 out of 93 (64.5%)patients. Fifty-three(88%) out of 60 patients were satisfied with the results of the surgery. Postoperative dysphagia resolved within 4-30 days with an average of 13 days. All patients surveyed regained normal swallowing function.

Conclusions: Four-level ACDF achieves a very high fusion rate in our institution with a very high satisfaction rate and comparable dysphagia rate. ACDF has proved to be a viable alternative for patients with surgical pathology of >3 levels.

Patient Care: We demonstrate that ACDF has proved to be a viable alternative for patients with surgical pathology of >3 levels

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the need and importance of acheiving fusion in 4 level ACDF 2) Discuss, in small groups what constitutes "acceptable fusion" 3) Identify pseudoarthrosis in ACDF, completed fusion and desirable end results after multi-level ACDF

References: 1. Chang et al. Neurosurgery, 2010 Four level anterior cervical discectomy and fusion with plate fixation: Radiographic and clinical results 2. Bolestra et al. Spine, 2000 Three and Four level ACDF with plate fixation 3. Koller et al. Eur Spine, 2007 4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results 4. Vukic et al. Coll. Anthropol., 2011 Hydroxyapatite Ceramics in Multilevel Cervical interbody Fusion – Is There a Role? 5. Shousha et al. Eur Spine, 2012 Four-level anterior cervical discectomies and cage-augmented fusion with and without fixation 6. Hwang et al. J Neurosurg (Spine), 2004 Three-level and four-level anterior cervical discectomies and titanium cage-augmented fusion with and without plate fixation