Comparative Study of Two-level Cervical Disc Herniation: Anterior Cervical Discectomy and Fusion (Acdf) Using Stand-alone Titanium Cage Versus Cage and Plate Fixation - a Retrospective Analysis of Complication Rates and Patient Satisfaction

Comparative Study of Two-level Cervical Disc Herniation: Anterior Cervical Discectomy and Fusion (Acdf) Using Stand-alone Titanium Cage Versus Cage and Plate Fixation - a Retrospective Analysis of Complication Rates and Patient Satisfaction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Study of Two-level Cervical Disc Herniation: Anterior Cervical Discectomy and Fusion (Acdf) Using Stand-alone Titanium Cage Versus Cage and Plate Fixation - a Retrospective Analysis of Complication Rates and Patient Satisfaction Cem Sever, Bekir Eray Kilinc, Ahmet Onur Akpolat, Tayfun Bozkaya, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5716561/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Mar, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 10 You are reading this latest preprint version Abstract Background: This study aims to compare the outcomes of two-level anterior cervical discectomy and fusion (ACDF) procedures using stand-alone cages versus cage and plate fixation in patients diagnosed with cervical disc herniation (CDH). Materials and Methods: This retrospective analysis included 60 patients who underwent two-level ACDF procedures. Patients were divided into two groups: one treated with stand-alone cages and the other with cage and plate fixation. Data on surgical duration, blood loss, fusion stability, and complication rates were collected. Clinical outcomes, including neck pain and functional status, were assessed using standard scoring systems. Results: Plate fixation provided superior fusion stability but was associated with longer surgery durations, higher intraoperative blood loss, and increased complication rates. Stand-alone cages reduced intraoperative trauma but demonstrated higher subsidence rates and prolonged fusion times. Both techniques resulted in significant improvements in neck pain and disability scores. Discussion: While both approaches are effective for managing cervical disc herniation, each has distinct advantages and limitations. Selecting the most appropriate technique based on patient-specific anatomical and clinical considerations is crucial to optimizing surgical outcomes. cervical disc herniation cervical discectomy anterior cervical discectomy stand-alone cage fixation cage and plate fixation hernia grading system Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Cervical disc herniation (CDH) is a common spinal condition that often requires surgical intervention when conservative treatments fail. Anterior cervical discectomy and fusion (ACDF) is a widely used technique for managing two-level disc herniations, providing effective relief from radiculopathy and myelopathy. The use of an anterior plate in two-level ACDF is believed to enhance stability, promote fusion, and reduce cage subsidence. However, the less invasive stand-alone cage technique may minimize complications such as dysphagia, esophageal injury, and hardware-related issues. While previous studies have evaluated functional outcomes and fusion rates in ACDF with and without anterior plates, limited data exists regarding their impact on complication rates and patient satisfaction in two-level procedures [ 1 – 3 ]. Since high complication rates not only increase morbidity risks but also negatively affect patient satisfaction-a critical measure of surgical success [ 4 – 7 ]. This retrospective study compares complication rates and patient satisfaction between two-level ACDF procedures with and without an anterior plate in patients with cervical disc herniation. The primary outcomes include perioperative and postoperative complications, as well as patient-reported satisfaction scores, providing insights into the optimal surgical approach for two-level CDH. We hypothesize that the use of an anterior plate in two-level CDH surgery increases complication rates compared to the stand-alone cage technique but improves fusion stability. Conversely, the stand-alone cage approach is expected to reduce complications but may result in longer fusion times and a higher risk of subsidence. MATERIALS AND METHODS Between January 2021 and March 2023, ACDF was performed on 60 patients diagnosed with CDH at our clinic. In 27 cases (Group 1) where greater lordosis was needed, and more stable fixation was considered necessary after cage placement, ACDF with plate was performed. In 33 cases (Group 2), where the neck anatomy was not suitable (e.g., slender neck structure) and additional stabilization was deemed unnecessary during the operation, ACDF using a stand-alone cage was performed. Both groups were retrospectively compared in terms of clinical outcomes, pain and functional scores, complication, and revision rates. The inclusion criteria for this study were: (1) presence of clinical signs and symptoms of cervical radiculopathy or cervical spondylotic myelopathy that had not improved with conservative management, (2) age range of 30 to 55 years, (3) confirmed disc herniation on magnetic resonance imaging (MRI) with evidence of nerve root or spinal cord compression, and (4) involvement of two contiguous disc levels between C3 and C7. The exclusion criteria included: (1) continuous or mixed ossification of the posterior longitudinal ligament (OPLL), (2) developmental cervical spinal stenosis, (3) pre-existing dysphagia, (4) severe cervical spinal deformity, (5) active rheumatoid arthritis, (6) prior history of invasive malignancy, (7) known allergy to the materials used in the surgical implants, (8) previous cervical spine trauma or surgery, (9) patients with bleeding diathesis, coagulation disorders, or those using anticoagulants for other reasons and (10) evidence of local or systemic infection. Surgical Technique All surgical procedures were performed by a single surgeon to ensure consistency. After determining the surgical level with fluoroscopy, the cervical spine was exposed using a standard anterior medial approach with an oblique skin incision. Discectomy, nerve decompression, and final plate preparations were performed according to previously reported standard techniques. During cage placement, lordosis was restored as much as possible using 4-degree lordotic angle titanium cages (Tasarım Medical Istanbul, Turkey). The cages were filled with demineralized bone matrix ( Figure 1 ). In the plate group, a 6-hole titanium plate (Tasarım Medical Istanbul, Turkey) was gently bent to increase lordosis, and cancellous screws were used to enhance bone fixation using a C-arm intensifier. Two fully threaded cancellous screws per vertebra were inserted divergently and secured to the plate using the integrated locking system to prevent screw pull-out. ( Figure 2 ). In both groups, extra care was taken during end-plate preparation and avoiding excessive decortication to prevent and reduce subsidence. A mini-VAC drain was placed on the anterior surface of the vertebra in all cases. Neuromonitoring was performed in all cases to monitor changes in nerve conduction. Outcome Measures Length of hospital stay, smoking habits, surgery times, fluoroscopy times, estimated blood loss, drainage amounts, drain duration, drain index, complication and revision rates were recorded. The severity of the hernia was graded in all patients preoperatively using T2 axial and sagittal MR images with the Hernia Grading System (HGS) [8]. The Visual Analog Scale (VAS) was used to evaluate neck and arm pain separately, while the impact of the condition on daily activities was assessed using the Neck Disability Index (NDI) [9]. Drain index were calculated by dividing the total amount of blood from the drain by the number of days the drain was in place. Perioperative complications and revision surgery rates were recorded, excluding complications unrelated to spinal surgery. Deep wound infections were defined as those requiring additional debridement. Radiological assessments included postoperative fusion rates, fusion duration, and subsidence measurements. Statistical Analysis Descriptive statistics of the data included mean, standard deviation, range, and percentage values. The distribution of the data was assessed using the Shapiro-Wilk test. Independent continuous variables were compared using the independent samples t-test or Mann-Whitney U test. For dependent variables, comparisons were made using the paired samples t-test or the Wilcoxon signed rank test. The Chi-square or Fisher's exact tests were used for comparing qualitative independent variables. A p-value of less than 0.05 was considered significant for all analyses. Statistical analyses were performed using Jamovi for Mac software (Version 2.5.4.0). Results Demographic and Perioperative Findings The mean age of Group 1 was 40.4±6.54 years and 42.8±6.10 years for Group 2, showing a slight age