Overview

Anterior cervical discectomy and fusion (ACDF) is a surgical procedure performed to treat a damaged disc in the neck area of your spine. Your doctor may recommend a discectomy if physical therapy or medication fails to help relieve your neck or arm pain caused by inflamed and compressed spinal nerves. ACDF is used to treat:

• Bulging and herniated disc: The gel-like material within the disc can bulge or rupture through a weak area in the surrounding wall (annulus). Irritation and swelling occurs when this material squeezes out and painfully presses on a nerve (Fig. 1).
  
  
• Degenerative disc disease: As discs naturally wear out, bone spurs form and the facet joints inflame. The discs dry out and shrink, losing their flexibility and cushioning properties. The disc spaces get smaller. These changes lead to stenosis or disc herniation.

This surgery requires a hospital stay from 1 to 3 days and recovery time takes between 4 to 6 weeks.

What is an anterior cervical discectomy & fusion (ACDF)?

Discectomy literally means "cutting out the disc." Anterior cervical discectomy is a surgical procedure that removes all or some of the disc. "Anterior" means that your doctor reaches the damaged disc from the front of your neck—a more convenient approach than from the back (posterior) of your neck. Depending on your particular case, one disc (single-level) or more (multi-level) may be removed.

Am I a candidate?

You may be a candidate for ACD surgery if:

• you have significant weakness in your hand or arm
• your arm hurts worse than your neck
• you have not improved with physical therapy or medication
• diagnostic tests (MRI, CT, myelogram) show that you have a herniated or degenerative disc

Your doctor may recommend treatment options, but only you can decide whether surgery is right for you. Be sure to look at all the risks and benefits before making a decision. Your surgeon may ask you to stop smoking before scheduling the surgery. Studies have proven that smoking decreases the body’s ability to create a fusion (1,2).

Who performs the procedure?

Spine surgery can be performed by a neurosurgeon or orthopedic surgeon. Many spine surgeons have specialized training in complex spine surgery. Ask your surgeon about their training, especially if your case is complex or you’ve had more than one spinal surgery.

What happens before surgery?

You may be scheduled for presurgical tests (e.g., blood test, electrocardiogram, chest X-ray) several days before surgery. In the doctors office you will sign consent forms and fill out paperwork so that the surgeon knows your medical history (allergies, medicines/vitamins, bleeding history, anesthesia reactions, previous surgeries). You may wish to donate blood several weeks before surgery. You should stop taking all non-steroidal anti-inflammatory medicines (Naproxin, Advil, etc.) and blood thinners (coumadin, aspirin, etc.) one week before surgery. Additionally, stop smoking, chewing tobacco, and drinking alcohol one week before and 2 weeks after surgery as these activities can cause bleeding problems.

What happens during surgery?

There are seven steps to the procedure. The operation generally takes 1 to 3 hours.

Step 1. Prepare the patient
You will lie on your back on the operative table and be given anesthesia. Once asleep, your neck area will be cleansed and prepped. If a fusion is planned and you have decided to use your own bone, the hip area will be cleansed and prepped to obtain a bone graft. If you’ve decided to use donor bone, a hip incision is unnecessary.

Step 2. Incision
A 2-inch skin incision is made in the front of your neck, slightly to the right side to avoid your trachea and esophagus (Fig. 2). The surgeon essentially makes a little tunnel to the spine, moving aside muscles in your neck and using retractors to hold back your trachea, esophagus, and arteries. Finally, the muscles that support the front of the spine are lifted and held aside so the surgeon can clearly see the bony vertebrae and discs.

Step 3. Prepare to remove disc
Once the bone is exposed, an X-ray is taken to locate the correct disc. In order for the damaged disc to be removed, the vertebrae above and below the disc must be held apart. Your surgeon first inserts a spreader into the body of each vertebra above and below the disc to be removed. Tension is placed on the spreader to gently separate the two vertebrae.

Step 4. Remove the damaged disc
The outer wall of the disc (annulus) is cut (Fig. 3). The surgeon removes about 2/3 of your disc using small grasping tools, and then looks through a surgical microscope to remove the rest of the disc. The posterior longitudinal ligament, which runs behind the vertebrae, is removed in order to reach the spinal canal and remove the disc material pressing on the spinal nerves.

