Original Article

Global Spine Journal

2024, Vol. 14(3) 949–955
No Difference in Two-Year Revisions Between © The Author(s) 2022
Article reuse guidelines:
Hybrid Fusion and Two-Level Anterior sagepub.com/journals-permissions
DOI: 10.1177/21925682221131548
journals.sagepub.com/home/gsj
Discectomy and Fusion: A National Database
Study

Jon Raso, BS1, Pramod N. Kamalapathy, BA1, Kevin Mo, BS2, Lawal Labaran, MD1,
Jesse Wang, MD1, Eric Solomon, BS2, and Hamid Hassanzadeh, MD3

Abstract
Study Design: Retrospective Cohort
Objective: This study utilized a large national database to compare two-year revision rates, in addition to complications and
costs, of hybrid surgery (HS) compared to two-level anterior cervical discectomy and fusion (ACDF).
Methods: This study used the PearlDiver Mariner dataset selecting for patients aged 18 and older who had at least 90-day active
longitudinal follow-up who underwent two-level ACDF or two-level Hybrid surgery (single level ACDF and single level CDA).
Patients with prior spinal trauma, infection, cancer, or posterior fusion were excluded. Primary outcomes measures were 90-
day major and minor medical complications, ED visits, readmissions, as well as two-year revisions. Patients were also assessed
for postoperative dysphagia, incidental durotomy, vascular injury, 90-day surgical site, and implant complications. Additionally,
hospitalization and postoperative costs were evaluated.
Results: There were 4570 two-level ACDF surgeries and 888 hybrid surgeries. After matching the cohorts, no statistical
differences in demographics were found. There were no differences in reoperation rates at all measured time points nor 2-year
complications. HS had a lower incidence of major (1.6% vs 3.1%, P = .003) and minor complications (3.0% vs 4.6%, P = .009) than
ACDF. 90-day readmission was lower in the HS cohort (2.8% vs 4.2%), P = .024. HS was associated with reduced hospitalization
costs -$2614 (-$3916 to -$904, P < .001). 3516 patients had ACDF, and 699 had HS with at least 2 years of follow-up.
Conclusion: Hybrid surgery is a safe and effective surgical treatment for cervical disease in appropriately selected patients.

Keywords
Hybrid, anterior cervical discectomy and fusion, Cervical

Introduction 1
Department of Orthopaedic Surgery, University of Virginia, Charlottesville,
VA, USA
Cervical degenerative disc disease (DDD) is a common source 2
Department of Orthopaedic Surgery, Johns Hopkins University National
of neck pain afflicting those over 60.1,2 Degenerative disc Capital Region, Bethesda, MD, USA
disease can cause compression of the spinal cord, leading to 3
Departmant of Orthopaedic Surgery, Johns Hopkins University, Baltimore,
progressive neurologic symptoms, thus decreasing an indi- MD, USA
vidual’s quality of life.2,3 With more than 138,000 cervical
Corresponding Author:
spine surgeries performed annually,4 anterior cervical dis- Hamid Hassanzadeh, Department of Orthopaedic Surgery, Johns Hopkins
cectomy and fusion (ACDF) is one of the most commonly University, 6420 Rockledge Drive, Suite 2200, Bethesda, MD 20817, USA.
utilized procedures in the surgical management of cervical Email: hhmd06@gmail.com

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use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the
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950 Global Spine Journal 14(3)

