Postoperative outcomes of multilevel versus single-level anterior cervical discectomy and fusion in patients with sarcopenia: a matched cohort study.

Highlight box

Key findings

• Patients with sarcopenia undergoing multilevel anterior cervical discectomy and fusion (ACDF) demonstrated significantly higher rates of postoperative rehabilitation utilization, prolonged opioid use, pseudoarthrosis, and new postoperative dysphagia compared with single-level ACDF patients.

What is known and what is new?

• ACDF is an effective treatment for cervical degenerative pathology, and sarcopenia has been associated with worse postoperative outcomes in spine surgery.

• This study demonstrates that among patients with sarcopenia, multilevel ACDF experienced higher postoperative complication rates compared with single-level ACDF cohort.

What is the implication, and what should change now?

• Sarcopenia should be incorporated into preoperative risk stratification and surgical planning for patients undergoing ACDF, particularly in multilevel procedures. Increased perioperative optimization and counseling may help reduce complications in this high-risk population.

Introduction

Degenerative cervical spine conditions are a leading cause of neck pain, radiculopathy, and myelopathy, contributing significantly to functional impairment, reduced quality of life, and increased healthcare utilization worldwide ( 1 ). As the population ages, the burden of cervical spine disease continues to rise, with increasing demand for both conservative and surgical interventions. In parallel, sarcopenia—a complex multifactorial condition marked by the age-related loss of muscle mass—has emerged as an important factor influencing postoperative outcomes with an increased incidence of complications, mortality, length of stay, and cost ( 2 , 3 ). The estimated global impact of sarcopenia was found to be as high as 16% among the elderly, with the number of people aged 60 and older estimated to grow to 2 billion by 2050 ( 4 , 5 ). Despite these implications, sarcopenia remains an emerging topic in spine surgery.

Anterior cervical discectomy and fusion (ACDF) remains a highly effective treatment for cervical spine pathology as it decompresses neural structures, restores cervical alignment, and stabilizes the spine ( 6 ). Single-level ACDF is indicated for focal pathology confined to one cervical segment causing radiculopathy or myelopathy. Multi-level ACDF is used for contiguous multilevel disease requiring broader decompression and alignment correction ( 1 , 6 ). In a systematic and meta-analysis review by Nassar et al. , 13 studies comprising 2,091 patients (1,078 one-level and 1,013 two-level ACDF) were included. Both approaches significantly improved radiographic and patient-reported outcomes. However, two-level ACDF had longer operative time (P<0.001), and a borderline higher risk of dysphagia (P=0.05) ( 1 ). Biomechanical studies demonstrated that cervical fusion increases intradiscal pressure and motion at adjacent segments ( 7 , 8 ). Finite element modeling of two-level fusion demonstrated stress increases of up to 96% in the annulus, nucleus, and endplates, with consistently greater stress magnitudes than one-level fusion ( 7 ). This elevated stress may accelerate disc degeneration, osteophyte formation, and adjacent segment disease, which may adversely affect postoperative outcomes following ACDF ( 8 ). Ultimately, increasing the number of fused levels increases the risk of revision, with rates of 3.4% per year for multilevel ACDF versus 2.9% per year for one-level ACDF (P<0.001) ( 9 ). Understanding the factors influencing fusion level selection is therefore critical to support clinical decision-making while acknowledging the unique risks demonstrated with multilevel fusion.

Although data on the impact of sarcopenia in cervical spine surgery are limited, studies have shown that patients with sarcopenia undergoing ACDF have worse outcomes, including less pain improvement [Visual Analog Scale (VAS) score: 0.93 vs. 3.29, P<0.05] and poorer long-term function [Neck Disability Index (NDI) score: 2.55 vs. 6.13, P<0.05] at 2 years ( 2 , 10 ). However, the impact of sarcopenia on either type of ACDF remains uninvestigated.

