Anterior Cervical Discectomy and Fusion (ACDF)

What is an ACDF?

An anterior cervical decompression and fusion (ACDF) is an operation done through the front of the neck (rather than the back) to relieve pressure on the spinal cord and/or nerves, as well as to stabilise the spine.  Usually a Discectomy (removal of the intervertebral disc) is performed to release pressure off the nerves, and a fusion (joining of two or more bones together) is done, usually with a plate and screws, to ensure stability.

Why might I need an anterior cervical discectomy (decompression) and fusion?

Cervical spine surgery may be needed for a variety of problems. Generally, surgery may be performed for degenerative disorders, trauma or instability.
An ACDF is usually performed for one or more of the following reasons:

  • To treat pressure on the spinal cord (caused by cervical canal stenosis/spondylosis or an intervertebral disc prolapse).
  • To treat pressure on one or more spinal nerves in the neck (caused by foraminal stenosis, cervical spondylosis, or an intervertebral disc prolapse)
  • To treat instability of the cervical spine (this may occur due to degenerative changes, arthritis, or trauma).

Surgery is usually recommended when all reasonable conservative measures (pain medications, nerve sheath injections, physical therapies, neck collars etc.) have failed. In cases of significant instability or neurological problems, surgery may be the most appropriate first treatment option.

What are the possible outcomes if treatment is not undertaken?

If your condition is not treated appropriately (and sometimes even if it is), the possible outcomes may include:

  • Ongoing pain
  • Paralysis/weakness/numbness
  • Functional impairment (clumsiness, poor fine motor skills and coordination)
  • Problems with walking and balance

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.
Achieving a 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 were:

  • 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 other techniques.
  • 93% of people who underwent ACDF with bone graft placement achieved fusion.
  • 100% of people who underwent ACDF with bone graft placement and plates and screws achieved fusion.

What are the specific risks of an ACDF?

Generally, surgery is fairly safe and major complications are uncommon,. The chance of a minor complication is around 3 or 4%, and the risk of a major complication is 1 or 2%. Over 90% of patients should come through their surgery without complications.
The specific risks of an ACDF include (but are not limited to):

  • Injury to the larynx (voice box), the nerves to the larynx (recurrent laryngeal nerve) causing vocal cord paralysis and a hoarse voice. This is usually temporary but may require further surgery, which can cause infection.
  • Injury to the oesophagus (food pipe) which may require further surgery.
  • Injury to carotid artery, which can cause a stroke. This can cause paralysis, which may be permanent.
  • Injury to the spinal cord resulting in quadriplegia, (paralysis of arms and legs). This may be temporary or permanent and may require further surgery.
  • Implant failure, movement or malposition.
  • Injury to nerve root causing a weak upper limb, which may be temporary or permanent.
    Infection in the wound causing redness, pain and possible discharge or abscess. (1 in 20 people). This may need antibiotics.
  • Ongoing neck or upper limb pain, which may be temporary or permanent.
  • Failure of fusion on the bone which may result in pain and may require further surgery.
  • Movement of graft or instrumentation resulting in swallowing difficulties, which may require surgery.
  • Ongoing upper limb numbness, which may be permanent.
  • Small areas of the lungs may collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
  • Clots in the legs (deep vein thrombosis or DVT with pain and swelling. Rarely part of this clot may break off and go to the lungs which can be fatal.
  • A heart attack because of strain on the heart or a stroke.
  • Death is possible due to the procedure
  • Increased risk in obese people of wound infection, chest infection, heart and lung
  • Adjacent level disease (see below)

What do you need to tell the doctor before surgery?

