Introduction: Although anterior cervical discectomy and fusion is a well-established technique for arthrodesis of the cervical spine, there are limited data on the use of allograft with plate in large series. There are even fewer such studies that incorporate three and four level fusions. We report our experience with 252 patients (530 levels).

Methods: 252 patients underwent anterior cervical discectomy and fusion (ACDF) with plate and allograft (91-one level, 74-two levels, 57-three levels, 30-four levels; 530 total levels) via a modified Smith-Robinson technique. Radiographic fusion was determined with plain X-rays at predetermined intervals. Fusion was defined as no lucent line and no hardware failure. Average follow-up was 22.5 months. Average age was 50 years (M 26, F 19). Comorbidities included 58 smokers and 16 diabetics. Patients wore an external orthosis for six weeks.

Results: There were six reoperations for junctional disease outside the original fusion construct. 16 patient developed junctional disease. 28 levels had residual radiographic lucent lines and/or hardware failure at most recent follow-up for a fusion rate of 94.7% (502/530). Complications occurred in 32 patients (6.0%). There included 16 instances of hardware failure and/or pseudoarthrosis, nine of which occurred in the three and four level group, dysphagia (9), vocal cord dysfunction (2), respiratory distress (2), wound hematoma (2), wound infection (1).

Conclusion/discussion: Extremely high fusion rates were recorded in this series, including three and four level constructs, with an acceptable complication rate. We believe that outstanding results are obtainable with allograft and plate, even at three or four levels. The principles of precise fit and fill of the interspace with a contoured graft and fixation with compression and instrumentation must be employed.