ACDF: Anterior Cervical Discectomy and Fusion

Written by Jeremy D. Earle, JD

March 5, 2022

Should I Get a Spinal Fusion After a Car Accident?

The procedure to remove a herniated or degenerative disc in the neck is anterior cervical discectomy and fusion (ACDF). This is a common procedure after car accidents in Colorado Springs.

To access and remove the disc, an incision is made in the throat. The bones above and below the  disc are fused using a graft. If physical therapy and drugs fail to cure your pinched nerve discomfort in your neck or arm, ACDF surgery may be an alternative. Patients are usually discharged the same day.

An anterior cervical discectomy and fusion is a procedure that involves removing and fusing the  discs in the neck.

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Here is What You Need to Know

The term “discectomy” implies “cutting off the disc.” From the neck to the low back, a discectomy may be done (lumbar). The surgeon enters the neck region from the front (anterior)  of the spine to access the injured disc. The disc and bone vertebrae are revealed by pushing the neck muscles, trachea, and esophagus aside.

Because the disc can be accessed without affecting the spinal cord, spinal nerves, or the strong neck muscles, surgery from the front is more accessible than surgery from the rear (posterior). One (single-level) or multiple (multi-level) discs may be removed, depending on your symptoms.

The gap between the bony vertebrae is vacant when the disc is removed. A spacer bone graft is  put into the open disc area to prevent the vertebrae from collapsing and rubbing together. The  graft acts as a link between the two vertebrae, allowing a spinal fusion to occur. Metal plates and  screws hold the bone transplant and vertebrae in place.

The body’s natural healing process starts after surgery, and new bone cells form around the transplant. The bone transplant should unite the two vertebrae and produce one solid piece of bone after 3 to 6 months. Similar to reinforced concrete, the instrumentation and fusion operate  together.

Bone grafts may be obtained from a variety of sources. Each variety has its own set of benefits  and drawbacks.

Autograft bone is your bone. Your bone cells are taken from your hip by the surgeon (iliac crest).  Because it contains bone-growing cells and proteins, this transplant has a greater rate of fusing.

The drawback is that you will have discomfort in your hipbone after surgery. A bone transplant is taken from your hip at the same time as the spine procedure. The harvested bone is roughly a  half-inch thick — just the top half layer is taken, not the full thickness.

Bone from a donor is used in allografts (cadaver). Bone from persons who have decided to give  their organs after they die is collected for a bone bank. This transplant contains no bone- growing  cells or proteins, yet it is easily accessible and removes the necessity for hip bone harvesting.

The core of an allograft is filled with shavings of live bone tissue extracted from your spine after  surgery, giving it a doughnut shape.

Man-made plastic, ceramic, or bioresorbable substances are used as bone transplant substitutes.  This graft material, also known as cages, is filled with shavings of live bone tissue extracted  from your spine during surgery.

You may have some range of motion loss after fusion, although this depends on your neck mobility before surgery and the number of levels fused. If just one level is fused, your range of motion may be comparable or even better than before surgery.

You may experience limitations in tilting your head and gazing up and down if more than two layers are fused. Motion-preserving artificial disc replacements have supplanted fusion. The prosthetic disc is put into the injured joint area and retains mobility, similar to knee replacement,  while fusion destroys motion. T

he findings are comparable when comparing artificial discs to ACDF, but the long-term effects of motion preservation and neighboring level illness remain unknown. Consult your surgeon to  determine if ACDF or artificial disc replacement is the best option for you.

WHAT DOES IT MEAN TO BE A CANDIDATE?

If you have:

diagnostic tests (MRI, CT, myelogram) reveal that you have a herniated or degenerative  disc

considerable weakness in your hand or arm arm discomfort that is greater than neck pain

symptoms that have not improved with physical therapy or medication may be a  candidate for discectomy.

The following conditions may benefit from ACDF treatment:

Herniated and bulging discs: Through a weak spot in the surrounding wall, the gel-like substance inside the disc might swell or burst (annulus). When this substance squeezes out and  uncomfortably pushes on a nerve, it causes irritation and edema.

