ACDF Surgery Overview
A cervical disc herniation can be removed through an anterior approach. Anterior approach refers to the front of the neck. This procedure relieves the spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness and tingling. Following are some important points;
- This procedure is called an anterior cervical discectomy. It allows the offending disc to be surgically removed. A discectomy is a form of surgical decompression, so the procedure may also be called an anterior cervical decompression.
- A fusion surgery is always done at the same time as the discectomy in order to stabilize the cervical segment.
- Together, the combined surgery is commonly referred to as an ACDF surgery, which stands for Anterior Cervical Discectomy and Fusion.
Advantages of Anterior Approach
The anterior approach of this surgery means that the surgery is done through the front of the neck. As opposed to the back of the neck, this approach has several typical advantages;
- Better Access to the Spine
The anterior approach can provide access to almost the entire cervical spine. This ranges from the C2 segment at the top of the neck down to the cervico-thoracic junction, which is where the cervical spine joins with the upper spine (thoracic spine).
- Less Post-Operative Pain
Spine surgeons often prefer this approach because it provides good access to the spine through a relatively uncomplicated pathway. All things being equal, the patient tends to have less incisional pain from this approach than from a posterior operation. Many of the previous patients of Spine Physicians Institute have found this to be true.
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After a skin incision is made in the front of the neck, only one thin vestigial muscle needs to be cut. Then the anatomic planes can be followed right down to the spine. The limited amount of muscle division or dissection helps to limit postoperative pain following the spine surgery.
The Steps for ACDF Surgery
The general procedure for an anterior cervical discectomy and fusion or ‘ACDF’ surgery includes the following steps:
- Anterior surgical approach
- The skin incision is one to two inches and horizontal. It is to be made on the left or right side of the neck. Surgeries involving three or more levels utilize a vertical oblique incision.
- The thin vestigial muscle under the skin, known as platysma, is then split in line with the skin incision, and the plane between the sternocleidomastoid muscle and the strap muscles is then entered.
- Next, a plane between the trachea/oesophagus and the carotid sheath can be entered.
- A thin fascia, i.e. flat layers of fibrous tissue, covers the spine, specifically the pre-vertebral fascia, which is dissected away from the disc space.
- Disc removal
- A needle is then inserted into the disc space. An X-ray is done to confirm that the spine surgeon is at the correct level of the spine.
- After the correct disc space has been identified on X-ray, the appropriate portions of the disc are then removed. It is done by first cutting the outer annulus fibrosis, specifically the fibrous ring around the disc, and removing the nucleus pulposus, i.e. the soft inner core of the disc.
- With an anterior cervical discectomy, most of the disc, but not all, is usually removed.
- Canal Decompression
- Dissection is carried out from the front to back of a ligament called the posterior longitudinal ligament.
- Often this ligament is gently removed to allow access to the spinal canal to remove any osteophytes, i.e. bone spurs, or disc material that may have extruded through the ligament.
- The dissection is always performed using an operating microscope or magnifying loupes to aid with visualization of the smaller anatomic structures.
- Cervical Fusion
- An anterior cervical fusion is almost always done as part of a cervical discectomy.
- The insertion of a bone graft into the evacuated disc space serves to prevent disc space collapse and promote a growing together of the two vertebrae into a single unit.
- With this procedure, the fusion prevents local deformity kyphosis and serves to maintain adequate room for the nerve roots and spinal cord.
Patients typically go home after an ACDF procedure after one night in the hospital. Most patients recover within 4 to 12 weeks, although it may take up to 18 months for the fusion to fully set up.
Preparation before Surgery
Optimizing your physical condition before surgery improves the recovery and outcome. The patient is advised to maintain a healthy, balanced diet before surgery. Smoking is severely discouraged. Smoking can significantly delay healing, increase risks, and adversely affect outcomes. Smoking cessation cannot occur with use of nicotine supplements such as nicotine patches and nicotine gum. Prior to surgery, the use of opioid pain medications is also discouraged. The decreased preoperative utilization of opioids correlates with better long-term outcome. It also allows for more reliable postoperative pain management.
Risks of Surgery
There are a number of potential risks and complications with ACDF surgery. However, the main postoperative problem most patients face is either difficulty swallowing or hoarseness for 2 to 5 days. It happens due to retraction of the oesophagus and trachea during the surgery.
