{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T04:58:31Z","timestamp":1785214711585,"version":"3.55.0"},"reference-count":35,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"4","license":[{"start":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T00:00:00Z","timestamp":1782864000000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,7]]},"abstract":"ABSTRACT<\/jats:title>\n \n Background:<\/jats:title>\n In multilevel disease, the risks and benefits of performing anterior versus posterior surgical approaches to the cervical spine remain debated. We sought to evaluate the radiographic and clinical outcomes of patients with multilevel cervical spondylotic myelopathy (CSM) treated with four- and five-level anterior cervical discectomy and fusion (ACDF), using tricortical iliac crest autograft and anterior plate fixation.<\/jats:p>\n <\/jats:sec>\n \n Materials and Methods:<\/jats:title>\n Between 2009 and 2021, 1428 patients who underwent cervical fusion were reviewed. Inclusion required four- or five-level ACDF fusion with a 2-year clinical follow-up. Exclusions required fusions <4 levels; corpectomies; additional posterior fixation; and surgeries for infection, trauma, or malignancy. Demographics, preoperative and postoperative Nurick grades, Visual Analog Scale (VAS) pain scores, radiographic alignment (C2\u2013C7 Cobb angle, T1 slope [T1S]), and fusion status were collected. Postoperative complications were categorized as early (0\u20133 months), intermediate (3\u201312 months), and late (13\u201324 months).<\/jats:p>\n <\/jats:sec>\n \n Results:<\/jats:title>\n \n Twenty-seven patients (63% of males), age 59.7 \u00b1 8.6 years, were included. Twenty-two patients underwent four-level and 5 underwent five-level ACDF. Significant improvements were observed in Nurick grade (2.78\u20131.15,\n P<\/jats:italic>\n < 0.001), VAS score for neck and arm pain (both\n P<\/jats:italic>\n < 0.001), Cobb angle (8.45\u00b0\u201313.39\u00b0,\n P<\/jats:italic>\n = 0.001), and T1S (28.81\u00b0\u201332.36\u00b0,\n P<\/jats:italic>\n < 0.001). Dysphagia was the most common early complication (29.6%), decreasing to 7.4% at late follow-up. Three patients (11.1%) developed adjacent segment disease. All patients achieved radiographic fusion.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion:<\/jats:title>\n Four- and five-level ACDF with tricortical iliac crest autograft yields excellent clinical and radiographic outcomes in patients with multilevel CSM, with high fusion rates and low complication profile over a 2-year follow-up.<\/jats:p>\n <\/jats:sec>\n \n Level of evidence:<\/jats:title>\n IV (retrospective case series).<\/jats:p>\n <\/jats:sec>","DOI":"10.4103\/jcvjs.jcvjs_24_26","type":"journal-article","created":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T12:00:20Z","timestamp":1784894420000},"page":"367-373","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Four- and five-level anterior cervical discectomy and fusion with iliac crest autologous bone graft and plate\u2013screw fixation: Radiographic and clinical outcomes with minimum 2-year follow-up"],"prefix":"10.4103","volume":"17","author":[{"given":"Tony","family":"Tannoury","sequence":"first","affiliation":[{"name":"Department of Orthopedic Surgery, Boston Medical Center, Boston, MA, USA"},{"name":"Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hayley","family":"Denwood","sequence":"additional","affiliation":[{"name":"NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sung Jun","family":"Son","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Los Angeles County-Harbor-UCLA Medical Center, Torrance, CA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Megan","family":"Berube","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Boston Medical Center, Boston, MA, USA"},{"name":"Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rehan R.","family":"Khan","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Boston Medical Center, Boston, MA, USA"},{"name":"Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daman