Anterior Cervical Discectomy & Fusion (ACDF)

Anterior Cervical Discectomy & Fusion :: Posterior Cervical Laminectomy :: Lumbar Laminectomy :: Lumbar Microdiscectomy :: Lumbar Decompression & Fusion :: Fusion for Scoliosis :: Pedicle Subtraction Osteotomy

If you are scheduled to undergo an anterior cervical discectomy and fusion, either the spinal nerves or the spinal cord is being pinched in your neck. These findings typically cause numbness, tingling, pain or weakness in your arm(s). If the spinal cord itself is compressed, you may experience difficulty with your balance when you walk, or you may have difficulty using your hands during tasks that require fine motor control. Most common causes of pinched nerves in the neck are disc herniations and arthritis. For more on cervical stenosis and cervical radiculopathy, click here.

Before surgery is recommended, several tests are performed to determine the exact cause of your neck and arm pain. Tests may include X-rays, MRI scan, CT scan, EMG test or CT myelogram. If these tests show that you have significant arthritic changes in your neck and compression of the spinal nerves, you may need surgery to relieve your symptoms if treatment with physical therapy & spine injections has not been successful.

 

There are 2 main goals of this surgery

  • To remove the pressure off the nerves and/or spinal cord in your neck
  • To fuse one or more levels of your cervical spine to provide stability to your neck after the pressure has been removed off the nerves

A common question is why a fusion has to be done. To relieve the pressure off the spinal cord and nerves, the disc has to be removed. The disc is the “cushioning” between the vertebrae in the neck. Once this disc has been surgically removed, if nothing is put back in its place, the bones will collapse on each other and you get “bone on bone” arthritis. This will lead to pain and deformity and more pinching of the nerves. To prevent these problems, after the disc is removed, bone graft is put back in the space that was previously occupied by the disc. Then a metal plate is held in place with screws to prevent any further motion at that level. This provides immediate stability to the spine.

 

Surgical Details

An incision will be made on the front of your neck, typically 3-4 cm in length. The critical structures in the neck (major artery, windpipe, esophagus, etc.) are identified and moved out of the way to access the cervical spine. Once the spine is exposed, the disc is removed at the level of interest. After the disc is removed, the spinal cord is identified and the pressure is taken off of it. Then the pressure is taken off the nerves on the right and left sides. After all offending structures that are compressing the nerves and the spinal cord are removed, a small piece of bone, known as the bone graft or cage, is inserted between the vertebrae. Your bone cells will grow in and around the bone graft to eventually form the fusion. A small metal plate will then be attached to the front of the vertebrae with small screws. This plate and screws are referred to as the instrumentation portion of the surgery. They help to keep the bone graft in place and give added support to the area while the fusion is healing. Once the plate is positioned, x-rays are taken in the operating room to ensure good placement of all the screws and the plate and the graft. Then, the incision is closed, dressings are applied and you will then be extubated and taken to the recovery room.

 

Preparing For Surgery

  • About 2-4 weeks prior to your surgery, you should see your primary care physician for a complete medical examination and for “medical clearance”. Your doctor may order tests prior to your surgery to evaluate your risk of being put under general anesthesia
  • If you take the following medications, stop taking them for 1 week prior to surgery
    • Aspirin, anti-inflammatory drugs (Ibuprofen, Advil, Motrin, Aleve, Naprosyn, Celebrex, Mobic, Arthrotec, Voltaren, etc.), Vitamin E and Glucosamine, all prescription diet medications or herbal supplements
    • If you take Plavix, Persantine, Ticlid, stop these medications 1 week prior to surgery but be certain to notify your primary care physician or cardiologist before you stop taking these medications
  • If you take Coumadin for any reason, you should stop taking Coumadin 5 days prior to surgery, but be certain to notify your primary care physician or cardiologist before your stop taking this medication to ensure it is safe for your situation
  • YOU SHOULD CONTINUE all other medications that you normally take
  • Please let me and the anesthesiologist know about alcohol use. If you drink more than 2 alcoholic beverages a day, you may experience withdrawal symptoms after surgery. Symptoms may include mild shakiness, sweating, hallucinations and other more serious life-threatening side effects. Interventions can be taken before surgery to minimize withdrawal symptoms
  • Do not eat or drink anything (including water) after midnight the night before your surgery
  • You should make plans to have some assistance at home after your surgery. The level of assistance you need depends on the extent of the surgery, your age, and general health

 

Surgical Risks

Anterior cervical discectomy and fusion (ACDF) is generally a safe and effective surgery. However, as with any surgical procedure, there are potential risks. Risks of the operation include, but are not limited to: infection, anesthesia complications, injury to the nerves and spinal cord, hoarseness, injury to the esophagus, incomplete resolution of pain, and dislodgement of the graft. General medical complications include pneumonia, heart attack, stroke and blood clots. These complications are uncommon, and many precautions are taken to prevent or minimize risks but because human biology is at times unpredictable, no surgery is risk free.

Please note that smoking prevents fusions and soft tissue from healing because it decreases blood supply to the fusion area. You should stop smoking prior to surgery and during the healing process. Smoking will have a significant negative impact on your healing process and ultimately, the outcome of the operation. The healing process lasts up to one year.

 

Hospital Course

On the day of surgery, I will see you before you go back to the operating room to answer any additional questions you may have. You will then be taken back to the operating room where the anesthesiologist will give you a general anesthestic. The duration of the operation is variable depending on how many levels need to be fused. For a 1 level ACDF, typical surgery time is 1.5 hours, for a 2 level ACDF, surgery time is 2-2.5 hours, and for a 3 level ACDF, surgery typically lasts around 2.5-3.0 hours.