DDD. However, adjacent segment disease (ASD) following Table 1. Hybrid surgery vs Two-Level ACDF Patient
ACDF remains a concern due to altered biomechanics of the Demographics.
cervical spine.5-8 Furthermore, ACDF for multilevel DDD ACDF Hybrid
results in increased cervical stiffness and adjacent segment
motion compared to single level fusions and thus the risk of n = 4570 n = 888 P-value
progressive ASD.9 Cervical disc arthroplasty (CDA) has
Age, years <44 1353 29.6% 261 29.6% 1.00
become a widely accepted motion-sparing alternative to the
45-54 1736 38.0% 338 38.0%
standard ACDF in appropriately selected patients by pre- 55-64 1133 24.8% 221 24.8%
venting excessive load on adjacent discs.10-16 65-74 283 6.1% 55 6.2%
Cervical disc arthroplasty has some advantages over 75-84 55 1.2% 13 1.2%
ACDF, yet it is contraindicated in patients with poor bone Gender (Female) 2476 54.1% 481 54.2% 1.00
quality, segment instability, disc height less than 3 mm, and
severe spondylosis.17 Multiple pathological cervical segments Comorbidities
can have unique characteristics, necessitating different pro- Obesity (BMI>30 kg/m2) 210 4.8% 42 4.7% 1.00
cedures for subsequent levels.18 Hybrid surgery (HS) was Chronic kidney disease 48 1.1% 12 1.4% .611
developed to combine the stability of ACDF and the motion COPD 514 11.6% 107 12.0% .765
preservation of CDA.19,20 Previous literature has shown that Diabetes mellitus 465 10.5% 96 10.8% .843
HS leads to improved natural biomechanics, and recovery of Peripheral vascular disease 136 3.1% 29 3.3% .849
range of motion.21,22 In addition, patient reported outcomes Congestive heart failure 30 .7% <11 ∼1% .891
have shown that HS leads to decreased pain following surgery Coronary artery disease 437 9.8% 90 10.1% .869
compared to two-level cervical fusion.21 Hypertension 1797 40.7% 363 40.9% .931
Given the novelty of this procedure, there is limited lit- Hyperlipidemia 1736 39.3% 351 39.5% .918
erature regarding postoperative outcomes following HS. Thus,
Substance use
the aim of this study was to employ a large national database to
evaluate rates of reoperation within 2 years of two-level History of tobacco use 964 21.8% 195 22.0% .957
ACDF vs HS, as well as cost-effectiveness, short-term and
Abbreviations: BMI, Body Mass Index; PVD, Peripheral Vascular Disease;
long-term complications. We hypothesize that patients un- COPD, Chronic Obstructive Pulmonary Disease.
dergoing HS will have lower rates of revision and decreased
postoperative complications compared to those undergoing
two-level ACDF. trauma, infection, malignancy, or posterior fusion were ex-
cluded from the population. Basic demographic information
and comorbidities of each cohort were queried and used to
Methods match the two cohorts including age, gender, obesity, tobacco
use, diabetes (DM), chronic pulmonary disease (COPD),
Data Source hyperlipidemia (HLD), hypertension (HTN), peripheral vas-
A retrospective database review was performed using the cular disease (PVD), chronic kidney disease (CKD), coronary
commercially available PearlDiver (PearlDiver Inc., Colorado artery disease (CAD), and congestive heart failure (CHF).
Springs, Colorado, USA; www.pearldiverinc.com) patient
records; this study used the Mariner dataset containing records
Outcomes
of over 121 million patients from 2010 to 2020 searchable by
International Classification of Diseases, Ninth Revision (ICD- The primary study outcome was rate of reoperation at various
9), International Classification of Diseases, Tenth Revision time points up to 2 years post procedure. Secondary study
(ICD-10), and Current Procedural Terminology (CPT) codes. outcomes included 90-day major and minor medical com-
Considering the data is de-identified and Health Insurance plications, emergency department (ED) visits, and read-
Portability and Accountability Act compliant, this study was missions. 90-day major medical complications included
exempt from institutional review board approval. pulmonary embolism (PE), pneumonia (PNA), myocardial
infarction (MI), cerebrovascular accident (CVA), sepsis.
Minor 90-day complications encompassed deep vein throm-
Study Population bosis (DVT), acute kidney injury (AKI), urinary tract infection
Inclusion and exclusion CPT, ICD-9, and ICD-10 codes are (UTI), transfusion, and wound complications. Patients were
summarized in (Appendix Table A1). The study population also queried for 90-day surgical complications which included
included all patients aged 18 years of age or older who un- surgical site infection, dysphagia, incidental durotomy, vas-
derwent two-level ACDF or two-level Hybrid surgery (single cular injury, and implant complications. Finally, cost of
level ACDF and single level CDA) with at least 90-day active hospitalization, and 90-day postoperative cost were assessed
longitudinal follow-up. Patients with a history of spinal using reported insurance reimbursement.
Raso et al. 951

Table 2. Surgical and Postoperative 90-day Outcomes.