Step 5. Decompress the nerve
Bone spurs (osteophytes) that press on your nerve root are removed and the intervertebral foramen, through which the spinal nerve exits, is enlarged with a drill (Fig. 4). This procedure is called a foraminotomy, and it gives your nerves more room to exit the spinal canal.

Step 6. Fusion (if necessary)
A fusion is usually performed after an anterior cervical discectomy to preserve the disc space and provide stability to the spine. There are several ways to create a fusion. The right one for you depends on your surgeon’s recommendation and your own choice (bone graft from your own hip or from a bone bank) (see Fusion).

Option 1: Bone graft. A drill is used to create a 1-millimeter shelf on both the underside of the upper vertebra and on the topside of the lower vertebra. A bone graft is taken from the top of your hipbone and placed into the shelf space between the vertebrae (Fig. 5).

Option 2: Interbody fusion cage. A tiny plastic or bioresorbable cage is filled with the leftover bone shavings and tapped into the shelf space.

The surgeon may reinforce the bone graft with a metal plate screwed into your vertebrae to provide stability during fusion and possibly a better fusion rate. An x-ray is taken to verify the position of the bone graft and any metal plating or screws.

Step 7. Closure
The spreader and retractors are removed. The muscle and skin incisions are sewn together with sutures. Steri-Strips are placed across the incision.

What happens after surgery?

You will wake up in the postoperative recovery area, called the PACU. Your blood pressure, heart rate, and respiration will be monitored, and your pain will be addressed. Once awake you will be moved to a regular room where your friends and family can visit. Patients that have had a bone graft taken from their hip may have more discomfort at their hip than their neck. Most patients are sent home the next day, however if you are experiencing swallowing problems or severe pain you may stay longer. You will be given written instructions to follow when you go home.

Discharge instructions

Discomfort

• Right after surgery, pain is managed with narcotic medications. Because narcotic pain pills are addictive, they are used for a limited period (2 to 4 weeks). Additionally, their regular use may cause constipation, so drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) may be bought without a prescription. Thereafter, pain is managed with acetaminophen (e.g., Tylenol).
• Hoarseness, sore throat, or difficulty swallowing may occur during the first 2 weeks.

Restrictions

• If you have had a fusion, do not use NSAIDs (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 3 to 6 months after surgery.
• Do not smoke. Smoking delays healing by increasing the risk of complications (e.g., infection) and inhibits the bones' ability to fuse.
• Do not drive for 2 to 4 weeks after surgery or until discussed with your surgeon.
• Avoid sitting for long periods of time.
• Avoid bending your head forward or backward.
• Do not lift anything heavier than 5 pounds, including children.
• Housework and yardwork are not permitted until the first follow-up office visit. This includes gardening, mowing, vacuuming, ironing, and loading/unloading the dishwasher, washer, or dryer.
• Postpone sexual activity until your follow-up appointment unless your surgeon specifies otherwise.

Activity

• Gradually return to your normal activities. Fatigue is common and expected. Let pain be your guide.
• Walking is encouraged; start with a short distance and gradually increase to 1 to 2 miles daily.
• An early exercise program of gentle stretching, conditioning, and strengthening may be advised. Exercise to the point of discomfort but not beyond.
• Learn the proper way to stand, sit, sleep, and lift. Generally, maintain a neutral spine (see Posture for a Healthy Back).
• If applicable, know how to wear a cervical collar before leaving the hospital. Wear it when walking or riding in a car.

Bathing/Incision Care

• You may shower 4 days after surgery unless instructed otherwise.
• If sutures/staples remain in place when you go home, they need to be removed. Ask your surgeon or call the office to find out when.

When to Call Your Doctor

• If the incision begins to separate or shows signs of infection, such as redness, swelling, pain, or drainage.

Recovery

Recovery at home generally lasts 4 to 6 weeks. X-rays may be taken after several weeks to verify that fusion is occurring. The surgeon will decide when to release you back to work at your follow-up visit.

A cervical collar or brace is sometimes worn during recovery to provide support and limit motion while your neck heals or fuses (see Braces & Orthotics). Your doctor may prescribe neck stretches and exercises or physical therapy once your neck has healed.

What are the results?

The arm pain usually goes away fairly quickly, although it may take weeks to months for the arm weakness and numbness to subside. It is important to keep a positive attitude and diligently perform your physical therapy exercises. Obtaining a successful fusion is largely up to you.

What are the risks?

