Anterior Cervical Discectomy and Fusion is abbreviated ACDF. During this type of cervical spine (neck) surgery, an intervertebral disc is removed (discectomy), and bone graft and/or an interbody device is inserted into the open space between the upper and lower vertebral bodies. An interbody device is an implant (e.g., cage, cylinder) that gives structure and support to the newly fused vertebrae.

Surgery may include decompression. Decompression means the surgeon removes portions of bone or tissue that are exerting pressure on a nerve root or the spinal cord. Osteophytes (bone spurs), scar tissue and thickened bone may compress nearby nerve structures.

ACDF may require spinal instrumentation to stabilize the cervical spine. The type of instrumentation used in cervical surgery usually includes plates and screws.  Instrumentation provides immediate spinal stability.  Bone graft can stimulate new bone growth and join the upper and lower vertebral bodies.  This process is called fusion. 

What to know before your ACDF surgery

Most cases of cervical nerve compression and/or herniated disc resolve after a few weeks or months of nonsurgical care. If your spine surgeon recommends surgery, the procedure, possible benefits and risks, as well as the recovery process will be explained to you in detail.

You must stop tobacco use before surgery.  Nicotine hinders bone growth, slows healing, increases the risk of infection and increases your risk of a failed fusion.
 
Tell your doctor about all the prescription and over-the-counter medications you take, including vitamins, herbal products and other supplements. Some types of drugs and supplements, such as blood thinners and anti-inflammatory medications, must be discontinued before surgery.  Your doctor will provide you with written instructions to avoid any confusion.

Your spine surgeon will give you written instructions about how to prepare for your surgery, e.g., do not have anything to eat or drink after midnight the evening before your procedure. You will also receive instructions regarding your discharge, e.g., you must make arrangements for someone to drive you home after your surgery or hospital stay. In addition, you can anticipate receiving information pertaining to activity restrictions, follow-up appointments, etc.

Potential risks or complications of ACDF include:

All medical procedures, nonsurgical or surgical, have some risk of complications.  Risks associated with surgery include allergic reactions, excessive bleeding, blood clots, infection, nerve injury, paralysis and death. The usual risks of general anesthesia apply and will be explained to you by your anesthesiologist.

• You may experience hoarseness and/or difficulty swallowing after surgery.  The recurrent laryngeal nerve, which innervates the vocal cords, is moved during surgery.  Usually, these problems are resolved within a few weeks or months.  Rarely is treatment by an ear, nose, and throat specialist (ENT) needed.
•  Your vertebrae may fail to fuse.  This is called nonunion or failed fusion and may require additional surgery.
•  Implants may break or dislodge, potentially requiring additional surgery.  The term implants refers to instrumentation and devices.
•  Bone graft may migrate or dislodge, resulting in nonunion and potentially requiring additional surgery.
• Spine surgery may not resolve symptoms such as pain, tingling, numbness, or weakness.  Sometimes disc material or bone spurs damage nerves permanently.  The longer a nerve has been irritated, the longer it may take to heal.
• Complications from ACDF may require additional treatment that includes medication or surgery.

Surgery day

Wear loose-fitting clothing and flat-heeled, slip-on shoes with closed backs to the hospital. A shirt with a button front closure may facilitate dressing prior to your discharge home.

If instructed, take medication the morning of surgery with small sips of water.

At the hospital

• The medical staff reviews your history, condition, medications, allergies, and other pertinent information with you.
• You are given a gown to change into and instructed to remove personal articles such as jewelry and dentures.  Your clothing and personal effects are safely secured.
• The nurse attaches monitors to you to track your heart rate, blood pressure, pulse, and oxygen levels.
• The anesthesiologist meets with you to discuss your care and to answer questions.
• An intravenous (IV) line is inserted into your arm or hand.  Medications to help you relax and prevent pain, nausea, and infection are administered through the IV.

