ACDF

Anterior Cervical Discectomy, Decompression and Fusion for the Treatment of Pain, Weakness, Numbness and Tingling in the Neck and Arm caused by Radiculopathy or Myelopathy

Edited By Michael J. Lee, M.D., Associate Professor, UW Orthopaedics & Sports Medicine Michael J. Lee, M.D.

Last updated: December 31, 2009

Overview

Some people experience a narrowing of the canal that surrounds the spine. This narrowing condition, called stenosis, can emerge at any region of the spine, from the cervical (neck) to the sacral (tailbone). In the cervical spine, stenosis creates pressure that not only can inflame the spinal nerves but also can radiate pain to a person’s arms and legs. Decompression and fusion surgery of the cervical spine can relieve the pressure and reduce the pain.

Stenosis can be an inherited condition, or can result from osteoarthritis or from a herniated disc – one that bulges out from between a pair of vertebrae. These disorders limit the space in which the spinal cord can flex, in turn compressing the cord and its nerve roots. This resulting inflammatory reaction causes pain, numbness, tingling, and weakness.

When a nerve root or a branch off of the spinal cord is affected, the condition is termed radiculopathy. Radiculopathy can be treated with surgical and nonsurgical measures. When the condition affects the spinal cord, it is termed myelopathy. In general, myelopathy does not improve with nonsurgical treatment. In very mild cases, myelopathy can be observed.

Radiculopathy and myelopathy can be diagnosed with a physical exam. This diagnosis can be further supported with imaging studies such as X-rays and magnetic resonance imaging (MRI).

Radiculopathy can be successfully treated with therapy, anti-inflammatory medication, and steroid injections. If these nonsurgical efforts fail, surgery should be considered. In general, the surgical goal is to relieve pain, and neurological symptoms caused by the radiculopathy.

Myelopathy, if symptomatic, is generally treated with surgical intervention. The surgeon’s goals in treating myelopathy are to prevent progression of the condition and avoid further neurological damage.

Surgical treatment can be done from the posterior (back) of the neck or from the anterior (front). This decision is affected by numerous factors including the nature of the condition, the patient’s underlying alignment, the number of levels affected, and more.

Anterior cervical decompression and fusion (ACDF) has been shown to be highly successful in relieving symptoms of radiculopathy and halting the progression of myelopathy.

Symptoms & Diagnosis

Characteristics of cervical stenosis

Radiculopathy commonly presents as arm pain, numbness and tingling down the arm, occasional weakness in specific muscle groups (depending on which nerve root is affected), and neck pain. Certain neck positions can aggravate the patient's symptoms.

Myelopathy can present as changes in walking patterns, clumsy hand coordination, in severe cases, bowel and bladder changes. Reflexes can be exaggerated with myelopathy.

Myelopathy and radiculopathy can occur at the same time and the patient can have a combination of these symptoms.

Types

Spinal stenosis can be caused trauma or injury, by bony growths, or can be inherited and degenerative.

Vertebral discs are the doughnut-shaped, shock-absorbing structures that sit between each vertebrae. An injury or trauma often herniates a disc, causing part of it to protrude from between two vertebrae and into the spinal canal. Depending on the location and extent of herniation, the patient can have radiculopathy, myelopathy, or both. In the same way, degenerative disc disease – the wearing down of the discs

Spinal stenosis also can be a result of advanced arthritis in the neck or upper back. Bone-spur formation can place pressure on the spinal cord and/or its nerve roots. Similarly, tumors can emerge around the spinal canal, putting pressure on the cord.

Congenitally, cervical stenosis presents as a naturally narrower spinal canal. This condition can make a person more prone to experience radiculopathy, especially if the narrowing progresses throughout life.

Similar conditions

The presence of certain neurological patterns and cervical stenosis highly suggests that the patient’s symptoms are coming from the cervical spine. However, other neurological conditions can mimic these symptoms. For example, if a nerve is compressed in the arm, rather than the neck, this can mimic symptoms of cervical stenosis. 

Occasionally, an electromyography (EMG) test can help differentiate the source of symptoms. In addition to other potential sites of nerve compression, certain metabolic conditions such as multiple sclerosis can mimic symptoms of cervical stenosis.

