Two-Level Noncontiguous Versus Three-Level Anterior Cervical Discectomy and Fusion A Biomechanical Comparison

Study Design. Biomechanical study. Objective. To determine biomechanical forces exerted on intermediate and adjacent segments after two-or three-level fusion for treatment of noncontiguous levels. Summary of Background Data. Increased motion adjacent to fused spinal segments is postulated to be a driving force in adjacent segment degeneration. Occasionally, a patient requires treatment of noncontiguous levels on either side of a normal level. The biomechanical forces exerted on the intermediate and adjacent levels are unknown. Methods. Seven intact human cadaveric cervical spines (C3-T1) were mounted in a custom seven-axis spine simulator equipped with a follower load apparatus and OptoTRAK three-dimensional tracking system. Each intact specimen underwent five cycles each of flexion/extension, lateral bending, and axial rotation under a +/- 1.5 Nm moment and a 100-Nm axial follower load. Applied torque and motion data in each axis of motion and level were recorded. Testing was repeated under the same parameters after C4-C5 and C6-C7 diskectomies were performed and fused with rigid cervical plates and interbody spacers and again after a three-level fusion from C4 to C7. Results. Range of motion was modestly increased (35%) in the intermediate and adjacent levels in the skip fusion construct. A significant or nearly significant difference was reached in seven of nine moments. With the three-level fusion construct, motion at the infra-and supra-adjacent levels was significantly or nearly significantly increased in all applied moments over the intact and the two-level noncontiguous construct. The magnitude of this change was substantial (72%). Conclusion. Infra-and supra-adjacent levels experienced a marked increase in strain in all moments with a three-level fusion, whereas the intermediate, supra-, and infra-adjacent segments of a two-level fusion experienced modest strain moments relative to intact. It would be appropriate to consider noncontiguous fusions instead of a three-level fusion when confronted with nonadjacent disease.