It is important that you tell your surgeon if you:

  • Have blood clotting or bleeding problems
  • Have ever had blood clots in your legs (DVT or deep venous thrombosis) or lungs (pulmonary emboli)
  • Are taking aspirin, warfarin, or anything else (even some herbal supplements) that might thin your blood
  • Have high blood pressure
  • Have any allergies
  • Have any other health problems

What Can I Expect? Before Surgery

  • You will have to get admitted atleast one day before surgery is planned.
  • After admission if your pre operative tests were not undertaken before admission will be undertaken. These include blood tests, X-rays, ECG and 2D Echo as per your underlying other co-morbidities.
  • You will be checked by our team- spine surgeon/assistant, anesthetist and physician who will assess your test results and determine your fitness for the surgery.
  • You may also get all the investigations and fitnesses done as out patient 2-3 days days prior to surgery.
  • We follow-safety first, so surgery will be confirmed after achieving fitness from our anesthetists and physicians.
  • You may not eat or drink anything after midnight, the night before surgery.
  • Note: However, you may continue to take your routine medications (for example, heart and blood pressure medications), on the morning of surgery with a sip of water (unless otherwise directed).  Please bring all your regular medications with you to hospital.
  • Consult with your surgeon if you are taking blood-thinning medications, NSAIDs, or Insulin. Examples include Coumadin (Warfarin), Plavix/Clavix (Clopidogrel), and Aspirin; Nonsteroidal Anti-inflammatory Drugs (NSAIDs) such as Motrin (Ibuprofen), Aleve (Naproxen), Feldene (Piroxicam); or Insulin. We advice that above mentioned medicines be discussed with your operating surgeon/ team during out patient visit itself.
  • Please be sure to take the following to the hospital admission;
    • All investigation reports
    • OPD file and papers
    • All prescriptions by your physician
    • MRI/Xray/C.T Scans
  • On arrival at the hospital, inform the receptionist that you are there to have an operation. You will be asked to show the hospital OPD file and accordingly admitted.

Who will perform surgery? Who else will be involved?

Surgery will be carried out by your surgeon. A surgical assistant will be present and an experienced consultant anaesthetist will be responsible for your general anaesthetic.

What are the costs of surgery?

Private patients undergoing surgery will generally have some out-of-pocket expenses.

  • A quotation for surgery will be issued, however this is an estimate only. The final amount charged may vary with the eventual procedure undertaken, operative findings, technical issues etc.
  • If you are planning to avail insurance benefit, you will have to inform the insurance company as well as the hospital before admission. Hospital mediclaim department will guide you of all the necessary steps needed to avail this facility

Separate accounts will be rendered by the anaesthetist and sometimes the assistant, and hospital bed excess charges may apply. Medical expenses may be tax deductible (you should ask your accountant).
You should fully understand the costs involved with surgery before going ahead, and should discuss any queries with your surgeon.

What is the consent process?

You and one of the relatives will be asked to sign a consent form before surgery. This form confirms that you understand all of the treatment options, as well as the risks and potential benefits of surgery. If you are unsure, you should ask for further information and only sign the form when you are completely satisfied.

After Surgery

  • During your first few hours on the ward, you will be monitored closely by the nursing staff. You will be given fluids by an intravenous drip and may have a drain coming from your wound. This is all normal procedure.  If you have any pain or feel any sickness it is important to inform the nursing staff so they can keep you comfortable and aid your recovery.  The majority of patients are allowed fluids to drink once you are awake, however with some surgery fluids and what you are allowed to eat will be restricted for the first day or so.
  • The vast majority of spinal patients are allowed to walk to the bathroom with the help of the nursing staff from when they are fully awake from surgery.  If you want to use the toilet, you must ask the nursing staff for assistance.
  • Unless specified by your surgeon, you will commence rehabilitation the day following your surgery.  This means all drips, drains and other appendages will be removed and you will be assisted out of bed on day 1 and walked to the bathroom for a shower.
  • You will be sat on the edge of your bed for meals and taken for short walks by the staff. The following day you will increase the amount of walking and may still require some assistance from the staff. You will sit out in the chair for short periods of time (meals etc.) It is very important that you do make every effort to get up and walk during this early stage of your rehabilitation.
  • Minor discomfort from the incision is common and can be relieved by pain medication.  You will be given regular pain relief but if this does not keep your pain under control, please speak to the nursing staff. Do not just wait till the next pain medication is due.  Some patients experience mild episodes of muscle spasms in their back and legs (after low back surgery) or in their neck and arms (after neck surgery). Ice/heat packs or muscle relaxants can be used to lessen the discomfort.
  • You may continue to experience pain, numbness, and weakness along the path of the nerve that was decompressed by surgery. These symptoms will gradually decrease over time.
    Speak with your surgeon’s office about the timing of your first post-operative office visit.
    The majority of patients discharge home after 2 days depending on the type of surgery you have had.