In this study, we aimed to compare postoperative surgical outcomes and complications in sarcopenic patients who underwent ACDF. Specifically, we sought to determine whether sarcopenic patients who underwent single-level ACDF experienced different postoperative outcomes and complication rates compared to sarcopenic patients who underwent multi-level ACDF, given that sarcopenia is associated with worse outcomes. We hypothesize that among patients with sarcopenia, those who underwent single-level ACDF will experience fewer postoperative complications and better outcomes compared to those who underwent multi-level ACDF. We present this article in accordance with the STROBE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-2026-0140/rc ).

Methods

Study design

This retrospective cohort study was conducted using the TriNetX LLC (Cambridge, MA, USA), a federated database providing access to deidentified electronic medical records from approximately 100 million patients across 117 healthcare organizations. On July 24, 2026, the database was queried to identify patients who underwent single-level or multi-level ACDF. The primary objective was to compare postoperative outcomes and complications associated with sarcopenia across these two surgical approaches at both short- and long-term follow-up. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Cohort selection and propensity match

Patients were identified within the database between 2006 and 2026 using Current Procedural Terminology (CPT) procedural codes. Individuals who underwent an ACDF procedure (CPT 22551) were included. Patients were stratified according to whether they underwent single (without CPT 22552) or multilevel ACDF (with CPT 22552) on the same index surgery day. Sarcopenia was identified using UMLS: International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) code-M62.5 ( 3 ).

Patients who underwent previous ACDF surgery or was diagnosed with disseminated malignant neoplasm, multiple myeloma, myasthenia gravis, and Parkinson disease were excluded.

Propensity score matching (1:1) was performed using the TriNetX algorithm to control for potential confounders, including age, obesity, sex, diabetes mellitus, chronic kidney disease, hypertension, osteoporosis, heart failure, tobacco use, chronic obstructive pulmonary disease, prior myocardial infarction, hepatic fibrosis, unspecified dementia, cerebrovascular disease, and generalized atherosclerosis. These variables align with components of the modified Charlson Comorbidity Index. Nearest-neighbor matching was applied with a tolerance of 0.01, ensuring that the difference in propensity scores between matched cohorts did not exceed P=0.01.

Outcome measures

Short-term postoperative outcomes were assessed at 3- and 6-month follow-up and included subsequent cervical surgery (revision/removal of device, ACDF), pseudoarthrosis, cervical nerve root injury, deep cervical infection (osteomyelitis, discitis), surgical-site complications (superficial and deep surgical site infections, wound dehiscence, hematoma, seroma), dural tear, feeding tube insertion, acute posthemorrhagic anemia or blood transfusion, new postoperative dysphagia, opioid use, new cervical radiculopathy, rehabilitation utilization, all-cause postoperative healthcare utilization (emergency room visits and hospital readmissions), and medical complications (venous thromboembolism, myocardial infarction, pneumonia, sepsis, cerebral infarction, ileus).

Long-term postoperative outcomes were evaluated at 1- and 2-year follow-up. These outcomes included subsequent cervical surgery (revision/removal of device, ACDF), pseudoarthrosis, new postoperative dysphagia, opioid use, and cervical radiculopathy. Dysphagia was evaluated through 1 year postoperatively to preserve the clinical relevance of the outcome to the index ACDF.

All outcomes were evaluated as cumulative incidence from the ACDF procedure to each follow-up time point (3-, 6-, 12-month, and 2-year). However, opioid use was analyzed using non-overlapping interval-based windows (1 to 90 days, 91 to 180 days, 181 to 365 days, and 366 to 730 days) to capture new events occurring within each period.

Patients were excluded from each outcome-specific analysis if they had cervical radiculopathy, feeding tube, and dysphagia prior to the index surgery. Additionally, for the opioid use analysis, patients were matched for preexisting opioid use disorders.

Outcomes with fewer than 10 events per cohort were not reported in accordance with TriNetX data restrictions.

Statistical analyses

All statistical analyses were performed using the TriNetX platform. Independent t-tests and Chi-squared tests were used to compare continuous and categorical variables between unmatched and matched cohorts, respectively. Postoperative complication rates were evaluated between the sarcopenic 2-level ACDF and sarcopenic 1-level ACDF cohorts with odds ratios (ORs) and 95% confidence intervals (CIs) calculated for each comparison. Continuous variables were reported as means with standard deviations, while categorical variables were presented as counts and percentages. A P<0.05 was considered statistically significant.