Degenerative disc disease (DDD) is a degenerative disc disease with Bone spurs that grow when discs wear down and the facet joints become inflamed. The discs lose their flexibility and  cushioning characteristics as they dry up and shrink. The disc gaps are shrinking. Canal stenosis  or disc herniation is the result of these alterations (Fig. 1).

The choice of surgery

After a few months of nonsurgical therapy, most herniated discs recover. Although your doctor  may suggest treatment alternatives, only you can determine if surgery is the best choice for you.  Before making a choice, be sure to weigh all of the risks and advantages. After six weeks of

conservative therapy, only 10% of persons with herniated discs have enough discomfort to contemplate surgery.

Your surgeon will also go through the risks and advantages of various bone transplant materials  with you. The gold standard for quick healing and fusion is an autograft, although the hip  incision may be uncomfortable and cause problems. For regular 1 and 2 level fusions in  nonsmokers, allograft (bone-bank) is more routinely employed and has shown to be just as  successful.

WHO IS THE ONE WHO DOES THE PROCEDURE?

A neurosurgeon or an orthopedic surgeon may perform spine surgery. Complex spine surgery is a specialty for many spine surgeons. Inquire about your surgeon’s training, particularly if your  condition is complicated or you’ve had many spinal surgeries.

WHAT OCCURS BEFORE THE OPERATION?

You will sign permission and other documents in the office so that the surgeon knows your medical history (allergies, medications/vitamins, bleeding history, anesthetic responses, past operations, and so on). Talk to your doctor about all of the drugs you’re taking, including prescription, over-the-counter, and herbal supplements.

Preoperative testing (e.g., blood tests, electrocardiograms, and chest X-rays) may be required many days before surgery. Consult your primary care physician about quitting specific drugs and  getting surgical clearance.

Seven days before surgery, stop using any nonsteroidal anti-inflammatory drugs (ibuprofen, Advil, etc.) and blood thinners (Coumadin, aspirin, Plavix, etc.). Stop using nicotine and drinking alcohol one week before and two weeks after surgery to prevent bleeding and healing  issues.

Before surgery, you may be requested to cleanse your skin with Hibiclens (CHG) or Dial soap. (Keep CHG out of your eyes, ears, nose, and genital regions.) It eliminates microorganisms and  prevents infections at surgical sites.

QUIT SMOKING.

Tobacco cessation is the most crucial thing you can do to guarantee a successful spine surgery. Cigarettes, vaping, cigars, pipes, chew, and snuff/dip are all examples of this. Nicotine inhibits  bone development and reduces the likelihood of effective fusion. Smoking also reduces blood  circulation, causing wound healing to be delayed and infection to be more likely. The dangers of  smoking are significant: fusion fails in 40% of smokers compared to 8% of nonsmokers [1].

Consult your doctor about nicotine alternatives, drugs (Chantix or Zyban), and counseling programs to help you stop.

ON THE DAY OF SURGERY

Before surgery, don’t eat or drink anything after midnight (unless the hospital tells you  otherwise). With a tiny sip of water, you may take allowed medications.

Use antibacterial soap in the shower. Wear loose-fitting clothes that have just been cleaned. Wear closed-back flat-heeled shoes.

Take off your make-up, hairpins, contacts, body piercings, nail paint, and other accessories. Take all valuables and jewelry with you and leave them at home.

Bring a list of your medicines, including doses and when you generally take them. Bring a list of any medication or food allergies.

Arrive at the hospital 2 hours before your planned procedure (surgery center 1 hour before). Time to finish required documentation and pre-procedure work-ups An anesthesiologist will  speak with you and discuss the benefits and dangers of anesthesia.

What occurs during the operation?

The method is broken down into seven phases. The procedure usually takes 1 to 3 hours.