difference. Both groups had comparable mean follow-up durations (Group 1: 35.1±6.91 months; Group 2: 35.0±5.73 months). Surgery levels are shown in Figure 3 , and HGS in Figure 4 . The HGS levels were similarly distributed between the two groups. In Group 1, 20% of patients were at HGS level 2, and 25% were at level 3, while in Group 2, these rates were 20% and 35%, respectively. Statistical analysis (p = 0.525) showed no significant difference between the groups. Group 1 had significantly longer fluoroscopy (42.3±5.90 minutes) and surgery times (159.8±12.8 minutes) compared to Group 2 (14.5±2.27 and 100.5±11.3 minutes, respectively; p < 0.001). Estimated blood loss, drainage volume, duration and drain index were higher in Group 1 (127±16.0 mL, 47.2±12.6 cc, 34.7±6.93 hours, 1.42±0.487, respectively) than in Group 2 (80±19.6 mL, 23.5±6.43 cc, 24.4±2.09 hours, 0.965± 0.265 respectively; p < 0.001). Subsidence and fusion duration were greater in Group 2 (1.26±0.622 mm, 6.21±0.992 months) compared to Group 1 (0.426±0.395 mm, 5.15±1.12 months). Smoking habits were similar in both groups (p = 0.313) ( Table 1 ). Pain and Disability Outcomes The initial VAS-neck pain scores were 6.63±0.926 for Group 1 and 6.36±0.962 for Group 2. Both groups experienced significant pain reduction at first week, first month, and third months postoperatively, with scores decreasing to 1.26±0.984 and 1.24±1.06, respectively, by 3 months. Similarly, initial VAS-arm pain scores (7.33±1.27 for Group 1 and 7.03±1.31 for Group 2) showed marked improvement, leveling off at 1.07±0.267 and 1.12±0.696 by 3 months. The NDI scores also significantly decreased from 28.5±4.28 (Group 1) and 25.3±4.42 (Group 2) to 2.33±4.57 and 2.18±5.90, respectively, by 3 months. Overall, significant improvements were noted in neck and arm pain and disability across all time points, with the greatest improvement occurring in the first week (p < 0.001) ( Table 2 ). Both VAS and NDI scores demonstrate the early effectiveness of surgical treatment (first week) in significantly reducing pain and disability levels. Improvement continued up to the third month, with no major differences observed between the groups, indicating that both surgical techniques provide similar mid-term pain and disability outcomes. Ultimately, the surgical treatment effectively reduced pain and disability for both groups. Group 1 had longer fluoroscopy and surgery durations, as well as higher blood loss and drainage amounts, while Group 2 showed longer fusion times and higher subsidence values. The hospital stay duration was concentrated at 1 or 2 days for both groups, with few patients staying 3 days. The p-value (p = 0.884) indicated no significant difference in hospital stay duration between the groups. All patients in Group 1 achieved fusion, whereas one patient in Group 2 did not (1.7%). This difference was not statistically significant (p = 0.362), indicating that both groups had high and comparable fusion rates. Surgical techniques did not significantly affect fusion rates. The average subsidence was 0.43±0.395 mm for Group 1 and 1.26±0.622 mm for Group 2, with an overall mean of 0.89 mm. Notably, subsidence greater than 1.5 mm occurred in 8 patients, all of whom were in Group 2, indicating a higher risk of significant cage settling in the stand-alone cage group compared to the plated group. The complication rate in Group 1, based on all patients, was determined to be 13.3%, while in Group 2, it was found to be 5%. A statistically significant difference in complication rates was found (p-value 0.041), suggesting that the surgical technique or treatment method affected the risk of complications in Group 1 ( Table 3 ). The reoperation rate was low in both groups (1.7%), with only one patient from each group requiring reoperation. In Group 1, one patient required reoperation due to plate loosening, whereas in Group 2, one patient underwent revision with corpectomy and mesh cage placement due to 3.5 mm subsidence and non-union. The p-value (p = 0.885) indicated no significant difference between the groups in terms of reoperation rates, showing that the treatment methods did not differ in this respect. Fluoroscopy times were significantly longer in Group 1 compared to Group 2 (p < 0.001), reflecting the additional imaging required for accurate placement of plates and screws. Similarly, surgery times were longer in Group 1 (p < 0.001), emphasizing the influence of surgical techniques on procedure duration. Estimated blood loss, drainage volume, drain duration, and drain index were significantly higher in Group 1 compared to Group 2 (p < 0.001), reflecting differences in surgical techniques. Fusion time was also significantly longer in Group 1 (p = 0.007), underscoring the influence of surgical methods on healing duration. No significant difference in smoking habits was identified between the groups (p = 0.313), indicating no association between smoking and treatment outcomes or surgical procedures. While no definitive link was found between smoking levels and subsidence, smoking significantly prolonged fusion time (p < 0.001). A trend was observed linking higher smoking levels to increased complication rates (p = 0.057), though it did not reach statistical significance. Interestingly, more complications were noted among non-smokers, but this relationship was not statistically significant. Notably, all reoperations occurred in patients with high smoking levels (30 or 40 smokers), suggesting a correlation between heavy smoking and the need for reoperation. DISCUSSION ACDF is widely regarded as the gold standard for treating cervical spondylopathy. This procedure effectively removes compressive elements such as herniated discs and osteophytes while simultaneously restoring the natural cervical curvature [10]. Additionally, the use of anterior cervical plating provides enhanced spinal stability and reduces the risk of pseudarthrosis [11-13]. Nevertheless, complications related to plating remain a significant concern, with their incidence increasing in proportion to the number of segments fused [12, 14]. To address these issues, self-anchored, stand-alone cages with a zero-profile design have been developed. These innovations aim to minimize plate-related complications and reduce operative time. Furthermore, anchored micro-plates have been proposed to deliver stability comparable to that achieved with traditional anterior plates and screws [15]. By retrospectively analyzing two-level ACDF procedures, we compared the use of stand-alone cages (without plates) to anterior plate use in terms of complications, fusion success, and patient satisfaction. Our findings contribute to the ongoing debate about the optimal surgical approach for multi-level cervical disc herniation surgery. Surgery Duration and Blood Loss The technical complexity of plate placement results in longer surgery and fluoroscopy times. A study reported that the use of a plate significantly increases operation duration [16]. Similarly, another study demonstrated greater intraoperative blood loss in cases involving plate use [17]. These findings underscore the importance of preoperative planning, especially for patients with additional morbidity risks. Our study also found that surgery duration, blood loss, and fluoroscopy times were significantly higher in the plate group. Patient-Reported Outcomes Both groups showed significant improvements in VAS and NDI scores postoperatively, confirming the overall effectiveness of ACDF in reducing pain and disability. This demonstrates ACDF’s efficacy as a surgical method for relieving pain and restoring function. A study reported that generally positive patient-reported outcomes despite higher complication rates [18]. In another study it was emphasized in their systematic review that both plated and non-plated procedures yield similar clinical outcomes [3]. However, patients in the stand-alone cage group may have experienced a faster reduction in pain due to less surgical trauma and a lower incidence of postoperative dysphagia. Impact of Smoking on Outcomes The impact of smoking on surgical outcomes remains significant. Our study found that high smoking consumption prolonged fusion times, consistent with findings by Lee et al. [5]. Some studies have also reported that smoking slows bone healing and increases the risk of pseudoarthrosis [18, 19]. Therefore, implementing preoperative smoking cessation programs and informing patients about the effects of smoking before surgery is crucial. Subsidence and Cervical Alignment Subsidence continues to be a concern with stand-alone cage constructs. Cage subsidence has emerged as a critical complication since the clinical introduction of stand-alone cages. Previous studies have reported a wide range of subsidence rates, from 0% to 61% in ACDF procedures using stand-alone cages similar to those applied in this research [1, 15, 20-23]. A study conducted a review involving 16 patients who underwent