Results

Population characteristics

A total of 2,873 patients who underwent single- and multi- level ACDF were identified. Of these, 1,662 patients were included in the sarcopenia multi-level ACDF cohort, and 1,211 sarcopenic single-level ACDF patients were included for matching ( Figure 1 ). Following 1:1 matching, 1,176 patients were included in the sarcopenia multi-level ACDF and sarcopenia single-level ACDF cohorts ( Table 1 ).

Short-term complications

Compared to sarcopenic single-level ACDF patients, sarcopenic patients who underwent multi-level ACDF demonstrated significantly higher rates of postoperative short-term complications. At 3 and 6 months, sarcopenic patients who underwent multilevel ACDF experienced higher rates of rehabilitation utilization (51.11% vs. 45.49%, OR: 1.25, P=0.006 at 3 months; 54.59% vs. 48.38%, OR: 1.28, P=0.003 at 6 months), opioid use (88.66% vs. 82.61%, OR: 1.65, P<0.001 at 3 months; 88.76% vs. 82.57%, OR: 1.67, P<0.001 at 6 months), and pseudoarthrosis (9.27% vs. 6.72%, OR: 1.42, P=0.02 at 3 months; 10.71% vs. 7.91%, OR: 1.40, P=0.02 at 6 months).

No significant differences were observed between cohorts in subsequent cervical surgery, cervical radiculopathy, surgical-site complications, new postoperative dysphagia, medical complications, acute posthemorrhagic anemia or blood transfusion, and all-cause postoperative healthcare utilization ( Figure 2 , Table 2 ).

Notably, feeding tube insertion, dural tear, cervical root injury and deep cervical infection were not available at 3 and 6 months due to counts fewer than 10.

Long-term complications

At the 1-year postoperative follow-up, sarcopenic patients who underwent multilevel ACDF demonstrated higher rates of pseudoarthrosis (12.07% vs. 9.18%, OR: 1.36, P=0.02) and new postoperative dysphagia (13.73% vs. 10.17%, OR: 1.41, P=0.02) compared with sarcopenic patients who underwent single-level ACDF. At the 2-year follow-up, no significant differences were observed between cohorts in opioid use, subsequent cervical surgery, or new cervical radiculopathy ( Table 3 ).

Discussion

This study evaluated postoperative surgical outcomes and complications in sarcopenic patients who underwent multilevel ACDF and single-level ACDF. Patients with sarcopenia who underwent multilevel ACDF had significantly worse short-term post-operative outcomes, such as opioid use, rehabilitation utilization, pseudoarthrosis, and new postoperative dysphagia.

A key explanation for these findings involves the altered biomechanical stresses following multilevel ACDF, which limits motion at the operated segment and redistributes stress across the cervical spine ( 7 , 11 ). In a finite element study by Lopez-Espina et al. utilizing single- and double-level fusion models, fusion increased stresses within the annulus, nucleus, and vertebral endplates by up to 96%, with greater adjacent segment stress observed in double-level constructs, potentially accelerating disc degeneration and osteophyte formation ( 7 ). Another cadaveric study by Eck et al. demonstrated that single-level cervical fusion at C5–C6 significantly increased intradiscal pressures at adjacent levels by 73.2% at C4–C5 and 45.3% at C6–C7 during flexion, along with increased segmental motion, providing a direct biomechanical mechanism for adjacent segment degeneration ( 12 ). These adverse effects may be further exacerbated in sarcopenic patients, where diminished paraspinal muscle support reduces the spine’s ability to compensate for altered postoperative loading.

