Strategies to Achieve Spinal Fusion in Multilevel Anterior Cervical Spine Surgery: An Overview



Anterior cervical fusion offers surgeons a safe and reliable surgical option for single-level and multilevel pathology; however, multilevel fusions pose a higher risk of complications than single-level fusions, including possible pseudoarthrosis, adjacent segment disease, sagittal imbalance, and construct subsidence. Various techniques can be used to mitigate risk in multilevel anterior cervical fusion.


We reviewed the literature to determine the best surgical strategies in multilevel anterior cervical fusion.


We searched the PubMed database for articles published from January 1980 through July 2019. Two authors identified relevant articles and then manually screened them for others to include in this review.


We initially identified 1936 articles and included 48 in our review. We found that clinical outcomes of multilevel anterior cervical fusion can be optimized through the use of biologics and graft selection, the evaluation of pre-existing deformity, the assessment of comorbidities, and the selection of fusion levels. Meticulous surgical technique in conjunction with modern surgical tools, such as instrumentation and biologics, allow surgeons to address complex cervical problems while limiting morbidity and enhancing clinical outcomes.


Multilevel anterior cervical fusions offer a relatively safe and reliable treatment option for both single-level and multilevel pathology.

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Correspondence to Michael H. McCarthy MD, MPH.

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Michael H. McCarthy, MD, MPH, and Joseph A. Weiner, MD, declare that they have no conflicts of interest. Alpesh A. Patel, MD, FACS, reports royalties from Amedica, Nuvasive, and Zimmer Biomet; stock ownership from Amedica, Nocimed, Vital 5, and Cytonics; personal fees as a consultant from Amedica, Relievant, Pacira, Nuvasive, and Zimmer Biomet; and board of director membership from Cervical Spine Research Society, outside the submitted work.

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McCarthy, M.H., Weiner, J.A. & Patel, A.A. Strategies to Achieve Spinal Fusion in Multilevel Anterior Cervical Spine Surgery: An Overview. HSS Jrnl 16, 155–161 (2020).

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  • current concepts
  • fusion
  • multilevel anterior cervical
  • anterior cervical discectomy and fusion (ACDF)