P.","family":"Dhunna","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Boston Medical Center, Boston, MA, USA"},{"name":"Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeongeun","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Boston Medical Center, Boston, MA, USA"},{"name":"Liberty University College of Osteopathic Medicine, Lynchburg, VA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yifei","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Boston Medical Center, Boston, MA, USA"},{"name":"Department of Orthopedic Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chadi","family":"Tannoury","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Boston Medical Center, Boston, MA, USA"},{"name":"Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,7,24]]},"reference":[{"key":"R1-20260728","doi-asserted-by":"crossref","first-page":"386","DOI":"10.14245\/ns.1938240.120","article-title":"Cervical spondylotic myelopathy: Natural course and the value of diagnostic techniques -WFNS spine committee recommendations","volume":"16","author":"Zileli","year":"2019","journal-title":"Neurospine"},{"issue":"Suppl 4","key":"R2-20260728","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1227\/NEU.0000000000000953","article-title":"The aging of the global population: The changing epidemiology of disease and spinal disorders","volume":"77","author":"Fehlings","year":"2015","journal-title":"Neurosurgery"},{"key":"R3-20260728","doi-asserted-by":"crossref","first-page":"20","DOI":"10.5312\/wjo.v7.i1.20","article-title":"Mechanical and cellular processes driving cervical myelopathy","volume":"7","author":"Dolan","year":"2016","journal-title":"World J Orthop"},{"key":"R4-20260728","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1016\/j.surneu.2008.02.045","article-title":"National trends in spinal fusion for cervical spondylotic myelopathy","volume":"71","author":"Lad","year":"2009","journal-title":"Surg Neurol"},{"key":"R5-20260728","first-page":"e3146","article-title":"Anterior techniques in managing cervical disc disease","volume":"10","author":"Kim","year":"2018","journal-title":"Cureus"},{"key":"R6-20260728","doi-asserted-by":"crossref","first-page":"E82","DOI":"10.1097\/BRS.0000000000002770","article-title":"Quantitative risk factor analysis of postoperative dysphagia after anterior cervical discectomy and fusion (ACDF) using the eating assessment tool-10 (EAT-10)","volume":"44","author":"Yew","year":"2019","journal-title":"Spine (Phila Pa 1976)"},{"key":"R7-20260728","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1097\/BRS.0000000000002273","article-title":"Anterior cervical discectomy and fusion outcomes over 10 years: A prospective study","volume":"43","author":"Buttermann","year":"2018","journal-title":"Spine (Phila Pa 1976)"},{"key":"R8-20260728","doi-asserted-by":"crossref","first-page":"256","DOI":"10.1007\/BF01322448","article-title":"Cervical radiculopathy: Pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study","volume":"6","author":"Persson","year":"1997","journal-title":"Eur Spine J"},{"key":"R9-20260728","doi-asserted-by":"crossref","first-page":"670","DOI":"10.1097\/00007632-200003150-00004","article-title":"Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review","volume":"25","author":"Sampath","year":"2000","journal-title":"Spine (Phila Pa 1976)"},{"key":"R10-20260728","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1055\/s-0033-1360723","article-title":"Neurologic recovery after anterior cervical discectomy and fusion","volume":"4","author":"Lehmann","year":"2014","journal-title":"Global Spine J"},{"key":"R11-20260728","doi-asserted-by":"crossref","first-page":"E752","DOI":"10.1097\/BRS.0000000000002511","article-title":"Comparing Health-related quality of life outcomes in patients undergoing either primary or revision anterior cervical discectomy and fusion","volume":"43","author":"Schroeder","year":"2018","journal-title":"Spine (Phila Pa 1976)"},{"key":"R12-20260728","doi-asserted-by":"crossref","first-page":"298","DOI":"10.3171\/spi.2007.6.4.2","article-title":"Anterior