After surgery, you will be taken to the recovery room where your blood pressure, temperature, pulse and respiration will be checked frequently. You will stay in the recovery room for one to three hours. Meanwhile, I will speak with your family or friends in the waiting room regarding your condition. You will then be transferred to a regular hospital room. You will be given IV fluids until you are able to drink on your own. You will also be given IV pain medication initially, and then oral pain medication depending on your level of pain.

Most patients are helped out of bed by the nursing staff on the day of surgery. After surgery, it is very important to get out of bed and start moving as soon as possible. You will have pain in your neck from the surgery which we will control with pain medications. Lying in bed for a long period of time can lead to blood clots forming in your legs and may predispose to complications such as pneumonia. To prevent these complications, you should make every effort to get out of bed and walk. Sometimes, you will need the help of a physical therapist to get out of bed and walk, but this is usually not necessary after this type of surgery.

You will also be allowed to drink liquids and may eat soft foods as tolerated. It is common for your throat to be sore after this surgery. This usually improves gradually over several days. In some cases however, the soreness may improve more slowly. It is common to feel like it is difficult to swallow after surgery. The sensation is usually described as “feels like there is a lump in my throat”. This is caused by tissue swelling. People usually find it easier to swallow soft foods such as yogurt, pudding, Jell-O, mashed potatos, soup, apple sauce, etc. Dry or crumbly foods such as baked or roasted meat, muffins, cake, or toast can be particularly difficult to swallow right after surgery. Be sure to take small bites and chew the food very well. Also, always have water on hand to help clear your throat. This sensation usually improves gradually over the first few weeks. In some cases however, it may improve more slowly.

Your wound drainage will be monitored closely. The drainage tube and original dressing are typically removed the day after surgery. A new dressing will be placed over your incision. When you return from surgery, you may have a drainage tube (Foley catheter) in your bladder that is connected to a collection bag. This is typically removed on the first day after surgery. Once you are able to drink, eat, and take your pain medication by mouth, your IV line will be removed. Most patients can go home either the next day or 2 days after surgery. You will be discharged from the hospital when the following goals have been met:

  • Your pain is reasonably controlled with oral pain medication
  • You are able to eat a meal without nausea or vomiting
  • You are able to walk safely on your own
  • You are able to urinate on your own
  • Your vital signs (temperature, blood pressure, heart rate, respiration) are normal

Although the nerve has been freed, it is still injured. The pain, numbness, or tingling in your arm(s) usually begins to improve shortly after the surgery. In some cases, it may take several days before an improvement is noticed. Nerves heal very slowly. It is common to still have some numbness, tingling, or discomfort for a few weeks after your surgery, but to a much lesser extent than before surgery. Every patient experiences this healing process differently

 

At Home After Surgery

The post-operative instructions outlined below will give you the best possible chance of having a positive outcome from this surgery:

  • Take short walks as your comfort allows. You can start walking the morning after your surgery. Gradually increase the amount of walking you do each day
  • Avoid all strenuous activities for 3 months. Do not lift anything heavier than 20 lbs for the first 2 months, especially avoiding overhead lifting
  • Wound care:
    • On the second day after your surgery, you can take a shower but keep your incision covered with gauze and Tegaderm dressing to keep the incision dry. After showering, pat the incision dry and cover it with a new dressing
    • Keep your incision covered with Tegaderm dressing for 1 week when you take a shower. After that, you can shower without anything covering your dressing as long as there is no drainage from the incision. Do not take baths or soak your incision (swimming, etc.) until your wound is fully healed, usually at around 3 weeks
    • Do not apply any lotions or creams to the incision
  • You must wear your collar at all times except to shower, and you may remove it briefly for personal hygiene (shaving). While the collar is off, you may look forward or slightly downward, but you must not look up. This motion extends your neck and can cause the bone graft to dislodge. Most people will need to wear the collar until the first post-operative appointment. At that time, I will determine if you are able to stop using the collar. In most cases, a collar will be worn for about 3-4 weeks. Some patients may have to continue to wear the collar for a longer period of time depending on their situation
  • Reasons to contact us immediately:
    • If there is any redness around the incision
    • If there is any drainage from the incision after the second day
    • If your arm pain or numbness is significantly worse than before surgery. You should expect some pain and stiffness in your neck from the surgery. This improves with time as the wound heals
    • If it is becoming more difficult to swallow instead of slowly getting easier
  • Call 911 immediately if it is getting harder to breathe because of the swelling in and around your throat OR if you have shortness of breath or chest pain
  • Return to work depends on your occupation and your employer’s acceptance of your activity restrictions
  • No driving for at least 3-4 weeks after surgery – this is because you cannot turn your head quickly after this operation and this puts you at risk of an accident
  • You may resume sexual activity as your comfort allows. Please keep in mind the activity restrictions listed above
      • I will see you in the office 2-3 weeks after your surgery. Please call for an appointment
      • Fusions heal slowly. It can take up to one year for a fusion to fully heal. You will need to see me periodically in the office during this healing period. We will check your progress by X-ray at each of your follow up appointments
      • At 10-12 weeks, formal physical therapy is initiated to improve neck range of motion and strengthen the neck, trapezius and other upper back and scapular stabilizing muscles. For patients who must return to hard physical labor, we utilize a work hardening program through the physical therapists prior to returning these patients to work