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Anterior Cervical Discectomy & Fusion (ACDF)
Overview of Anterior Cervical Discectomy & Fusion (ACDF)
Anterior cervical discectomy and fusion (ACDF) is a
surgical procedure performed to remove a herniated or degenerative disc
in the cervical (neck) spine.
If you are
interested in spine surgery or a treatment for your spine pain, please
contact us to determine what option is
best for you, what your insurance will cover and any additional surgery
approach the spine from
the front, through the throat area. After the disc is removed, the vertebrae
above and below the disc space are fused together. Your doctor may recommend
discectomy if physical therapy or medication fail to relieve your neck or
arm pain caused by inflamed and compressed
spinal nerves. Patients typically
go home the same day; recovery time takes 4 to 6 weeks.
Degenerative disc disease causes the discs (purple) to dry
out. Tears in the disc annulus can allow the gel-filled nucleus material
to escape and compress the spinal cord causing numbness and weakness.
Bone spurs may develop which can lead to a narrowing of the nerve root
canal (foraminal stenosis). The pinched spinal nerve becomes swollen and
What is an anterior cervical
discectomy & fusion (ACDF)?
Discectomy literally means "cutting out the disc." A
discectomy can be performed anywhere along the spine from the neck
(cervical) to the low back (lumbar). Your
surgeon reaches the damaged disc
from the front (anterior) of the spine — through the throat area. By moving
aside the neck muscles, trachea, and esophagus, the disc and bony vertebrae
are accessed. In the neck area of the spine, an anterior approach is more
convenient than a
posterior (back) because the disc can be reached without
disturbing the spinal cord, spinal nerves, and the strong neck muscles of
the back. Depending on your particular case, one disc (single-level) or more
(multi-level) may be removed.
After the disc is removed, the space between the
bony vertebrae is empty. To prevent the vertebrae from collapsing and
rubbing together, the
surgeon fills the open disc space with a
The graft serves as a bridge between the two vertebrae to create a
fusion. The bone graft and vertebrae are often immobilized and held together
with metal plates and screws.
Following surgery the body begins its natural
healing process and new bone cells are formed around the graft. After 3 to 6
months, the bone graft should join the vertebrae above and below to form one
solid piece of bone. With instrumentation and fusion working together, the
bone may actually grow around the plates and screws – similar to reinforced
Bone grafts come from many sources. Each type has
advantages and disadvantages.
- Autograft bone comes from you. The
takes your own bone cells from the
hip (iliac crest). This graft has
a higher rate of fusion because it has bone-growing cells and
proteins. The disadvantage is the pain in your hipbone after
surgery. Harvesting a bone graft from your hip is done at the same
time as the spine surgery. The harvested bone is about a half inch
thick – the entire thickness of bone is not removed, just the top
- Allograft bone comes from a donor (cadaver). Bone-bank bone is
collected from people who have agreed to donate their organs after
they die. This graft does not have bone-growing cells or proteins,
yet it is readily available and eliminates the need to harvest bone
from your hip. Allograft is shaped like a doughnut and the center is
packed with shavings of living bone tissue taken from
- Bone graft substitute comes from man-made plastic, ceramic, or
bioresorbable compounds. Often called cages, this graft material is
packed with shavings of living bone tissue taken from your spine
After fusion you may notice some range of motion
loss, but this varies according to neck mobility before surgery and the
number of levels fused. If only one level is fused, you may have similar or
even better range of motion than before surgery. If more than two levels are
fused, you may notice limits in turning your head and looking up and down.
New motion-preserving artificial disc replacements have emerged as an
alternative to fusion. Similar to
knee replacement, the artificial disc is
inserted into the damaged joint space and preserves motion, whereas fusion
eliminates motion. Outcomes for
artificial disc compared to ACDF (the gold
standard) are similar, but long-term results of motion preservation and
adjacent level disease are not yet proven. Talk with your
whether ACDF or artificial disc replacement is most appropriate for your
Who is a candidate for
Anterior Cervical Discectomy Fusion?
You may be a candidate for
discectomy if you have:
- diagnostic tests (MRI, CT, myelogram) show
that you have a
- significant weakness in your hand or arm
- arm pain worse than neck pain
- symptoms that have not improved with physical therapy or
ACDF may be helpful in treating the following
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.
- 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
foraminal or central
stenosis or disc herniation (Fig. 1).
The surgical decision
herniated discs heal after a few months of
nonsurgical treatment. Your doctor may recommend treatment options, but only
you can decide whether surgery is right for you. Be sure to consider all the
risks and benefits before making your decision. Only 10% of people with
herniated disc problems have enough pain after 6 weeks of nonsurgical
treatment to consider surgery.
Your surgeon will also discuss the risks and
benefits of different types of bone graft material.