skip-level ACDF at 32 noncontiguous levels using self-locking stand-alone PEEK cages [22]. Their findings indicated that three cages (3/32) in two patients (2/16) experienced subsidence. In a separate retrospective analysis, Zhou et al. [21] assessed outcomes in 15 patients undergoing 3-level ACDF with self-locking stand-alone cages, reporting subsidence in four cages across three patients. While the subsidence rate per level was comparable between these studies, the subsidence rate per patient increased with a greater number of fused segments. Additionally, it was found that all three patients who experienced subsidence were older women, suggesting that lower bone mineral density might be a significant factor contributing to subsidence. Other contributing factors include end plate damage, excessive segmental distraction, or the use of oversized cages [23, 24]. Subsidence is often observed within the first three months postoperatively, as bone fusion occurring by that time may inhibit further subsidence progression [25, 26]. In a study it was highlighted that subsidence could lead to the loss of cervical lordosis and potential long-term complications [1]. In our study, meticulous preparation of the end plates minimized this risk; however, more extensive studies are needed to evaluate long-term effects. In our study, no cases of subsidence greater than 1.5 mm were recorded in Group 1, with an average subsidence measurement of 0.43 mm. In contrast, Group 2 exhibited eight cases of subsidence more than 1.5 mm, with an average of 1.26 mm. The overall average subsidence was 0.89 mm. These results indicate a significantly lower subsidence in Group 1, potentially reflecting more efficient load distribution and decreased contact stress at the graft-bone interfaces in this group. Our findings indicate that cage design and surgical technique play a critical role in reducing subsidence risk. Complications and Fusion Rates Our data showed higher complication rates in the plated group (13.3%) compared to the stand-alone cage group, consistent with existing literature. Complications such as dysphagia, hardware-related issues, and adjacent segment degeneration are more commonly associated with the use of anterior cervical plates. The mechanical pressure exerted by plates and screws, along with their interference with surrounding anatomical structures, is thought to be a primary cause of these complications. It was reported that identified higher rates of complications and the need for surgical revisions in patients undergoing multi-level ACDF with plate constructs [19]. Similarly, another study reported plate-related issues, including dysphagia and adjacent segment disease [27]. In contrast, the stand-alone approach helps mitigate the risk of plate-related complications but is associated with a higher incidence of cage subsidence. For instance, it was documented increased subsidence rates in non-plated constructs [28]. Dysphagia remains a prevalent complication after anterior cervical spine surgery, especially in multi-level ACDF cases [29-31]. Although the exact pathogenesis is not fully understood, some studies suggest that the zero-profile design of stand-alone cages can decrease the long-term incidence of dysphagia by reducing implant irritation to the esophagus [12, 30]. The shorter operative time and reduced blood loss observed with self-locking stand-alone cages are thought to result in less traction and decreased prevertebral soft tissue damage, which may contribute to lower dysphagia rates. Nevertheless, this benefit appears limited, as evidence shows that dysphagia rates generally decline within six months postoperatively, with only a small number of patients experiencing moderate or severe symptoms beyond this period, even when anterior plates are utilized [12, 30]. In our study, only one patient in plate group experienced mild dysphagia at the final follow-up. Additionally, some researchers suggest that postoperative dysphagia could result from direct trauma to the esophagus and surrounding tissues during surgery [12, 31]. The use of self-locking stand-alone cages simplifies the surgical process by minimizing the need for extensive esophageal retraction. A researcher demonstrated that zero-profile stand-alone cages were associated with a significantly lower risk of dysphagia (0 out of 30 patients) at three months postoperatively compared to anterior plate use (9 out of 33 patients) [15]. Consistently, our findings revealed a lower dysphagia rate in stand-alone cage group compared to plate group across all time points, though this difference did not reach statistical significance. This integration provides a comprehensive analysis of the complications associated with ACDF techniques, underscoring the trade-offs between the use of anterior plates and stand-alone cages in terms of dysphagia, stability, and the risk of subsidence. Despite the complications, anterior plate use offered better fusion outcomes. It was demonstrated that plates reduce cage subsidence and maintain cervical lordosis, improving long-term results [1]. Similarly, a researcher found that plate use enhances fusion rates and neck pain scores [3]. Some other researchers also emphasized the role of plates in enhancing segmental lordosis and stability, promoting fusion [2, 4]. It was noted that while both methods are effective for pain management, plate use better preserves structural integrity in the long term [32]. Although fusion time was longer in the stand-alone group (6.21 months), this did not significantly affect overall patient outcomes. Both groups had satisfactory fusion rates, but the plated group had more stable fusion with reduced segmental motion, as supported by Nabhan et al. [33]. A study suggested the use of zero-profile spacers as a less invasive alternative to minimize complications associated with plate use [6]. Such innovative approaches may guide future surgical advancements. Limitations and Future Research The retrospective design and limited sample size of our study present some limitations. Prospective, randomized controlled trials are needed to confirm these findings. Further comparative studies on cost-effectiveness and long-term clinical outcomes will help inform surgical decision-making. Our study has certain limitations, including the challenges associated with accurately assessing bone fusion using plain radiographs and the impracticality of performing CT scans on every patient. As a result, the potential for measurement errors must be considered in our analysis. Additionally, anatomical differences and surgical techniques among patients could be potential sources of bias. Furthermore, this research did not investigate the relationship between bone mineral density and cage subsidence, nor did it examine changes in the biomechanics of the cervical spine following these two surgical procedures. The retrospective nature of our study, along with the limited sample size and relatively short follow-up duration, also presents constraints. Therefore, further well-designed, randomized, multicenter prospective studies with extended follow-up periods are necessary to validate these findings. CONCLUSION Our study highlights that both stand-alone cages and anterior plate fixation have distinct advantages and disadvantages. While the use of anterior plates provides greater fusion stability, it is associated with higher complication rates, including prolonged operative duration, increased blood loss, and extended fluoroscopy time. In contrast, the stand-alone approach is less invasive, resulting in shorter surgery and reduced intraoperative blood loss, though it carries a higher risk of cage subsidence. Therefore, the choice of surgical technique should be carefully tailored to the patient’s specific anatomical characteristics and lifestyle factors to optimize outcomes and minimize complications. Declarations Conflict of interest: On behalf of all authors, the corresponding author states that there is no conflict of interest. Ethical Approval: IRB was subsequently obtained (decision number: KSYLEAH-KAEK 2024/81). Informed Consent: Informed consent was obtained from patients. 