Single-level Anterior Cervical Decompression and Fusion (ACDF) was initially performed using Iliac Crest Bone Graft (ICBG) . Fusion rates improved when a surgical technique change, the addition of anterior plate fixation, was incorporated decades later [2,3]. Single level ACDFs with a machined allograft and plate fixation technique eventually became the industry standard as it demonstrated equivalent fusion rates with fewer complications than single level ACDFs with ICBG. This surgical technique was extended for use in patients with contiguous disk herniations. Multilevel ACDFs performed with machined allografts or interbody spacers and a two-level plate offered shorter operative times, less blood loss, better restoration of lordosis, and less immediate pain . Successful multi-level ACDFs were strongly influenced by the bone graft source , the smoking addiction , and the construct stability . Placement of two additional fixation screws in the central vertebral body, another improvement in the surgical technique, increased the construct strength compared to constructs with screws only placed into the end vertebral bodies . Using allografts for multilevel ACDFs was a device disadvantage as they often resulted in high non-union rates [9,10].
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