Anterior Cervical Approaches for 2-Level Radiculopathy

STUDY DESIGN: Anonymous, survey-based study. OBJECTIVE: The primary objective of this study is to understand and assess the factors influencing the choice of cervical fusion, disc arthroplasty, and hybrid procedures for radiculopathy in the setting of 2-level cervical degenerative pathology. SUMMARY OF BACKGROUND DATA: Anterior cervical discectomy and fusion (ACDF) has long been the gold standard for treating cervical degenerative pathologies. Cervical disc arthroplasty (CDA) usage has rapidly increased over the past decade, but hybrid constructs (a combination of ACDF and an adjacent disc arthroplasty) are rarely performed. METHODS: A multidimensional survey (designed using a modified Delphi approach) was distributed worldwide to surgeons in the AO Spine membership. Questions were focused on surgical preferences, challenges, and barriers with various anterior cervical techniques. Imaging studies of several patients presenting with radiculopathy and 2-level cervical degenerative pathology were presented to assess surgical recommendations. RESULTS: A total of 267 surgeons participated in this survey, representing 5 regions worldwide. The majority of participants practice in Europe and Southern Africa (31.5%), followed by Asia Pacific (27.3%), North America (16.5%), Latin America (15.7%), and the Middle East and Northern Africa (8.9%). When presented with 2-level degenerative conditions, ACDF represents the most frequently selected individual surgical option (45.75% among the 4 clinical cases). However, substantial variability exists, with many surgeons favoring motion-preserving or hybrid approaches depending on clinical context. Preservation of motion at the index level (71.7%) and the absence of adjacent segment disease (71.7%) were considered advantages of a hybrid construct compared with a 2-level ACDF. Respondents considered that the more advantageous location of CDA would be based on the clinical scenario, with CDA preferred above the ACDF level. CONCLUSION: When considering anterior cervical approaches to address radiculopathy, cervical fusions remain far more commonly performed globally, compared with CDA for 2-level degenerative cervical pathology. Despite their potential advantages in preserving motion and reducing adjacent-segment degeneration, hybrid procedures are less frequently performed, and fewer surgeons consider themselves experts in this technique. LEVEL OF EVIDENCE: Level V.