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Anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty (CDA) for two contiguous levels cervical disc degenerative disease: a meta-analysis of randomized controlled trials. Eur Spine J. 2017;26(4):985-997. Ghobrial B, Price A, Pretorius J, Elkhwad H. Clinical and Radiological Outcomes of Anchored Stand-Alone Cage Compared to Conventional Plating in Multilevel Anterior Cervical Discectomy and Fusion: A Systematic Review. Cureus, 2024;16(10):e72386. Tables Table 1 and 2 are available in the Supplementary Files section. Table 3: Complications and revisions of the groups Complications and Revisions Grup 1 (n:27) Grup 2 (n:33) Toplam (n:60) Infection n: 0 n: 0 n: 0 Hematoma n: 2 n: 0 n: 2 Dysphagia n: 3 n: 0 n: 3 Dural penetration n: 0 n: 0 n: 0 Neurological deficit n: 0 n: 0 n: 0 Adjacent intervertebral disc degeneration n: 2 n: 2 n: 4 Subsidence (>1.5 mm) n: 0 (mean: 0,43 mm) n: 8 (mean: 1,26 mm) n: 8 (mean: 0,89 mm) Reoperation n: 1 n: 1 n: 2 Additional Declarations No competing interests reported. Supplementary Files Table1and2.docx Cite Share Download PDF Status: Published Journal Publication published 10 Mar, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Revision requested 13 Jan, 2025 Reviews received at journal 08 Jan, 2025 Reviews received at journal 04 Jan, 2025 Reviewers agreed at journal 02 Jan, 2025 Reviewers agreed at journal 30 Dec, 2024 Reviewers agreed at journal 30 Dec, 2024 Reviewers invited by journal 27 Dec, 2024 Editor assigned by journal 27 Dec, 2024 Submission checks completed at journal 27 Dec, 2024 First submitted to journal 26 Dec, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5716561","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":395497344,"identity":"a885dedb-87cc-4486-8efd-87e88c4eff59","order_by":0,"name":"Cem Sever","email":"","orcid":"","institution":"The Pearl International Hospital","correspondingAuthor":false,"prefix":"","firstName":"Cem","middleName":"","lastName":"Sever","suffix":""},{"id":395497346,"identity":"928f6815-a0ed-42bc-92db-59fadab093e2","order_by":1,"name":"Bekir Eray 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medicine","correspondingAuthor":false,"prefix":"","firstName":"Abdulhamit","middleName":"","lastName":"Misir","suffix":""}],"badges":[],"createdAt":"2024-12-26 13:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5716561/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5716561/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-025-05654-x","type":"published","date":"2025-03-10T15:58:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":72644475,"identity":"f030fcd5-dcde-4180-bc1b-404331177951","added_by":"auto","created_at":"2024-12-30 16:40:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":692656,"visible":true,"origin":"","legend":"\u003cp\u003edemineralized filled cages\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5716561/v1/c87d8d6c85b87c56ff7986e6.png"},{"id":72644476,"identity":"bfe6775d-3662-404d-9776-a05768ce0d28","added_by":"auto","created_at":"2024-12-30 16:40:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":826776,"visible":true,"origin":"","legend":"\u003cp\u003ePlate usage for integrated locking system to prevent screw pull-out\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5716561/v1/45b2609e8a08e0a825fb3422.png"},{"id":72646006,"identity":"0273a5e4-2a53-4247-99ce-5f69cb84f522","added_by":"auto","created_at":"2024-12-30 16:48:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":117606,"visible":true,"origin":"","legend":"\u003cp\u003eCervical level distribution of the groups\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5716561/v1/3553bcd5775b991346ffa117.png"},{"id":72644489,"identity":"1659ca66-a8aa-4d8d-8b55-ff59c4200638","added_by":"auto","created_at":"2024-12-30 16:40:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":71604,"visible":true,"origin":"","legend":"\u003cp\u003eHernia Grading System (HGS) Distribution of the patients in Group 1 and Group 2\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5716561/v1/aa7c2773366d5541a35f7a95.png"},{"id":78689044,"identity":"2f249733-8201-486e-a535-76c9bc02831c","added_by":"auto","created_at":"2025-03-17 16:10:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3090636,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5716561/v1/aca9c6d3-c370-4a8e-b94e-640f04b28505.pdf"},{"id":72644473,"identity":"6a39c5fb-fe37-4d60-aa12-f1840a7d5672","added_by":"auto","created_at":"2024-12-30 16:40:27","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":107831,"visible":true,"origin":"","legend":"","description":"","filename":"Table1and2.docx","url":"https://assets-eu.researchsquare.com/files/rs-5716561/v1/4daf75b40424c1e522525c9f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eComparative Study of Two-level Cervical Disc Herniation: Anterior Cervical Discectomy and Fusion (Acdf) Using Stand-alone Titanium Cage Versus Cage and Plate Fixation - a Retrospective Analysis of Complication Rates and Patient Satisfaction\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCervical disc herniation (CDH) is a common spinal condition that often requires surgical intervention when conservative treatments fail. Anterior cervical discectomy and fusion (ACDF) is a widely used technique for managing two-level disc herniations, providing effective relief from radiculopathy and myelopathy. The use of an anterior plate in two-level ACDF is believed to enhance stability, promote fusion, and reduce cage subsidence. However, the less invasive stand-alone cage technique may minimize complications such as dysphagia, esophageal injury, and hardware-related issues.\u003c/p\u003e \u003cp\u003eWhile previous studies have evaluated functional outcomes and fusion rates in ACDF with and without anterior plates, limited data exists regarding their impact on complication rates and patient satisfaction in two-level procedures [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Since high complication rates not only increase morbidity risks but also negatively affect patient satisfaction-a critical measure of surgical success [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis retrospective study compares complication rates and patient satisfaction between two-level ACDF procedures with and without an anterior plate in patients with cervical disc herniation. The primary outcomes include perioperative and postoperative complications, as well as patient-reported satisfaction scores, providing insights into the optimal surgical approach for two-level CDH.\u003c/p\u003e \u003cp\u003eWe hypothesize that the use of an anterior plate in two-level CDH surgery increases complication rates compared to the stand-alone cage technique but improves fusion stability. Conversely, the stand-alone cage approach is expected to reduce complications but may result in longer fusion times and a higher risk of subsidence.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eBetween January 2021 and March 2023, ACDF was performed on 60 patients diagnosed with CDH at our clinic. In 27 cases (Group 1) where greater lordosis was needed, and more stable fixation was considered necessary after cage placement, ACDF with plate was performed. In 33 cases (Group 2), where the neck anatomy was not suitable (e.g., slender neck structure) and additional stabilization was deemed unnecessary during the operation, ACDF using a stand-alone cage was performed. Both groups were retrospectively compared in terms of clinical outcomes, pain and functional scores, complication, and revision rates.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria for this study were: (1) presence of clinical signs and symptoms of cervical radiculopathy or cervical spondylotic myelopathy that had not improved with conservative management, (2) age range of 30 to 55 years, (3) confirmed disc herniation on magnetic resonance imaging (MRI) with evidence of nerve root or spinal cord compression, and (4) involvement of two contiguous disc levels between C3 and C7. The exclusion criteria included: (1) continuous or mixed ossification of the posterior longitudinal ligament (OPLL), (2) developmental cervical spinal stenosis, (3) pre-existing dysphagia, (4) severe cervical spinal deformity, (5) active rheumatoid arthritis, (6) prior history of invasive malignancy, (7) known allergy to the materials used in the surgical implants, (8) previous cervical spine trauma or surgery, (9) patients with bleeding diathesis, coagulation disorders, or those using anticoagulants for other reasons \u0026nbsp;and (10) evidence of local or systemic infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll surgical procedures were performed by a single surgeon to ensure consistency. After determining the surgical level with fluoroscopy, the cervical spine was exposed using a standard anterior medial approach with an oblique skin incision. Discectomy, nerve decompression, and final plate preparations were performed according to previously reported standard techniques. During cage placement, lordosis was restored as much as possible using 4-degree lordotic angle titanium cages (Tasarım Medical Istanbul, Turkey). The cages were filled with demineralized bone matrix (\u003cstrong\u003eFigure 1\u003c/strong\u003e). In the plate group, a 6-hole titanium plate (Tasarım Medical Istanbul, Turkey) was gently bent to increase lordosis, and cancellous screws were used to enhance bone fixation using a C-arm intensifier. Two fully threaded cancellous screws per vertebra were inserted divergently and secured to the plate using the integrated locking system to prevent screw pull-out. (\u003cstrong\u003eFigure 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eIn both groups, extra care was taken during end-plate preparation and avoiding excessive decortication to prevent and reduce subsidence. A mini-VAC drain was placed on the anterior surface of the vertebra in all cases. Neuromonitoring was performed in all cases to monitor changes in nerve conduction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLength of hospital stay, smoking habits, surgery times, fluoroscopy times, estimated blood loss, drainage amounts, drain duration, drain index, complication and revision rates were recorded. The severity of the hernia was graded in all patients preoperatively using T2 axial and sagittal MR images with the Hernia Grading System (HGS) [8]. The Visual Analog Scale (VAS) was used to evaluate neck and arm pain separately, while the impact of the condition on daily activities was assessed using the Neck Disability Index (NDI) [9]. Drain index were calculated by dividing the total amount of blood from the drain by the number of days the drain was in place. Perioperative complications and revision surgery rates were recorded, excluding complications unrelated to spinal surgery. Deep wound infections were defined as those requiring additional debridement. Radiological assessments included postoperative fusion rates, fusion duration, and subsidence measurements.