Comparison of Outcomes for Anterior Cervical Discectomy and Fusion With and Without Anterior Plate Fixation

A Systematic Review and Meta-analysis

Jeremie D. Oliver, BS; Sandy Goncalves, MS; Panagiotis Kerezoudis, MD; Mohammed Ali Alvi, MD; Brett A. Freedman, MD; Ahmad Nassr, MD; Mohamad Bydon, MD


Spine. 2018;43(7):E413-E422. 

In This Article

Abstract and Introduction


Study Design. Systematic review and meta-analysis.

Objective. To compare postoperative surgical, radiographic, and patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) with and without plate fixation.

Summary of Background Data. ACDF has evolved significantly over the years, including the placement of an anterior plate construct. Although promoting bony osseo-integration at the fusion site, there are a number of plate-related complications that can arise. The non-plating approach is less invasive, however, greater rates of cage subsidence have been associated with this model.

Methods. We performed an electronic literature search for human studies that directly compared ACDF with and without anterior plate fixation. Outcomes of interest comprised of postoperative dysphagia, fusion success, and cage subsidence as well as patient reported outcomes, including the Neck Disability Index (NDI) scores and Visual Analog Scale (VAS) for both neck and arm pain.

Results. A total of 15 studies (12 observational and 3 randomized controlled trials) and 893 patients (57% males) were included. Overall, ACDF with plate fixation was associated with significantly higher vertebral fusion rates (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.16–3.37), lower subsidence rates (odds ratio [OR] 0.31, 95% CI 0.18–0.52), and more favorable VAS-neck pain scores at last follow-up (mean difference [MD] 0.59, 95% CI -0.78 to -0.41). Conversely, ACDF procedures without plate fixation had marginally better long-term VAS-arm pain scores (mean difference [MD] 0.2, 95% CI 0.04–0.36). No difference was found with regards to dysphagia (OR 1.21, 95% CI, 0.57–2.56) and NDI (MD 0.06, 95% C.I -0.54 to 0.42).

Conclusion. Available evidence, although limited, suggests superior surgical outcomes in ACDF procedures with anterior plate fixation (increased fusion, decreased subsidence) and slightly better VAS-neck pain scores at last follow-up. Future longitudinal, multicenter randomized controlled trials should be completed to validate any associations found in this study.

Level of Evidence: 3


Anterior cervical discectomy and fusion (ACDF) is the most commonly performed cervical spine procedure in the United States with over 90,000 ACDF patients identified between 2006 and 2010.[1] Since its inception and adoption into clinical practice, the procedure has evolved to include the placement of an anterior plate construct (ACDF-P); a technique that encourages immediate stability and cervical lordosis, while promoting osseointegration and preventing cage subsidence.[2] This technique is nevertheless associated with plate-related complications including postoperative dysphagia, screw breakage and pullout, and screw-plate migration.[3] Conversely, although a non-plated approach (ACDF-NP) is known to be less-invasive and does not require vertebral screw fixation, it comes at the expense of increased risk of cage subsidence and pseudarthrosis.[4,5] Recent literature has reached equivocal results with regards to the superiority of anterior plate fixation over stand-alone cage placement.[6] In light of these findings, we reviewed all available evidence comparing the two procedures in terms of postoperative surgical, clinical, radiographic, and patient reported outcomes.