Preparing to Go Home

Post operative care and instructions:

  • Keep your dressing dry and clean for 7 days after surgery to prevent infection.  Leave dressings intact unless damp or ooze present from wound. (If dressing damp or wound has oozed, get someone to change it for you with the dressings provided to you from the ward.)
  • Ensure they wash hands carefully first.
  • You may have sponge baths avoiding the area of dressing.
  • It is important if you have a low toilet, to consider loaning a plastic extension, or over the toilet seat. These can be hired from some chemists.
  • Incision and dressing care may vary from patient to patient. Please make sure you
  • understand your surgeon’s instructions before you leave the hospital.
  • Wear cervical collar provided for you at the hospital as instructed (if supplied).
  • Change position regularly, do not lie in one position for too long (you will get stiff and sore).
  • Take pain medication regularly as prescribed and advised. (Do not keep taking pain medication unless you really need it once the pain of the operation has worn off).
  • No stooping, bending or twisting of your back. Keep your back straight and bend your knees using your thigh muscles.
  • No sitting in soft chairs or sofas that allow your back to curve. Sitting may be uncomfortable, so limit your time sitting in a chair (20-30 minutes).
  • Sit and stand straight, do not sit slouched or leaning over to one side in a chair.
  • No stretching to reach high cupboards or shelves.
  • No jogging. Short, frequent short walks are better than long walks.
  • No lifting, housework or yard work during the first six (6) weeks or until allowed by your doctor.
  • No driving or long car journeys until consulting with your surgeon at the first post-operative visit

Follow the Guidelines for Physical Activity after Surgery

  • Light activities such as walking may be started as per your surgeons advise from second day of surgery. Your physical activities should progress gradually by alternating activity with rest. Plan for short, regular walks with rest periods.
  • Each day increase your walking distance on a gradual basis.
  • Once your sutures have been removed and the wound has completely healed (usually 2-3 weeks post-operation) you may go swimming (mainly just walking in the pool and a little gentle swimming.  (No pool games or diving in.)
  • Sexual activity is permitted within the bounds of your comfort. Consult with your surgeon.
    Discuss returning to work during your doctor’s appointment.

What do I need to tell my surgeon about after the operation?

You should notify your surgeon and should also see your GP if you experience any of the following after discharge from hospital:

  • Increasing leg pain, weakness or numbness
  • Worsening back pain
  • Problems passing urine or controlling your bladder or bowels
  • Problems with your walking or balance
  • Fever
  • Swelling, redness, increased temperature or suspected infection of the wound
  • Leakage of fluid from the wound
  • Pain or swelling in your calf muscles (ie. below your knees) Chest pain or shortness of breath
  • Any other concerns

When to Call Your Doctor

Call Your Doctor if You Experience Any of the Following Symptoms

  • If you feel warm or chilled, take your temperature. Call your doctor with a temperature of 38.3 °C or above.
  • Increasing redness and swelling at the incision site.
  • Changes in the amount, appearance, or odour of drainage from your incision.
  • New or increased changes in sensation/presence of numbness in extremities.
  • Severe pain that is not relieved by medication and rest.
  • Questions or problems not covered by these instructions.