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics of the data included mean, standard deviation, range, and percentage values. The distribution of the data was assessed using the Shapiro-Wilk test. Independent continuous variables were compared using the independent samples t-test or Mann-Whitney U test. For dependent variables, comparisons were made using the paired samples t-test or the Wilcoxon signed rank test. The Chi-square or Fisher\u0026apos;s exact tests were used for comparing qualitative independent variables. A p-value of less than 0.05 was considered significant for all analyses. Statistical analyses were performed using Jamovi for Mac software (Version 2.5.4.0).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographic and Perioperative Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean age of Group 1 was 40.4\u0026plusmn;6.54 years and 42.8\u0026plusmn;6.10 years for Group 2, showing a slight age difference. Both groups had comparable mean follow-up durations (Group 1: 35.1\u0026plusmn;6.91 months; Group 2: 35.0\u0026plusmn;5.73 months). Surgery levels are shown in \u003cstrong\u003eFigure 3\u003c/strong\u003e, and HGS in \u003cstrong\u003eFigure 4\u003c/strong\u003e. The HGS levels were similarly distributed between the two groups. In Group 1, 20% of patients were at HGS level 2, and 25% were at level 3, while in Group 2, these rates were 20% and 35%, respectively. Statistical analysis (p = 0.525) showed no significant difference between the groups. Group 1 had significantly longer fluoroscopy (42.3\u0026plusmn;5.90 minutes) and surgery times (159.8\u0026plusmn;12.8 minutes) compared to Group 2 (14.5\u0026plusmn;2.27 and 100.5\u0026plusmn;11.3 minutes, respectively; p \u0026lt; 0.001). Estimated blood loss, drainage volume, duration and drain index were higher in Group 1 (127\u0026plusmn;16.0 mL, 47.2\u0026plusmn;12.6 cc, 34.7\u0026plusmn;6.93 hours, 1.42\u0026plusmn;0.487, respectively) than in Group 2 (80\u0026plusmn;19.6 mL, 23.5\u0026plusmn;6.43 cc, 24.4\u0026plusmn;2.09 hours, 0.965\u0026plusmn; 0.265 respectively; p \u0026lt; 0.001). Subsidence and fusion duration were greater in Group 2 (1.26\u0026plusmn;0.622 mm, 6.21\u0026plusmn;0.992 months) compared to Group 1 (0.426\u0026plusmn;0.395 mm, 5.15\u0026plusmn;1.12 months). Smoking habits were similar in both groups (p = 0.313) (\u003cstrong\u003eTable 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePain and Disability Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe initial VAS-neck pain scores were 6.63\u0026plusmn;0.926 for Group 1 and 6.36\u0026plusmn;0.962 for Group 2. Both groups experienced significant pain reduction at first week, first month, and third months postoperatively, with scores decreasing to 1.26\u0026plusmn;0.984 and 1.24\u0026plusmn;1.06, respectively, by 3 months. Similarly, initial VAS-arm pain scores (7.33\u0026plusmn;1.27 for Group 1 and 7.03\u0026plusmn;1.31 for Group 2) showed marked improvement, leveling off at 1.07\u0026plusmn;0.267 and 1.12\u0026plusmn;0.696 by 3 months. The NDI scores also significantly decreased from 28.5\u0026plusmn;4.28 (Group 1) and 25.3\u0026plusmn;4.42 (Group 2) to 2.33\u0026plusmn;4.57 and 2.18\u0026plusmn;5.90, respectively, by 3 months. Overall, significant improvements were noted in neck and arm pain and disability across all time points, with the greatest improvement occurring in the first week (p \u0026lt; 0.001) (\u003cstrong\u003eTable 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eBoth VAS and NDI scores demonstrate the early effectiveness of surgical treatment (first week) in significantly reducing pain and disability levels. Improvement continued up to the third month, with no major differences observed between the groups, indicating that both surgical techniques provide similar mid-term pain and disability outcomes. Ultimately, the surgical treatment effectively reduced pain and disability for both groups. Group 1 had longer fluoroscopy and surgery durations, as well as higher blood loss and drainage amounts, while Group 2 showed longer fusion times and higher subsidence values.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe hospital stay duration was concentrated at 1 or 2 days for both groups, with few patients staying 3 days. The p-value (p = 0.884) indicated no significant difference in hospital stay duration between the groups.\u003c/p\u003e\n\u003cp\u003eAll patients in Group 1 achieved fusion, whereas one patient in Group 2 did not (1.7%). This difference was not statistically significant (p = 0.362), indicating that both groups had high and comparable fusion rates. Surgical techniques did not significantly affect fusion rates.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe average subsidence was 0.43\u0026plusmn;0.395 mm for Group 1 and 1.26\u0026plusmn;0.622 mm for Group 2, with an overall mean of 0.89 mm. Notably, subsidence greater than 1.5 mm occurred in 8 patients, all of whom were in Group 2, indicating a higher risk of significant cage settling in the stand-alone cage group compared to the plated group.\u003c/p\u003e\n\u003cp\u003eThe complication rate in Group 1, based on all patients, was determined to be 13.3%, while in Group 2, it was found to be 5%. A statistically significant difference in complication rates was found (p-value 0.041), suggesting that the surgical technique or treatment method affected the risk of complications in Group 1 (\u003cstrong\u003eTable 3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eThe reoperation rate was low in both groups (1.7%), with only one patient from each group requiring reoperation. In Group 1, one patient required reoperation due to plate loosening, whereas in Group 2, one patient underwent revision with corpectomy and mesh cage placement due to 3.5 mm subsidence and non-union. The p-value (p = 0.885) indicated no significant difference between the groups in terms of reoperation rates, showing that the treatment methods did not differ in this respect.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFluoroscopy times were significantly longer in Group 1 compared to Group 2 (p \u0026lt; 0.001), reflecting the additional imaging required for accurate placement of plates and screws. Similarly, surgery times were longer in Group 1 (p \u0026lt; 0.001), emphasizing the influence of surgical techniques on procedure duration.\u003c/p\u003e\n\u003cp\u003eEstimated blood loss, drainage volume, drain duration, and drain index were significantly higher in Group 1 compared to Group 2 (p \u0026lt; 0.001), reflecting differences in surgical techniques. Fusion time was also significantly longer in Group 1 (p = 0.007), underscoring the influence of surgical methods on healing duration.\u003c/p\u003e\n\u003cp\u003eNo significant difference in smoking habits was identified between the groups (p = 0.313), indicating no association between smoking and treatment outcomes or surgical procedures. While no definitive link was found between smoking levels and subsidence, smoking significantly prolonged fusion time (p \u0026lt; 0.001). A trend was observed linking higher smoking levels to increased complication rates (p = 0.057), though it did not reach statistical significance. Interestingly, more complications were noted among non-smokers, but this relationship was not statistically significant. Notably, all reoperations occurred in patients with high smoking levels (30 or 40 smokers), suggesting a correlation between heavy smoking and the need for reoperation.