Research Activities, February 2011: Outcomes/Effectiveness Research: Higher in-hospital complication rate for primary posterior versus primary anterior cervical fusion

Outcomes/Effectiveness Research
Higher in-hospital complication rate for primary posterior versus primary anterior cervical fusion

Surgical procedures have long been used in the treatment of various types of neck and back pain. Over the past 30 years, cervical spine fusion operations to treat trauma, cervical spondylosis (abnormal weakening of the cartilage and bones of the neck), and other problems have increased dramatically. Both anterior (ACDF) and posterior cervical fusion (PCDF) procedures have seen sharp increases.

A team of researchers from the Hospital of Special Surgery and Weill Cornell Medical College found that PCDF was associated with a twofold increased mortality risk compared with ACDF, even after controlling for patients' overall burden of illness and demographic characteristics. The incidence of complications and mortality was 4.14 percent and 0.26 percent among patients undergoing ACDF and 15.35 percent and 1.44 percent for patients undergoing PCDF, respectively.

Patients undergoing ACDF had shorter hospital stays and their procedures were more frequently performed at nonteaching institutions. The PCDF group was older and consequently had more medical conditions. Those in the group were more likely to be male, to be treated for trauma, and to be operated on in large, urban, teaching centers. One obvious explanation for the older age of the PCDF group is the increased reliance on posterior fusion procedures for multilevel cervical spondylosis, a condition more commonly seen in the elderly. Although traditional teaching has cautioned against multilevel ACDF exceeding three segments in elderly patients, implant improvements have given reason to rethink this. The choice of ACDF versus PCDF is affected by location and type of stenosis (narrowing of the spinal canal that compresses the spinal cord and nerves), number of affected levels, and vertical alignment.

These findings, despite their limitations, should aid in surgical decisionmaking in the subset of cases in which performing either of the two procedures appears reasonable, note the researchers. Their study sample included 228,113 hospital admissions in which a primary cervical spine procedure was performed between 1998 and 2006. Of these, 91.7 percent were ACDF procedures and 8.3 percent were PCDF procedures. Data came from the National Inpatient Sample (NIS) supported by the Agency for Healthcare Research and Quality (AHRQ).

This study was partly supported by an AHRQ grant (HS16075) to the Cornell Center for Education and Research on Therapeutics (CERT). For more information on the CERTs program, go to http://www.certs.hhs.gov.

More details are in "Increased in-hospital complications after primary posterior versus primary anterior cervical fusion," by Stavros G. Memtsoudis, M.D., Alexander Hughes, M.D., Yan Ma, Ph.D. and others in the September 9, 2010, Clinical Orthopedic and Related Research available online.
Research Activities, February 2011: Outcomes/Effectiveness Research: Higher in-hospital complication rate for primary posterior versus primary anterior cervical fusion