Comparison of the Inpatient Complications and Health Care Costs of Anterior versus Posterior Cervical Decompression and Fusion in Patients with Multilevel Degenerative Cervical Myelopathy: A Retrospective Propensity Score-Matched Analysis

Abstract

Background: The optimal surgical approach for multilevel degenerative cervical myelopathy (DCM) is unclear, and there is significant variation in practice patterns. We sought to compare inpatient complications and costs of anterior (ACDF) versus posterior cervical decompression and fusion (PCDF).

Methods: Patients who underwent multilevel ACDF or PCDF for DCM were identified from the National Inpatient Sample for 2004-2014 using ICD-9-CM codes. Propensity score matching was performed with age, sex, comorbidities, hospital bed size, and use of intraoperative monitoring as covariates. Hospitalization charges/costs, length of stay (LOS), discharge disposition, and inpatient morbidity/mortality were compared between matched ACDF and PCDF groups.

Results: Propensity score matching generated a cohort of 13,884 patients (n = 6,942 ACDF; n = 6,942 PCDF). PCDF was associated with greater LOS (mean difference [MD] +1.7 days, P < 0.001) and less frequent routine discharge home (odds ratio [OR] 0.26, P < 0.01). With regard to complications, PCDF had a higher rate of myocardial infarction (OR 1.6, P = 0.007), pulmonary embolism (OR 2.6, P = 0.009), deep vein thrombosis (OR 3.7, P < 0.001), neurological complications (OR 1.7, P = 0.037), hardware-related complications (OR 2.7, P < 0.001), wound infection/breakdown (OR 6.8, P < 0.001), and cerebrospinal fluid leak (OR 1.7, P = 0.011). By contrast, rates of postoperative hematoma (OR 0.61, P = 0.007), hoarseness (OR 0.13, P < 0.001), and dysphagia (OR 0.20, P < 0.001) were higher after ACDF. Mortality was comparable. Hospital charges (MD +$26,259, P < 0.001) and costs (MD +$7,728, P < 0.001) were significantly higher for PCDF.

Conclusions: At a national level, for multilevel DCM, we found PCDF to be associated with greater LOS, in-hospital costs, and general medical and surgical complications. ACDF carried higher risk of postoperative hematoma, hoarseness, and dysphagia.

Keywords: Anterior cervical discectomy and fusion; Cervical laminectomy; Cervical spondylotic myelopathy; Degenerative cervical myelopathy; Evidence-based medicine; Posterior cervical decompression and fusion; Spinal fusion.