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eACDF is widely regarded as the gold standard for treating cervical spondylopathy. This procedure effectively removes compressive elements such as herniated discs and osteophytes while simultaneously restoring the natural cervical curvature [10]. Additionally, the use of anterior cervical plating provides enhanced spinal stability and reduces the risk of pseudarthrosis [11-13]. Nevertheless, complications related to plating remain a significant concern, with their incidence increasing in proportion to the number of segments fused [12, 14]. To address these issues, self-anchored, stand-alone cages with a zero-profile design have been developed. These innovations aim to minimize plate-related complications and reduce operative time. Furthermore, anchored micro-plates have been proposed to deliver stability comparable to that achieved with traditional anterior plates and screws [15].\u003c/p\u003e\n\u003cp\u003eBy retrospectively analyzing two-level ACDF procedures, we compared the use of stand-alone cages (without plates) to anterior plate use in terms of complications, fusion success, and patient satisfaction. Our findings contribute to the ongoing debate about the optimal surgical approach for multi-level cervical disc herniation surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgery Duration and Blood Loss\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe technical complexity of plate placement results in longer surgery and fluoroscopy times. A study reported that the use of a plate significantly increases operation duration [16]. Similarly, another study demonstrated greater intraoperative blood loss in cases involving plate use [17]. These findings underscore the importance of preoperative planning, especially for patients with additional morbidity risks. Our study also found that surgery duration, blood loss, and fluoroscopy times were significantly higher in the plate group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient-Reported Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth groups showed significant improvements in VAS and NDI scores postoperatively, confirming the overall effectiveness of ACDF in reducing pain and disability. This demonstrates ACDF\u0026rsquo;s efficacy as a surgical method for relieving pain and restoring function. A study reported that generally positive patient-reported outcomes despite higher complication rates [18]. In another study it was emphasized in their systematic review that both plated and non-plated procedures yield similar clinical outcomes [3]. However, patients in the stand-alone cage group may have experienced a faster reduction in pain due to less surgical trauma and a lower incidence of postoperative dysphagia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImpact of Smoking on Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe impact of smoking on surgical outcomes remains significant. Our study found that high smoking consumption prolonged fusion times, consistent with findings by Lee et al. [5]. Some studies have also reported that smoking slows bone healing and increases the risk of pseudoarthrosis [18, 19]. Therefore, implementing preoperative smoking cessation programs and informing patients about the effects of smoking before surgery is crucial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubsidence and Cervical Alignment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubsidence continues to be a concern with stand-alone cage constructs. Cage subsidence has emerged as a critical complication since the clinical introduction of stand-alone cages. Previous studies have reported a wide range of subsidence rates, from 0% to 61% in ACDF procedures using stand-alone cages similar to those applied in this research [1, 15, 20-23]. A study conducted a review involving 16 patients who underwent skip-level ACDF at 32 noncontiguous levels using self-locking stand-alone PEEK cages [22]. Their findings indicated that three cages (3/32) in two patients (2/16) experienced subsidence. In a separate retrospective analysis, Zhou et al. [21] assessed outcomes in 15 patients undergoing 3-level ACDF with self-locking stand-alone cages, reporting subsidence in four cages across three patients. While the subsidence rate per level was comparable between these studies, the subsidence rate per patient increased with a greater number of fused segments. Additionally, it was found that all three patients who experienced subsidence were older women, suggesting that lower bone mineral density might be a significant factor contributing to subsidence. Other contributing factors include end plate damage, excessive segmental distraction, or the use of oversized cages [23, 24].\u003c/p\u003e\n\u003cp\u003eSubsidence is often observed within the first three months postoperatively, as bone fusion occurring by that time may inhibit further subsidence progression [25, 26]. In a study it was highlighted that subsidence could lead to the loss of cervical lordosis and potential long-term complications [1]. In our study, meticulous preparation of the end plates minimized this risk; however, more extensive studies are needed to evaluate long-term effects.\u003c/p\u003e\n\u003cp\u003eIn our study, no cases of subsidence greater than 1.5 mm were recorded in Group 1, with an average subsidence measurement of 0.43 mm. In contrast, Group 2 exhibited eight cases of subsidence more than 1.5 mm, with an average of 1.26 mm. The overall average subsidence was 0.89 mm. These results indicate a significantly lower subsidence in Group 1, potentially reflecting more efficient load distribution and decreased contact stress at the graft-bone interfaces in this group. Our findings indicate that cage design and surgical technique play a critical role in reducing subsidence risk. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications and Fusion Rates\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur data showed higher complication rates in the plated group (13.3%) compared to the stand-alone cage group, consistent with existing literature. Complications such as dysphagia, hardware-related issues, and adjacent segment degeneration are more commonly associated with the use of anterior cervical plates. The mechanical pressure exerted by plates and screws, along with their interference with surrounding anatomical structures, is thought to be a primary cause of these complications. It was reported that identified higher rates of complications and the need for surgical revisions in patients undergoing multi-level ACDF with plate constructs [19]. Similarly, another study reported plate-related issues, including dysphagia and adjacent segment disease [27]. In contrast, the stand-alone approach helps mitigate the risk of plate-related complications but is associated with a higher incidence of cage subsidence. For instance, it was documented increased subsidence rates in non-plated constructs [28].\u003c/p\u003e\n\u003cp\u003eDysphagia remains a prevalent complication after anterior cervical spine surgery, especially in multi-level ACDF cases [29-31]. Although the exact pathogenesis is not fully understood, some studies suggest that the zero-profile design of stand-alone cages can decrease the long-term incidence of dysphagia by reducing implant irritation to the esophagus [12, 30]. The shorter operative time and reduced blood loss observed with self-locking stand-alone cages are thought to result in less traction and decreased prevertebral soft tissue damage, which may contribute to lower dysphagia rates. Nevertheless, this benefit appears limited, as evidence shows that dysphagia rates generally decline within six months postoperatively, with only a small number of patients experiencing moderate or severe symptoms beyond this period, even when anterior plates are utilized [12, 30]. In our study, only one patient in plate group experienced mild dysphagia at the final follow-up.\u003c/p\u003e\n\u003cp\u003eAdditionally, some researchers suggest that postoperative dysphagia could result from direct trauma to the esophagus and surrounding tissues during surgery [12, 31]. The use of self-locking stand-alone cages simplifies the surgical process by minimizing the need for extensive esophageal retraction. A researcher demonstrated that zero-profile stand-alone cages were associated with a significantly lower risk of dysphagia (0 out of 30 patients) at three months postoperatively compared to anterior plate use (9 out of 33 patients) [15]. Consistently, our findings revealed a lower dysphagia rate in stand-alone cage group compared to plate group across all time points, though this difference did not reach statistical significance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis integration provides a comprehensive analysis of the complications associated with ACDF techniques, underscoring the trade-offs between the use of anterior plates and stand-alone cages in terms of dysphagia, stability, and the risk of subsidence.