Recent biomechanical studies support the role of sarcopenia in adverse spinal loading. In a recent finite element study by Cui et al. , an 80% paraspinal muscle quality model following ACDF showed increased adjacent segment disc pressure, higher implant stress, elevated capsular ligament stress, and increased adjacent segment range of motion (ROM), while the muscle training model (120%) showed superior biomechanical indices ( 13 ). Similarly, Ignasiak et al. reported that severe sarcopenia increased spinal compression by up to 36% (318 N) at the upper thoracic spine and shear loading by up to 75% along the entire spine, while Cheng et al. demonstrated in a cadaveric model with simulated muscles that spinal stability is more significantly affected by muscle dysfunction than by disc degeneration ( 14 , 15 ). However, these biomechanical mechanisms remain speculative in the present study, as our database did not include parameters to directly evaluate their contribution. Further studies incorporating detailed clinical, radiographic, and functional assessments are needed to better characterize the mechanisms underlying these findings.

Opioid use

Sarcopenia has been identified as an independent risk factor for prolonged postoperative opioid use even in other surgical populations ( 3 , 16 ). The persistent opioid utilization in sarcopenic patients who underwent multi-level ACDF is likely multifactorial. In our study, these patients demonstrated 65% greater odds of opioid use at 3 months postoperatively, consistent with prior evidence from a retrospective cohort of 3,805 surgical patients showing that sarcopenia was independently associated with higher opioid prescription rates at 3 months [adjusted OR (aOR) 1.11, 95% CI: 1.05–2.45] and 6 months (aOR 1.89, 95% CI: 1.12–4.96) ( 16 ). From a biomechanical standpoint, the multilevel fusion increases adjacent segment motion and stress, which may lead to sustained nociceptive input ( 10 , 17 ). In the setting of sarcopenia, reduced neck muscle mass compromises spinal stability and decreases the pain perception threshold while exacerbating postoperative pain due to the neck muscles’ role in regulating peripheral pain signaling which may explain the sustained opioid utilization observed in sarcopenic patients who underwent multilevel ACDF vs. single-level ACDF ( 18 ). These highlights the clinical importance of early sarcopenia risk stratification and targeted perioperative optimization strategies to potentially reduce prolonged postoperative opioid utilization following multilevel ACDF.

Pseudoarthrosis

Pseudoarthrosis was the most consistent adverse outcomes observed in this study, with sarcopenic multilevel ACDF demonstrating significantly higher rates throughout the 1-year follow-up. These findings are supported by Dalton et al. , which specifically examined the impact of cervical paraspinal muscle quality on pseudarthrosis after ACDF (1–4 levels). Even mild fatty infiltration of the sternocleidomastoid (SCM), measured by Goutallier grade, independently increased the odds of pseudarthrosis 3.46-fold (OR 3.46, P=0.009) after controlling for age, sex, body mass index (BMI), and number of levels fused. Notably, the pseudoarthrosis group had a significantly higher proportion of multilevel (3- and 4-level) ACDF (30.4% vs. 17.6% for 3-level; 7.25% vs. 1.47% for 4-level; P=0.01) ( 19 ). Successful spinal arthrodesis relies not only on adequate mechanical stability but also on a favorable biological environment for bone healing. Beyond muscle health, other patient-specific factors, including bone quality, may influence the outcomes. Genetic and epigenetic factors have been suggested to contribute variability in spinal fragility risk and may be considered alongside assessments of muscle mass and spinal alignment during preoperative evaluation ( 20 ).

Rehabilitation utilization

Our study demonstrated that sarcopenic patients undergoing multilevel ACDF have significant greater rehabilitation utilization during the first six postoperative months. In a large retrospective analysis of 309,230 ACDF patients, conducted by Lantz et al. , fusion ≥3 levels (OR 1.22, P<0.001) and 2-level fusion (OR 1.08, P<0.001) were independent predictors of postoperative physical therapy utilization. Additionally, higher comorbidity burden (Elixhauser Comorbidity Index ≥4, OR 1.13) and osteoporosis (OR 1.19), conditions closely associated with sarcopenia, independently predicted greater physical therapy (PT) utilization. Among physical therapy users, the mean initiation was at 88 days (median 61 days), with an average of 7.4 visits, placing the bulk of rehabilitation within the first 6 postoperative months ( 21 ). The increased rehabilitation utilization observed in our study likely reflects the greater functional demands and slower recovery associated with multilevel fusion in patients with diminished muscle reserve, emphasizing the need for proactive postoperative rehabilitation strategies.