Incidence and risk factors

Recent studies estimate cervical stenosis to be as common as 5 percent of the general population, nearly 7 percent of people 50 or older, and 9 percent of population 70 or older. It is unknown what rate of patients with cervical stenosis experience symptoms or do not experience symptoms.  

Diagnosis

Radiculopathy and myelopathy are diagnosed with physical exam. A variety of physical exam tests examining muscle groups, the distribution of numbness and tingling, and the quality of reflexes allows the physician to identify which nerves are affected.

X-rays and magnetic resonance imaging (MRI) serve to confirm diagnoses and provide more detailed information to help determine the appropriate surgery. Occasionally, in a clinically challenging patient, an electromyography (EMG) and nerve-conduction testing are done to isolate the area of nerve injury.

Treatments

Medications

Radiculopathy (nerve root compression) can be successfully treated with anti-inflammatory medication such as ibuprofen or Naproxen, which are sold over the counter at drugstores and groceries. These medications decrease the inflammation and can relieve the patient’s symptoms.

If these medications fail, a steroid injection around the affected nerve can be performed. The steroid injection delivers a higher concentration of anti-inflammatory medication directly around the affected nerve.

Myelopathy (spinal cord compression) generally does not respond to anti-inflammatory medication as well as radiculopathy.

It is important that the patient be aware of the possible side effects of these medications, including stomach irritation, kidney problems and bleeding. If the patient has a history of difficulty with these medications, other treatment options should be considered.
For each medication, patients should learn possible interactions with other drugs, the recommended dosage, and the cost.

Exercises

In general, exercises do not relieve myelopathy (spinal cord compression). Therapy can provide some relief for radiculopathy. Traction exercises can help relieve stenosis affecting nerve roots. These exercises can provide enough relief until the radiculopathy has resolved.

Possible benefits of anterior cervical decompression and fusion (acdf)


With anterior cervical decompression and fusion, the surgeon removes the offending disc(s) and/or vertebral bodies, and the spine and its nerve roots are decompressed in the front. This part of the procedure directly takes pressure off of the spinal cord and its nerve roots.

After the decompression, a bone graft is placed to replace the removed tissue. This bone graft partially fuses the cervical spine and stabilizes the neck. The bone may be taken from the patient’s own pelvis (autograft) or from the tissue bank (allograft –cadaver bone). Cadaver bone has been shown to have excellent healing rates and avoids a second incision in the patient at the hip.

In addition to the bone graft, a small titanium plate is placed at the vertebral levels above and below the affected vertebra to give additional stability to the fusion after placement of the bone graft.

Types of surgery recommended

The cervical stenosis can be approached from the anterior (front) or from the posterior (back) of the patient. The decision to approach the spine from the front is dependent upon many factors, including:

  • how many levels of discs and vertebraeare involved
  • the overall alignment of the cervical spine
  • the presence of radiculopathy, myelopathy, or both
  • the presence of neck pain
  • the extent of arthritis, and more
The surgeon weighs these factors and the results of a full diagnostic workup, and recommends the surgical approach and procedure.

Who should consider anterior cervical decompression and fusion (acdf) ?

Generally patients with symptomatic myelopathy are appropriately treated with surgery to prevent progression of their condition. Patients with very mild myelopathy can be observed.

Patients with radiculopathy can initially be treated nonsurgically. Anti-inflammatory medication, therapy, and steroid injections can treat radiculopathy. If these treatments fail and symptoms persist, surgical intervention is generally recommended.

What happens without surgery?

Radiculopathy often can resolve with non-operative treatments. If radiculopathy does not improve with non-surgical approaches, it is reasonable to examine surgery as an option. Myelopathy, in general, does not improve without surgery. With myelopathy, the surgeon’s goal is to prevent progression of the condition and further neurological damage. Although patients can recover neurological function after a surgical procedure for myelopathy, the recovery rate is variable. A patient usually can recognize as neurological deficits progress: walking becomes more difficult; increasing weakness and burning sensation or tingling in arms and legs; and more problems with fine motor control of their hands. In severe cases, bladder and bowel problems emerge.

Surgical options

The cervical spine may be approached from the front or the back of the neck. If approached in the front, an anterior decompression and fusion is usually performed. If approached from the back, a number of options exist. The decision to recommend one surgical procedure over another depends on many factors already discussed.

A decompression from the back can be performed with or without a fusion. The question of whether fusion is appropriate should be addressed directly with your doctor.