\u003c/p\u003e\n\u003cp\u003eDespite the complications, anterior plate use offered better fusion outcomes. It was demonstrated that plates reduce cage subsidence and maintain cervical lordosis, improving long-term results [1]. Similarly, a researcher found that plate use enhances fusion rates and neck pain scores [3]. Some other researchers also emphasized the role of plates in enhancing segmental lordosis and stability, promoting fusion [2, 4]. It was noted that while both methods are effective for pain management, plate use better preserves structural integrity in the long term [32]. Although fusion time was longer in the stand-alone group (6.21 months), this did not significantly affect overall patient outcomes. Both groups had satisfactory fusion rates, but the plated group had more stable fusion with reduced segmental motion, as supported by Nabhan et al. [33]. A study suggested the use of zero-profile spacers as a less invasive alternative to minimize complications associated with plate use [6]. Such innovative approaches may guide future surgical advancements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations and Future Research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe retrospective design and limited sample size of our study present some limitations. Prospective, randomized controlled trials are needed to confirm these findings. Further comparative studies on cost-effectiveness and long-term clinical outcomes will help inform surgical decision-making.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study has certain limitations, including the challenges associated with accurately assessing bone fusion using plain radiographs and the impracticality of performing CT scans on every patient. As a result, the potential for measurement errors must be considered in our analysis. Additionally, anatomical differences and surgical techniques among patients could be potential sources of bias. Furthermore, this research did not investigate the relationship between bone mineral density and cage subsidence, nor did it examine changes in the biomechanics of the cervical spine following these two surgical procedures. The retrospective nature of our study, along with the limited sample size and relatively short follow-up duration, also presents constraints. Therefore, further well-designed, randomized, multicenter prospective studies with extended follow-up periods are necessary to validate these findings.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOur study highlights that both stand-alone cages and anterior plate fixation have distinct advantages and disadvantages. While the use of anterior plates provides greater fusion stability, it is associated with higher complication rates, including prolonged operative duration, increased blood loss, and extended fluoroscopy time. In contrast, the stand-alone approach is less invasive, resulting in shorter surgery and reduced intraoperative blood loss, though it carries a higher risk of cage subsidence. Therefore, the choice of surgical technique should be carefully tailored to the patient\u0026rsquo;s specific anatomical characteristics and lifestyle factors to optimize outcomes and minimize complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of interest:\u003c/h2\u003e\n\u003cp\u003eOn behalf of all authors, the corresponding author states that there is no conflict of interest.\u003c/p\u003e\n\u003ch2\u003eEthical Approval:\u003c/h2\u003e\n\u003cp\u003eIRB was subsequently obtained (decision number: KSYLEAH-KAEK 2024/81).\u003c/p\u003e\n\u003ch2\u003eInformed Consent:\u003c/h2\u003e\n\u003cp\u003eInformed consent was obtained from patients.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eNo funding was received in relationship with this study\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eCS: Data acquisition, investigation, writing \u0026ndash; original draft review \u0026amp; editing, data analysis, methodology, project administration.BEK: Writing-review \u0026amp; editing, data analysis, project administrationAOA, TB: Methodology, data analysisAK, AM: Data acquisition, visualization, project administration\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChen Y, L\u0026uuml; G, Wang B, Li L, Kuang L. A comparison of anterior cervical discectomy and fusion (ACDF) using self-locking stand-alone polyetheretherketone (PEEK) cage with ACDF using cage and plate in the treatment of three-level cervical degenerative spondylopathy: a retrospective study with 2-year follow-up. Eur Spine J. 2016 Jul;25(7):2255-62. \u003c/li\u003e\n\u003cli\u003eKim CH, Chung CK, Hahn S. Autologous iliac bone graft with anterior plating is advantageous over the stand alone cage for segmental lordosis in single-level cervical disc disease. Neurosurgery 2013;72:257\u0026ndash;65; discussion 266.\u003c/li\u003e\n\u003cli\u003eOliver JD, Goncalves S, Kerezoudis P, Alvi MA, Freedman BA, Nassr A, Bydon M. Comparison of Outcomes for Anterior Cervical Discectomy and Fusion With and Without Anterior Plate Fixation: A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2018;1;43(7):E413-E422. \u003c/li\u003e\n\u003cli\u003eKwon W-K, Kim PS, Ahn SY, Song JY, Kim JH, Park Y-K, et al. Analysis of Associating Factors With C2-7 Sagittal Vertical Axis After Two-level Anterior Cervical Fusion: Comparison Between Plate Augmentation and Stand-alone Cages. Spine 2017;42:318\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003eLee SE, Chung CK, Kim CH. Difference in canal encroachment by the fusion mass between anterior cervical discectomy and fusion with bone autograft and anterior plating, and stand-alone cage. J ClinNeurosci 2016;29:121-7.\u003c/li\u003e\n\u003cli\u003eShi S, Zheng S, Li X-F, Yang L-L, Liu Z-D, Yuan W. Comparison of a Stand-Alone Anchored Spacer Versus Plate-Cage Construct in the Treatment of Two Noncontiguous Levels of Cervical Spondylosis: A Preliminary Investigation. World Neurosurg 2016;89:285-92.\u003c/li\u003e\n\u003cli\u003eTabaraee E, Ahn J, Bohl DD, Collins MJ, Massel DH, Aboushaala K, et al. Comparison of Surgical Outcomes, Narcotics Utilization, and Costs After an Anterior Cervical Discectomy and Fusion: Stand-alone Cage Versus Anterior Plating. Clin Spine Surg 2017;30(9):E1201-E1205\u003c/li\u003e\n\u003cli\u003eYu Q, Chen J, Wang H, Ma L. An analysis of different modalities of Bone Mineral Densitometry evaluation in cage subsidence in anterior cervical discectomy and fusion. Frontiers in Surgery 2024;11:1472080.\u003c/li\u003e\n\u003cli\u003eBenDebba M, Heller J, Ducker TB, Eisinger JM. Cervical spine out comes questionnaire: its development and psychometric properties. Spine 2002;27:2116\u0026ndash;23.\u003c/li\u003e\n\u003cli\u003eLi J, Wu Y, Liu H, Guo C, Zhang J, Huang K,Rong, X. Does Two-level Hybrid Surgery Promote Early Fusion Compared with Two-level Anterior Cervical Discectomy and Fusion?. The Spine Journal 2024;18:S1529-9430(24)01230-0.\u003c/li\u003e\n\u003cli\u003eSong KJ, Taghavi CE, Lee KB, Song JH, Eun JP. The efficacy of plate construct augmentation versus cage alone in anterior cervical fusion. Spine (Phila Pa 1976). 2009;15;34(26):2886-92. \u003c/li\u003e\n\u003cli\u003eYang L, Gu Y, Liang L, Gao R, Shi S, Shi J, Yuan W. Stand-alone anchored spacer versus anterior plate for multilevel anterior cervical diskectomy and fusion. Orthopedics 2012;35:e1503-e1510 \u003c/li\u003e\n\u003cli\u003eZhang Y, Jidong J, Jinchun W. Long-term effectiveness of stand-alone anchored spacer in multilevel anterior cervical discectomy and fusion compared with cage-plate system: a systematic review and meta-analysis.\u0026quot; European Spine Journal 2024;1-13.\u003c/li\u003e\n\u003cli\u003eNing X, Wen Y, Xiao-Jian Y, Bin N, De-Yu C, Jian-Ru X, Lian Shun J. Anterior cervical locking plate-related complica tions; prevention and treatment recommendations. Int Orthop 2008;32:649-655\u003c/li\u003e\n\u003cli\u003eWang Z, Jiang W, Li X, Wang H, Shi J, Chen J, Meng B, Yang H. The application of zero-profile anchored spacer in anterior cervical discectomy and fusion. Eur Spine J (2015) 24:148\u0026ndash;154\u003c/li\u003e\n\u003cli\u003eArshi A, Wang C, Park HY, Blumstein GW, Buser Z, Wang JC, Shamie AN, Park DY. Ambulatory anterior cervical discectomy and fusion is associated with a higher risk of revision surgery and perioperative complications: an analysis of a large nationwide database. Spine J. 2018 Jul;18(7):1180-1187. \u003c/li\u003e\n\u003cli\u003eGerdhem, L., Vlachogiannis, P., Gerdhem, P., \u0026amp; MacDowall, A. Cage only or Cage with plate fixation in Anterior Cervical Discectomy and Fusion surgery-Analysis of a national multicenter dataset. The Spine Journal 2024;9;S1529-9430(24)01190-2. \u003c/li\u003e\n\u003cli\u003eMullins J, Pojskić M, Boop FA, Arnautović KI. Retrospective single-surgeon study of 1123 consecutive cases of anterior cervical discectomy and fusion: a comparison of clinical outcome parameters, complication rates, and costs between outpatient and inpatient surgery groups, with a literature review. J Neurosurg Spine. 