4- And 5-Level Anterior Fusions Of The Cervical Spine

Performing arthrodesis on four or five levels in the cervical spine is an infrequent surgical procedure, even in high-volume spine centers. Currently, multilevel discectomies and corpectomies are typically only necessary for the treatment of degenerative conditions, post-traumatic or post-surgical deformities, and instability related to neoplasms.

In such cases, the prevalence of diffuse spinal canal constriction and kyphosis is high, and the viable surgical alternatives are mainly anterior. Re-establishing cervical lordosis may be advantageous in terms of neurological recovery and clinical outcomes.

The biomechanical basis for successful multilevel anterior cervical procedures should be highlighted in light of the results and challenges associated with 4- and 5-level cervical fusions. Literature has raised concerns about the limitations of graft, cage, and plate failures, especially in multilevel corpectomies, despite the use of plates with rigid screw-plate locking mechanisms.

Confirmed complications associated with multilevel strut grafting and end-construct plate fixation without posterior fixation include dislodgement or loosening of the graft, cage, or plate at screw-plate or screw-bone interfaces, postsurgical kyphosis, and pseudoarthrosis.

As the number of decompressed levels increased, there was an increase in the rate of failures. Some of the possible outcomes include injury to the vascular system, esophagus, or nerves. A direct relationship has been observed between the mechanical stability of the fusion construct and the fusion rates in the spine.

The hybrid technique is a solution to this concern in multilevel procedures. A successful alternative to multilevel corpectomies for patients requiring decompression and fusion at three or more levels is to perform discontinuous corpectomies combined with adjacent-level discectomy while retaining the intervening body.

This approach has been effective in avoiding plate loosening or graft migration. The hybrid technique enhances the natural mechanical stability of the construct, aids in correcting kyphotic deformity, preserves the reconstructed alignment, and reduces the risk of deterioration at the screw-bone interface. The use of hybrid or continuous ACDF techniques increases the number of graft/bone interfaces that need to undergo osseous union compared to long interbody grafts and cages.

The stability of the spine that is achieved with an anterior cervical screw-plate system depends on several factors such as the plate design, the quality of bone-screw and plate-screw interfaces, the diameter and depth of the major screw, and the density of the bone. A larger and longer screw placement can enhance the initial stability of cervical osteosynthesis, as observed in our patients.

Screw toggling refers to a phenomenon where forces from non-fixed cantilever beam screws cause damage to both the bone and the screw-bone interface. The screw can move and come into contact with the interface between the bone graft and plate, which can reduce the contact surface and potentially decrease the likelihood of achieving a solid fusion.

Currently, clinical failures of constrained anterior cervical plates (with or without dynamic features) are typically not due to implant breakage or bending, but rather at the interface between the bone and instrumentation.

Loosening of screws in the CS-plate may occur due to the implant’s rigid long fixed-moment arm cantilever beam, which may not provide sufficient resistance to translational forces, resulting in the deterioration of the screw-bone interface and eventual failure.

The longer the implant, the more susceptible it is to these effects. To enhance resistance against axial and translational loads, additional points of fixation can be incorporated, as is the case with the hybrid technique or by using posterior fixation.

In terms of maintaining reconstructed lordosis and construct rigidity, CS plate systems are generally more effective than NC-ones. When 360 stabilization techniques are utilized in testing or measuring, there is a high level of certainty, especially in cases where long corpectomies are performed.

In such cases, it has been demonstrated that posterior stabilization on its own is more effective than anteriorly plated reconstructions. The combination of the hybrid technique and multilevel ACDF can provide ample decompression even in cases of significant cervical stenosis. This approach also reduces the number of corpectomy levels needed, consequently decreasing the requirement for posterior support.

Influence Of Cervical Lordosis

The sagittal plane neutral geometry of the cervical spine is crucial to maintaining an upright posture with minimal muscular effort. However, cervical kyphosis (CK) can cause overload of the anterior parts of the spine and result in painful attenuation of the posterior ligaments and facet capsules, muscle fatigue, and imbalance.

Failed surgical restoration of lordosis is one of the main causes of CK. Although a ‘normal’ or ‘pathological’ cervical curvature has not been defined, it is essential to restore a lordotic curvature to balance the sagittal profile and prevent further kyphosis.