Step 1: Prep the Patient

Anesthesia will be administered to you while you are lying on your back on the operating table.  The region around your neck is cleaned and prepared as you sleep. The hip region is also readied  for a bone transplant if a fusion is planned, your bone will be utilized. If a donor’s bone is  utilized, there is no need for a hip incision.

Step 2: Cut a hole in your skin.

On the right or left side of your neck, a 2-inch skin incision is created (Fig. 2). By pulling muscles in your neck aside and retracting the trachea, esophagus, and arteries. Finally, the muscles that support the front of the spine are raised and pushed aside, allowing the surgeon to  view the bony vertebrae and discs.

Step 3: Identify the disc that has been damaged.

The surgeon uses a fluoroscope (a special X-ray) to find the afflicted vertebra and disc by inserting a small needle into the disc. A specific retractor is used to spread the vertebral bones above and below the injured disc apart.

Step 4: Take the disc out.

The disc’s outer wall is slashed (Fig. 3). The surgeon uses tiny gripping instruments to remove  roughly two-thirds of your disc, then uses a surgical microscope to remove the remaining disc.  To get to the spinal canal, the ligament that runs behind the vertebrae is removed. Any disc  material that is putting pressure on the spinal nerves is removed.

Step 5: Release the pressure on the nerve.

Bone spurs that are pressing on your nerve root are surgically removed. A drill is used to expand the foramen through which the spinal nerve escapes (Fig. 4). A foraminotomy is a treatment that  allows your nerves to escape the spinal canal with extra space.

Step 6: Make a fusion bone transplant.

The open disc area is prepared on the top and bottom using a drill to remove the outer cortical  layer of bone.

INCISION CARE

If your incision is covered with Dermabond skin adhesive, you may wash the day following surgery. Every day, gently wash the affected area with soap and water. Do not  pick or rub the glue. Allow airing to dry.

You may shower two days following surgery if you have staples, steri-strips, or stitches.

Every day, gently wash the affected area with soap and water. Allow airing to dry.

Cover the wound with a dry gauze bandage if there is any drainage. Call the office if  drainage soaks through two or more dressings in one day.

Avoid soaking the incision in a bath or swimming pool. Avoid putting lotion or ointment on the wound.

Clean bed sheets are essential for a good night’s sleep.

After each shower, change into clean clothing. Until your incision heals, no pets in the  bed.

It’s typical for the incision to have some clear, pinkish discharge. Keep an eye out for redness that spreads, colorful discharge, and separation.

At your follow-up visit, staples, steri-strips, and sutures will be removed.

MEDICATIONS

As your discomfort lessens, reduce the volume and frequency of your massages.

Follow the directions on your pain medication. Don’t take the pain reliever if you don’t  need it.

Narcotics have the potential to induce constipation. Drink plenty of water and consume meals rich in fiber. Stool softeners and laxatives may aid with bowel movement. Over-   the-counter choices include Colace, Senokot, Dulcolax, and Miralax.

If your uncomfortable constipation does not improve, see your doctor about additional  options.

Ask your surgeon before using anti-inflammatory pain medicines (Advil, Aleve). They  may cause your fusion to fail by preventing new bone formation.

Acetaminophen is an option (Tylenol).

ACTIVITY

would Wear your brace at all times except while sleeping, bathing, or icing if you were  provided one.

Reduce discomfort and swelling by icing your incision 3-4 times a day for 15-20 minutes.

Every 3-4 hours, get up and walk for 5-10 minutes. As you’re able, gradually increase your  walking time.

WHEN SHOULD YOU CONTACT YOUR DOCTOR?

A fever of more than 101.5°F (unrelieved by Tylenol). Nausea or vomiting that does not go away.

Excruciating, unrelieved agony. Symptoms of an infection in the incision.

Itching or rash around the incision (allergy to Dermabond skin glue). Swelling and discomfort in one leg’s calf.

Arms or legs are tingling, numbness, or weakness for the first time. Feeling dizzy, confused, nauseous, or drowsy.