approaches to fusion of the cervical spine: A metaanalysis of fusion rates","volume":"6","author":"Fraser","year":"2007","journal-title":"J Neurosurg Spine"},{"key":"R13-20260728","doi-asserted-by":"crossref","first-page":"607","DOI":"10.2106\/00004623-195840030-00009","article-title":"The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion","volume":"40-A","author":"Smith","year":"1958","journal-title":"J Bone Joint Surg Am"},{"key":"R14-20260728","doi-asserted-by":"crossref","first-page":"496","DOI":"10.21037\/jss.2018.06.16","article-title":"Outcomes and revision rates following multilevel anterior cervical discectomy and fusion","volume":"4","author":"Laratta","year":"2018","journal-title":"J Spine Surg"},{"key":"R15-20260728","doi-asserted-by":"crossref","first-page":"747","DOI":"10.1097\/BRS.0b013e3181bc3420","article-title":"Pseudarthrosis in multilevel anterior cervical fusion with rhBMP-2 and allograft: Analysis of one hundred twenty-seven cases with minimum two-year follow-up","volume":"35","author":"Shen","year":"2010","journal-title":"Spine (Phila Pa 1976)"},{"key":"R16-20260728","doi-asserted-by":"crossref","first-page":"410","DOI":"10.1097\/00002517-199810000-00008","article-title":"Early failure of long segment anterior cervical plate fixation","volume":"11","author":"Vaccaro","year":"1998","journal-title":"J Spinal Disord"},{"key":"R17-20260728","doi-asserted-by":"crossref","first-page":"1125","DOI":"10.1016\/j.spinee.2013.07.474","article-title":"Revision rates and complication incidence in single- and multilevel anterior cervical discectomy and fusion procedures: An administrative database study","volume":"14","author":"Veeravagu","year":"2014","journal-title":"Spine J"},{"key":"R18-20260728","doi-asserted-by":"crossref","first-page":"776","DOI":"10.1177\/2192568218770763","article-title":"Clinical outcomes after four-level anterior cervical discectomy and fusion","volume":"8","author":"Kreitz","year":"2018","journal-title":"Global Spine J"},{"key":"R19-20260728","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1177\/1602400313","article-title":"Four-level anterior cervical discectomy and fusion for cervical spondylotic myelopathy","volume":"24","author":"Wang","year":"2016","journal-title":"J Orthop Surg (Hong Kong)"},{"key":"R20-20260728","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1016\/j.jocn.2019.12.002","article-title":"Post-operative dysphagia in patients undergoing a four level anterior cervical discectomy and fusion (ACDF)","volume":"72","author":"Ebot","year":"2020","journal-title":"J Clin Neurosci"},{"key":"R21-20260728","doi-asserted-by":"crossref","first-page":"885","DOI":"10.3171\/2015.10.SPINE15795","article-title":"Long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion","volume":"24","author":"De la Garza-Ramos","year":"2016","journal-title":"J Neurosurg Spine"},{"key":"R22-20260728","doi-asserted-by":"crossref","first-page":"639","DOI":"10.1227\/01.NEU.0000367449.60796.94","article-title":"Four-level anterior cervical discectomy and fusion with plate fixation: Radiographic and clinical results","volume":"66","author":"Chang","year":"2010","journal-title":"Neurosurgery"},{"key":"R23-20260728","doi-asserted-by":"crossref","first-page":"2055","DOI":"10.1007\/s00586-007-0398-7","article-title":"4- and 5-level anterior fusions of the cervical spine: Review of literature and clinical results","volume":"16","author":"Koller","year":"2007","journal-title":"Eur Spine J"},{"key":"R24-20260728","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1093\/brain\/95.1.87","article-title":"The pathogenesis of the spinal cord disorder associated with cervical spondylosis","volume":"95","author":"Nurick","year":"1972","journal-title":"Brain"},{"key":"R25-20260728","doi-asserted-by":"crossref","first-page":"557","DOI":"10.2106\/JBJS.M.00167","article-title":"Dynamic radiographic criteria for detecting pseudarthrosis following anterior cervical arthrodesis","volume":"96","author":"Song","year":"2014","journal-title":"J Bone Joint Surg