As one of the most common neurosurgical and spine orthopedic procedures performed, Anterior Cervical Discectomy with Fusion (ACDF) through grafting and plating remains an effective means of alleviating cervical radiculopathy and/or cervical myelopathy. The success in alleviating radicular symptoms is in the 70-90% range 1-3, while myelopathy has lower success around 50-60% 4. Even though a straightforward procedure, there are multiple key places for complications or misadventure.
Patients presenting with neck pain, radicular symptoms such as numbness, tingling, paresthesias, or muscle spasms should undergo a trial of conservative treatment. The treatment can include anti-inflammatories, muscle relaxants, and possibly a one week taper of oral steroids (all of the treatments must be individualized for patient’s risk of bleeding, over sedation in elderly, and reaction to steroids). Along with medications physical therapy, massage treatments, acupuncture, gentle chiropractic manipulation, and cervical traction can be done to see if symptoms are relieved. In up to 80-90% of cases the onset of symptoms will abate with these conservative measures. If non pain related weakness or myelopathy are demonstrated on examination or if instability is present in cervical spine series X-rays (AP, LAT, FLEX, EXT) then proceeding with conservative therapy should be more judicious and moving toward definitive imaging studies preferably MRI or in patients with pacemakers or other implants that preclude MRI imaging, cervical CT/myelogram. Imaging studies that confirm patient symptoms and physical findings may provide indications for proceeding with an ACDF.
The key anatomy is the areolar plane between the sternocleidomastoid muscle fascia laterally and the strap muscle fascia, pharyngeal, tracheal, and esophageal adventitia medially 5. By making sure you are in this plane the dissection to the prevertebral fascia is essentially bloodless and easily done.
Other key anatomy is the location of the vertebral artery in the foramen transversarium from C6 to C2 (but there are developmental anomalies where the vertebral artery does not enter the foramen transversarium until higher 6 or where the foramen transversarium is atypically dilated or medial).
Checking the preoperative MRI for location of the foramen transversarium location is especially helpful in preparing for the atypical location. Along the lateral margin of the vertebral bodies lies the sympathetic plexus which can sustain heat damage with bovie cautery when chasing bleeding along the vertebral body.
The esophagus is at risk when large anterior osteophytes are present; redo surgery is being performed; previous radiation or infection has occurred; or during initial approach to the vertebral bodies from retraction or dissection.
The recurrent laryngeal nerve can be injured as it runs in the tracheoesophageal groove on either the approach, over retraction during the procedure, or coagulation on closing.
The nerve takes a more consistent course on the left as it leaves the vagus nerve and wraps around the arch of the aorta, while on the right side it wraps around the subclavian artery and does not enter the tracheoesophageal groove until later.
This has not been shown to have any effect, but in women where the cervical disc spaces are slightly higher in relation to men, a lower ACDF may put the nerve in jeopardy. A more likely nerve injury can occur with the superior and external laryngeal nerves which can be injured as it passes to the trachea lateral to medial, resulting in voice and pitch related problems if injured from retraction. In any ACDF, injury to the spinal cord, exiting nerves or CSF leak is possible. Although still controversial for use in all cases, somatosensory, motor evoked, and EMG monitoring is useful for assessment in any cases where spinal cord compromise and compression is involved.
- Cervical myelopathy
- Cervical instability or anterior column failure
- Vertebral Osteomyelitis or Discitis
- Vertebral body metastasis or primary vertebral body tumors
- Spondylosis, Kyphosis
- Calcified posterior longitudinal ligament, not appropriate for posterior decompression
- Postlaminectomy kyphosis
- Far lateral soft disc can be approached posteriorly without need for fusion
- Posterior ligamentous injuries with instability may require 360 degree approach
- Ossification of the Posterior Longitudinal Ligament better treated with posterior approach
- High cervical disc, requiring possible naso-tracheal intubation
- Lower cervical disc in barrel chested or low lying disc levels, as the disc space in the lower cervical spine are angled downward precluding perpendicular approach to disc space
Either general endotracheal anesthesia or nasotracheal anesthesia if high cervical approach (C3/4 or C2/3) is required.
Patients are done as outpatients and admitted overnight to observe for hematoma or swallowing difficulty or can go home same day if after 6-8 hours no complications have occurred in simple ACDF. Keep HOB at 30-45 degrees postoperatively to minimize any postoperative venous bleeding or oozing.
- Swallowing difficulty
- Injury to vertebral or carotid artery or jugular vein
- Injury to recurrent, superior, or external laryngeal nerves resulting in voice, breathing, or swallowing problems
- CSF leak
- Caridi JM, Pumberger M, Hughes AP. Cervical Radiculopathy: a review. HSS J. 2011 Oct;7(3):265-72. Epub 2011 Sep 9.
- Matz PG, Holly LT, Groff MW, Vresilovic EJ, Anderson PA, Heary RF, Kaiser MG, Mummaneni PV, Ryken TC, Choudhri TF, Resnick DK; Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Indications for anterior cervical decompression for the treatment of cervical degenerative radiculopathy. J Neurosurg Spine. 2009 Aug;11(2):174-182. doi: 10.3171/2009.
- Matz PG, Anderson PA, Holly LT, Groff MW, Heary RF, Kaiser MG, Mummaneni PV, Ryken TC, Choudhri TF, Vresilovic EJ, Resnick DK; Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. The natural history of cervical spondylotic myelopathy. J Neurosurg Spine. 2009 Aug;11(2):104-111. doi: 10.3171/2009.
- Holly LT, Matz PG, Anderson PA, Groff MW, Heary RF, Kaiser MG, Mummaneni PV, Ryken TC, Choudhri TF, Vresilovic EJ, Resnick DK; Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Clinical prognostic indicators of surgical outcome in cervical spondylotic myelopathy. J Neurosurg Spine. 2009 Aug;11(2):112-8. doi: 10.3171/2009.
- Fountas, KN, Kapsalaki EZ, Nikolokakos LG, Smisson HF, Johnston KW, Grigorian AA, Lee GP, Robinson Jr. JS. Anterior Cervical Discectomy and Fusion. Associated Complications. Spine (Phila Pa 1976). 2007 Oct 1;32(21):2310-7.
- Curylo LJ, Mason HC, Bohlman HH, Yoo JU. Tortuous course of the vertebral artery and anterior cervical decompression: a cadaveric and clinical case study. Spine (Phila Pa 1976). 2000 Nov 15;25(22):2860-4. PMID: 11074670.