New postoperative dysphagia

Dysphagia is a well-recognized complication of anterior cervical spine surgery and is thought to be multifactorial, potentially resulting from esophageal denervation, hematoma formation, nerve root injury, and soft tissue swelling ( 22 ). In a meta-analysis of 10 studies involving 4,018 patients, multilevel ACDF was associated with a significantly higher incidence of postoperative dysphagia than single-level ACDF (6.6% vs. 4.0%; OR: 1.42, 95% CI: 1.05–1.91), with the difference persisting at 12–24 months of follow-up ( 22 ). These findings are consistent with our results, in which sarcopenic patients following multilevel ACDF demonstrated significantly higher rate of new postoperative dysphagia at 1 year compared with those following single-level ACDF. Sarcopenic dysphagia may be exacerbated by weakness of both skeletal and swallowing musculature, in addition to the effects of poor nutritional status and surgical trauma ( 23 ). These factors may be further amplified in multilevel ACDF, where more extensive surgical exposure and prolonged soft tissue retraction increase tissue injury and delay recovery of swallowing function. Xie et al. demonstrated a clear-dose response relationship between number of levels fused and dysphagia in which immediate postoperative dysphagia rates were 87.5% for ≥3-level, 64.0% for 2-level, and 43.9% for 1-level ACDF P=0.001, with the number of fused levels identified as the most important risk factor for long-term dysphagia ( 24 ). Clinicians should maintain a high index of suspicion for persistent dysphagia in sarcopenic patients following multilevel ACDF and incorporate routine swallowing surveillance to facilitate early recognition and timely intervention.

Recognition of sarcopenia as a predictor of adverse postoperative outcomes highlights the importance of preoperative optimization strategies. Incorporating enhanced recovery after surgery (ERAS) protocols, including preoperative physical and psychological preparation, management of modifiable risk factors, opioid-sparing approaches, and postoperative protocols focused on early mobilization, nutrition, functional recovery, and timely discharge may represent a potential approach to improving outcomes in sarcopenic patients following ACDF ( 25 ).

Limitations

This study provides a controlled assessment of sarcopenic patients undergoing multi-level ACDF compared to single-level ACDF. However, several limitations should be acknowledged. Although propensity score matching was employed to control for confounders, residual confounding is likely, particularly for variables not captured by the database. Additionally, the study lacks detailed imaging data, such as measurements of muscle mass and spinal alignment, which may limit the ability to fully elucidate the underlying biomechanical mechanisms. Because sarcopenia was identified using ICD-10 diagnosis codes rather than objective measures of muscle mass, strength, or physical performance, underdiagnosis, misclassification, and selection bias remain possible. Accordingly, these findings should be interpreted as applying to patients with clinically documented sarcopenia in the database rather than to all patients who would meet contemporary objective diagnostic criteria for sarcopenia. Additionally, this study was unable to determine the optimal surgical approach for patients with lower bone density, as the database lacked detailed information regarding surgical strategy selection, bone density parameters, and radiographic characteristics. Pseudoarthrosis was identified using administrative diagnosis codes rather than direct radiographic assessment. Therefore, the database could not confirm fusion status using imaging criteria, determine the specific cervical level involved, or distinguish symptomatic from asymptomatic nonunion. Nevertheless, this is the first study to compare postoperative outcomes between sarcopenic multi-level and single-level ACDF, offering unique insights into postoperative complications and effects.

Conclusions

Among patients with sarcopenia, multilevel ACDF was associated with higher rates of postoperative opioid use, rehabilitation utilization, pseudoarthrosis, and new postoperative dysphagia complications compared with those undergoing single-level ACDF. These findings suggest that sarcopenia, combined with altered postoperative biomechanics, and increased surgical complexity may contribute to persistent neurologic symptoms, prolonged pain burden, and delayed recovery following multilevel cervical fusion. Given the emerging recognition of sarcopenia as a predictor of adverse postoperative outcomes, clinicians should consider it during preoperative risk stratification, surgical planning, and patient counseling.

Supplementary

The article’s supplementary files as

Acknowledgments

None.

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-2026-0140/rc

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-2026-0140/coif ). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

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