What is ACDF Surgery?

What is anterior cervical discectomy and fusion (ACDF) surgery?

Anterior cervical discectomy and fusion surgery (also known as ACDF) is a surgical procedure used to relieve pressure on the spinal cord or the nerve roots in the neck (cervical spine) and concurrently to perform a spinal fusion, where two or more of the bones in the neck are joined together using a plate, screws, and bone graft.

ACDF surgery is most commonly performed for cervical radiculopathy (pinched nerve in the neck causing neck and arm pain) or cervical myelopathy (spinal cord compression causing difficulty with hand function or walking balance).

These conditions can both be caused by degenerative disc disease or bulging discs or herniated discs.

Anterior cervical discectomy and fusion surgery is typically recommended if patients have persistent pain symptoms despite at least 6-12 weeks of conservative management with physical therapy, medications, and activity modification.  It may be recommended sooner if these is evidence of spinal cord dysfunction or significant weakness or numbness.

Anterior cervical discectomy and fusion procedure

Anterior means approaching the spine through the front of the neck to give direct access to the diseased disc, spinal cord and nerves to be able to relieve compression safely.  Cervical refers to spine in the neck. Discectomy means to remove the diseased disc. Fusion means to join two bones together so they ultimately heal into a single bone.

During an ACDF procedure, you are positioned on your back on the operating room table.  The procedure is performed under general anesthesia.

After cleaning the skin and applying sterile drapes, an approximately 2 inch incision is made on the left or right side of your neck over the diseased spinal levels.  The neck muscles, trachea, esophagus, and arteries and veins are moved to the side to access the front of the spine. An x-ray is obtained to confirm that the surgeon is at the correct diseased disc level or levels.

Specialized retractors are then placed to protect the structures of the neck and to spread the bones apart slightly.  The disc is then removed in its entirely under microscopic visualization. Bone spurs that have formed from degenerative disc disease and aging-related changes are then removed using a high-speed burr and small biting instruments.

The ligament that covers the spinal canal is then also removed to visualize the spinal cord and remove any bone or herniated disc fragments in the spinal canal that may be irritating the spinal cord or nerve roots.

The bone is then prepared for fusion and a bone graft is placed into the empty disc space.

This can be the patient’s own bone (autograft usually taken from the hip), allograft (bone graft obtained from a bone bank), or a metal or plastic cage filled with bone graft substitute.

A plate and screws are then fixed to the front of the spine to provide an internal brace and stability to help the spinal fusion to heal successfully. The retractors are then removed and the incision is closed.

What to expect after ACDF surgery?

Anterior cervical discectomy and fusion surgery is most successful for patients with arm pain that is worse than neck pain, or those with signs of spinal cord dysfunction such as difficulty with hand dexterity or walking balance.  The vast majority of patients with severe arm pain that is caused by a pinched nerve in the neck wake up in the recovery room after ACDF surgery with near complete resolution of the arm pain they had before surgery.

If a drain is placed at the time of surgery to remove any bleeding from the surgical site, it is typically removed later in the evening on the day of surgery or the following morning.  Patients may be placed into a brace after ACDF surgery depending on a variety of factors.

ACDF Surgery Recovery

Patients typically can go home either on the same day after anterior cervical discectomy and fusion surgery or the following morning after surgery, depending on how many levels were operated on.  Patients typically remain in a brace for 4-6 weeks after surgery, and it can be removed for showering and eating. If numbness, tingling, or weakness was present before anterior cervical discectomy and fusion surgery, this will typically resolve over the course of weeks to months.

In some instances the numbness and weakness may not completely recover depending on how long symptoms were present before ACDF surgery and if any permanent damage to the nerves or spinal cord had already occured before surgery.

Post-operative visits are recommended at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after anterior cervical discectomy and fusion surgery to monitor the healing of the fusion with x-rays.  For the first 6 weeks while the patient is in the collar, activities are restricted to lifting no more than 10 lbs, and no overhead activities. Between 6 weeks and 3 months after surgery the patient can slowly increase their activities.

It typically takes between 6-12 months for the fusion to fully heal; however, by 3 months the fusion is typically healed enough to allow full return back to normal activities.

Walking daily or even twice daily for exercise is encouraged immediately after anterior cervical discectomy and fusion surgery as this increases the blood flow throughout the body and spine and encourages healing of the fusion.  Patients should not take regular NSAIDS (e.g. ibuprofen, naproxen, Advil, Aleve, etc.) for the first 3 months after ACDF surgery as these medications can impair the bone healing process.

ACDF Surgery Risks

While all spinal operations carry some risks, in general the risks of ACDF surgery are lower than some other spinal procedures.  In particular, the risk of infection is much lower than procedures performed through the back of the neck or elsewhere in the spine.

The most common risks and side effects of ACDF surgery are:

  • Problems swallowing after surgery, also called dysphagia.  This occurs in every patient undergoing an ACDF procedure, and it is typically temporary and resolves over 1-2 weeks, although 3-4% of patients can experience persistent dysphagia that lasts over 3 months.

  • Voice hoarseness, also called dysphonia.  This can occur if there is an injury or stretch of the nerves that control the vocal cords.  If this occurs it typically resolves over weeks to months although in rare cases it can be permanent.

  • Failure of successful fusion or pseudarthrosis.  This occurs more commonly than most surgeons realize and is thought to be almost 10% after a one-level ACDF and is higher in patients undergoing multi-level ACDF surgery.  Patient specific factors that increase this risk include smoking, obesity, diabetes or otherwise poor medical health. Smoking is the single greatest factor that increases the chance of failure of ACDF surgery as nicotine is toxic to the spine and decreases the blood flow available to promote successful healing.  Quitting smoking prior to surgery is essential to a successful outcome from ACDF surgery. If a patient has a pseudarthrosis, over half of these patients have no symptoms or only minimal symptoms and don’t need any further surgery.

  • Adjacent level degeneration.  This refers to degenerative disease that can occur above or below an ACDF at the next level due to transfer of stress and motion.  This can result in the need for further surgery at other levels. The exact rate of this with modern ACDF techniques is not precisely known, but is likely 2-3% per year.

Other risks that are more rare but possible after anterior cervical discectomy and fusion surgery include:

  • Potential damage to the spinal cord or nerves

  • Damage to the carotid arteries or vertebral arteries that could result in stroke or death

  • Damage to the trachea or esophagus

If you have more questions or would like to schedule an appointment with Dr. Nemani to see if you are a candidate for an anterior cervical discectomy and fusion (ACDF), please call 919-781-5600 or book an appointment online.