Anterior Cervical Discectomy & Fusion

Overview and Indications

Anterior cervical discectomy and fusion (ACDF) is performed for patients with a symptomatic, painful herniated disc in the neck. Anterior cervical discectomy and fusion is the most common neck surgery performed by spine surgeons. It is performed to remove a portion of the intervertebral disc, the herniated or protruding portion that is compressing the spinal cord and nerve root. However, in order to do so generally involves removing nearly the entire disc, which must be replaced with a piece of bone graft and mended (fused) together to maintain stability.

Surgical Technique

The surgery is performed utilizing general anesthesia. A breathing tube (endotracheal tube) is placed and the patient breathes using a ventilator during the surgery. Preoperative intravenous antibiotics are given. Patients are positioned in the supine (lying on the back) position, generally using a standard flat operating table. The surgical region (neck area) is cleansed with a special cleaning solution. Sterile drapes are placed, and the surgical team wears sterile surgical attire such as gowns and gloves to maintain a bacteria-free environment.

A 2-4 centimeter (depending on the number of levels) transverse incision is made in one of the creases of neck, just off the midline. The cervical fascia is gently divided in a natural plane, between the esophagus and carotid sheath (area containing the blood vessels in the neck). Small retractors and an operating microscope are used to allow the surgeon to visualize the anterior (front part) vertebral body and discs. After the retractor is in place, an x-ray is used to confirm that the appropriate spinal level(s) is identified.

A complete discectomy (removal of the disc, including the protruding fragment) is typically performed, allowing the spinal cord and nerves to return to their normal size and shape when the compressive lesions are removed. Small dental-type instruments and biting/grasping instruments (such as a pituitary rongeur and kerrison rongeur) are used to remove the herniated disc. All surrounding areas are also checked to ensure no compressive spurs or disc fragments are remaining. The size of the empty disc space is measured; a graft size is chosen so as to restore the normal disc space height and the graft is then gently tapped into the disc space, in between the two vertebral bodies. A small titanium metal plate is frequently placed, affixed to the vertebrae with small screws, to impart immediate stability to the construct and allow for optimal bone healing and fusion. X-rays are then used to confirm appropriate position and alignment of the graft and hardware.

The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with a few strong sutures. The skin can usually be closed using special surgical glue, leaving a minimal scar and requiring no bandage.

The total surgery time is approximately 2 to 3 hours, depending on the number of spinal levels involved.

Post-Operative Care

Most patients are able to go home 1-2 days after surgery. Before patients go home, physical therapists and occupational therapists work with patients and instruct them on proper techniques of getting in and out of bed and walking independently. Patients are instructed to avoid bending and twisting of the neck in the early postoperative period (first 2-4 weeks). Patients can gradually begin to bend and twist their neck after 2-4 weeks as the pain subsides and the neck and back muscles get stronger. Patients are also instructed to avoid heavy lifting in the early postoperative period (first 2-4 weeks).

Brace

Most patients are placed in either a soft cervical collar or padded, plastic neck brace. This reduces the stress on the neck area and helps decrease pain. It can also be used to improve bone healing by maintaining the neck in a rigid position, especially in the first few weeks and months after surgery.

Wound Care

The wound area can be left open to air. No bandages are required. Small surgical tapes affixing the suture should be left in place. The area should be kept clean and dry.

Showering/Bathing

Patients can shower immediately after surgery, but should keep the incision area covered with a bandage and tape, and try to avoid the water from water hitting directly over the surgical area. After the shower, patients should remove the bandage, and dry off the surgical area. . Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery.

Driving

Patients may begin driving when the pain has decreased to a mild level and mobility of the neck has improved, which is usually between 10-14 days after surgery. Patients need to be able to turn their neck and body enough to see right and left while driving. Patients should not drive while taking pain medicines (narcotics). When driving for the first time after surgery, patients should make it a short drive only and have someone come with them, in case the pain flares up and they need help driving back home. After patients feel comfortable with a short drive, they can begin driving longer distances alone.

Return to Work and Sports

Patients may return to light work duties as early as 2-3 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to heavy work and sports as early as 8-12 weeks after surgery, when the surgical pain has subsided and the neck and back strength has returned appropriately with physical therapy.

Doctor's Visits and Follow-Up

Patients will return for a follow-up visit to see the doctor approximately 8-12 days after surgery. The incision will be inspected and one suture will be removed. Medications will be refilled if necessary. Patients will usually return to see Dr. Spoonamore every 4-6 weeks thereafter, and an x-ray will be taken to confirm the fusion area is stable and healing appropriately. At 6-10 weeks after surgery, patients will be given a prescription to begin physical therapy for gentle neck exercises.

Results and Outcome Studies

The results of anterior cervical discectomy and fusion surgery in the treatment of a painful, cervical herniated disc are generally excellent. Numerous research studies in medical journals demonstrate greater than 88-97% good or excellent results from anterior cervical discectomy and fusion surgery. The fusion rate is significantly improved with the use of a small titanium plate, and typically obviates the need for extensive use of a neck brace postoperatively. Most patients are noted to have a rapid improvement of their pain and return to normal function following surgery.

Selected Bibliography

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Clements DH, O'Leary PF. Anterior cervical discectomy and fusion. Spine 1990;15:1023.

Cloward RB. The anterior approach for ruptured cervical discs. J Neurosurg 1958; 15: 602.

Garvey TA, Eismont FJ. Diagnosis and treatment of cervical radiculopathy and myelopathy. Orthop Rev 1991;20:595.

Gore DR, Sepic SB. Anterior cervical fusion for degenerated or protruded discs: A review of 146 patients. Spine 1984; 9: 667-71.

Herkowitz HN. The surgical management of cervical spondylitic radiculopathy and myelopathy. Clin Orthop Rel Res 1989;239:94.

Palit M, Schofferman J, Goldthwaite N, et al. Anterior discectomy and fusion for the management of neck pain. Spine 1999:242224.

Riley L, Robinson R, Johnson K, et al. The results of anterior interbody fusion of the cervical spine. J Neurosurg 1969;30:127.

Robinson RA, Walker AE, Ferlic DC, et al. The results of anterior interbody fusion of the cervical spine. J Bone Joint Surg Am 1962;44:1569.

Smith GW, Robinson RA. The treatment of certain cervical spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am 1958;40:607.

Wang JC, McDonough PW, et al. Increased fusion rates With cervical plating for two-level anterior cervical discectomy and fusion spine. Spine 2000;25:41.

White AA, Southwick WO, Deponte RJ, et al. Relief of pain by anterior cervical spine fusion for spondylosis. J Bone Joint Surg Am 1973;55:525.

William JL, Allen MD, Harkess JW. Late results of cervical discectomy and interbody fusion: Some factors influencing the results. J Bone Joint Surg Am 1968; 50: 277.