ACDF Hybrid Hybrid vs ACDF

n = 4570 n = 888 Adjusted OR (95% CI) P-value

Major Complications 140 (3.1%) 14 (1.6%) .43 (.23-.73) .003

Minor Complications 212 (4.6%) 27 (3.0%) .58 (.37-.86) .009
Dysphagia 285 (6.2%) 41 (4.6%) .62 (.35-1.04) .089
Implant 35 (.8%) <11 .56 (.16-1.42) .284
Durotomy <11 <11 .85 (.04-5.06) .886
Vascular Injury <11 <11 5.24 (.31-87.5) .248
90-Day ER Visit 552 (12.1%) 103 (11.6%) .91 (.72-1.14) .458
90-Day Readmission 194 (4.2%) 25 (2.8%) .61 (.39-.92) .024
Infection 90 Days 55 (1.2%) <11 .52 (.20-1.13) .139
Abbreviations: PE, Pulmonary embolism; PNA, pneumonia; CVA, Cerebrovascular accident; AKI, acute kidney injury; UTI, urinary tract infection; DVT, deep
vein thrombosis; MI, myocardial infarction Bolded variables indicate significance with P <0.029 (Bonferroni Correction).

Table 3. Total Hospital and 90-Day Postoperative Cost.

Beta

ACDF Hybrid Hybrid vs ACDF

n = 4570 n = 888 P value Adjusted β (95% CI)

Total in-hospital cost $11,404 ± 18,447 $8,815 ± 12,966 <.001 -2614 [-3916 to -904]
90-Day Postoperative Cost $2,888 ± 9,572 $2,470 ± 5989 .189 -442 [-1102 to 217]

Statistical Analysis significant differences in 90 day or two-year reoperations rates

Pearson chi-squared test was used to assess differences in de-
mographics and preexisting comorbidities. Multivariable logistic
regression was used to determine the odds ratio (OR) and cor-
responding 95% confidence interval (95% CI) of HS vs ACDF
on the postoperative outcomes after adjusting for demographic
factors and pertinent comorbidities. A subset of patients with at
least 2 years of active longitudinal follow-up were used to assess
outcomes at 2-years following index surgery. R software em-
bedded within the PearlDiver database (R Foundation for Sta-
tistical Computing, Vienna, Austria) was used for all statistical
analysis. Statistical significance was set at P < .05.
Results
following the index surgery (P > .05). Two-year rates of
implant complications and pseudarthrosis following surgery
were similar across groups (P > .05) (Table 4).
90-day Postoperative Complications. Hybrid surgery was as-
sociated with a significant decrease in major complications
(1.6% vs 3.1 %, OR .43, 95% CI .23-.73, P = .003) and minor
complications (3.0 % vs 4.6 %, OR .580, 95% CI .37-.86, P =
.009) compared to the ACDF group. Rates of incidental
durotomy, vascular injury, and postoperative dysphagia were
similar across both cohorts (P > .05). HS was also associated
with decreased 90-day readmission compared to the ACDF
group (2.8 % vs 4.2 %, OR .61, 95% CI .39-.92, P = .024)
(Table 2).

ACDF and Hybrid
Patient demographics and Comorbidities. There were 4570 pa-
tients who underwent two-level primary ACDF, and 888 primary
hybrid surgeries. There were no statistical differences in age,
gender, comorbidities, and tobacco use when comparing the
ACDF group to the matched Hybrid cohort (Table1).
Surgical and 90-Day Postoperative Costs. Hybrid surgery was
associated with decreased cost of hospitalization. Specifically,
HS was associated with a savings of -$2614 (-$3916 to -$904,
P < .001). There was no difference in 90-day postoperative
cost between the cohorts ($2470 vs $2,888, P = .189)
(Table 3).

