Study Design.: Retrospective cohort study. Objective.: To compare anterior cervical disc replacement (ACDR) and anterior cervical discectomy and fusion (ACDF) in smokers and nonsmokers. Summary of Background Data.: Smoking is a well-established risk factor after fusion-based spine surgery, whereas ACDR does not depend on bony fusion. This prompts interest in ACDR for smokers, but comparative data remain limited. Methods.: Patients aged ≥18 years undergoing ACDR or ACDF for cervical myelopathy or radiculopathy from 2017 to 2023 were stratified by smoking status. Primary outcomes were length of stay (LOS), adjacent segment disease (ASD), reoperation, and subsidence; secondary outcomes were PROMIS Global Mental Health (GMH) and Global Physical Health (GPH) through 2 years. Regression within each stratum adjusted for age, Charlson Comorbidity Index, and operative levels. Procedure-by-smoking interactions were fitted on the full cohort, with Firth penalized regression for sparse outcomes, mixed-effects models for PROMIS, and time-to-event analysis for complications. Results.: 242 patients were included (60 ACDR, 182 ACDF). Among non-smokers, ACDR was associated with lower reoperation (2.4% vs. 13.9%; adjusted OR 3.91, P =0.036) and subsidence (12.2% vs. 25.2%; adjusted OR 2.12, P =0.047), shorter LOS (+0.31 d for ACDF, P =0.006), and higher 2-year GPH (50.5±6.6 vs. 44.1±6.8, P <0.001). Among smokers, only the shorter LOS persisted (+0.43 d, P =0.02); no differences were seen in reoperation, subsidence, ASD, or patient-reported outcomes. In interaction testing, only 2-year GPH reached significance. Conclusions.: The advantages of ACDR among non-smokers were absent in smokers. These findings indicate that smoking may attenuate the procedure-specific advantages of ACDR and that smoking status should be considered a possible determinant of surgical effectiveness. Smoking cessation should be emphasized as an integral component of preoperative counseling and surgical planning, and the choice between ACDR and ACDF in active smokers should be made with the understanding that the expected benefits of ACDR may not be present in this population.

Study Design.: Systematic review and meta-analysis. Objective.: To compare functional, radiographic, and complication outcomes among ACDF, PCDF, and laminoplasty for multilevel cervical spondylotic myelopathy (CSM). Summary of Background Data.: CSM is a major source of patient morbidity in the United States. Three surgical approaches are commonly employed for this degeneration: ACDF, PCDF, and laminoplasty. Comparative data is warranted to guide approach selection. Methods.: In accordance with PRISMA guidelines, PubMed, Embase, CENTRAL, and Scopus were searched through February 2026 to identify comparative studies reporting outcomes among adult patients undergoing ACDF, PCDF, or laminoplasty for multilevel (≥3 levels) CSM. Twelve studies comprising 1,129 patients met inclusion criteria and were organized into three pairwise comparisons: ACDF versus laminoplasty, PCDF versus laminoplasty, and ACDF versus PCDF. Functional, radiographic, and complication outcomes were comparatively assessed. Continuous outcomes were pooled as mean differences (MD) with 95% confidence intervals (CI). Dichotomous outcomes were pooled as odds ratios (OR) with 95% CI. Heterogeneity was assessed using the I² statistic. Results.: JOA score improvement did not differ between ACDF and laminoplasty (MD=−0.20, P =0.43) or ACDF and PCDF (MD=1.06, P =0.21). VAS neck pain favored ACDF over laminoplasty (MD=−1.05, P =0.03). ACDF demonstrated reduced cervical range of motion (MD=−9.14°, P <0.001) compared with laminoplasty. Hospital stay was shorter after ACDF (MD=−2.62 days, P =0.002) and longer after PCDF (MD=1.19 days, P <0.001) relative to laminoplasty. ACDF was associated with lower rates of axial pain (Peto OR=0.21, P =0.007) and C5 palsy (Peto OR=0.27, P =0.049) but higher rates of dysphagia (Peto OR=5.88, P <0.001) compared with laminoplasty. SSI was more frequent after PCDF than laminoplasty (Peto OR=4.27, P =0.01). Conclusions.: ACDF, PCDF, and laminoplasty demonstrated similar neurological recovery for multilevel CSM. Procedure-specific differences in cervical range of motion, length of stay, and complication profiles support approach selection guided by preoperative alignment and patient-specific concerns.

Background/Objectives: Chlorhexidine and iodine-based preparations are both widely used, and the existing literature suggests a possible advantage of chlorhexidine in clean elective surgery. Whether this extends to instrumented degenerative spine surgery is unknown. We asked whether chlorhexidine-based skin preparation reduces 90-day postoperative infection compared with iodine-based preparation after instrumented degenerative cervical or lumbar spine surgery. Methods: A retrospective TriNetX cohort study was performed among adults undergoing instrumented degenerative cervical or lumbar spine surgery. Patients were stratified by anatomic region and by preoperative preparation exposure: chlorhexidine-based versus iodine-based. Moreover, 1:1 propensity-score matching was performed within each anatomic stratum on demographics, Charlson Comorbidity Index (CCI), diabetes, smoking, obesity and BMI, immunosuppression, methicillin-resistant Staphylococcus aureus (MRSA) carrier status, and index procedure codes. The primary outcome was 90-day postoperative infection. Secondary outcomes were superficial and deep surgical site infection, MRSA infection, incision and drainage, debridement, sepsis, urinary tract infection, and pneumonia. Results: After matching, the cervical cohort included 3528 patients per group and the lumbar cohort 4164 per group. Postoperative infection did not differ in the cervical cohort (1.76% vs. 1.59%; risk ratio [RR] 1.11, 95% confidence interval [CI] 0.77–1.58; p = 0.578) or the lumbar cohort (3.17% vs. 3.29%; RR 0.96, 95% CI 0.76–1.22; p = 0.757). Superficial and deep infection, MRSA infection, debridement, sepsis, urinary tract infection, and pneumonia did not differ significantly in either cohort. Conclusions: No statistically significant difference in 90-day postoperative infection was found between chlorhexidine-based and iodine-based skin preparation after instrumented degenerative cervical or lumbar spine surgery.