Five-Level Anterior Cervical Discectomy And Fusion

Anterior cervical discectomy and fusion (ACDF) is a common treatment modality that has shown good clinical results in patients with cervical degenerative disc disease. ACDF remains the procedure of choice for most patients given its satisfactory clinical outcomes and proven radiological fusion ranging from 90-100%. Five-level ACDF is a very rare type of surgery, even in large spine centers. This type of procedure is unique because, beyond three or four levels, the surgeon needs to switch from a transverse incision to a longitudinal incision along the medial sternocleidomastoid (SCM) muscle border, which is less preferred for cosmetic reasons. Another reason why this procedure is seldom performed is that extreme multilevel ACDF is associated with higher complication and failure rates. Literature covers one, two, and three-level anterior surgeries, but there are few studies reporting the outcomes of five-level ACDF. In the few studies that do report five-level ACDF, the data is controversial. Some studies show the risk of adjacent-segment disease increasing with a higher number of fused levels and increasing incidences of reoperation. Other studies show no changes in the risk of adjacent segment disease in multilevel ACDF in comparison with single-level ACDF. One study even showed a decreased level of adjacent-segment disease and reoperation rates in multilevel ACDF when compared to single-level ACDF. To contribute to current knowledge, we share our experience with five-level ACDF. We report the case of a 63-year-old female who presented with complaints of progressively worsening weakness in the upper extremities. MRI of her cervical spine demonstrated multilevel degenerative disc disease throughout C3-T1 with reversal of normal lordosis and a kyphotic deformity. We performed a successful ACDF at C3-T1 as well as partial corpectomy of the C5 and C6 vertebrae. We did it through a standard transverse incision from the midline to the medial border of the SCM within a preexisting neck crease, demonstrating that in select patients, extreme multilevel ACDF can be performed with proper anatomical dissection and without the need for multiple or longitudinal incisions.