Biomechanical Analysis of 3-Level Anterior Cervical Discectomy and Fusion Under Physiologic Loads Using a Finite Element Model

Objective: Pseudarthrosis and adjacent segment degeneration (ASD) are 2 common com-plications after multilevel anterior cervical discectomy and fusion (ACDF). We aim to iden-tify the potential biomechanical factors contributing to pseudarthrosis and ASD following 3-level ACDF using a cervical spine finite element model (FEM). Methods: A validated cervical spine FEM from C2 to C7 was used to study the biomechani-cal factors in cervical spine intervention. The FEM model was used to simulate a 3-level ACDF with intervertebral spacers and anterior cervical plating with screw fixation from C4 to C7. The model was then constrained at the inferior nodes of the T1 vertebra, and physi-ological loads were applied at the top vertebra. The pure moment load of 2 Nm was applied in flexion, extension, and lateral bending. A follower axial force of 75 N was applied to re-produce the weight of the cranium and muscle force, was applied using standard proce-dures. The motion-controlled hybrid protocol was utilized to comprehend the adjustments in the spinal biomechanics. Results: Our cervical spine FEM demonstrated that the cranial adjacent level (C3-4) had significantly more increase in range of motion (ROM) (+90. 38%) compared to the caudal adjacent level at C7-T1 (+70. 18%) after C4-7 ACDF, indicating that the cranial adjacent level has more compensatory increase in ROM than the caudal adjacent level, potentially predisposing it to earlier ASD. Within the C4-7 ACDF construct, the C6-7 level had the least robust fixation during fixation compared to C4-5 and C5-6, as reflected by the small-est reduction in ROM compared to intact spine (-71. 30% vs.-76.36% and-77.05%, respec-tively), which potentially predisposes the C6-7 level to higher risk of pseudarthrosis. Conclusion: Biomechanical analysis of C4-7 ACDF construct using a validated cervical spine FEM indicated that the C3-4 has more compensatory increase in ROM compared to C7-T1, and C6-7 has the least robust fixation under physiological loads. These findings can help spine surgeons to predicate the areas with higher risks of pseudarthrosis and ASD, and thus developing corresponding strategies to mitigate these risks and provide appropri-ate preoperative counseling to patients.