Jang et al. analyzed 71 patients with 142 total spinal levels who underwent double-level ACDF (C4-5-6 and C5-6-7) with an allograft and plate at Seoul hospital between January 2012 and December 2018. Fusion grades were assessed using computed tomography and the Bridwell interbody fusion grading system at 1 year postoperatively. Radiological parameters were obtained from lateral cervical radiographs collected preoperatively and 1 month and 1 year after surgery.

There was no difference in fusion between the C4-5-6 and C5-6-7 ACDF procedures, but the fusion rate and Bridwell fusion grade at the caudal surgery level were lower than those at the cranial surgery level (93 vs. 79%, p < 0.001). The lower endplate of the caudal fusion level showed the most common pseudarthrosis (18 of 71 [25%]). There was no difference in radiological parameters and clinical outcomes between the fusion and pseudarthrosis groups.

In double-level ACDF procedures, the nonfusion rate was higher at the caudal fusion levels, especially at the lower endplates of the caudal fusion levels ¹⁾

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