Anterior Cervical Decompression and Fusion Surgery

 

 

A cervical disc herniation can be removed through an anterior approach (through the front of the neck) to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness and tingling.

  • This procedure is called an anterior cervical discectomy and 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

The anterior approach of this surgery, which means that the surgery is done through the front of the neck as opposed to the back of the neck, has several typical advantages:

  • Better access to the spine. The anterior approach can provide access to almost the entire cervical spine, 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 postoperative 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 our previous patients from throughout Dallas, Irving, Red Oak, Plano, Southlake, Grapevine, Colleyville, Duncanville and throughout the DFW metroplex have found this to be true.

After a skin incision is made in the front of the neck, only one thin vestigial muscle needs to be cut, after which 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.

Specifically, the general procedure for an anterior cervical discectomy and fusion – or ACDF – surgery includes the following steps:

  1. Anterior surgical approach
  • The skin incision is one to two inches and horizontal, and is be made on the left or right hand side of the neck. Surgeries involving three or more levels utilize a vertical oblique incision.
  • The thin vestigial muscle (platysma) under the skin 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/esophagus and the carotid sheath can be entered.
  • A thin fascia (flat layers of fibrous tissue) covers the spine (pre-vertebral fascia), which is dissected away from the disc space.
  1. Disc removal
  • A needle is then inserted into the disc space, and 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 by first cutting the outer annulus fibrosis (fibrous ring around the disc) and removing the nucleus pulposus (the soft inner core of the disc).
  • With an anterior cervical discectomy, most of the disc (but not all) is usually removed.
  1. 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 (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.
  1. 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 ‘fusion’ preventing local deformity kyphosis and serving to maintain adequate room for the nerve roots and spinal cord.

Patients typically go home after an anterior cervical discectomy and fusion after one night in the hospital. Most patients recover within about 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 will certainly improve your recovery and outcome. Maintain a healthy, balanced diet before surgery. Stop Smoking. 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, try to minimize the use opiod pain medications, as decreased preoperative utilization correlates with both better long term outcomes and allows for more reliable postoperative pain management.

Risks of Surgery

While there are a number of potential risks and complications with ACDF surgery, the main postoperative problem most patients face is either difficulty swallowing or hoarseness for 2 to 5 days due to retraction of the esophagus 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 (a.k.a. non-union or pseudoarthrosis)
  • Persistent swallowing or speech disturbance
  • Nerve root damage
  • Damage to the spinal cord (extremely rare with the advent of neuromonitoring)
  • Bleeding
  • Infection
  • Damage to the trachea/esophagus.

The rate of occurrence of potential risks and complications is highly variable and dependent mainly on a combination of:

  1. The results of the individual surgeon with ACDF surgery (meaning that the frequency of complications varies between surgeons), and;
  2. Individual patient risk factors, such as the condition of the disc, the patient’s physical condition (bone strength, diabetes, etc.), whether or not the patient smokes, and other factors.

I pride myself in having an extremely low complication rate, far below the published norms. I attribute this to having greater than ten years of experience, constantly staying up to date with the spine surgical literature, and due to the fellowship training I received at the Mayo Clinic in Rochester, Minnesota.

Risks are minimized by the utilization of Intraoperative Neuromonitoring (IONM). IONM offers insight into the nervous system during spinal surgeries. Use of IONM facilitates the surgical process and 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 have.  After the surgery, you can expect to have a cervical collar in place.  I think all patients need some time at home recovering after surgery, usually at least a week. 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, I recommend allowing the fusion to fully heal which requires an entire 3 months off of work. Generally, I 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 to you to allow for such. Remember, no one knows your work environment better then you, thus our work release are always predicated on your consensus.

The Procedure

When you arrive for your surgery, you will meet the anesthesiologist, neuromonitoring technician, and surgical nurses.  They will discuss with you their procedures and probably make you feel more at ease. Usually, Total Intravenous Anesthesia (TIVA) will be given for your surgery. This allows for the best neurophysiologic monitoring. You will be given antibiotics to prevent infection, and support stockings along with sequential compression devices will be placed on your legs. We will then go to operating room and I will perform your procedure. Most ACDF’s require between one to two hours, and postoperatively you spend about an hour in the recovery team. Routinely, patients slowly resume a normal diet and are up and ambulating the day of surgery. During the surgery, I will call out to the waiting room and give your family routine updates

Aftercare

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 will remain overnight at the hospital. Usually, the next day you will be discharged home. 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, often at times, I will prescribe a cervical bone stimulator to promote bone healing. In these cases, you will be contacted at home post-operatively by the representative 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.

At the first postop visit that is usually scheduled for six weeks after your date of surgery, 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. You may schedule this visit at any of our office locations which are conveniently located to Dallas, Irving, Red Oak, Plano, Southlake, Grapevine, Colleyville and Duncanville.

Rehab 

Successful ACDF surgery not only is the result of the procedure, but also very importantly is the result of aftercare and rehabilitation. The initial rehab program is simply composed of performing routine day to day activities while observing your post-operative restrictions. I encourage patients to participate in a daily walking program, progressing at their level of comfort. I do not start formal physical therapy until the three month post-operative visit, if warranted.

During this process, please do not hesitate to ask questions. My 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 “easy” for you and requires some work, remember that you are having the surgery because we expect a good result. I wish you a speedy recovery.

 

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