Anterior Cervical Discectomy and Fusion (ACDF) Treatment
One of the most common procedure performed in cervical spine is ACDF. Due to the fact that the anterior cervical pathology cannot be managed from the posterior approaches because, any manipulation of the cervical cord may result in the cervical cord trauma and injury. This is different than the lower lumbar procedures as the cord end at that level, and manipulation through the posterior approaches are possible.
This procedure is commonly done in patients who have a prolapse intervertebral disc or osteophytes and are complaining of pain in the neck or upper limbs with radiculopathy, along with numbness and paresthesia with weakness and balance problems.
Before advising surgery to such patients, we try to manage them conservatively for 4-6 weeks advising them rest and medication which include anti-inflammatory and muscle relaxants. Failure of this treatment is followed by physiotherapy, acupuncture and chiropractor treatment. Later, if the symptoms does not subside, then we advise advanced radiological investigations like MRI, to know the extent of disease. If there are small disc protrusions or bony spurs or osteophytes, then nerve root injections may be perused while in severe compression surgery is advisable.
Surgery is advised early if the patient develop sudden weakness or the conservative treatment fails. Surgical options commonly offered are
- Minimally invasive foraminotomy,
- Anterior cervical discectomy and fusion (ACDF) or
- Artificial cervical disc replacement (ACDR).
Minimally invasive foraminotomy: This procedure is usually performed in a unilateral disc with pressure over the exiting nerve root in young patients. In this, using a guide wire under fluoroscopic guidance the concerned level is reached and then serial dilators are introduced splitting the muscles. Then the bone is drilled to expose the nerve root and the disc or osteophyte is removed and decompression is done.
Artificial cervical disc replacement (ACDR): It is a good option in young patients with one or two level disease and helps in full cervical spine mobility>.
Anterior cervical discectomy and fusion (ACDF): An incision is given over the anterior cervical crease in the neck according to level of vertebra to be exposed. The blood vessels are retracted laterally and esophagus and trachea medially to reach the anterior cervical spine. Level confirmed using C-ARM. Then the disc is removed and nerve root is freed. The disc space is filled with a cage or a bone graft and fixed with the plate and screws, so that the graft stays in place and result in the bony fusion of two vertebral bodies.
Before the advent of metallic or other cages, the bone graft harvested from the iliac crest was used which result in excellent fusion. But the patient experience more pain at the iliac crest region. Sometimes, no graft was kept and the bony fusion use to happen by “settling” but in such cases the normal cervical lordosis is lost.
A patient undergoing ACDF has been advised to wear a cervical collar for around 3-4 months post procedure.