Reoperation and Long-term Outcomes. There were 3516 pa-

Discussion
tients who underwent ACDF, and 699 who underwent HS with HS has gained traction in recent years as an effective alter-
at least 2 years of longitudinal follow-up. There were no native to ACDF; however existing literature on postoperative
952
Table 4. ACDF vs Hybrid Long-term Outcomes.
ACDF
Reoperation n = 3516
90 days 49 (1.4%)
6 months 64 (1.8%)
1 year 92 (2.45%)
2 years 128 (3.5%)
Implant complication (2 yr.) 131 (3.7%)
Pseudarthrosis (2 yr.) 94 (2.7%)
outcomes is limited. The present study found overall lower
rates of medical complications, as well as readmission in the
HS cohort within 90 days postoperatively compared to
standard ACDF. In addition, HS had a lower hospitalization
cost compared to those undergoing two-level ACDF, but 90-
day postoperative cost was similar for both cohorts. Similarly,
there were no differences in long-term complications fol-
lowing surgery.
Hybrid surgery was developed to combine the advantages
of both ACDF and CDA in the treatment of multi-level
cervical DDD. Historically, ACDF has been shown to be a
safe, efficacious treatment for cervical DDD; yet it is asso-
ciated with loss of cervical mobility at fused segments,
causing compensatory motion at adjacent segments.5-8 This
can lead to degeneration at those adjacent segments, neces-
sitating future procedures.23 Meanwhile CDA is a safe,
motion-preserving alternative to traditional ACDF, yet indi-
cations are narrow.24-27 Furthermore, there is still a paucity of
studies demonstrating the long-term efficacy of CDA com-
pared to ACDF. HS gives the provider the opportunity to tailor
the treatment of multi-level cervical DDD to the specific
pathology of each vertebrae, which may expand its range of
indications while preserving motion and mitigating adjacent
segment disease.28
Previous literature has demonstrated similar short term
perioperative outcomes between HS and ACDF.18,29-31 Studies
completed using national claims databases found no significant
differences in 30 day perioperative complications between two-
level ACDF and two level HS.18,31 The present study, which
includes a larger sample size and longer follow-up period found
that HS was associated with fewer overall major and minor
complications within 90 days postoperatively. Furthermore, there
were no increased risk in surgical complications, including
dysphagia and surgical site infection following HS. 18,29,30,32
This may be explained by the fact that patients selected in the HS
group tend to be younger, and healthier, which the present study
attempted to control for by matching.18,31 In addition to age and
comorbidities, strict surgical indications are often used to screen
patients for HS. Common contraindications are similar to those
described for CDA and include advanced osteoporosis, facet
arthropathy, or DDD.33,34
Global Spine Journal 14(3)
Hybrid ACDF vs Hybrid
n = 699 Adjusted OR (95% CI) P-value
<11 .70 (.29-1.46) .389
<11 (2.6%) .76 (.36-1.43) .442
14 (3.24%) .78 (.42-1.34) .409
21 (4.5%) .96 (.59-1.51) .892
19 (2.7%) .89 (.52-1.41) .636
<11 .54 (.25-1.03) .081
Given the novel nature of HS, studies assessing long-term
reoperation in HS are limited. Zigler et al. found that in 115
hybrid surgeries followed for a mean of 6.5 years, only 6 required
reoperation with 5 due to adjacent segment disease, and 1 due to
pseudarthrosis.35 HS implant failure is also rare, and is not
usually the cause of reoperation.32,34,35 Scott-Young et al. re-
ported similarly low revision rates of 1.9% following HS, with
the most common perioperative indication for reoperation as
drainage of hematoma.34 This complication appears to be
common as previous studies have also highlighted an increased
risk of hematomas requiring surgical drainage after HS.31,36
While the present study was unable to assess the reason for
reoperation, the rates of two-year reoperation was 4.5%, similar
to literature findings with rates ranging from 0 to 8%.30,34,35
To date, few studies exist comparing the cost-effectiveness
of HS to ACDF. The majority of previous research has as-
sessed two level CDA and two level ACDF.37-39 These studies
have shown that while CDA is a more expensive surgery,
ACDF is associated with longer time to recovery, and greater
overall cost due to loss of productivity.37,39,40 The present
study revealed that patients undergoing HS are associated with
decreased cost of hospitalization compared to the ACDF
group, but the 90-day postoperative costs were similar across
cohorts. While matching was utilized in this study, it remains
challenging to account for every covariate. Patient cohorts
undergoing ACDF are likely to have a greater comorbidity
burden resulting in increased hospital costs.18,31 Further
studies are necessary to assess cost-utility of HS compared to
two-level ACDF surgeries.
Inherent limitations exist with any database study. A na-
tional database such as PearlDiver relies on accurate data entry
and is always subject to input error. However, it is estimated
that the administrative errors are roughly only 1.1-1.3%.41
This study was also unable to assess important clinical factors
such as changes in functional status using validated scales like
the neck disability index or assess postoperative changes in
range of motion. Additionally, intraoperative variables, and
specific surgical technique for ACDF and hybrid (graft with
plating vs anchored or non-anchored cages) could not be
assessed. Finally, assessment of longer follow-up past 2 years
was limited by adequate sample size. Regardless, the present
Raso et al.
study provides support that HS is not only cost-effective, but
also a safe alternative to ACDF in appropriate candidates.
Conclusion
The present study adds to the growing consensus that HS is at
least as safe and effective as other surgical treatments for
treating cervical disease in appropriately selected patients.
Hybrid surgery provides similar long-term reoperation rates as
ACDF, with a lower rate of 90-day complications, readmission
and decreased total hospital costs.
Author’s Note
IRB: This study was deemed exempt by the institutional review board
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, au-
thorship, and/or publication of this article.
Level of Evidence
III
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Appendix

