Orthopaedic Spine Center Graham Calvert MD James Woodall MD PhD Anterior Cervical Discectomy and Fusion (ACDF) Normal Discs The cervical spine consists of the bony vertebrae, discs, nerves and other structures. The vertebrae, which stack up to create your spinal column, surround and protect your spinal cord. The discs are located between each vertebra. Discs consist of a fibrous outer layer (annulus) surrounding a gelatinous center (nucleus). They allow motion between vertebrae, act as shock absorbers, and distribute the stress and strain placed on your spine. Herniated Discs When a disc weakens, the outer layer may not be able to hold the center of the disc in place and the disc may bulge which can irritate nerves. In advanced cases it may actually rupture (herniate) through the annulus and pinch the spinal nerves. This can cause numbness, weakness, and/or pain, which radiates down the arm into the hand; or can cause difficulty with fine motor movements. If pressure on the spinal nerves continues, nerve damage can occur and cause either numbness or muscle weakness as well. Most patients with herniated discs do well without surgery; however a small percentage may require surgery. There are rare circumstances in which some patients require immediate surgery. These include progressive neurologic loss such as increased weakness or paralysis.
Treatment Options for Herniated Cervical Discs Conservative Management: Many herniated discs get better with time, antiinflammatory medications, and physical conditioning. Cervical traction or steroid injections may help relieve the pain and inflammation around the nerves. If these attempts at conservative care do not relieve symptoms or if there is progressive neurological damage, surgery may be necessary. One surgical option for this condition is an anterior cervical discectomy and fusion. Anterior Cervical Discectomy and Fusion Anterior Cervical Discectomy & Fusion (ACDF) is an operation to remove a herniated disc (discectomy) in the neck. This surgery involves a 3 4 inch diagonal incision on the front (anterior) of your neck. Because the incision follows a natural skin fold, the resulting scar can be very cosmetic. The doctor protects the nerve roots and safely removes the herniated disc, eliminating pressure on the nerve. Next, bone graft is placed where the disc was, allowing the two vertebrae to grow together as one (fusion). Finally, a small metal plate may be screwed into place to hold the bone graft while the fusion heals. The purpose of this surgery is to relieve arm/hand pain, numbness, weakness, or lack of coordination and fine motor control caused by pressure on the nerves. The success rate of relieving arm pain is very high. The surgery typically lasts 1 1½ hours, depending on the number of discs operated upon, whether or not previous surgery has been performed, and the severity of pressure on the nerves. Blood loss is minimal so no blood donations are necessary before the operation. Time spent in the hospital is brief most patients can go home one to two days after the surgery. The most common complaint of patients after this surgery is difficulty with swallowing. This is due to the surgical approach necessary to access the front of the cervical spine. This usually resolves over a few weeks after surgery, but may necessitate eating only liquids or soft solids during that period. Patients usually wear a soft collar for comfort for 2-6 weeks. It is beneficial to sleep upright for approximately one week following surgery to help decrease swelling in the neck.
Risks of Surgery Surgery and anesthesia involve stresses to many organs and tissues in the body. Incisions and handling tissues during surgery can result in many problems. The benefits of surgery must be carefully weighed against these risks. Some more common or serious problems are listed here. Spinal Cord or Nerve Root Injury: Permanent injury to the spinal cord or nerve roots is extremely rare. It is not unusual, however to experience minor temporary tingling, numbness, weakness or pain which resolves over several weeks. All precautions will be taken but rarely, more serious nerve injuries may occur, effecting walking, balance, bowel or bladder functions. Failure of fusion: On rare occasions the bone graft does not heal properly. The likelihood of this is greatly increased by smoking or using nicotine of any kind. This can cause the hardware to fail, and the bone graft may shift. In these cases, additional surgery may be needed. For this reason we recommend quitting smoking at least one month before surgery and refraining from smoking for at least 3 months after surgery. Smoking also causes more rapid degeneration of the spine, and continuing to smoke increases the likelihood of requiring treatment at another level of the neck. Dural Tear: Leakage of spinal fluid can occur due to a tear in the tissue (called the dura ) holding the spinal fluid and containing the nerves. On rare occasions additional surgery may be needed. Infection: Infection is always a post-operative risk and occurs in approximately 1 2% of surgical patients, varying by surgery type. Infections may be superficial or deep into the bone. You are given antibiotics before and after the surgery to help prevent this complication. Please follow the instructions for wound care to help prevent infection. Airway Compromise: Extremely rarely swelling within the neck can cause difficulty with breathing. If this occurs in the hospital, a breathing tube may need to be kept in place. If this occurs at home, it is an emergency and requires transportation to an emergency room. Other complications: Other possible complications include blood clots, pneumonia and complications related to the general anesthesia. Persistent hoarseness and/or swallowing problems may last for several weeks. Please call us if this persists.
Activities and Exercise / Rehabilitation Adequate rehabilitation is crucial for a successful result. Many patients with spinal injuries have suffered from spinal pain for some time. This may result in considerable weakening of the spinal muscles due to lack of exercise, so you should return to your normal activities slowly. The primary form of rehabilitation after ACDF is an aggressive walking program. You should start immediately after discharge, walking more and more each day. In general, we recommend two to three episodes of exercise per day. The average patient can be walking 15 minutes twice a day by their first postoperative visit and 30 40 minutes twice a day by six weeks after surgery. Walk more if you are so inclined! Expectations Patients routinely experience a dramatic, remarkable reduction in their arm pain. If the nerve has been irritated for a long time, then a more gradual reduction of the arm pain is to be expected. As the nerve heals, expect tingling or a warm feeling. Depending on how long the symptoms have been present, strength is usually the second symptom to improve. Numbness in your arm / hand is the last to resolve and, if present for long enough prior to surgery, may be permanent. Neck pain associated with the incision is largely improved within two to three weeks. Increased pain with prolonged sitting and driving is also expected and, for safety reasons, we recommend refraining from driving for approximately three weeks.
Call the MSMOC Spine Center if you experience any of the following Temperature greater than 101.5 degrees Increased redness, swelling, bleeding, or other drainage at your incision site Changes in or difficulty controlling your bowel or bladder functions Increased weakness or numbness to your legs Increased or unusual pain not relieved by pain medication Wound Care At your first post-operative visit we will inspect your incision and remove any stitches if necessary. Do not soak your incision. No bathtub, swimming or hot tub until you have received permission from your surgeon. Leave any butterfly or steri-strip bandages that cover the incision in place until they fall off on their own. It is okay to shower after 72 hours. Cover the incision with a clear waterproof bandage while showering and replace dressing after showering to assure the incision is dry, then place a new clean and dry bandage. Medications Prescribed narcotic medications may cause constipation. To help with this please increase your fluid intake as well as fiber intake (fruits, vegetables, whole grains. Also, walking as much as possible will help. Activity Limitations Avoid twisting your back, and avoid forced bending of your back either forward or backward. Also, avoid sitting for prolonged periods of time as this position puts the most pressure on the discs. Reach for objects on the floor by bending your knees, not by bending at the waist. Do not drive until you have received permission from your physician.