Anterior Cervical Discectomy & Fusion (ACDF)

Most herniated discs heal after a few months of nonsurgical treatment. Your doctor may recommend and try several treatment options before surgery.

You may need this surgery if a disc is damaged from herniation or injury, for example, and no longer adequately supports the spine or provides cushioning between its neighboring discs. A damaged disc can cause pain in the back, arms and legs.

ACDF surgery may be an option if physical therapy or medications fail to relieve your neck or arm pain caused by pinched nerves.

You may be a candidate for discectomy if you have:

• Diagnostic tests (MRI, CT, myelogram) show that you have a herniated or degenerative disc,
• Significant weakness in your hand or arm,
• Arm pain worse than neck pain, or
• Symptoms that have not improved with physical therapy or medication.

ACDF may be helpful in treating the following conditions:

• Bulging and herniated disc: The gel-like material within the disc can bulge or rupture through a weak area in the surrounding wall. Irritation and swelling occur 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, and the disc spaces get smaller. These changes lead to canal stenosis or disc herniation.

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.

Achieving a spinal fusion varies depending on the technique used, your general health and your dedication to your physical therapy regimen. Physical therapy is strongly recommended for a full recovery in mobility and strength.

Your surgeon will also discuss the risks and benefits of surgery as well as the pros and cons of the different types of bone graft material.

The neurosurgeons at Semmes Murphey Clinic have specialized training in complex spine surgery. In fact, many of the surgeons at SMC have invented or perfected techniques and tools to help make spine surgery less intrusive and more successful.

ACDF surgery begins with an incision made in the throat area to access the disc. The spine is actually more accessible from the front of the neck than from the back because the disc can be reached without disturbing the spinal cord, spinal nerves, and the strong neck muscles.

After the disc is removed, the space between the bony vertebrae is empty. To prevent the vertebrae from collapsing and rubbing together, a spacer is inserted to fill the open disc space.

This replacement, usually a bone graft, serves as a bridge between the two vertebrae to create a spinal fusion. The bone graft and vertebrae are fixed in place with metal plates and screws.

Following surgery, the body begins its natural healing process in which new bone cells grow around the graft. After 3 to 6 months, the bone graft should join or fuse with the two vertebrae to form one solid piece of bone.

Bone grafts come from many sources. Each type has advantages and disadvantages.

• Autograft bone: comes from you and is the gold standard for rapid healing and fusion. But the hip incision can be painful and at times lead to complications.
  • The surgeon takes bone cells from your own hip. This graft has a higher rate of fusion because it has bone-growing cells and proteins.
• The disadvantage is the pain in your hip 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 half layer.
• Allograft bone: comes from a cadaver donor and is more commonly used. It has proven to be as effective for routine one- and two-level fusions in non-smokers.
  • 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.
• The allograft is shaped like a doughnut and the center is packed with shavings of living bone tissue taken from your spine during surgery.
• Substitute bone graft: comes from man-made plastic, ceramic, or bioresorbable compounds.
  • As these improve, they are growing in use.
• Often called cages, this graft material is packed with shavings of living bone tissue taken from your spine during surgery.

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 a 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.

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.

Both procedures have similar operative benefits with respect to reduction of arm pain and numbness, and potential reduction of neck pain with good success rates ranging from 85-95%.

Talk with your surgeon about whether ACDF or artificial disc replacement is most appropriate for you.

Risks include:

• Infection
• Bleeding
• spinal fluid leak
• decreased range of motion secondary to removal of the discs and fusion
• Dysphagia (difficulty swallowing-typically transient)
• Cosmetic scar visible on the front of the neck
• hoarseness or voice changes (usually subsides)
• Failure of the bone graft space to incorporate with the adjacent vertebral bodies
• Injury to the nerve root and/or the spinal cord, and instrumentation loosening

You may be scheduled for presurgical tests (e.g., blood test, electrocardiogram, chest X-ray) several days before surgery. An anesthesiologist will talk with you and explain the effects of anesthesia and its risks.

Before the day of your procedure, your doctor and surgical team will meet with you to thoroughly describe your specific surgery and tell you exactly what to do to prepare.

They will review your prescribed and over-the-counter medications along with your medical conditions. Some medications may need to be continued or stopped prior to your surgery.

You probably have answered these questions before, but it is important that this information be checked and rechecked to be certain no errors are made.

Please follow your specific instructions, but there are some general preparations:

• You should not eat or drink for six hours before the procedure.
• Your nurse or doctor will inform you which of your regular medications to take or avoid the day of your procedure.
• If this surgery is to be performed as an outpatient at Semmes Murphey’s Ambulatory Surgery Center, you must arrange to have someone remain at the surgery center until you are discharged and to drive you home afterward.
• The most important thing you can do to ensure the success of your spinal surgery is to quit smoking. Nicotine prevents bone growth and puts you at higher risk for a failed fusion. Smoking also decreases your blood circulation, resulting in slower wound healing and an increased risk of infection.

Morning of surgery:

• Shower using antibacterial soap
• Dress in freshly washed, loose-fitting clothing
• Wear flat-heeled shoes with closed backs
• If you have instructions to take regular medication the morning of surgery, do so with small sips of water
• Remove make-up, hairpins, contacts, body piercings, nail polish, etc.
• Leave all valuables and jewelry at home (including wedding bands)
• Bring a list of medications (prescriptions, over-the-counter, and herbal supplements) with dosages and the times of day usually taken
• Bring a list of allergies to medication or foods

You will awaken in the postoperative recovery area, called the PACU. Blood pressure, heart rate, and respiration will be monitored.

Patients who have had bone graft taken from their hip may feel more discomfort in their hip than neck incision. Any pain will be addressed.

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).

Most patients having a 1 or 2 level ACDF are sent home the same day. However, if you have difficulty breathing or unstable blood pressure, you may need to stay overnight.

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.

Your physician may recommend physical therapy to help you strengthen your back and gain more mobility. The SMC onsite physical therapy team will consult with your doctor and talk with you before developing a unique rehabilitation plan for you. This plan will be based on your situation and goals.

Restrictions:

• If you had a fusion, do not use non-steroidal anti-inflammatory drugs (aspirin, ibuprofen, Advil, Motrin, Nuprin, naproxen sodium, Aleve) for 6 months after surgery. These may cause bleeding and interfere with bone healing
• Do not smoke. Smoking delays healing by increasing the risk of infection and inhibits the bones' ability to fuse
• Do not drive for two to four 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, like a gallon of milk
• 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

Activity:

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 starting with a short distance and gradually increasing to one- to two-miles daily. A physical therapy program may be recommended.

If applicable, a cervical collar before leaving the hospital, and when walking or riding in a car.

You may shower one to four 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 do so.

Call your doctor if you run a temperature exceeding 101⁰ F, if the incision begins to separate, turn red, swell or drain.

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 stress management
• No smoking

This information was provided by the specialists at Semmes Murphey Clinic. Readers are encouraged to research trustworthy organizations for information. Please talk with your physician for websites and sources that will enhance your knowledge and understanding of this issue and its treatments.