Testosterone Replacement Therapy is Associated With Increased Risk of Pseudarthrosis After Single-Level Anterior Cervical Discectomy and Fusion: A Propensity Matched Analysis

Objective To evaluate whether preoperative testosterone replacement therapy (TRT) use is associated with increased risks of pseudarthrosis and reoperation following single-level anterior cervical discectomy and fusion (ACDF). Methods The TriNetX Research Network was queried to identify adult males aged 18 to 89 years who underwent single-level ACDF. Patients were separated into a TRT exposure group within 1 year before initial ACDF procedure as well as comparator cohort without TRT exposure that was matched 1:1 using propensity score matching based on age, race, and relevant medical comorbidities. Patients were followed longitudinally for 2 years from the index procedure to assess postoperative outcomes. The primary outcomes were pseudarthrosis and reoperation. Risk ratios and time-to-event hazard ratios were calculated along with 95% confidence intervals. Results After propensity score matching, 494 matched pairs reached balance across all baseline characteristics. Patients receiving TRT demonstrated a 70% increased risk of pseudarthrosis (RR 1.70, CI 1.20–2.39; HR 1.71 CI 1.19 – 2.46) compared to the non-TRT cohort. TRT use was not associated with an increased risk of reoperation (RR 0.92 CI 0.59–1.43; HR 0.87, CI 0.55-1.38) following ACDF. Conclusions Preoperative testosterone replacement therapy was associated with increased risk of pseudarthrosis, but not reoperation following ACDF. These findings suggest that TRT may represent an important patient-specific risk marker in patients undergoing ACDF. Given the observational design and potential for residual confounding, these findings should not be interpreted as evidence of a causal effect.