2018;28(6):630-641. \u003c/li\u003e\n\u003cli\u003eVeeravagu A, Cole T, Jiang B, Ratliff JK. Revision rates and complication incidence in single- and multilevel anterior cervical discectomy and fusion procedures: an administrative database study. Spine J. 2014;14(7):1125-31. \u003c/li\u003e\n\u003cli\u003eGrasso G, Giambartino F, Tomasello G, Iacopino G. Anterior cervical discectomy and fusion with roi-c peek cage: cervical alignment and patient outcomes. Eur Spine J 2014;23:650-657.\u003c/li\u003e\n\u003cli\u003eZhou J, Li X, Dong J, Zhou X, Fang T, Lin H, Ma Y. Three-level anterior cervical discectomy and fusion with self locking stand-alone polyetheretherketone cages. J Clin Neurosci 2011;18:1505-1509.\u003c/li\u003e\n\u003cli\u003eWang HR, Li XL, Dong J, Yuan FL, Zhou J. Skip-level anterior cervical discectomy and fusion with self-locking stand alone peek cages for the treatment of 2 noncontiguous levels of cervical spondylosis. J Spinal Disord Tech 2013;28:E286\u0026ndash;E292\u003c/li\u003e\n\u003cli\u003eKim CH, Chung CK, Jahng T, Park SB, Sohn S, Lee S. Segmental kyphosis after cervical interbody fusion with stand alone polyetheretherketone (peek) cages. J Spinal Disord Tech 2015;28:E17\u0026ndash;E24\u003c/li\u003e\n\u003cli\u003eKao T, Wu C, Chou Y, Chen H, Chen W, Tsou H. Risk factors for subsidence in anterior cervical fusion with stand-alone polyetheretherketone (peek) cages: a review of 82 cases and 182 levels. Arch Orthop Traum Su 2014;134:1343-1351.\u003c/li\u003e\n\u003cli\u003eZhang B, Kong Q, Feng P, Liu J, Ma J. Does Bone Preservation at the Anterior Edge of the Vertebral Body Affect the Subsidence of Zero-Profile Cages After Anterior Cervical Discectomy and Fusion? World Neurosurgery. 2024;12(5):S1878-8750(24)01917-X.\u003c/li\u003e\n\u003cli\u003eFujibayashi S, Neo M, Nakamura T. Stand-alone interbody cage versus anterior cervical plate for treatment of cervical disc herniation: sequential changes in cage subsidence. J Clin Neu rosci 2008;15:1017-1022\u003c/li\u003e\n\u003cli\u003eTasiou A, Giannis T, Brotis AG, Siasios I, Georgiadis I, Gatos H, Tsianaka E, Vagkopoulos K, Paterakis K, Fountas KN. Anterior cervical spine surgery-associated complications in a retrospective case-control study. J Spine Surg. 2017;3(3):444-459. \u003c/li\u003e\n\u003cli\u003ePinder EM, Sharp DJ. Cage subsidence after anterior cervical discectomy and fusion using a cage alone or combined with anterior plate fixation. J OrthopSurg 2016;24:97-100.\u003c/li\u003e\n\u003cli\u003eCharalampidis A, Hejrati N, Ramakonar H, Kalsi PS, Massicotte EM, Fehlings MG. Clinical outcomes and revision rates following four-level anterior cervical discectomy and fusion. Scientific Reports, 2022;12(1): 5339\u003c/li\u003e\n\u003cli\u003eWang Z, Zhu R, Yang H, Gan M, Zhang S, Shen M, Chen C, Yuan Q. The application of a zero-profile implant in anterior cervical discectomy and fusion. J Clin Neurosci 2014;21:462\u0026ndash;466\u003c/li\u003e\n\u003cli\u003eSon DK, Son DW, Kim HS, Sung SK, Lee SW, Song GS. Comparative study of clinical and radiological outcomes of a zero-profile device concerning reduced postoperative dysphagia after single level anterior cervical discectomy and fusion. J Korean Neurosurg S 2014;56:103\u003c/li\u003e\n\u003cli\u003eZou S, Gao J, Xu B, Lu X, Han Y, Meng H. Anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty (CDA) for two contiguous levels cervical disc degenerative disease: a meta-analysis of randomized controlled trials. Eur Spine J. 2017;26(4):985-997. \u003c/li\u003e\n\u003cli\u003eGhobrial B, Price A, Pretorius J, Elkhwad H. Clinical and Radiological Outcomes of Anchored Stand-Alone Cage Compared to Conventional Plating in Multilevel Anterior Cervical Discectomy and Fusion: A Systematic Review. Cureus, 2024;16(10):e72386.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Complications and revisions of the groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eComplications and Revisions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrup 1 (n:27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGrup 2 (n:33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003eToplam (n:60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eHematoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003en: 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eDysphagia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003en: 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eDural penetration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eNeurological deficit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eAdjacent intervertebral disc degeneration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003en: 4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eSubsidence (\u0026gt;1.5 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 0\u003c/p\u003e\n \u003cp\u003e(mean: 0,43 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 8\u003c/p\u003e\n \u003cp\u003e(mean: 1,26 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003en: 8\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(mean: 0,89 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eReoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en: 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003en: 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cervical disc herniation, cervical discectomy, anterior cervical discectomy, stand-alone cage fixation, cage and plate fixation, hernia grading system","lastPublishedDoi":"10.21203/rs.3.rs-5716561/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5716561/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eThis study aims to compare the outcomes of two-level anterior cervical discectomy and fusion (ACDF) procedures using stand-alone cages versus cage and plate fixation in patients diagnosed with cervical disc herniation (CDH).\u003c/p\u003e\u003ch2\u003eMaterials and Methods:\u003c/h2\u003e \u003cp\u003eThis retrospective analysis included 60 patients who underwent two-level ACDF procedures. Patients were divided into two groups: one treated with stand-alone cages and the other with cage and plate fixation. Data on surgical duration, blood loss, fusion stability, and complication rates were collected. Clinical outcomes, including neck pain and functional status, were assessed using standard scoring systems.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003ePlate fixation provided superior fusion stability but was associated with longer surgery durations, higher intraoperative blood loss, and increased complication rates. Stand-alone cages reduced intraoperative trauma but demonstrated higher subsidence rates and prolonged fusion times. Both techniques resulted in significant improvements in neck pain and disability scores.\u003c/p\u003e\u003ch2\u003eDiscussion:\u003c/h2\u003e \u003cp\u003eWhile both approaches are effective for managing cervical disc herniation, each has distinct advantages and limitations. Selecting the most appropriate technique based on patient-specific anatomical and clinical considerations is crucial to optimizing surgical outcomes.\u003c/p\u003e","manuscriptTitle":"Comparative Study of Two-level Cervical Disc Herniation: Anterior Cervical Discectomy and Fusion (Acdf) Using Stand-alone Titanium Cage Versus Cage and Plate Fixation - a Retrospective Analysis of Complication Rates and Patient Satisfaction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-30 16:40:23","doi":"10.21203/rs.3.rs-5716561/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-13T23:38:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-08T16:59:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-04T15:19:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181727795607522777557016956757012107845","date":"2025-01-02T06:55:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291133078536106642524532766524862352636","date":"2024-12-30T21:10:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229424997939539443431181805739435783830","date":"2024-12-30T19:40:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-12-28T04:29:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-12-28T02:54:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-12-27T12:23:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2024-12-26T13:42:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4bbdef27-3dd2-4441-aa2a-a752ed24b47f","owner":[],"postedDate":"December 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T16:04:12+00:00","versionOfRecord":{"articleIdentity":"rs-5716561","link":"https://doi.org/10.1186/s13018-025-05654-x","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2025-03-10 15:58:16","publishedOnDateReadable":"March 10th, 2025"},"versionCreatedAt":"2024-12-30 16:40:23","video":"","vorDoi":"10.1186/s13018-025-05654-x","vorDoiUrl":"https://doi.org/10.1186/s13018-025-05654-x","workflowStages":[]},"version":"v1","identity":"rs-5716561","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5716561","identity":"rs-5716561","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}