Table A1

Inclusion Codes

TDA CPT-22856
ACDF CPT-22551, CPT-22554, CPT-22585
ACDF Multi-level CPT-22585, CPT-22552

Exclusion Codes

Posterior Cervical CPT- 22590, CPT-22600, CPT-22840

Procedures
Spinal Trauma ICD-9-CM: 805.10, 805.2-5, 805.8-9, 806.00, 806.04-05, 806.4-5, 806.8-9, 905.1
ICD-10-CM: M48.40XA, M48.42XA, M48.42XS, M48.44XA, M48.46XA, M48.47XA, M48.48XA, M48.50XA,
M48.52XA, M48.53XA, M48.54XA, M48.55XA, M48.56XA, M80.08XA, M80.88XA, S12.00A, S12.00B,
S12.01A, S12.01XA, S12.01XB, S12.02XA, S120.30A, S120.31A, S120.40A, S120.41A, S120.41B, S120.90A,
S120.90B, S120.91A, S120.91B, S121.00A, S121.00D, S121.90A, S121.91A, S122.00A, S122.01A, S122.30A,
S122.90A, S122.90B, S122.91A, S122.91B, S123.00A, S123.00B, S123.01A, S123.01B, S123.30A, S123.90A,
S123.91A, S123.91B, S124.00A, S124.00B, S124.01A, S124.01B, S124.30A, S124.90A, S124.91A, S125.00A,
S125.00B, S125.01A, S125.90A, S125.90B, S125.91A, S126.00A, S126.00A, S126.01A, S126.30A, S126.31A,
S126.91A, S220.00A, S220.01A, S220.02A, S220.08A, S220.09A, S220.09B, S220.10A, S220.11A, S220.12A,
S220.18A, S220.19A, S220.20A, S220.22A, S220.28A, S220.29A, S220.29B, S220.30A, S220.30B, S220.31A,
S220.32A,S220.32A, S220.32B, S220.32B, S220.38A, S220.39A, S220.40A, S220.40B, S220.41A, S220.41B,
S220.42A, S220.48A, S220.49A, S220.50A, S220.51A, S220.52A, S220.58A, S220.59A, S220.60A, S220.61A,
S220.62A, S220.68A, S220.69A, S220.69B, S220.70A, S220.70B, S220.71A, S220.72A, S220.72B, S220.78A,
S220.78B, S220.79A, S220.79B, S220.80A, S220.80B, S220.81A, S220.81B, S220.82A, S220.82B, S220.88A,
S220.88B, S220.89A, S220.89B, S320.00A, S320.00B, S320.01A, S320.01B, S320.02A, S320.02B, S320.08A,
S320.09A, S320.10A, S320.10B, S320.11A, S320.11B, S320.12A, S320.12B, S320.18A, S320.19A, S320.20A,
S320.20B, S320.21A, S320.22A, S320.28A, S320.29A, S320.30A, S320.31A, S320.32A, S320.38A, S320.39A,
S320.40A, S320.41A, S320.42A, S320.48A, S320.49A, S320.51A, S320.52A, S320.58A, S320.59A, S329.XXA,
S329.XXB, S329.XXD, S329.XXG, S329.XXK, S329.XXS
Spinal Neoplasm ICD-9-CM: 192.2, 198.3, 225.3, 237.5
ICD-10-CM: C41.2, C72.0, D16.6, D33.4, D43.4
Spinal Infection ICD-9-CM: 324.1, 324.9
ICD-10-CM: M46.39, G06.1, G07