Effectiveness

In the hands of an experienced surgeon, decompression and fusion surgery is usually very effective in relieving symptoms of nerve root compression, and in preventing progression of nerve damage from spinal cord involvement. After the patient has healed from the fusion procedure, the positive effects of surgery level can last decades.

Urgency

Anterior cervical decompression and fusion for radiculopathy is not generally emergent. A trial of initial non-operative treatment is usually appropriate.

To treat myelopathy, the surgery is more urgent, however not emergent unless is a progressive neurologic deficit exists. At times, particularly in traumatic settings, surgical intervention is warranted on an emergent basis. Generally, it is recommended that patients with symptoms of myelopathy be treated sooner rather than later to prevent further neurological damage.

Risks

Any surgical procedure carries a certain amount of risk. These risks include, but are not limited to, infection, bleeding, nerve injury, and swallowing difficulty.

With this procedure, the fusion may not heal properly and a second surgery may need to be performed. There are also risks of anesthesia. Although risks exist to the procedure, the complication rate is low. Generally, patients do not require a blood transfusion, as blood loss for these surgeries is very low.

Managing risk

In the rare event of a complication, measures can be taken to counter them. If an infection emerges in the early postoperative period, a surgical cleansing of the wound can be performed. If there is a nonunion, or if the bone graft does not fuse and the patient has symptoms because of this nonunion, a fusion can be performed posteriorly, or the fusion can be revised from the front.

Preparation

If the patient is a smoker, the patient should cease all smoking prior to the surgery. Studies have shown that smoking decreases the likelihood that the bone graft will fuse into place. The patient should cease smoking for at least 6 months after the surgery to allow time for the bone graft to heal completely.

Generally, blood transfusion is not necessary, so donation of blood units is not needed, as is common in other surgical procedures.

Prior to the surgery, the patient should have a thorough understanding of the risks, benefits, and potential complications of surgical vs. nonsurgical treatment. In addition, the patient should have an excellent understanding of the goals of surgery. Depending on the condition, the goals of surgery range from preventing further neurological damage to relieving pain and symptoms.

Timing

When the patient is myelopathic, it might suggest urgency for the decompression and fusion procedure depending on the severity of the condition.

Costs

The patient’s insurance provider can provide a reasonable estimate of the following:

  • the surgeon's fee
  • the hospital fee
  • the degree to which these should be covered by the patient's insurance

Surgical team

A fellowship-trained spine surgeon should perform this procedure, as it is technically demanding. It should be performed at a medical center where these procedures are done routinely.

Finding an experienced surgeon

Surgeons specializing in spinal procedures may be located through the American Academy of Orthopedic Surgeons Web site, university schools of medicine, and county or state medical or orthopedic organizations. 

Facilities

Surgery is usually performed in a major medical center that performs these procedures on a regular basis. These centers have surgical teams and facilities specially designed for this type of surgery. In addition, neurological monitoring should be used, depending on the patients’ condition and this should be avail. They also have nurses and therapists who are accustomed to assisting patients in their recovery.
Technical details

After the anesthesia is administered and the patient is given prophylactic antibiotic, a horizontal incision (3 cm to 4 cm) is made on the front of the neck. This incision is made in line with the way the skin runs, so it can heal along skin lines with minimal scarring.

Dissection through superficial muscle layers, around the midline esophagus and airway structures, and onto the cervical spine is then performed. Retractors are placed. An intra-operative X-ray is performed to confirm the appropriate level of surgery.

The intervertebral disc is then completely removed. A foraminotomy can also be performed; this is the direct decompression of the space through which the nerve root travels. Disc material or bone spurs can impinge in this area, and place pressure on the nerve root.

After discectomy (removal of the disc) and foraminotomy (decompression of the nerve root), partial or complete removal of the vertebral body can be done. The decision to remove the vertebra (corpectomy) is dependent upon the nature of the condition. This may or may not be necessary.

After adequate decompression of the spinal cord and or nerve roots, a bone graft is then impacted into place where the disc was removed, between the two vertebrae.

A small titanium plate is then placed on top of the bone graft and into the bone above and below Screws are placed into the bone above and below to hold the plate in place. This plate gives additional stability to the structure.

The surgical wound is then washed out, and the layers are closed with suture. The skin is closed with an absorbable suture, and there is no need for suture or staple removal. A drain is placed for 24 hours and is removed the next day.