For an ACDF surgery, the main potential risks and complications that could occur include;
- Inadequate symptom relief after the surgery
- Failure of bone graft healing to create a fusion, also known as non-union or pseudoarthrosis
- Persistent swallowing or speech disturbance
- Nerve root damage
- Damage to the spinal cord (this risk is extremely rare due to the advent of neuromonitoring)
- Damage to the trachea/oesophagus
Factors which Increase the Occurrence of Risks
The rate of occurrence of potential risks and complications is highly variable. They are dependent mainly on a combination of;
- The results of the individual surgeon with ACDF surgery. It means that the frequency of complications varies surgeon to surgeon.
- Individual patient risk factors, such as the condition of the disc, the patient’s physical condition (such as bone strength, diabetes, etc.), whether or not the patient smokes, and other factors.
Spine Physicians Institute prides itself in having an extremely low complication rate. It is far below the published norms. We attribute this to having greater than ten years of experience, constantly staying up to date with the spine surgical literature, and due to the excellent fellowship training our physicians have received.
Minimization of the Risks
Risks are minimized by the utilization of Intraoperative Neuromonitoring (IONM). Following are its attributes;
- IONM offers insight into the nervous system during spinal surgeries.
- Use of IONM facilitates the surgical process.
- It can reduce surgical risk by providing critical information and alerts to surgeons of potential harm or compromise to the spinal cord or neural structures.
- IONM provides better insight into a patient’s condition during surgery to support better decision-making that enables the practice of better medicine.
On the day of your surgery you will meet a member of IONM team that will provide your neuromonitoring for you during your surgery.
Time Away from Work
How much time you need off work primarily depends on the type of work you do. After the surgery, you can expect to have a cervical collar in place. Our physicians recommend all patients need some time at home recovering after surgery. The recovery time must be at least a week long.
During the postoperative period, you will observe restrictions to your activity level until your fusion has healed. A spinal fusion usually takes about 3 months to heal. During the first six weeks as you are diligently wearing the cervical collar you will not be able to drive a car.
If your job is sedentary, then you may feel comfortable returning to work within a few weeks. However, if your work is very strenuous, we recommend allowing the fusion to fully heal. It will require an entire 3 months off of work.
Generally, we advise patients to inform their employers that they are going to require the full 3 months to recover from surgery. If post-operatively, you feel you can return sooner, our office will always be happy to provide the proper documentation.
Remember, no one knows your work environment better then you. That is why our work release are always predicated on your consensus.
- Upon arriving for surgery, you will meet the anaesthesiologist, neuromonitoring technician, and surgical nurses. They will discuss with you their procedures and make you feel more at ease.
- Usually, Total Intravenous Anaesthesia (TIVA) will be given for your surgery. This allows for the best neurophysiologic monitoring.
- You will be given antibiotics to prevent infection. Support stockings along with sequential compression devices will be placed on your legs.
- You will be taken into the operating room and the surgeon will perform your procedure.
Most ACDF procedures require between one to two hours. You will spend about an hour in the recovery room post operation. Routinely, patients slowly resume a normal diet within a day. They are up and ambulating the day of surgery as well. During the surgery, the surgeon will also call out to the waiting room and give your family routine updates.
When you awaken after surgery, you will receive pain medication and your nurses will closely monitor you. You will slowly resume a normal diet and start physical therapy immediately after surgery. You must remain overnight at the hospital for monitoring. You will be discharged the next day. On discharge, you will be given a detail set of discharge instructions and prescription pain medications.
For patients with risk factors, such as a history of smoking, or who are undergoing a multi-level fusion, our physicians will prescribe a cervical bone stimulator to promote bone healing. In these cases, you will be contacted at home post-operatively by the representative of Spine Physicians Institute for the bone stimulator company who will make arrangements to get you this unit for your use.
The support stockings you are given in the hospital should be utilized for the first six weeks after surgery. These reduce the risk of blood clots after surgery.
The first postop visit is usually scheduled for six weeks after your date of surgery. On that day, we will check radiographs of your neck. Depending upon how much healing is present at that time, we will decide whether we can begin discontinuing the use of your collar.
Successful ACDF surgery is not only the result of the procedure, but also the aftercare and rehabilitation. The initial rehab program is simply composed of performing routine day to day activities while observing your post-operative restrictions. We encourage patients to participate in a daily walking program, progressing at their level of comfort. We do not start formal physical therapy until the three-month post-operative visit, if warranted.
During this process, the patients are urged to not hesitate to ask questions. Our team is always available to help you. Our goal is to give you best possible care in the most safe and pleasant way possible. Although surgery is not always an easy choice for you and requires some work, remember that you are having the surgery because we expect a good result. We wish you a speedy recovery.
For more questions, contact our offices located in Dallas, Irving, Red Oak, Plano, Southlake, Grapevine, Colleyville and Duncanville marketplaces.