Clinical and radiological outcomes after three- and four-level anterior cervical discectomy and fusion: A single-center case series of 113 patients with a minimum 2-year follow-up.

Background: Anterior cervical discectomy and fusion (ACDF) is a standard procedure for cervical spine disorders, although multilevel ACDF (≥3 levels) is less frequently performed. This study evaluates the long-term clinical outcomes and effects on cervical sagittal balance following three- and four-level ACDF. Materials and Methods: We retrospectively analyzed patients treated for cervical spondylotic myelopathy with multilevel ACDF over 11 years. Patients were divided into two groups: three-level (Group 1) and four-level (Group 2). Clinical and radiological outcomes were assessed postoperatively and at 3, 12, and 24 months. Outcome measures included the Visual Analog Scale, neck disability index, Japanese Orthopaedic Association (JOA) score, and Odom's criteria. Radiological evaluation included C2-C7 Cobb angle, sagittal vertical axis (SVA), and C7 slope. Results: A total of 113 patients (mean age 54.35 years) were included in the study. Most presented with neck pain and brachial neuralgia, with moderate-to-severe myelopathy on JOA scoring. Preoperative imaging frequently showed loss of cervical lordosis or kyphosis, with magnetic resonance imaging confirming multilevel cord compression. Of the cohort, 102 patients underwent three-level ACDF and 11 underwent four-level ACDF. Complications occurred in 14.1% of cases, mainly transient dysphagia. At a mean follow-up of 35.6 months, both groups demonstrated significant improvements in clinical scores and sagittal alignment. Conclusion: Multilevel ACDF is a safe and effective treatment for cervical spondylotic myelopathy, offering sustained clinical and radiological improvement with acceptable complication rates.