Anterior cervical discectomy and fusion

Original Editors - Stacy Callow

Top Contributors - Carina Therese Magtibay, Kim Jackson, Stacy Callow, Lucinda hampton, Elodie Baele and WikiSysop - Elodie Baele

Definition/Description

cervical vertebrae

Anterior Cervical Discectomy and Fusion (ACDF) is a common neck surgery performed by spine specialists. Reasons for ACDF include:

• To treat a herniated disc in the neck
• To remove bone spurs that are irritating nerves
• To create more space for pinched nerves
• To stabilize the neck bones

The surgery has two main parts:

1. Discectomy: Removing the problem disc or bone spurs
2. Fusion: Joining the neck bones to keep them stable

This procedure helps relieve pain and other symptoms caused by pressure on the nerves in your neck.

Clinically Relevant Anatomy

• The cervical spine has 7 vertebrae, labeled C1-C7
• C1 and C2 are 'atypical' with unique shapes:
  • C1 (Atlas): Supports skull weight, allows nodding ("YES" motion)
  • C2 (Axis): Enables head rotation ("NO" motion)
• C3-C7 are 'typical' vertebrae
• Primary motions:
  • C2-C4: Mainly rotation
  • Lower cervical unit: Primarily side-bending
• Cervical spine's main functions:
  • Support the skull
  • Allow head and neck movement

Neck function is usually the first thing evaluated in any emergency as it serves as a conduit for the communication between the brain and the body. As the bony part of the neck, the cervical spine's primary function is to support the skull while still allowing for movement.

Indications for procedure

• Diagnostic tests (MRI, CT, myelogram) that show a herniated or degenerative disc in the cervical region
• Degenerative conditions, including disc herniation’s and spinal stenosis8
• Cervical spine trauma and resulting issues including instability, radiculopathy, myelopathy, osteomyelitis, spondylosis, vertebral body tumors
• Significant weakness in hand or arm
• Arm pain worse than neck pain
• If physical therapy or medications fail to relieve your neck or arm pain caused by pressure on the spinal nerves
• Cervical spondylotic myelopathy

Outcome Measures

Treatment effectiveness following spine surgery can be measured with the help of physician-oriented metrics, patient-reported outcome questionnaires and radiographic outcomes:

• Japanese Orthopedic Association (JOA) Score - a clinician-focused tool that evaluates the neurological status of a patient across 6 domains, serving as an indicator of patient satisfaction and functional recovery following surgical intervention.
• Neck Disability Index (NDI) Score - a commonly used self-report measure for neck pain consisting of 10 items intended to gauge how neck pain is affecting a patient's ADLs.
• Visual Analogue Scale (VAS) Neck Pain Score - a patient-reported measure of pain intensity.
• Radiographic Outcomes - Several objective measures using plain films can give insight as to how the surgery went such as: C2-C7 Cobb Angle, T1 Slope,C2-7 SVA, T1 Slope – C2-7 Angle

Medical Management

Surgical Process

• The surgeon makes an incision in the front of the neck
• They move aside neck muscles, trachea, and esophagus to reach the spine
• The damaged disc is removed ("discectomy")
• A bone graft is inserted in the empty space between vertebrae
• Metal plates and screws fix the bone graft in place
• This creates a "fusion" between the vertebrae above and below
• Over 3-6 months, new bone grows around the graft
• The vertebrae and graft form one solid piece of bone
• This process is similar to reinforced concrete

.

Complications

Each surgery has risks, the possible complications of ACDF will depend on the ability of the surgeon and the patient’s personal risk factors, such as: smoking, physical condition, diabetes, condition of the affected disc, bone strength, etc.Graft complications:

• Graft Dislodgement - displacement of the graft beyond the leading edge of the upper and lower vertebral bodies by a distance greater than 2 mm on lateral radiographs
• Graft Subsidence - a loss of height of the fusion segments on lateral plain radiographs

A 2025 study found that about 16% of patients who had Anterior Cervical Discectomy and Fusion (ACDF) surgery experienced complications. The most common problems after surgery included:

• Excessive neck swelling
• Failure of the bones to fuse properly
• Difficulty swallowing
• Sinking of the implant or bone graft
• Worsening of spinal cord symptoms
• Hoarseness
• Weakness in the C5 nerve area
• Damage to the recurrent laryngeal nerve

The research also found that certain factors before and during surgery were linked to higher chances of complications. This study was the largest review of its kind looking at ACDF complications and what might cause them.

Physical Therapy Management

Planning for a physiotherapy programme after ACDF should be customized for each patient and may also vary according to the surgeon's protocols. The following is a rough timeline for rehabilitation:

1st phase: Active Resting Phase (0–3 weeks)

• Mobilised under the supervision of a physiotherapist on the first postoperative day.
• Encouraged to remain mobile and change position frequently, at least 30-min intervals.
• Avoid cervical hyperextension and keep the low back in correct posture.
• Recommended to avoid lifting, bending, and hyperextending for 6 weeks
• Maintaining patients’ return to normal social and business lives without pain is harder in the early postoperative period. The most important aspect at this stage is maintaining relaxation of fasciculated and edematous nape–neck muscles with rehabilitation and subsequently strengthening these muscles with isometric exercises

2nd phase: Early Protective Phase (4–8 weeks)

• Restoring cervical curvature exercises within pain-free limits are commenced.
• Education on cervical protection principles and and correct posture are reinforced.

3rd phase: Dynamic Phase (8 weeks to 6 months)

• Cervical tilt exercises and, depending on tolerance, core stretching exercises should be started 6 weeks after surgery.
• Kinetic chain strengthening exercise programme consisting of proprioceptive exercises tailored to the needs of patients should be included.

4th phase: Return to Sports (6 months later)

• Low-resistance high-repeating activities are preferred but it is ultimately the patient's preference that will determine sports activities to do. Special precautions must be in place for specific activities.
• If returning to contact sports, risks of trauma and falling should be discussed in detail.

Prognosis

• Among young adults, long-term satisfaction with ACDF is high. Even though nearly half of the patients experienced some persistent neck symptoms later in life, the long-term prognosis of having the operation at a younger age seems to be good.
• Although further studies are needed for stronger evidence, a systematic review and meta-analysis suggests superior surgical outcomes in ACDF procedures with anterior plate fixation (increased fusion, decreased subsidence) and slightly better VAS-neck pain scores at last follow-up compared to no anterior plate fixation.
• Multilevel ACDF is favored over Anterior Cervical Corpectomy and Fusion (ACCF) if the compression is confined to the disc space. However, multilevel ACDF is associated with an increased risk of pseudarthrosis, as high as 54% in three-level fusions. On the other hand, ACCF is commonly preferred over multilevel ACDF in cases retrovertebral pathology (eg. traumatic disruption of the vertebral body, osteomyelitis, neoplasms and ossification of the posterior longitudinal ligament) as these conditions require expanded decompression or removal of the vertebral body.