No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications of ACDF that should be considered:

Vertebrae failing to fuse
There are many reasons why vertebrae fail to fuse. These include smoking, osteoporosis, obesity, and malnutrition. Smoking is by far the greatest factor that can prevent a fusion from occurring. Nicotine is a toxin that inhibits bone-growing cells. If you continue to smoke after your operation, you could undermine the fusion process.

Anesthesia
A very small number of people experience problems with the medication that puts them to sleep. Discuss any concerns you have with your anesthesiologist.

Hoarseness and swallowing difficulties
Sometimes the recurrent laryngeal nerve that innervates the vocal cords does not work for several months after surgery. This may cause temporary hoarseness.

Throbophlebitis
Also called Deep Venous Thrombosis (DVT), is a potentially serious condition in which blood clots form inside the veins of your legs. These clots may break free and travel to your lungs, causing collapse or even death.

There are several ways to prevent DVT. If your blood is moving it is less likely to clot, so get up and out of bed as soon as possible. Support hose and pulsatile stockings keep the blood from pooling in your veins and push it back to your heart.

Lung problems
Your lungs need to work their best after surgery to provide your tissues with enough oxygen to heal. If they have collapsed areas, then mucus and bacteria can build up providing an environment for pneumonia to develop. Your nurse will encourage you to breathe deeply and cough often.

Nerve damage
Any operation on the spine comes with the risk of damaging the nerves or spinal cord. Damage can cause numbness or even paralysis.

Infection
Tell your doctor if the wound becomes red, swollen or painful so that it can be treated with antibiotics.

Hardware fracture
The metal screws, rods and plates used to stabilize your spine are called “hardware.” The hardware may move or break before your vertebrae are completely fused. If this occurs a second surgery may be needed to fix the hardware.

Implant migration
Similar to a hardware fracture, migration occurs when the metal hardware stabilizing your spine moves from the correct position soon after surgery. If this happens, a second operation may be necessary.

Persistent pain
Be sure to go into surgery with realistic expectations about your pain. Surgery doesn’t remove all your pain, but allows you to return to improved function. Discuss your expectations with your doctor.

Transitional syndrome
The vertebrae above and below a fusion may take on extra stress and eventually degenerate and cause pain.

Pseudo arthrosis
Literally means “false joint.” This occurs when a fractured bone hasn’t healed or when a fusion is unsuccessful. The motion between the unhealed segments can cause pain.

Sources & links

If you have more questions, please contact the Mayfield Spine Institute at 800-325-7787 or 513-221-1100. Additional information is available on the web.

Sources

1. Bose B: Anterior cervical instrumentation enhances fusion rates in multilevel reconstruction in smokers. J Spinal Disord 14:3-9, 2001.
2. Hilibrand AS, Fye MA, Emery SE, et. al.: Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am 83-A:668-73, 2001.

Links

www.spineuniverse.com
www.yoursurgery.com
www.spine-health.com

Glossary

anesthesiologist: a doctor who specializes in monitoring your life functions during surgery so that you don’t feel pain.

annulus (annulus fibrosis): tough fibrous outer wall of an intervertebral disc.

anterior: from the front.

anterior longitudinal ligament (ALL): a strong fibrous ligament that courses along the anterior surface of the vertebral bodies from the base of the skull to the sacrum.

bone graft: bone harvested from ones self (autograft) or from another (allograft) for the purpose of fusing or repairing a defect.

cervical: the neck portion of the spine made of seven vertebrae.

discectomy: a type of surgery in which herniated disc material is removed so that it no longer irritates and compresses the nerve root.

fusion: to join together two separate bones into one to stop movement and provide stability.

herniated disc: a condition in which disk material protrudes through the disk wall and irritates surrounding nerves causing pain.

interbody cage: a devicemade of titanium or carbon-fiber that is placed in the disc space between two vertebrae. It has a hollow core packed with bone morsels to create a bone fusion.

intervertebral foramen: the hole through which the spinal nerve exits the spinal canal.

osteophytes: bony overgrowths that occur from stresses on bone, also called bone spurs.

posterior longitudinal ligament (PLL): a strong fibrous ligament that courses along the posterior surface of the vertebral bodies within the spinal canal from the base of the skull to the sacrum.

vertebra (plural vertebrae): one of 33 bones that form the spinal column, they are divided into 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal. Only the top 24 bones are moveable.

updated: 7.2004
reviewed by: Robert Bohinski, MD