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Mark A. Wolgin, MD, Orthopaedic Surgeon

Specialist (Fellowship Trained) in Spinal and Foot/Ankle Surgery, Albany, GA, Office Phone 229-883-4707

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Anterior Cervical Discectomy and Fusion
 
One of the main procedures in treating cervical disc herniations and degenerative (worn out) discs, after failure of non-operative treatment, is the procedure referred to as ACDF, which stands for:
 
Anterior (done from the front)
Cervical (refers to the neck)
Discectomy (removal of disc, decompression of nerves) and
Fusion
 

 

When the discs of the cervical spine wear out, the symptoms produced can include

 

Neck Pain

Headaches

Pain between the shoulder blades or above the shoulders (trapezius)

Pain and/or numbness radiating down the arms

and when spinal cord compression is present, loss of balance and coordination, problems walking, loss of bowel or bladder control.  If any of the symptoms of spinal cord compression are present, URGENT EVALUATION IS INDICATED!

 

 

Here are some details of the surgery:  an incision is made on the front of the neck, usually in a skin crease so as to be not so obvious from a cosmetic standpoint.  The only structure that is cut is the skin.  All the other structures are separated by dissecting between them.

 

The interval between the muscles of the neck is developed, and the front of the spine is approached by retracting the trachea and esophagus to one side, and the carotid artery to the other.  Retractors are put in place to keep the soft tissues out of the way during the procedure.  In most cases, the operating microscope is used.

 

 

Once the front of the spine is reached and retractors are in place, the disc is removed, the nerve roots are decompressed, and a bone graft, or a spacer with a bone graft substitute, is placed. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

After placing the bone graft, a plate is applied to the front of the spine to prevent the graft from dislodging.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Here's an example case:

 

This is an x-ray of the cervical spine of a 50 yr old woman who after a lifting injury had pain in her neck and between her shoulder blades, and also some numbness to the thumb on the right side (C6 nerve root distribution). 

 

The C5-C6 disc, indicated here by an asterisk, is notably more narrow than the disc spaces of the adjacent segments.

 

Since she did not improve with non-surgical treatment (medications, physical therapy, traction), she was taken to surgery for anterior cervical discectomy and fusion at C56.  She had immediate relief of her arm pain in the recovery room.  Her pre-operative neck pain was improved, but it took about two months for her neck and shoulder blades to feel like there was very good relief of pain.

 

 

 

 

 

 

 

 

 

Results after surgery.

 

 

 

 

 

 

After surgery, you will be advised to wear a soft collar for approximately one month, mainly when you are out of bed.

 

 

 

 

 

 

 

 

 

 

Results after healing.  Note that the two bones look like they have melted together into one.  For this case, the bone graft used was a piece from a cadaver from the bone bank.  This fusion is solidly healed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pictured here to the right is another example of a solid fusion, but this one has the interbody spacer and the bone graft substitute.  The bridging bone looks like a cloud forming between the vertebral bodies above or below.  Since the spacer used is invisible on xray, the metallic markers are embedded in the plastic so we can be sure that it hasn't moved.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Once a fusion heals, however, the mechanics of the neck will be changed, just like if you had a fusion of your ankle, it would put different stresses on your knee.  For a short video on the motion at the segment near a fusion, click on the video to the left.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Another example:  two level fusion, with the healed bone looking like a cloud in between the vertebral bodies:  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Three level fusion example:

 

 

 

 

 

 

This 55 yr old woman had severe enough degeneration to cause a forward bending of the cervical spine between the C4 and C5 vertebrae, with degeneration noted also between C5-6, and C6-7 as shown by the narrow disc spaces.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lateral view (looking from the side) after C4-7 fusion.  In this case, instead of placing a piece of bone between the vertebral bodies, a spacer was used.  This spacer, which is made of a type of special plastic, has a hole in the middle for packing of bone graft along with bone graft substitute, and metallic markers to that the spacer can be seen on X-ray.

 

 

 

 

 

 Front to back (AP) view below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

At one year after surgery, the bone which has formed in the disc spaces looks white, and is consistent with fusion.  Also, there is no evidence of screw loosening (see below).

 

 

 

 

 

 

 

 

 

 

Occasionally, a four level fusion is required.  This patient had spinal cord compression at four levels.  Sometimes this many levels will require a second surgery to also fuse from behind as well as there is a significant chance that one of the four levels will potentially not fuse.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

However, while the chance of success for cervical fusions is very high, not every fusion heals.  In this patient, who is a smoker (take note, patients who smoke!), 11 months after his intial operation, there is evidence of screw loosening on his X-ray.

 

 

 

  

 

 

The salvage for this case was to fuse the ununited segment from behind.  The patient went on to fusion after this second surgery. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In this case, the lower of the two fusion levels didn't fuse.  After placing the screws from behind, the fusion in the front showed evidence of healing, and the patient's symptoms resolved.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Here is a case where a plate pulled out. 

(please note, since I've been in Albany, this is the only case of plate pull-out I have had!).

 

The patient, who is an 84 year old female, had an uneventful (no problems with the surgery) three level spinal cord decompression and fusion.  On the first day in the hospital, she thought her neck felt swollen, so a CT s

 

can was done to look for a hematoma, or blood collection.  No hematoma was found, but on this reconstruction view, the plate and screws can be seen to be properly in place, right next to the bone.

 

 

 

 

 

 

 

 

 

 

 

However, at home, the patient felt so much better, she was lifting gallon jugs of milk and inadvertently pulled out her plate.  She had no symptoms, but the pull out was noted on her xray taken two weeks after surgery.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The patient was taken back to surgery where another, slightly shorter plate was replaced on the front, and the fusion was additionally stabilized with screws in the back part (posterior) of the spine, and she is healing and doing well.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Link to Risks of Surgery.