Comparison of Cost and Perioperative Outcome Profiles for Primary and Revision Posterior Cervical Fusion Procedures

Michael L. Martini, PhD; Rebecca B. Baron, BS; Jonathan S. Gal, MD; Sean N. Neifert, BS; William H. Shuman, BA; Alexander J. Schupper, MD; Emily K. Chapman, BS; Ian T. McNeill, MD; Jeremy Steinberger, MD; John M. Caridi, MD


Spine. 2021;46(19):1295-1301. 

In This Article

Abstract and Introduction


Study Design: Retrospective analysis.

Objective: To compare perioperative outcomes and hospitalization costs between patients undergoing primary or revision posterior cervical discectomy and fusion (PCDF).

Summary of Background Data: While prior studies found differences in outcomes between primary and revision anterior cervical discectomy and fusion (ACDF), risk, and outcome profiles for posterior cervical revision procedures have not yet been elucidated.

Methods: Institutional records were queried for cases involving isolated PCDF procedures to evaluate preoperative characteristics and outcomes for patients undergoing primary versus revision PCDF between 2008 and 2016. The primary outcome was perioperative complications, while perioperative and resource utilization measures such as hospitalization length, required stay in the intensive care unit (ICU), direct hospitalization costs, and 30-day emergency department (ED) admissions were explored as secondary outcomes.

Results: One thousand one hundred twenty four patients underwent PCDF, with 218 (19.4%) undergoing a revision procedure. Patients undergoing revision procedures were younger (53.0 vs. 60.5 yrs), but had higher Elixhauser scores compared with the non-revision cohort. Revision cases tended to involve fewer spinal segments (3.6 vs. 4.1 segments) and shorter surgical durations (179.3 vs. 206.3 min), without significant differences in estimated blood loss. There were no significant differences in the overall complication rates (P = 0.20), however, the primary cohort had greater rates of required ICU stays (P = 0.0005) and non-home discharges (P = 0.0003). The revision cohort did experience significantly increased odds of 30-day ED admission (P = 0.04) and had higher direct hospitalization (P = 0.03) and surgical (P < 0.0001) costs.

Conclusion: Complication rates, including incidental durotomy, were similar between primary and revision PCDF cohorts. Although prior surgery status did not predict complication risk, comorbidity burden did. Nevertheless, patients undergoing revision procedures had decreased risk of required ICU stay but greater risk of 30-day ED admission and higher direct hospitalization and surgical costs.

Level of Evidence: 3


Posterior cervical discectomy and fusion (PCDF) is performed for a range of cervical spinal pathologies, including spondylosis, spinal stenosis, and myelopathy.[1] Despite the efficacy of these procedures in treating these conditions, revision cervical procedures may be indicated for a number of reasons, including infection, hardware failure, adjacent segment disease, disease recurrence, and pseudarthrosis.[2–5] Although the rates of revision cervical procedures may be high, they vary considerably by procedure type and the extent of the original surgery. In general, posteriorly approached procedures appear to have higher revision rates than corresponding procedures approached anteriorly, and laminectomy and fusion procedures tend to have among the highest revision rates across procedure types.[3] As such, posteriorly approached fusion procedures have among the highest reported revision rates in cervical spine surgery, ranging from 2% to 27% at 41 months.[6,7] Furthermore, while rates of cervical spine surgery in the United States have increased over two decades,[8–10] recent studies have suggested that growth in the rate of revision cervical procedures is actually outpacing growth of primary cervical fusions.[10] Together, these trends suggest that revision surgery in patients who underwent posterior cervical fusions is an important topic of investigation.

To date, very few studies have examined the risk and outcome profiles of revision surgery specifically in the cervical spine. In one study focusing on anteriorly approached cervical discectomy and fusion (ACDF) procedures, revision surgeries led to significantly increased rates of adverse outcomes, including thrombotic events, surgical site infections, and 30-day readmissions.[11] Thus, while literature exists comparing patient outcomes for primary and revision ACDF procedures, no study has made these comparisons for PCDF procedures. Therefore, the aim of the present study was to address this deficit in the literature by comparing perioperative outcomes and cost for patients undergoing revision PCDF procedures to those of patients who have not had a previous cervical procedure using retrospectively acquired data from cases performed at a large urban medical center in the United States.