Anterior Cervical Discectomy and Fusion (ACDF)

Overview

Anterior Cervical Discectomy and Fusion (ACDF) may be used to relieve symptoms from a damaged cervical disc by removing disc material and stabilizing the spine with a fusion. It can be considered for cervical radiculopathy or myelopathy related to herniated discs or degenerative changes when symptoms persist despite non-surgical care or when neurologic impairment is present. The procedure typically involves an anterior (front-of-neck) approach, decompression of nerve structures, placement of a graft or implant, and often plate-and-screw fixation. Outcomes can include reduced arm pain and improved neurologic function, while fusion and adjacent-segment changes may influence longer-term results.

Indications

This procedure may be considered when:

• •Cervical radiculopathy from a herniated disc that may cause arm pain, numbness, or weakness and that can persist despite a span of non-surgical management.
• •Cervical spondylosis with foraminal stenosis that may compress a nerve root and correlate with symptoms and imaging findings.
• •Cervical myelopathy from disc-osteophyte complex or central canal stenosis that can be associated with gait imbalance, hand clumsiness, or hyperreflexia.
• •Progressive neurologic deficit that may be attributable to cervical nerve root or spinal cord compression.
• •Recurrent disc herniation at a previously treated level when revision anterior decompression and stabilization may be considered.
• •Segmental instability or deformity at the affected level(s) where fusion may be used to improve alignment and stability after decompression.
• •Selected traumatic or degenerative disc disruptions where anterior decompression and fusion may be part of a broader stabilization strategy.

How It Works

The procedure typically involves several coordinated steps:

• •Preoperative imaging review (often MRI and/or CT) can be used to correlate symptoms with the target level(s) and to assess stenosis, osteophytes, and alignment.
• •An anterior cervical approach typically uses an intermuscular plane to reach the prevertebral fascia, which can reduce posterior muscle disruption compared with posterior approaches.
• •Fluoroscopic localization can confirm the operative level(s), which may reduce wrong-level surgery risk.
• •A retractor system may be placed to maintain exposure while minimizing pressure on the esophagus, trachea, and neurovascular structures.
• •The disc space is entered and disc material is removed; decompression can include removal of herniated fragments and trimming of uncovertebral or posterior osteophytes.
• •Neural decompression may be confirmed by visualizing the posterior disc space and foraminal regions; the posterior longitudinal ligament may be partially removed in selected cases to improve decompression.
• •Endplate preparation can create a bleeding bony surface that may support fusion biology while attempting to preserve structural integrity to limit implant subsidence.
• •An interbody graft or cage is inserted to restore disc height, which can indirectly enlarge foraminal space and reduce nerve root compression.
• •Bone graft material (autograft, allograft, or biologic adjuncts depending on context) may be used to promote arthrodesis across the disc space.
• •Anterior plate fixation can provide immediate segmental stability and may reduce micromotion that can interfere with fusion, particularly in multi-level constructs.
• •Final imaging can confirm implant position, alignment, and level; neuromonitoring changes, when used, can be reviewed for intraoperative neurologic integrity.
• •Fusion maturation typically spans months as bone forms across the interbody space; clinical improvement may occur earlier due to decompression, while radiographic fusion can develop more gradually.

Risks

As with any surgical procedure, potential risks include:

• •Dysphagia (swallowing difficulty) can occur due to soft-tissue retraction and postoperative swelling; it may be transient but can persist in some cases.
• •Hoarseness or voice change may occur from irritation or injury to the recurrent laryngeal nerve; severity can range from mild to clinically significant.
• •Hematoma or airway-compromising neck swelling can occur postoperatively and may require urgent evaluation and intervention due to potential airway obstruction.
• •Infection (superficial or deep) can occur; deep infection may involve hardware and can require prolonged management and possible reoperation.
• •Nonunion (pseudarthrosis) may occur when fusion does not consolidate; it can be associated with persistent pain or hardware stress and may require revision surgery.
• •Adjacent segment degeneration can develop over time at levels above or below the fusion, potentially leading to new symptoms and additional treatment.
• •Nerve root or spinal cord injury can occur, potentially causing new weakness, sensory changes, or myelopathic findings; risk may vary by anatomy and disease severity.
• •Dural tear and cerebrospinal fluid leak can occur, particularly in revision surgery or when ossification is present; it can require intraoperative repair and postoperative precautions.
• •Implant-related complications such as graft or cage subsidence, migration, plate/screw loosening, or malposition can occur and may affect alignment or neurologic structures.
• •Vascular or visceral injury (including carotid sheath structures, esophagus, or trachea) can occur rarely and may lead to serious complications requiring specialized management.

Recovery Expectations

Recovery follows a gradual progression:

• •First 24–72 hours: Monitoring typically focuses on airway status, swallowing/voice changes, pain control, and neurologic checks; discharge may occur within this span for uncomplicated cases, while some cases can require a longer hospital span.
• •First 1–2 weeks: Incision healing and soft-tissue swelling often improve; activity is generally limited to light daily tasks, and follow-up may include wound assessment.
• •Weeks 2–6: Gradual increase in walking and basic activities can occur; a cervical collar may be used in some protocols for part of this span depending on surgeon preference and construct factors.
• •Weeks 6–12: Return to desk-based work and light duties may be possible for some individuals depending on symptoms and job demands; physical therapy may be introduced or progressed when appropriate.
• •Months 3–6: Fusion maturation can progress; imaging may be used to assess alignment and early fusion signs; heavier lifting and higher-impact activity can remain restricted in many protocols during this span.
• •Months 6–12: Radiographic fusion can become more evident; residual neck stiffness can persist, and functional recovery may continue to improve across this span.
• •Beyond 12 months: Long-term monitoring may focus on symptom recurrence, adjacent-segment issues, and hardware-related concerns when present.

Alternatives

Depending on individual circumstances, alternatives may include:

• •Non-surgical management such as activity modification, physical therapy, and symptom-directed medications may be used for a span before surgery is considered in many cases.
• •Epidural steroid injection or selective nerve root block may be used in selected radiculopathy cases to reduce inflammation-related pain for a variable span.
• •Posterior cervical foraminotomy may be considered for lateral/foraminal nerve root compression in selected patients and may preserve motion at the treated level.
• •Cervical disc arthroplasty (artificial disc replacement) may be considered for selected single-level or two-level disease to preserve motion, depending on anatomy and contraindications.
• •Posterior cervical decompression procedures (such as laminoplasty or laminectomy with fusion) may be considered for multi-level myelopathy or when posterior pathology predominates.
• •Observation with serial neurologic assessment and imaging may be used in mild or stable cases where symptoms and neurologic findings can be monitored.

Sources

• AAOS OrthoInfo - Cervical Radiculopathy (Pinched Nerve)
• AAOS OrthoInfo - Cervical Spondylotic Myelopathy (Spinal Cord Compression)
• MedlinePlus (NIH) - Herniated Disk