The patient is placed in a soft neck collar postoperatively, typically for a few weeks.

Anesthetic

General anesthesia is necessary to perform this procedure. For spine procedures, it is generally advisable to have the patient go to sleep for their anesthesia than to be partially awake. With such meticulous dissection around the spinal cord and nerve tissue, sudden inadvertent patient motion may result in injury.

Length of anterior cervical decompression and fusion (acdf)

Cervical stenosis can occur at one particular location in the cervical spine, or at multiple levels. The length of the procedure depends on the number of levelsand whether the vertebral body is being removed. In general, the procedure takes 45 minutes to two hours.

Pain and pain management Shortly after the patient awakens from surgery, the patient is given a PCA (patient-controlled analgesia) machine. This is a button that allows the patient to self-administer pain medicine through the IV. The pain medicine most commonly used is akin to morphine. This is usually discontinued the next day, and the patient is given oral pain medications.
 
 
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Use of medications Initially pain medication usually is administered intravenously or intramuscularly. Sometimes patient controlled analgesia (PCA) is used to allow the patient to administer the medication as needed. Hydrocodone or Tylenol with codeine are taken by mouth. Intravenous pain medications are usually needed only for the first day. Oral pain medications are usually needed only for the first two weeks after the procedure.

Effectiveness of medications

Pain medications can be very powerful and effective. Their proper use lies in the balancing of their pain relieving effect and their other, less desirable effects. Good pain control is an important part of the postoperative management.

Important side effects

Pain medications can cause drowsiness, slowness of breathing, and difficulties in emptying the bladder and bowel, nausea, vomiting and allergic reactions. Patients who have taken substantial narcotic medications in the recent past may find that usual doses of pain medication are less effective. For some patients, balancing the benefit and the side effects of pain medication is challenging. Patients should notify their surgeon if they have had previous difficulties with pain medication or pain control.

Hospital stay

After surgery, the patient usually spends an hour or two in the recovery room. The patient then goes to the hospital floor overnight. The next day, the drain is removed and the patient is switched to oral pain medication. Patients are commonly discharged the day after surgery, but occasionally remain in the hospital for an additional day.

Hospital discharge

The patient will be wearing a soft cervical collar after the procedure for a few weeks until the next follow-up visit. In the early postoperative period, the patient should limit activity. Walking is encouraged, but there should be no heavy lifting or sports. Once the collar is removed, the patient may resume day-to-day activities, but is still restricted from strenuous activity such as sports. The fusion can take as long as six months to fully heal and the patient will be under some restriction for that time period; however after the first three months, the average patient is able to perform most daily activities comfortably.

Convalescent assistance

Driving is usually discouraged in the early postoperative period. Turning the head may be more difficult in this time period. This limitation in motion does not allow for safe driving.

Early on, patients will require assistance. Patients should not lift heavy objects for six weeks, nor should the patient be subjected to repetitive bending. Patients should ease themselves back into the activities of daily living.

Physical therapy

The use of physical therapy is variable from patient to patient and can be used for overall rehabilitation if the patient needs conditioning.

The goal of physical therapy is long-term pain management and increased function; it will not change the shape of the spinal canal.

Supervised cervical stenosis physical therapy may continue for weeks or months.

Rehabilitation options

If prescribed, it is often most effective for the patient to carry out exercises so that they are done frequently, effectively and comfortably. Usually, a physical therapist instructs the patient in the exercise program and advances it at a rate that is comfortable for the patient.

Can rehabilitation be done at home?

Depending on the physical therapist’s prescribed program, some exercises likely can be performed independently at home.

Summary of anterior cervical decompression and fusion (acdf) for cervical stenosis

Cervical stenosis is a narrowing of the space for the spine at the neck. This can stem from an inherited, genetic trait, from advanced arthritis, or from a herniated disc that bulges beyond the spinal vertebrae and presses against the spinal canal. Compression on the spinal cord results in myelopathy.

Compression on a protruding branch of the spinal cord results in radiculopathy. In general, myelopathy does not improve with non-operative treatment, but radiculopathy can. When non-operative measures do not relieve symptoms adequately, surgical intervention should be considered.

In the hands of an experienced surgeon, anterior cervical spine decompression and fusion (ACDF) usually is very effective in relieving symptoms of radiculopathy, and preventing progression of nerve damage in myelopathy.