About the ACDF procedure and Recovery Room

• You are positioned on your back on the operating table.  Medication administered through your IV causes you to fall asleep.  When you are asleep, the anesthesiologist inserts a tube through your mouth and into your throat to keep your airway open during surgery.  The procedure is performed using general anesthesia.
• Your head is positioned, and the neck area is prepared.  If your surgeon plans to use your own bone for the bone graft, your hip area will also be prepared. Obtaining the bone graft from your hip is also a surgical procedure.
• An incision about 2 inches long is made at the side of your neck.  The spine surgeon carefully moves aside the neck muscles, trachea (windpipe), esophagus (membrane/tube to the stomach), and arteries.  Retractors hold these anatomical structures in place.  The layer of muscle over the front of your spine is moved aside to allow the surgeon to see the bony vertebrae and discs.
• Using image-guidance such as fluoroscopy (real-time X-ray), the surgeon passes a thin needle into the disc to confirm the operative level.
• The disc is removed (discectomy) using small grasping and cutting instruments.
• The ligament that runs behind the vertebral body may be shaved to remove any thickened or hardened areas, or it may be removed entirely.
• The spinal canal and nerve roots are inspected, and visible disc material is removed.
• The nerve roots are identified and decompressed by removing bone or bone spurs that are pressing on them.  The surgeon may enlarge the neuroforamen, or passageways between the vertebral bodies through which nerve roots exit the spine, to relieve nerve pressure.
• The endplates (connecting the disc to the vertebral body) are roughened using a drill or other tool and made to bleed.  This encourages the fusion process.
• If bone is to be taken from your hip (autograft), an incision is made at the top of your hip bone (about where you place your hands on your hips), and a small wedge of the bone's inner layer is removed.  This wedge is inserted between the vertebral bodies.  Alternatively, your spine surgeon may use donated bone (allograft) or a bone graft substitute.  Bone graft substitutes are made from ceramic, plastic or bioresorbable compounds.
• If an intervertebral device (such as a cage) is used, it is filled with bone shavings (autograft) and/or other bone products.  The device is implanted between the vertebrae.
• This process is repeated for any additional levels to be fused.
• A metal plate is placed over the grafted area and held in place by screws affixed to the vertebral bodies. 
• X-ray or fluoroscopy is performed to ensure the correct placement of the graft and implants.
• The retractors are removed, the muscle and other structures are allowed to move back into place, and the wound is closed with sutures and dressed with a bandage.
• You wake up in the recovery room.  Some patients report immediate pain relief upon awakening.  You may be given some ice chips to swallow and/or moisten your mouth. While in the Recovery Room,  a nurse will monitor your condition and arrange for your transfer to a hospital room.

Discharge and recovery after ACDF

After you meet recovery milestones such as the ability to walk, safely move about, urinate, eat (soft or light foods) and drink, you are discharged.  You are sent home with a prescription for pain medication.  Many patients find they no longer need pain medication after only a few days.  Pain is then managed with acetaminophen (Tylenol).

At home, instructions may include:

• Resume your regular medication as directed by your spine surgeon.
• Do not take nonsteroidal anti-inflammatory drugs (NSAIDs such as aspirin, ibuprofen, Motrin, Aleve, Advil) until your spine surgeon clears you.  These drugs can cause bleeding and inhibit fusion.
• Short-term application of an ice pack can help reduce pain or tenderness.  Do not apply heat.  The wound usually heals in about two weeks.
• If bone graft was taken from your hip, you may experience pain or soreness in that area.  Use an ice pack and take frequent breaks to walk around or change position.  Avoid sitting or lying down for extended periods of time.
• You may be given a soft cervical collar to wear full-time or during certain activities. Your surgeon will instruct you on its use.
• Take care of your bandage as instructed by your spine surgeon, including when you should shower, when to remove the bandage, and how long to keep the incision dry after surgery.  
• You may experience hoarseness, sore throat or difficulty swallowing.  This is normal and should be resolved in one to four weeks.
• Do not smoke or use tobacco products.  Nicotine delays healing and increases your risk for fusion problems (nonunion).
• Drink extra fluids and increase your dietary fiber to manage constipation which can occur after surgery.
• Do not drive until cleared by your spine surgeon.

Call your spine surgeon if:

• Your temperature exceeds 101° F
• The incision begins to separate or shows signs of infection.  Signs of infection include redness, swelling, pain and/or drainage (light blood or clear fluid is normal).
• Swallowing problems interfere with breathing or the ability to drink water.

General guidelines for the first two weeks after surgery

• Avoid sitting for extended periods of time
• Avoid extreme bending of your neck
• Do not lift anything heavier than five pounds or as directed by your spine surgeon.
• Do not do household chores without your surgeon's clearance.  This includes activities such as vacuuming, ironing, dishwashing, laundry and gardening or yard work.
• Do not take a tub bath or get into a hot tub or swimming pool until cleared by your spine surgeon.

General guidelines after two weeks

• Gradually return to normal activity
• Begin a walking regimen; start with short distances and increase the distance as you build endurance.

Some patients may experience a tingling or warm sensation in the arm on the side where surgery was performed. This can occur as the nerves heal. If symptoms worsen, please contact your spine surgeon.

Follow-up with your spine surgeon

Remember to keep all of your postoperative appointments and never hesitate to call your spine surgeon's office if you have questions or concerns.