Does Implant Choice Matter? Clinical and Radiological Outcomes of 3-Level Anterior Cervical Discectomy and Fusion With Standalone Anchored Cage vs Plate-Cage System

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) remains the gold-standard surgical treatment for multilevel degenerative cervical myelopathy. While anterior plate-cage (PC) constructs have traditionally been used to enhance stability and lordosis, they are associated with increased soft-tissue dissection and plate-related complications. Standalone anchored cage (SAAC) systems have emerged as a lower-profile alternative with proven efficacy in single- and 2-level disease; however, evidence supporting their use in 3-level contiguous ACDF remains limited. OBJECTIVE: To compare the clinical, radiological, and perioperative outcomes of 3-level ACDF performed using SAAC vs conventional PC constructs. METHODS: A retrospective comparative study was conducted on 50 patients who underwent 3-level contiguous ACDF between 2017 and 2024 at 2 tertiary centers. Twenty-five patients received SAAC, and 25 received PC constructs. Clinical outcomes (visual analog scale, Neck Disability Index, and modified Japanese Orthopedic Association) and radiological parameters (segmental alignment, C2-C7 lordosis, segmental height, and fusion rates) were assessed preoperatively and up to 24 months postoperatively. Mixed-effects modeling was used to adjust for baseline differences. Both groups achieved comparable and clinically meaningful improvements in pain, neurological function, and disability at 2 years. Radiological outcomes, including alignment correction, height maintenance, subsidence, and fusion rates, were similar after adjustment for baseline factors. Complication profiles, including dysphagia and implant-related events, did not differ significantly between groups. CONCLUSIONS: In 3-level ACDF, SAAC constructs provide clinical and radiological outcomes comparable to PC systems at 2 years while offering significant perioperative advantages. SAAC performed robustly even in older, more comorbid patients, supporting its role as a safe and effective alternative for multilevel cervical degenerative disease. CLINICAL RELEVANCE: Standalone anchored cages may be considered an alternative to plate-cage constructs for 3-level ACDF, offering shorter operative time and lower blood loss with similar clinical and radiological outcomes at 2 years. LEVEL OF EVIDENCE: Level 3.