Study design: Review of clinical file information and postoperative imaging, collected prospectively over a period of 14 years, in anticipation of study.

Objectives: 1) Assessment of technical success in achieving anterior cervical fusion without internal fixation; 2) assessment of postoperative neck pain relevant to technical success or failure of fusion; and 3) assessment of morbidity arising from iliac crest bone graft donor site.

Summary of background data: After anterior cervical discectomy and bone grafting for cervical radiculopathy or the intractable pain of cervical spondylosis, common clinical practice varies widely between the extremes of internal fixation in all cases, and never applying fixation. The clinical information and relevant imaging of 97 consecutive patients, 46 male, was reviewed at 12 months after surgery.

Methods: All surgery was performed at no more than 2 contiguous levels, by one surgeon (S.M.E.). After anterior discectomy alone, or combined with posterior vertebral body margin osteophytectomy, anterior bone grafting (Smith-Robinson) was performed at each level using a tricortical autogenous iliac crest bone block inserted under compression. In the interests of maximizing resource allocation and minimizing potential complications, all surgery was completed without internal fixation. A postoperative semirigid cervical collar was prescribed for 2 months.

Results: In 54 patients having 1-level fusion, there were 6 pseudarthroses (11%). In 43 patients having 2-level fusion, 12 patients demonstrated pseudarthroses (28% of patients) at a total of 18 levels (21% of levels). Only 2 of the 97 patients had pain related to the donor site.

Conclusions: These results tend to confirm published reports of high pseudarthrosis rates in anterior cervical fusions carried out at 2 or more levels without fixation, as against improved fusion rates when internal fixation is applied. The authors are inclined to change their practice to include internal fixation in the form of anterior plating for fusions carried out at more than one level. Patients with technically successful fusions were less likely to have postoperative neck pain. Donor site pain was not a significant postoperative complication.