The great majority of patients who have neck pain do not require any type of operation. However, in more serious cases, a surgeon may suggest an anterior cervical fusion, ACDF surgery, to try to reduce the neck pain.
ACDF stands for Anterior Cervical Discectomy and Fusion - a surgical procedure performed to treat a damaged disc in the neck area of spine. ACDF is a very effective operation which is used to treat two possible conditions:
Bulging and herniated disc
It is well known that the gel-like material within the disc can bulge or rupture through a weak area in the surrounding wall causing different symptoms such as irritation and swelling.
Degenerative disc disease
Discs can naturally wear out causing the bone spurs to form and the facet joints to inflame. The discs then dry out and shrink, losing their flexibility and cushioning properties. Mild cases of cervical spondylosis often require no treatment or may respond to conservative treatment. More severe cases of cervical spondylosis may require treatment ranging from neck traction to stronger medications and even surgery. In most cases, this surgery requires a hospital stay from 1 to 3 days and recovery time takes between 4 to 6 weeks.
Indications for the operation
Person may be a candidate for ACD surgery if she or he:
- has significant weakness in your hand or arm
- has pain in arm which is worse than in neck
- has not improved with physical therapy or medication
- diagnostic tests (MRI, CT, myelogram) show herniated or degenerative disc
Anterior cervical discectomy & fusion (ACDF)
Discectomy literally means cutting out the disc.
Anterior cervical discectomy is a surgical procedure that removes all or some of the disc. The surgeon reaches the damaged disc from the front of patient’s neck.
To keep the normal height of the disc space and prevent the vertebrae from collapsing and rubbing together, sometimes the surgeon fills the space with a bone graft. Fusion means joining two or more bones together to stop movement between them and provide stability.
Instrumented Cervical FusionIn the last couple of years, instead of bone grafting, there has been an increase in the use of metal plates, screws, and rods. Several researches have proven that bone heals best when it is held still, without motion in between. However, the neck is a difficult part of the body to hold still. That’s why casts and braces are used in an attempt to reduce the motion in the neck and to increase the success rates of a spinal fusion.
Preoperative tests and careSince it is a rather serious operation, every patient should be scheduled for pre-surgical tests such as blood test, electrocardiogram, chest X-ray. The surgeon usually speaks with a patient and takes medical history because of possible allergies, medicines/vitamins, bleeding history, anesthesia reactions, previous surgeries. The patient should stop taking all non-steroidal anti-inflammatory medicines and blood thinners one week before surgery. Additionally, patients should stop smoking, chewing tobacco, and drinking alcohol one week before and 2 weeks after surgery as these activities can cause bleeding problems. The operation is done under central anesthesia.
The operationThe patient is positioned on their back and, after the anesthesia is administered, a small incision is made on either the right or left side of the neck. The trachea and esophagus are moved towards to middle, and the carotid artery and jugular vein are moved toward the side. When surgeon visualizes the spine, he removes about 2/3 of the disc using small grasping tools, and then looks through a surgical microscope to remove the rest of the disc. The posterior longitudinal ligament, which is located behind the vertebrae, is removed. A titanium plate may be used to secure the bone plug and provide some extra stability until the bone graft causes a fusion. There are some instances in which it may be preferable to use the patients own bone. The operation is done and the incision is then closed with stitches. Patients can generally resume normal activity in about four weeks after surgery, but this should be discussed with a physician.
Operation risksNo surgery is without risks. Beside the common complications such as bleeding, infection, blood clots, neurological deterioration and reactions to anesthesia which are possible after any operation, there are some specific complications characteristic to this operation.
Some of the possible risks are:
Sometimes vertebrae simply don’t fuse! There are many reasons why vertebrae fail to fuse and some of the common reasons are smoking, osteoporosis, obesity, and malnutrition.
Problems with anesthesia
A very small number of people experience problems with the medication that puts them to sleep. Discuss any concerns you have with your anesthesiologist.
Sometimes the recurrent laryngeal nerve that innervates the vocal cords does not work for several months after surgery. This may cause temporary hoarseness.
This is a potentially serious condition in which blood clots form inside the veins of your legs. The problem is that these clots may break free and travel to lungs, causing collapse or even death.
Every operation on the spine comes with the risk of damaging the nerves or spinal cord.
Sometimes the metal screws, rods and plates used to stabilize spine may move or break before vertebrae are completely fused.
Persistent postoperative pain
The surgery doesn’t remove all pain, but allows a patient to return to improved function.
Post - operative care, expectations and restrictionsSuccessful recovery from anterior cervical discectomy requires that a patient approaches the operation and recovery with confidence. Full recovery will also depend on having a strong, positive attitude, setting small, realistic goals for improvement.
RecoveryRecovery generally lasts 4 to 6 weeks and X-rays may be taken after several weeks to verify that fusion is occurring.
Although patients often dislike it, a cervical collar or brace is sometimes worn during recovery to provide support and limit motion. After this period a patient should gradually return to normal activities. Fatigue is common and expected. Walking is encouraged. Most of the patients reported that an early exercise program of gentle stretching, conditioning, and strengthening could be extremely beneficial.
Post-operative careRight after the surgery, pain should be managed with narcotic medications because pain could be extremely strong. However, because narcotic pain pills are addictive, they are used for a limited period (2 to 4 weeks). Sore throat, or difficulty swallowing may occur during the first 2 weeks but all these symptoms should disappear soon.
- Patients are advised not to use NSAIDs such as Aspirin; ibuprofen, Advil, Motrin, and others at least 3 to 6 months after surgery.
- Patient must not smoke because smoking delays healing by increasing the risk of complications
- They shouldn’t drive for 2 to 4 weeks after surgery and avoid sitting for long periods of time.
- No meter how good they feel no patient should not lift anything heavier than 5 pounds
- Every sexual activity should be avoided unless surgeon specifies otherwise
Further damage can be avoided by:
- Skipping high-impact activities, such as running and high-impact aerobics
- Doing exercises to maintain neck strength, flexibility and range of motion
- Taking breaks when driving, watching TV or working on a computer to keep from holding head in the same position for long periods
- Practicing good posture, with your neck aligned over shoulders
- Protecting neck from injury by using a seat belt when in a car and avoiding activities that strain your neck