Anterior Cervical Discectomy and Fusion (ACDF) is a classic surgical procedure for treating cervical degenerative diseases. First described in the 1950s, it has become one of the most common spinal surgeries. This article provides a comprehensive introduction to the indications, surgical procedure, postoperative recovery, and latest advancements in ACDF surgery.
Overview of ACDF Surgery
ACDF is performed through an anterior approach to the neck, removing pathological intervertebral disc tissue to relieve compression on nerve roots or the spinal cord. An interbody fusion device or autologous bone is then implanted in the disc space to achieve bony fusion between adjacent vertebrae. This surgical method is considered the “gold standard” for treating cervical disc herniation and cervical spondylosis due to its direct decompression, high fusion rate, and relatively low complication rate.
Surgical Indications
ACDF is primarily indicated for the following cervical conditions:
- Cervical radiculopathy: Radicular pain, numbness, or weakness in the upper limbs caused by disc herniation or osteophyte compression of nerve roots that does not respond to conservative treatment.
- Cervical myelopathy: Spinal cord compression causing symptoms such as limb numbness, weakness, fine motor dysfunction, or gait instability.
- Discogenic cervical pain: Refractory neck pain caused by disc degeneration, confirmed by discography.
- Cervical instability or spondylolisthesis: Segmental cervical instability caused by trauma or degeneration.
- Cervical infection or tumor: Cases requiring surgical lesion removal and stability reconstruction.
Detailed Surgical Technique
Preoperative Preparation
- Comprehensive imaging evaluation (X-ray, MRI, CT, etc.)
- Fasting for 8 hours before surgery
- Prophylactic antibiotics
- Posture training (some patients need to practice neck extension)
Surgical Steps
- Anesthesia and Positioning: General anesthesia, supine position with mild neck extension.
- Approach: A 3-5 cm transverse incision along the neck skin lines (usually right-sided approach).
- Exposure: Separation along natural tissue planes, retracting the tracheoesophageal sheath and neurovascular bundle.
- Localization: C-arm fluoroscopy to confirm the target level.
- Decompression: Removal of the pathological disc and posterior osteophytes to completely relieve neural compression.
- Fusion: Implantation of a fusion device (PEEK, titanium alloy or allograft bone) or autologous iliac bone.
- Fixation: In most cases, additional anterior plate and screw fixation.
- Closure: Placement of a drainage tube and layered suturing.
Technical Advancements
- Zero-profile fixation systems: Reduce esophageal irritation.
- Artificial disc replacement: Preserves segmental motion as an alternative to fusion.
- Minimally invasive techniques: Microscope or endoscope-assisted procedures.
- Navigation and robotic assistance: Improves screw placement accuracy.
Postoperative Management and Rehabilitation
During Hospitalization
- Drain removal within 24-48 hours postoperatively.
- Early ambulation (usually on the first postoperative day).
- Cervical collar protection for 2-6 weeks (depending on fusion level and fixation strength).
- Pain management and thrombosis prevention.
Post-Discharge Care
- Wound care: Keep dry, sutures removed at 2 weeks.
- Activity restrictions: Avoid strenuous exercise and excessive neck movement.
- Gradual functional exercise: Under physician guidance.
- Regular follow-up: X-ray evaluations at 1, 3, 6, and 12 months postoperatively to assess fusion.
Rehabilitation Timeline
- 2-6 weeks: Soft tissue healing phase, mainly rest.
- 6-12 weeks: Early bone healing phase, gentle neck movements begin.
- 3-6 months: Bone healing consolidation phase, gradual return to daily activities.
- After 6 months: Most patients can resume non-physical work.
- After 1 year: Final fusion evaluation.
Surgical Outcomes and Complications
Treatment Efficacy
- Radicular symptom relief rate: 85%-95%.
- Spinal cord function improvement rate: 70%-80% (depends on preoperative severity and duration).
- Fusion success rate: 90%-95% for single-level, slightly lower for multi-level.
- Neck pain relief: Significant improvement in 70%-80% of patients.
Potential Complications
- Common complications:
- Dysphagia (about 50% initially, mostly temporary).
- Hoarseness (temporary recurrent laryngeal nerve injury, about 3%-5%).
- Anterior neck numbness (due to cutaneous nerve injury).
- Severe but rare complications:
- Spinal cord or nerve root injury (<1%).
- Esophageal perforation (0.1%-0.3%).
- Cerebrospinal fluid leak (1%-2%).
- Implant failure or fusion failure (3%-5%).
- Adjacent segment degeneration (about 3%/year in long-term follow-up).
Comparison of ACDF with Other Surgical Approaches
Compared with posterior approaches:
- ACDF is more suitable for anterior compression pathologies.
- Anterior surgery allows direct decompression, while posterior surgery provides indirect decompression.
- Anterior approach avoids chronic neck pain caused by posterior muscle stripping.
Compared with artificial disc replacement:
- ACDF sacrifices segmental motion but provides reliable fusion.
- Artificial discs preserve motion but long-term outcomes require further observation.
- ACDF has broader indications and lower costs.
Future Directions
- Advances in biomaterials: Fusion devices with osteoinductive capabilities, biodegradable materials.
- Stem cell technology: Promotes disc regeneration rather than simple removal.
- Surgical robot: Improves precision and safety.
- Application of Enhanced Recovery After Surgery (ERAS): Optimizes perioperative management.
- Mixed reality navigation: Enhances surgical visualization.
Conclusion
After more than half a century of development, ACDF has become a safe and effective method for treating cervical degenerative diseases. With advancements in materials science, biotechnology, and digital medicine, ACDF is evolving toward greater precision, minimally invasive techniques, and personalization. For patients meeting surgical indications, ACDF can effectively relieve nerve compression symptoms and improve quality of life. However, surgical decisions should be based on comprehensive evaluation and performed by experienced spinal surgeons, coupled with standardized postoperative rehabilitation, to achieve optimal outcomes.