Autograft is the gold
standard for rapid healing and fusion, but the graft harvest can be painful
and at times lead to complications. Autograft is more commonly used these
days as it has proven to be as effective for routine 1 and 2 level fusions
Who performs the procedure?
at United Spine & Joint can perform spine surgery. Our
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 ACDF
You may be scheduled for pre-surgical tests (e.g.,
blood test, electrocardiogram, chest X-ray) several days before surgery. In
the doctor’s office, you will sign consent and other forms so that the
surgeon knows your medical history (allergies, medicines/vitamins, bleeding
history, anesthesia reactions, previous surgeries). Discuss all medications
(prescription, over-the-counter, and herbal supplements) you are taking with
your health care provider. Some medications need to be continued or stopped
the day of surgery.
Stop taking all non-steroidal anti-inflammatory
medicines (Naprosyn, Advil, Motrin, Nuprin, Aleve, etc.) and blood thinners
(Coumadin, Plavix, etc.) 1 to 2 weeks before surgery as directed by the
stop smoking, chewing tobacco, and drinking alcohol 1
week before and 2 weeks after surgery because these activities can cause
bleeding problems. No food or drink is permitted past midnight the night
The most important thing you can do to ensure the success of your spinal
quit smoking. This includes cigarettes, cigars, pipes, chewing
tobacco, and smokeless tobacco (snuff, dip). Nicotine prevents bone growth
and puts you at higher risk for a failed fusion. Patients who smoked had
failed fusions in up to 40% of cases, compared to only 8% among non-smokers. Smoking also decreases your blood circulation, resulting in slower
wound healing and an increased risk of infection. Talk with your doctor
about ways to help you quit smoking: nicotine replacements, pills without
nicotine, and tobacco counseling programs.
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 is cleansed and prepped. If a
fusion is planned
and your own bone will be used, the hip area is also prepped to obtain a
bone graft. If a donor bone will be used, the hip incision is unnecessary.
Step 2: Make an incision
A 2-inch skin incision is made on the right or left side of your neck. The
surgeon makes a tunnel to the spine by moving aside muscles in your
neck and retracting the 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
With the aid of a fluoroscope (a special X-ray), the
surgeon passes a thin
needle into the disc to locate the affected vertebra and disc.
To remove the damaged disc, 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.
Gentle tension is placed on the spreader to separate the two vertebrae.
Step 4: Remove the disc fragments
The outer wall of the disc (annulus) is cut. The
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 to reach
the spinal canal. Any disc material pressing on the spinal nerves is
Step 5: Decompress the nerve
Bone spurs (osteophytes) that press on your nerve root are removed. The
foramen, through which the spinal nerve exits, is enlarged with a drill. This procedure, called a
foraminotomy, gives your nerves more room
to exit the spinal canal.
Step 6. Prepare a bone graft fusion
Using a drill, the open disc space is prepared on the top and bottom by
removing the outer cortical layer of bone to expose the blood-rich
cancellous bone inside. This “bed” will hold the
bone graft material that
you and your surgeon selected:
- Bone graft from your hip. A skin and muscle
incision is made over the crest of your hipbone. Next, a chisel is
used to cut through the hard outer layer (cortical bone) to the
inner layer (cancellous bone). The inner layer contains the
bone-growing cells and proteins. The bone graft is then shaped and
placed into the “bed” between the vertebrae (Fig. 5).
- Bone bank or fusion cage. A cadaver bone graft or bioplastic
cage is filled with the leftover bone shavings containing
bone-growing cells and proteins. The graft is then tapped into the
surgeon may reinforce the bone graft with a
metal plate screwed into the 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 the metal plate and screws.
New option: artificial disc replacement.
Instead of a bone graft or fusion cage, an
artificial disc device is
inserted into the empty disc space. In select patients, it may be beneficial
to preserve motion. Talk to your doctor – not all insurance companies will
pay for this new technology and out-of-pocket expenses may be incurred.
Step 7. Close the incision
The spreader and retractors are removed. The muscle and skin incisions are
sewn together with sutures. Steri-Strips or biologic glue is placed across
What happens after ACDF
You will awaken in the postoperative recovery area,
called the PACU. Blood pressure, heart rate, and respiration will be
monitored. Any pain will be addressed. Once awake, you will be moved to a
regular room where you’ll increase your activity level (sitting in a chair,
walking). Patients who have had bone graft taken from their hip may feel
more discomfort in their hip than neck incision. Most patients having a 1 or
2 level ACDF are sent home the same day. However, if medical complications
such as difficulty breathing or unstable blood pressure develop, you may
need to stay overnight. You will be given written instructions to follow
when you go home.
- After surgery, pain is managed with
narcotic medication. Because narcotic pain pills are addictive, they
are used for a limited period (2 to 4 weeks). As their regular use
can cause constipation, drink lots of water and eat high fiber
foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) can be
bought without a prescription. Thereafter, pain is managed with
acetaminophen (e.g., Tylenol).
- Hoarseness, sore throat, or difficulty swallowing may occur in
some patients and should not be cause for alarm. These symptoms
usually resolve in 1 to 4 weeks.
