The impact of operative level on reoperation rates and short-term patient-reported outcomes in 3-level anterior cervical discectomy and fusion

PURPOSE: To examine whether clinical outcomes and patient-reported outcomes (PROMs) differ when patients are stratified by operative level in 3-level ACDF procedures. METHODS: In this retrospective single-institution cohort study, patients undergoing 3-level ACDF (2014-2020) were reviewed for demographics, clinical outcomes, and PROMs. Patients with operative indications of infection/cancer/trauma/deformity were excluded. Patients with incomplete preoperative or 1-year postoperative PROMs were also excluded. PROMs, including SF-12, VAS Neck, VAS Arm, mJOA, and NDI, were assessed preoperatively and at 3, 6, and 12 months postoperatively. One-year MCID achievement was calculated using established thresholds. Patients were stratified and compared by construct level (C3-C6, C4-C7, and C5-T1). RESULTS: Patients undergoing C3-C6 fusions were older than those in the C4-C7 group (62.7 versus 58.1 years, P = 0.007). The C5-T1 cohort had a higher 2-year reoperation rate compared to the C4-C7 cohort (18.2% versus 0.77%, P = 0.048). Baseline VAS Arm scores were worse in the C4-C7 group, with greater improvement at 1 year compared to the C3-C6 group (-3.45 versus - 2.27, P = 0.047). A transient difference in NDI at 3 months resolved by 6 months. MCID achievement rates across all PROMs did not differ significantly between groups. CONCLUSION: In patients undergoing 3-level ACDF, the operative level was associated with reoperation rates and baseline symptom profiles. However, the likelihood of achieving clinically meaningful improvements was similar across levels. Our findings support the need for construct-specific preoperative counseling while reinforcing the overall efficacy of 3-level ACDF across cervical levels.