Preoperative Alignment and Interbody Cage Design Influence Radiographic Outcomes Following Anterior Cervical Discectomy and Fusion

<b>Background</b>: Anterior cervical discectomy and fusion (ACDF) is a widely performed procedure for treating degenerative cervical spine conditions. While it effectively addresses neural decompression and restores segmental alignment, the interplay of baseline alignment and implant-specific factors on postoperative segmental alignment remains underexplored. This study evaluates the influence of preoperative cervical alignment and interbody cage design on segmental alignment changes following 1- to 3-level ACDF. <b>Methods</b>: Following institutional review board approval, we identified 258 patients undergoing ACDF for degenerative pathology between 1 January 2010 and 31 December 2023. Preoperative and postoperative radiographs were analyzed for cervical alignment, disc height, and segmental lordosis. Cage dimensions, lordosis, and positioning relative to vertebral landmarks were recorded. Multivariable linear regression models evaluated predictors of postoperative disc height, segmental lordosis, and their respective changes. <b>Results</b>: Postoperative disc height was positively associated with greater cage height (β = 1.13 mm per mm, <i>p</i> < 0.001) and negatively associated with greater cage lordosis (β = -0.10 mm per °, <i>p</i> = 0.001). Segmental lordosis was positively influenced by cage height (β = 0.78° per mm, <i>p</i> = 0.002) and lordosis (β = 0.42° per °, <i>p</i> = 0.002) but was negatively correlated with the distance of the cage from the anterior edge of the cranial vertebra (β = -1.76° per mm, <i>p</i> = 0.004). Greater preoperative segmental kyphosis predicted more significant postoperative lordosis correction (β = -1.07° per °, <i>p</i> < 0.001). <b>Conclusions</b>: This study underscores the importance of preoperative alignment and interbody cage design in achieving optimal segmental correction following ACDF. While cage height primarily drives disc height restoration, surgical technique, particularly anterior placement of the cage, is pivotal for enhancing segmental lordosis. These findings support personalized surgical planning to optimize alignment and patient outcomes.