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ACDF

ACDF stands for anterior cervical discectomy and fusion. This is a neck surgery that implies the removal of a damaged cervical disc in order to relieve the pressure and alleviate the correlated pain. The disc that is removed can be herniated or degenerative.

In order to qualify for this intervention, patients should:

• present a herniated or degenerative disc diagnosis in the form of a CT, MRI, or myelogram
• feel neck or arm pain
• feel hand or arm weakness
• prove that other types of therapy (physical or medication) did not manage to alleviate the symptoms

The conditions that can be treated through ACDF are:

• bulging and herniated disc
• degenerative disc disease

This procedure successfully alleviates arm pain in 92 to 100% of cases and neck pain in 73 to 83% of cases.

Typically, an ACDF procedure is more beneficial for patients who suffer from arm pain than those who suffer from neck pain. Spinal fusion can be successfully achieved if the right techniques are deployed and the patient’s general health is good (e.g. if the patient is a smoker or not).

It takes approximately 2 hours to perform this intervention which requires 7 distinct steps.

• preparing the patient
• making an incision
• locating the damaged disc
• removing the disc
• decompressing the nerve
• preparing a bone graft fusion
• closing the incision

More exactly, the following series of steps are performed to complete an ACDF procedure:

• the patient is anesthetized and lies on his or her back
• the neck area is cleansed and prepped
• if the patient’s own bone is used for the fusion, the hip has to be prepared for a bone graft
• there is no hip incision if the bone will be taken from a donor
• an incision is made on the patient’s side of the neck. It will measure approximately 2 inches
• The neck’s muscles are moved aside and the patient’s arteries, trachea, and esophagus are retracted so that the surgeon can access the spine
• the surgeon needs to have full visibility into the discs and the bony vertebrae. To achieve it, he or she must lift the muscles supporting the spine and hold them aside
• the damaged vertebra and disc are located by passing a needle in the disc, with the help of a fluoroscope
• a retractor is used for spreading apart the vertebrae bones situated above or below the affected disc
• then, the surgeon cuts the outer wall of the disk and removes approximately 2 thirds of it with the help of grasping tools
• the remaining part of the disc is removed with the aid of a surgical microscope
• afterward, the surgeon gets to the spinal canal by removing the ligament lying behind the vertebrae
• if there are traces of disc material that press the spinal nerves, the doctor will remove them
• the same happens with the bone spurs pressing the nerve’s root
• the doctor uses a drill to enlarge the foramen that serves as a passageway for the spinal nerve. This process is called foraminotomy
• then, the blood-rich cancellous bone is revealed after the removal of the outer cortical layer. Here is where the bone graft material will be placed.
• the surgeon removes the spreader retractors
• the skin incision is closed through suturing
• the doctor puts biological glue or steri-strips on the incision

The anterior approach of this surgery has several typical advantages:

• better access to the spine
• by opting for the anterior approach, the doctor can gain extensive access to the cervical spine (starting from the upper part of the neck and reaching the cervicothoracic junction)
• less postoperative pain
• it provides good access to the spine through a relatively uncomplicated pathway
• the patient tends to have less incisional pain from this approach than from a posterior operation
• the division of the muscle or the dissection is limited so that the postoperative pain can be minimized

The main postoperative problem most patients face is difficulty swallowing for 2 to 5 days due to the retraction of the esophagus during the surgery.

Anterior cervical discectomy may lead to some complications. Some of the most common risks include:

• poor postoperative symptom relief
• lack of bone graft fusion
• infection
• significant swallowing
• speech impairment
• nerve root problems
• spinal cord problems (in about 1 in 10,000 cases)
• bleeding
• trachea or esophagus problems
• hardware fracture

With nonsurgical treatment, patients usually need several months to heal a herniated disc. Other options besides surgery are available, but you have to discuss them with your doctor and make the right decision. About 10% of the patients with herniated discs who have used conservative treatment for about a month and a half consider surgery because the pain is still persistent.

This is a case of a 33-year-old female with excruciating neck and left arm pain and weakness. The pain radiated down to her thumb and middle finger.

She had an MRI that demonstrated an eccentric to the left disc herniation at C5-6 (Figure 1) and a central disc herniation at C6-7 (Figure 2). She had tried non-surgical management in the form of medications, injections, and physical therapy. but these failed. She ultimately underwent a 2 level ACDF at C5-7. She immediately noted increased strength and decreased arm pain after the surgery, with only a mild amount of neck discomfort.

Magnetic Resonance Image C5-6
MRI image through C5-6 demonstrating
left-sided disc herniation.

Magnetic Resonance Image C6-7
MRI image through C6-7 demonstrating
central disc herniation.

Postoperative Lateral X-Ray
Lateral x-ray after 2 level ACDF