Purpose <p>Early revision surgery after elective anterior cervical discectomy and fusion (ACDF) is uncommon but clinically important, as it may reflect early mechanical failure, procedure-related morbidity, or postoperative complications requiring repeat operative intervention. Contemporary national data specifically evaluating predictors of early revision after elective ACDF remain limited. The purpose of this study was to determine the incidence of revision surgery requiring readmission within 90 days after elective ACDF and to identify baseline clinical and index-admission postoperative factors associated with this outcome.</p> Methods <p>A retrospective cohort study was performed using the Nationwide Readmissions Database from 2020 to 2022. Adult patients undergoing elective ACDF were identified using ICD-10-PCS procedure codes. Cases associated with trauma, malignancy, non-elective indications, or infection as the indication for the index ACDF hospitalization were excluded. Index procedures performed between January and September were included to allow complete 90-day follow-up. The primary outcome was early revision spinal surgery requiring readmission within 90 days of the index hospitalization, defined by readmission procedure codes for revision fusion, decompression, or hardware removal. Secondary outcomes included 90-day all-cause readmission and readmission resource utilization. Univariate comparisons were performed using t tests and chi-square testing. Multivariable logistic regression models were used to identify independent associations with early revision surgery.</p> Results <p>A total of 30,696 patients undergoing elective ACDF were included. Mean age was 57.7 ± 12.6 years, and 51.7% were female. Within 90 days, 2,198 patients (7.2%) were readmitted and 303 patients (1.0%) underwent early revision spinal surgery requiring readmission. Patients requiring early revision were older than those who did not undergo revision (60.9 ± 11.3 vs. 57.6 ± 12.6 years, <i>p</i> &lt; 0.001), and were more likely to have hypertension (61.1% vs. 45.1%, <i>p</i> &lt; 0.001) and congestive heart failure (3.0% vs. 1.2%, <i>p</i> = 0.005). Diabetes mellitus was more frequent in the early revision group but was not statistically significant on univariate analysis (26.4% vs. 22.7%, <i>p</i> = 0.132) and was not independently associated with revision in the multivariable model (OR 0.98, 95% CI 0.75–1.28; <i>p</i> = 0.879). On multivariable analysis, age (OR 1.016, 95% CI 1.006–1.026; <i>p</i> = 0.002), hypertension (OR 1.85, 95% CI 1.45–2.37; <i>p</i> &lt; 0.001), and congestive heart failure (OR 2.99, 95% CI 1.48–6.07; <i>p</i> = 0.002) were independently associated with early revision. In a separate model of index-admission postoperative complications, dysphonia (OR 3.96, 95% CI 1.69–9.28; <i>p</i> = 0.002) and surgical site infection (OR 15.95, 95% CI 4.75–53.56; <i>p</i> &lt; 0.001) were associated with revision surgery within 90 days.</p> Conclusions <p>In this national cohort of elective ACDF procedures, early revision surgery requiring readmission within 90 days occurred in 1.0% of patients. Older age, hypertension, and congestive heart failure were independently associated with increased revision risk, while dysphonia and surgical site infection recorded during the index admission were associated with subsequent early revision. Diabetes mellitus was evaluated but was not independently associated with early revision. Because procedure-level details, surgical level, laterality of approach, implant-related factors, and same-hospitalization reoperations were not fully available in the NRD, these findings should be interpreted as associations rather than causal determinants of early surgical failure.</p> Levels of evidence <p>Level III.</p>