Am"},{"key":"R26-20260728","doi-asserted-by":"crossref","first-page":"1610","DOI":"10.1016\/j.spinee.2022.04.020","article-title":"What is the role of dynamic cervical spine radiographs in predicting pseudarthrosis revision following anterior cervical discectomy and fusion?","volume":"22","author":"Lambrechts","year":"2022","journal-title":"Spine J"},{"key":"R27-20260728","doi-asserted-by":"crossref","first-page":"396","DOI":"10.3171\/jns.1968.29.4.0397","article-title":"Anterior cervical fusion by the smith-robinson approach","volume":"29","author":"Aronson","year":"1968","journal-title":"J Neurosurg"},{"key":"R28-20260728","doi-asserted-by":"crossref","first-page":"530","DOI":"10.1016\/j.wneu.2019.06.144","article-title":"Comparison of anterior cervical decompression and fusion versus laminoplasty in the treatment of multilevel cervical spondylotic myelopathy: A meta-analysis of clinical and radiological outcomes","volume":"130","author":"Montano","year":"2019","journal-title":"World Neurosurg"},{"key":"R29-20260728","doi-asserted-by":"crossref","first-page":"2745","DOI":"10.1007\/s00586-018-5677-y","article-title":"Multi- versus single-level anterior cervical discectomy and fusion: Comparing sagittal alignment, early adjacent segment degeneration, and clinical outcomes","volume":"27","author":"Basques","year":"2018","journal-title":"Eur Spine J"},{"key":"R30-20260728","doi-asserted-by":"crossref","first-page":"1583","DOI":"10.1007\/s00586-013-2817-2","article-title":"Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy: A systemic review and meta-analysis","volume":"22","author":"Zhu","year":"2013","journal-title":"Eur Spine J"},{"key":"R31-20260728","doi-asserted-by":"crossref","first-page":"919","DOI":"10.1093\/neuros\/nyy144","article-title":"Comparison of outcomes following anterior versus posterior fusion surgery for patients with degenerative cervical myelopathy: An analysis from quality outcomes database","volume":"84","author":"Asher","year":"2019","journal-title":"Neurosurgery"},{"key":"R32-20260728","doi-asserted-by":"crossref","first-page":"2016","DOI":"10.1016\/j.spinee.2015.05.010","article-title":"Pseudoarthrosis rates in anterior cervical discectomy and fusion: A meta-analysis","volume":"15","author":"Shriver","year":"2015","journal-title":"Spine J"},{"key":"R33-20260728","doi-asserted-by":"crossref","first-page":"E4","DOI":"10.3171\/2023.6.FOCUS23303","article-title":"Pseudarthrosis after four-level anterior cervical discectomy and fusion without posterior fixation","volume":"55","author":"White","year":"2023","journal-title":"Neurosurg Focus"},{"key":"R34-20260728","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1016\/j.jocn.2018.11.040","article-title":"Fusion rate following three- and four-level ACDF using allograft and segmental instrumentation: A radiographic study","volume":"62","author":"Wewel","year":"2019","journal-title":"J Clin Neurosci"},{"key":"R35-20260728","doi-asserted-by":"crossref","first-page":"70","DOI":"10.3171\/2019.1.SPINE181019","article-title":"Outpatient and inpatient readmission rates of 3- and 4-level anterior cervical discectomy and fusion surgeries","volume":"31","author":"Khalid","year":"2019","journal-title":"J Neurosurg Spine"}],"container-title":["Journal of Craniovertebral Junction and Spine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.lww.com\/10.4103\/jcvjs.jcvjs_24_26","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T04:00:23Z","timestamp":1785211223000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.lww.com\/10.4103\/jcvjs.jcvjs_24_26"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7]]},"references-count":35,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026]]}},"URL":"https:\/\/doi.org\/10.4103\/jcvjs.jcvjs_24_26","relation":{},"ISSN":["0974-8237","0976-9285"],"issn-type":[{"value":"0974-8237","type":"print"},{"value":"0976-9285","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7]]},"assertion":[{"value":"2026-01-19","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-04-23","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}