Hybrid and ACDF techniques are useful in the reconstruction of cervical lordosis. The segmental distraction and lordotic restoration obtained using wedged interbody grafts/cages with ACPS are useful in foraminal and central decompression as the cord slightly shifts posteriorly, away from mainly anteriorly situated stenosis. Mean correction in patients with 2- and 3-level corpectomies was 6.8 in the series.

Adjacent Disc Degeneration

The impingement of adjacent-level ACPs during primary and secondary migration can lead to adjacent-level pathology and implant loosening, causing changes in construct geometry.

Although symptomatic secondary plate impingement is observed only once in a series of patients, its incidence should be prevented by enhanced constructed rigidity. Symptomatic adjacent-level pathology after ACDF is reviewed as high as 15%. The progression of ADD also seems to reflect the normal course of adjacent levels not included in the fusion construct at the index procedure.

If there is sufficient TCL and lordosis at the fusion block with an anteriorly located stenosis accompanying ADD, the authors currently recommend implant removal and ACDF at the involved segment. In case of ADD, particularly at the CTJ, 360 stabilization should be considered to prevent construct failure due to the long lever-arm resulting from the preexisting cephalad fusion block.

Clinical Failures In Multilevel Anterior Cervical Constructs

The clinical outcomes of multilevel cervical anterior fusion vary and there is a lack of details on the number of instrumented vertebrae, decompressed levels, and the usage of the Halo. Anecdotal reports of construct failures in multilevel corpectomies with stand-alone strut grafts have been reviewed as high as 10-50%. Studies suggest that anterior devices in multilevel fusions and corpectomy cases should be supported by posterior stabilization, particularly pedicle screw fixation.

However, added posterior stabilization comes with added risks, particularly in elderly and frail patients, such as a higher rate of infection, surgical morbidity, increased hospital stay, myofascial pain, and axial neck pain. Added stabilization with circumferential instrumentation of plated multilevel discectomies and corpectomies can improve outcomes.

Clinical Outcome And Surgical Complications

Surgical complications for 4- and 5-level anterior fusions are comparable and even lower than what is reported in the literature. Temporary dysphagia is observed in 17.6% and transient hoarseness in 11.8% of patients.

The incidence of RLN symptoms is the highest with 9.5% in anterior redo surgeries. No serious complications such as dural, neural, esophageal, or vertebral artery injury are observed. The majority of patients show good or excellent outcomes following an average follow-up of 27.4 months. Loss of cervical motion is not a significant concern, and the evidence of PACS has no adverse effect on clinical outcomes.

The majority of patients show a lordotic cervical posture at follow-up, and reconstruction of cervical lordosis is favorable. However, further investigation is needed to determine the amount of lordosis that needs to be reconstructed and the cut-offs below which clinical outcomes decrease.

If a comprehensive approach including complete decompression, distraction, grafting, reconstruction of a cervical posture with lordosis, and the use of anterior cervical plating system is implemented, it is possible to attain favorable clinical outcomes in multilevel ACDF procedures.

Constrained plates within ACPS provide greater stability to the structure compared to non-constrained plates. It is advisable to plan for early stabilization and fusion with 360-degree coverage, such as after corpectomies involving more than two levels.

Based on the risks associated with using current anterior non-locking and locking plate systems to stabilize multilevel corpectomies in the cervical spine, it is necessary to develop stronger anterior fixation devices that can eliminate the need for posterior supplemental fusion in highly unstable multilevel decompressions.

If you are interested in knowing more about 4- and 5-level anterior fusions of the cervical spine you have come to the right place!

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Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
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19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
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20:42 08 May 23
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15:02 02 Mar 23
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21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
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20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
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16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
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21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
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19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
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21:28 23 May 22
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23:31 19 May 22
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17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
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19:54 16 May 22
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00:48 13 May 22
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23:17 12 May 22
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19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
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19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
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20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
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03:25 09 Apr 22
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22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
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16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
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02:49 24 Mar 22
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14:53 03 Mar 22
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01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
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21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
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18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
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19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
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18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
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17:26 17 Nov 20
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16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
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Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

Please take a look at my profile page and don't hesitate to come in and talk.