PREVENTION AND RECOVERY

Two weeks following surgery, schedule a follow-up visit with your surgeon. The recovery period  is usually between 4 and 6 weeks. After a few weeks, X-rays may be done to confirm that fusion  has occurred. At your follow-up appointment, the surgeon will determine when you may return  to work.

During recovery, a cervical collar or brace may be worn to support and restrict mobility as your neck heals or fuses (see Braces for Your Neck). Once your neck has recovered, your doctor may recommend neck stretches and exercises, as well as physical therapy.

If a bone transplant was removed from your hip, you might suffer discomfort, soreness, and stiffness at the incision site. Get up every 20 minutes or so and move around or take a stroll.  Long durations of sitting or lying down are not recommended.

Neck discomfort recurrences are frequent. Prevention is the key to preventing recurrence: Lifting methods that work

Proper sitting, standing, moving, and sleeping position Appropriate physical activity program

A comfortable work environment

Maintaining a healthy weight and lean body mass Relaxation methods and a good mindset

No smoking is permitted. W

hat are the outcomes?

In 92 to 100 percent of patients, an anterior cervical discectomy relieves arm discomfort.  Arm weakness and numbness, on the other hand, may last for weeks or months. In 73 to 83  percent of patients, neck discomfort is eased. ACDF is more beneficial to persons with arm  discomfort than it is to people with neck pain. Maintain a cheerful mindset while doing your  physical therapy activities.

It takes to complete a spinal fusion depends on the procedure employed and your overall health (smoker). The results of research comparing three techniques: ACD, ACDF, and ACDF with  plates and screws were:

67 percent of those who had ACD (no bone transplant) had a spontaneous fusion. Compared to the other procedures, ACD alone causes an abnormal forward curvature of the spine (kyphosis).

ACDF with bone graft insertion resulted in infusion in 93 percent of patients.

All patients who had ACDF with bone grafts, plates, and screws had a successful fusion.

WHAT ARE THE POTENTIAL DANGERS?

There are dangers associated with every procedure. Bleeding, infection, blood clots (deep vein  thrombosis), and anesthetic responses are common consequences of surgery. There is a higher risk of problems if a spinal fusion is performed concurrently with a discectomy. The following  are some of the potential issues associated with ACDF:

Hoarseness and difficulty swallowing Temporary hoarseness may develop in certain circumstances. During surgery, the recurrent laryngeal nerve, which controls the vocal cords, is  impacted. This nerve may take many months to heal. Hoarseness and swallowing issues may  continue in a small percentage of instances (less than 1/250), requiring further therapy from an   ear, nose, and throat specialist.

Vertebrae that haven’t fused. Bones do not fuse for a variety of reasons. Smoking, osteoporosis,  obesity, and malnutrition are some of the most common. By far, the most significant element that  may impede fusion is smoking. Nicotine is a poison that prevents bone cells from developing. If  you continue to smoke following your spinal surgery, the fusion process may be jeopardized.

A hardware break. “Hardware” refers to the metal screws and plates used to brace the spine. Before the bones are entirely bonded, the hardware may shift or shatter. If this happens, a second  operation to repair or replace the hardware may be required.

Migration of bone grafts. The bone graft may shift from its proper place between the vertebrae in  a small percentage of patients (1 to 2%). If no hardware (plates and screws) is utilized or if  numerous spinal levels are fused, this is more likely to happen. A second operation may be  required if this happens.

Extra stress and strain are transmitted to the discs and bones above and below the fusion when a  spine segment is fused. The additional wear and strain might cause the neighboring level to  deteriorate and create discomfort.

Nerve injury or chronic pain. Any spine operation has the potential of causing nerve or spinal  cord damage. Numbness or even paralysis might occur as a result of the damage. However, nerve  injury caused by disc herniation is the most typical cause of prolonged discomfort. Some disc herniations may permanently destroy a nerve, rendering it inoperable. The compressed nerve  does not bounce back like furniture on a carpet. Spinal cord stimulation or other therapies may  help in certain situations.

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