- If you had a fusion, do not use
non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin;
ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 6
months after surgery. NSAIDs may cause bleeding and interfere with
Do not smoke. Smoking delays healing by increasing the risk of
complications (e.g., infection) and inhibits the bones' ability to
- 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 (e.g., gallon of
- Housework and yard-work 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.
- You may need help with daily activities
(e.g., dressing, bathing), but most patients are able to care for
themselves right away.
- Gradually return to your normal activities. Walking is
encouraged; start with a short distance and gradually increase to 1
to 2 miles daily. A physical therapy program may be recommended.
- If applicable, know how to wear a cervical collar before leaving
the hospital. Wear it when walking or riding in a car.
- You may shower 1 to 4 days after surgery.
Follow your surgeon’s specific instructions. No tub baths, hot tubs,
or swimming pools until your health care provider says it’s safe to
- If you have staples or stitches when you go home, they will need
to be removed. Ask your surgeon or call the office to find out when.
When to Call Your Doctor
- If your temperature exceeds 101° F, or if the incision begins to
separate or show signs of infection, such as redness, swelling,
pain, or drainage.
- If your swallowing problems interfere with your ability to
breathe or drink water.
Recovery and prevention
Schedule a follow-up appointment with your
for 2 weeks after surgery. Recovery time 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
A cervical collar or brace is sometimes worn during
recovery to provide support and limit motion while your neck heals or fuses. Your doctor may prescribe neck stretches and
exercises or physical therapy once your neck has healed.
If you had a bone graft taken from your hip, you may
experience pain, soreness, and stiffness at the incision. Get up frequently
(every 20 minutes) and move around or walk. Don’t sit or lie down for long
periods of time.
Recurrences of neck pain are common. The key to
avoiding recurrence is prevention:
- Proper lifting techniques
- Good posture during sitting, standing, moving, and sleeping
- Appropriate exercise program
- An ergonomic work area
- Healthy weight and lean body mass
- A positive attitude and relaxation techniques (e.g., stress
- No smoking
What are the results?
Anterior cervical discectomy is successful in
relieving arm pain in 92 to 100% of patients. However, arm weakness and
numbness may persist for weeks to months. Neck pain is relieved in 73 to 83%
of patients. In general, people with arm pain benefit more from ACDF
than those with neck pain. Aim to keep a positive attitude and diligently
perform your physical therapy exercises.
spinal fusion varies depending on the
technique used and your general health (smoker). In a study that compared
three techniques: ACD, ACDF, and ACDF with plates and screws, the outcomes
- 67% of people who underwent ACD (no bone
graft) achieved fusion naturally. However, ACD alone results in an
abnormal forward curving of the spine (kyphosis) compared with the
- 93% of people who underwent ACDF with bone graft placement
- 100% of people who underwent ACDF with
bone graft placement and
plates and screws achieved fusion.
What are the risks?
No surgery is without risks. General complications
of any surgery include bleeding, infection,
blood clots (deep vein
thrombosis), and reactions to anesthesia. If spinal fusion is done at the
same time as a discectomy, there is a greater risk of complications.
Specific complications related to ACDF may include:
Hoarseness and swallowing difficulties. In some
cases, temporary hoarseness can occur. The recurrent laryngeal nerve,
which innervates the vocal cords, is affected during surgery. It may
take several months for this nerve to recover. In rare cases (less than
1/250) hoarseness and swallowing problems may persist and need further
treatment with an ear, nose and throat specialist.
Vertebrae failing to fuse. Among many reasons
why vertebrae fail to fuse, common ones include smoking,
malnutrition. Smoking is by far the greatest factor that
can prevent fusion. Nicotine is a toxin that inhibits bone-growing
cells. If you continue to smoke after your spinal surgery, you could
undermine the fusion process.
Hardware fracture. Metal screws, rods, and
plates used to stabilize the 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 or replace the hardware.
Bone graft migration. In rare cases (1 to 2%),
the bone graft can move from the correct position between the vertebrae
soon after surgery. This is more likely to occur if hardware (plates and
screws) are not used to secure the bone graft. It’s also more likely to
occur if multiple vertebral levels are fused. If this occurs, a second
surgery may be necessary.
Transitional syndrome (adjacent-segment
disease). This syndrome occurs when the vertebrae above or below a
fusion take on extra stress. The added stress can eventually degenerate
the adjacent vertebrae and cause pain.
Nerve damage or persistent pain. Any operation
on the spine comes with the risk of damaging the nerves or spinal cord.
Damage can cause numbness or even paralysis. However, the most common
cause of persistent pain is nerve damage from the disc herniation
itself. Some disc herniations may permanently damage a nerve making it
unresponsive to decompressive surgery. In these cases, spinal cord
stimulation or other treatments may provide relief. Be sure to go into
surgery with realistic expectations about your pain. Discuss your
expectations with your